A man in his sixties with acute back pain and increasing weakness in his lower limbs

European and Norwegian consensus-based guidelines for the management of acute low back pain endorse red flag screening. Red flag symptomatology may ignore important information in the case history and clinical findings. An active man in his sixties presented with acute low back pain with radiation to the left thigh. A paramedic visited the patient at home and found no serious disease. Over a period of 4 hours, progressive loss of sensation and weakness in both legs developed. He arrived at the Accident and Emergency Department with paralysis, reduced sensation distal to the hips, absent reflexes, urinary retention and reduced sphincter tone. INR was 2.6. MR scan showed an intradural haematoma compressing Th9-L1, and dislocation of medulla and conus. This was followed by urgent Th10-12 laminectomy and evacuation of subdural haematoma, and thereafter rehabilitation. Three years later, he has sequelae for spinal cord injury at level Th12 with impaired mobility and function in the legs. This case highlights that patients with ongoing anticoagulation and acute back pain have increased risk of spinal haematoma requiring emergency treatment. Anticoagulation therapy should therefore be included in red flag screening of acute back pain.