Patients should be advised that severe pain does not necessarily mean there is a serious problem. However, urgent referrals are required for the following signs and symptoms:7,11

Cauda equina

·       sciatica in both legs

·       sudden and severe loss of muscle and joint control in both legs and/or feet

·       difficulty in starting to urinate or impaired sensation of urinary flow (which may lead to irreversible overflow urinary incontinence)

·       loss of sensation of rectal fullness or weak rectal sphincter (which may lead to irreversible faecal incontinence)

·       numbness or pins and needles sensation in the perianal, perineal or genital areas

Spinal fracture

·       sudden onset of severe central spinal pain which is relieved by lying down

·       a history of major trauma

·       structural spinal deformity

·       point tenderness on the spine

Cancer

·       severe, unremitting pain, even when lying down

·       aching night pain that prevents or disturbs sleep

·       pain aggravated by straining (for example, at stool, or when coughing or sneezing)

·       thorax pain

·       no improvement after 4-6 weeks of analgesics and activity/exercise

·       gradual onset of symptoms, especially in those over 50 years of age

·       unexplained weight loss

·       past history of cancer

Infection

·       fever

·       tuberculosis or recent urinary tract infection

·       diabetes

·       immunosuppressed/immunocompromised (eg HIV, cancer treatments etc)

·       intravenous drug use history