Most back pain is not dangerous, but a small number of warning signs mean you should seek medical care rather than manage it yourself, and a few mean you should go to an emergency department straight away. Fewer than one in a hundred people who see a clinician for back pain have a serious underlying cause. This guide explains which signs matter, why, and what to do about each one, so you can act on the rare emergency without living in fear of the ordinary ache.
This page is for education and does not replace assessment, diagnosis, or treatment by a qualified health professional. If you think you are having a medical emergency, do not wait for an appointment.
Part of our complete guide to Understanding Pain
- New trouble passing urine, or new loss of control of your bladder or bowels.
- Numbness or altered sensation around the saddle area: the buttocks, inner thighs, genitals, or anal region (for example, reduced feeling when wiping).
- Numbness, tingling, or weakness in both legs.
- New loss of sexual sensation.
- Chest pain, jaw pain, or pain that comes with shortness of breath, sweating, or nausea.
In South Africa, call 112 from any mobile, or 10177 for an ambulance. These signs can point to conditions where every hour counts, and acting quickly protects you.
Most back pain is not a sign of anything serious
It helps to start with the reassuring picture, because fear of serious illness is itself a common reason people suffer more than they need to. The large majority of back pain, somewhere around nine in ten cases, has no serious underlying disease. It comes from the muscles, joints, discs, and nerves doing what they do, often settles with time and gentle movement, and does not show up as anything sinister on a scan (our guide to whether pain means damage explains why scans so often look alarming in people who are perfectly well).
Serious causes do exist, and they fall into a small number of groups: problems with the nerves at the base of the spine, fractures, infections, and cancer that has spread to the spine. They are uncommon, but they are the reason a few warning signs are taken seriously. The aim of this guide is to help you recognise the handful of situations that change the plan from managing the pain yourself to having it checked, without leaving you anxious about every twinge.
Signs that need emergency care straight away
Two situations call for an emergency department rather than a wait-and-see approach or a booked appointment.
The first is cauda equina syndrome. This is when the bundle of nerves at the base of the spine becomes compressed, and it can threaten permanent loss of bladder, bowel, and sexual function if it is not treated quickly. It is rare, but it is a true emergency. The warning signs are new difficulty passing urine or new loss of bladder or bowel control, numbness around the saddle area, numbness or weakness in both legs, and loss of sexual sensation. These can come on suddenly or build over a day or two, and not all of them need to be present. Even one or two, especially if they are new or getting worse, mean you should go to an emergency department now, not on Monday. The urgency here comes from the change in nerve function, however mild or severe the pain itself feels.
The second is pain that may not be coming from your back at all. Chest pain, jaw pain, or pain in the upper back or shoulder that arrives with shortness of breath, sweating, or nausea can be the heart rather than the spine, and it should always be treated as a reason to seek urgent help. The same applies to a sudden, severe, tearing pain. When pain is accompanied by these symptoms, the safest assumption is that it needs ruling out at once.
Signs that mean see a clinician promptly
A larger group of signs are less urgent but still need a clinician's eye. They mean you should see your chiropractor or doctor within the next few days. Each one slightly raises the chance that something other than ordinary back pain is going on, and your clinician can decide whether further checks are needed.
- A history of cancer, with new back pain or a change in your usual pain. This is the single most useful warning sign, because cancer can spread to the spine.
- Unexplained weight loss alongside the pain.
- Fever, night sweats, or feeling generally unwell with the pain, which can point to an infection.
- Pain that repeatedly wakes you at night, or that is no better, or worse, when you lie down and rest.
- Pain after a significant accident, such as a fall from height or a vehicle collision. In older people, or anyone with thinning bones, even a minor fall can be enough to fracture a vertebra.
- Weakness, numbness, or pins and needles in an arm or leg that is getting worse rather than settling.
- Pain that climbs steadily and rapidly rather than fluctuating up and down in the way ordinary pain does.
- A first episode of significant back pain after the age of 50, particularly if it comes with any of the above.
- Long-term use of corticosteroid medication, which can weaken bone.
- Pain that simply is not improving after a few weeks of sensible self-management.
A single sign here is a prompt to have things checked by a professional, and usually has an innocent explanation.
Why one warning sign usually is not cause for panic
Warning signs are easy to misread. Studies have found that up to eight in ten people with recent back pain have at least one so-called red flag, while fewer than one in a hundred turn out to have a serious cause. A single warning sign on its own is common and usually means very little.
