Yellow flag signs are psychological factors shown to be indicative of long-term chronicity and disability. A negative attitude that back pain is harmful or potentially severely disabling Fear avoidance behavior and reduced activity levels An expectation that passive, rather than active, treatment will be beneficial A tendency to depression, low morale, and social withdrawl Social or financial problems

Previous history malignancy (however long ago) Age 16< or >50 with NEW onset pain Weight loss (unexplained) Previous longstanding steroid use Recent serious illness Recent significant infection

Saddle anaesthesia Reduced anal tone Hip or knee weakness Generalised neurological deficit Progressive spinal deformity Urinary retention

Non-mechanical pain (worse at rest) Thoracic pain Fevers/ rigors General malaise Urinary retention

High index of suspicion Majority of information in history Simple inspection of back with movement Simple neurological examination Heel/ toe walk, squat

Back pain Leg weakness Limb numbness Ataxia Urinary retention (with overflow) Hyper-reflexia Extensor plantars Clonus

Bilateral leg pain Back pain Urinary retention Perianal sensory loss Erectile dysfunction Reduced anal tone

Urgent when red flags present To include: Myeloma screen ESR, CRP, FBC, U+E, Ca2+ Plain xray particularly osteoporosis / infection Consider MRI