Hemangiomas are the most common benign tumours affecting the spine, with an incidence of 10–12% of the general population. Although most hemangiomas are asymptomatic, there are aggressive forms which can develop symptoms, leading patients to show signs of disability. This case report aims to highlight the importance of red flags screening, and to report the physiotherapist’s clinical reasoning that led him to refer his patient to other healthcare professionals. This case also illustrated the pre- and post-surgical treatment of a specific low back pain case in a patient affected by aggressive vertebral hemangioma and spinal cord compression. The patient is a 52-year-old man, who reported intense pain in his sacral region about three months prior, which worsened while in sitting position. The physiotherapist proceeded with a complete medical history investigation and clinical examination. After an impaired neurological examination, the patient was referred to another health professional, who diagnosed multiple vertebral hemangiomas in the patient’s lumbosacral tract. The therapeutic intervention included the patient’s post-surgical rehabilitation following a vascular embolization. This case report shows the importance of proper patient screening. Indeed, during patients’ assessment, it is paramount to recognize red flags and to investigate them appropriately. An early referral of patients with conditions that require the support and expertise of other professionals can lead to a timely diagnosis and avoid costly and unnecessary rehabilitation procedures. In this case, the interdisciplinary collaboration between physiotherapist and neurosurgeon was crucial in guiding the patient towards recovery.

Introduction: While low back pain (LBP) is most often associated with musculoskeletal issues, in a minority of cases, it can be caused by serious underlying conditions such as cancer. Recognizing malignancy early remains a major clinical challenge, as the warning signs, known as red flags (RFs), are often vague and inconsistent. Methods: A comprehensive search of six databases (PubMed, Scopus, Google Scholar, Web of Science, Cochrane Library, and SciELO) and grey literature was conducted for studies published from January 1999 to March 2025. Eligible sources included studies describing adult patients with cancer presenting with LBP. Study selection and data extraction were independently performed by two reviewers. Results: We included 70 studies, most of which were case-based, along with reviews and observational research. In these studies, cancer prevalence among patients with LBP ranged from 0.1% to 1.6%, with metastatic disease being the most common finding. A prior history of cancer emerged as the most reliable red flag (specificity up to 0.99), while other signs and symptoms were less consistent. Notably, combining multiple RFs, such as a history of cancer and unexplained weight loss, significantly improved the diagnostic accuracy (LR+ = 10.25 in one study). Conclusions: While current evidence is limited and largely based on case-based studies, some RFs, particularly a history of cancer, show greater diagnostic value. In patients with LBP associated with underlying malignancy, RFs seem to be more useful for ruling in rather than ruling out (i.e., screening) serious pathologies. Most RFs have poor standalone accuracy; however, considering combinations of RFs within the broader clinical context may improve early detection of spinal malignancy in patients with LBP.

Low back pain (LBP) is defined as pain and discomfort occurring under the costal arch and above the inferior gluteal folds, with or without leg pain. The most common type of low back pain is “non-specific low back pain”. It is defined as such because there is no specific pathology that can be the cause. Instead, “specific low back pain” is caused by diseases such as infections, tumors, osteoporosis, ankylosing spondylitis, fractures, inflammatory processes, radicular syndromes, cauda equina syndrome, etc. It is the most common musculoskeletal disorder in the world and the most cause of disability. Most low back pain is benign in nature and specific diagnoses are uncommon; however in some specific cases this clinical presentation of signs and symptoms could hide much more serious conditions. The second most frequent serious pathology, after fracture, that may initially appears as low back pain is tumor pathology (0.2% and 7.0%), condition that turns out to be so dangerous as to be the second leading cause of death in the world according to the WHO. Red flags are signs and symptoms that raise suspicion of the presence of serious diseases; these are clinical aspects of alert that can justify referral to the doctor/specialist and can contraindicate physiotherapy treatment. Clinicians must therefore be able to recognize clinical presentations that are potentially dangerous to the patient that may require further evaluation or emergency referral. Failure to immediately recognize these conditions could lead to incorrect diagnoses resulting in worsening outcomes over time. The tools that will guide the clinician in recognizing the red flags in low back pain are a through medical history and a complete physical examination. Currently we have very little clarity and agreement in the literature about the Red Flags that should be better investigated, a scoping review is strongly required and corresponded to the objectives of this project.