A clinician's concern is usually driven by a combination of signs, the way they change over time, and the wider picture of your health, rather than by any one sign alone. A history of cancer is the most significant of them. When several appear together, such as weight loss, night pain, and feeling unwell, the case for a careful check grows stronger. For someone who is otherwise well, a single item on the list is usually a reason to mention it and have it looked at when convenient.
This is also why scans are not the answer to a worried mind. Imaging early, in the absence of warning signs, tends to turn up the normal age-related changes that almost everyone has, which leads to more worry and more treatment without better outcomes. The sensible path is to know the signs, act on the ones that matter, and otherwise let ordinary pain be ordinary.
What to do, depending on what you are seeing
If you have any of the emergency signs, go straight to an emergency department or call 112 or 10177. Do not wait, and do not book a routine appointment instead.
If you have one or more of the prompt signs, see your chiropractor or doctor within the next few days and tell them which signs you have noticed and how they are changing. If you are not sure how urgent it is, phone a clinic and ask. It is always reasonable to check.
If you have back pain and none of these signs, you are most likely dealing with ordinary, non-dangerous pain, and the most helpful things are usually staying gently active, keeping up your normal routine as much as you can, and getting good advice on movement (our pillar guide on understanding pain covers why this works). If you would like that pain properly assessed and a clear plan to recover, that is the kind of musculoskeletal pain I help with.
Back pain, but none of the warning signs above? I can assess what is driving it and build you a plan to move and recover with confidence.
If any of the emergency signs are present, please go to an emergency department instead.
Frequently asked questions
When should I worry about back pain?
Certain warning signs matter more than how severe the pain feels. Seek emergency care for new bladder or bowel problems, saddle-area numbness, weakness in both legs, or chest or jaw pain with breathlessness. See your chiropractor or doctor promptly for back pain alongside a history of cancer, unexplained weight loss, fever, unrelenting night pain, significant injury, or worsening weakness or numbness.
What are the red flags for back pain?
Red flags are signs that slightly raise the chance of a serious cause: a cancer history, unexplained weight loss, fever, night pain, major trauma, progressive weakness or numbness, and the cauda equina signs (bladder or bowel changes, saddle numbness, weakness in both legs). They prompt a check, but on their own they rarely mean something is wrong.
What is cauda equina syndrome?
It is a rare emergency in which the nerves at the base of the spine are compressed, risking permanent loss of bladder, bowel, and sexual function. Warning signs include new urinary problems, loss of bladder or bowel control, saddle-area numbness, and numbness or weakness in both legs. It needs emergency assessment and an urgent scan.
Is most back pain dangerous?
No. Around nine in ten cases of back pain have no serious underlying disease, and fewer than one in a hundred people seen for back pain have a serious cause. Most pain settles with time and gentle movement.
Should I get a scan for my back pain?
Not usually, and not early, unless you have warning signs. Scanning in their absence tends to reveal normal age-related changes that are common in pain-free people, which can cause needless worry without improving recovery.
I have one warning sign but feel otherwise fine. What should I do?
Mention it to your chiropractor or doctor and get it checked when you reasonably can. A single sign in someone who is otherwise well is common and usually not serious, but it is sensible to have it looked at, especially if more signs appear or things change.
Sources
Selected references, with confirmed DOI or PubMed links.
- Downie A, et al. (2013). Red flags to screen for malignancy and fracture in patients with low back pain: systematic review. BMJ, 347, f7095. doi:10.1136/bmj.f7095
- Henschke N, et al. (2009). Prevalence of and screening for serious spinal pathology in patients presenting to primary care with acute low back pain. Arthritis & Rheumatism, 60(10), 3072–3080. doi:10.1002/art.24853
- Greenhalgh S, Selfe J (2019). Red Flags: A Guide to Identifying Serious Pathology of the Spine. (background reference)
- Hartvigsen J, et al. (2018). What low back pain is and why we need to pay attention. The Lancet, 391(10137), 2356–2367. doi:10.1016/S0140-6736(18)30480-X
- Todd NV, Dickson RA (2016). Standards of care in cauda equina syndrome. British Journal of Neurosurgery, 30(5), 518–522. doi:10.1080/02688697.2016.1187254
This page is for education and does not replace assessment, diagnosis, or treatment by a qualified health professional. If you notice any of the emergency signs above, go to an emergency department or call 112 or 10177.
