Back pain in patients under 20 may not be a “red flag”


By James Hiett

Back pain in patients under the age of 20 is seen as “red flag”—a potential indicator of spinal tumours or spinal infection. James Hiett reports the results of his study, which suggest that this “red flag” is of dubious significance

Back pain is common in all age groups and, according the UK’s National Institute for Health and Clinical Excellence (NICE)1, there is no correlation between age and prevalence of back pain. Despite this, back pain in the under 20s is seen as a “red flag”.

In 1994, the Clinical Standards Advisory Group (CSAG) produced a report for low back pain for the UK Department of Health. It listed the clinical indicators, also known as the “red flags”, for serious spinal pathologies. One such red flag was back pain in people less than 20 years of age, as there have been several reports of back pain in this age group being associated with spinal tumours or spinal infection2. However, the vast majority of back pain patients who are less than 20 years of age have benign spinal complaints.

Treating all types of back pain costs the NHS more than £1,000 million per year1, and with ever increasing demands within the NHS and an escalating number of back pain patients being referred to secondary care (a 20% increase over the last year within our unit), our unit [Peninsula Spinal Unit, Royal Devon and Exeter NHS Foundation Trust] questioned whether the red flag status of back pain in patients under 20 was justified. We wanted to know if, ultimately, these patients could be managed in the same as adults with back pain using established primary and secondary care pathways.

Retrospective review

We retrospectively reviewed the clinical notes of all back pain patients aged less than 20 who presented at our unit during 2011. Of these, only one patient was diagnosed with a potentially serious pathology and the majority of patients (65%) were diagnosed with non-specific mechanical back pain.

Buchanan et al reported similar findings and concluded that in the absence of other red flags, serious pathology in this age group was rare—although non-specific mechanical pain is common2. Other studies have also suggested that back pain is common in children. For example: Szpalski et al3, as part of a two-year prospective study, reported a back pain incidence of 17.8% among children aged 9–12; Boćkowski et al suggested a 20% incidence in school-aged children4,  and Watson et al reported a prevalence rate of 24% in children aged 11–14 years5.

In our cohort of patients, the pathologies identified mirrored those of the adult population both in clinical presentation and clinical outcome, with symptoms being most commonly reported within the lumbar spine. Additionally, there was a similar conversion rate of 7% (from non-operative management) to surgery to that seen in adult patients.

However, despite back pain clearly being a common problem in children, primary care physicians—due to a fear of missing a serious condition and a fear of not following the guidelines for the age group correctly—make a growing number of unnecessary referrals to secondary care. These referrals put extra strain on already limited resources. Additionally, in our experience, there is a high rate of imaging in the under 20 age group (98%) with MRI investigation being the preferred modality.


Back pain by itself in patients aged less than 20 does not appear to justify its red flag status. However, the presence of certain clinical features alongside back pain can be a red flag. For example, back pain plus significant night pain, constant, progressive and severe pain, or alteration in neurological status is far more likely to indicate a serious pathology than back pain by itself. Therefore in the absence of other red flags, it would appear more rational to treat these patients in primary care in a similar way to the adult population.

Ultimately the treatment, investigation and management of back pain—whatever the age of the patient—uses NHS resources that are limited. Thus, we need to ensure that we are using them appropriately.


1. NICE. Nice Guidelines: Low Back Pain: Early Management of Persistent Non-Specific Low Back Pain.

2. Buchanan E. Journal of Bone and Joint Surgery 2008; 90-B (supplement III 457)

3. Szpalski et al. European Spine Journal 2002. 459–64

4. Boćkowski et al. Department of Pediatric Neurology and Rehabilitation, Medical University of Białystok, Poland 2007

5. Watson et al. Pain 2002; 97:87–92


James Hiett, Peninsula Spinal Unit, Royal Devon and Exeter NHS Foundation Trust, Exeter, UK