Most red flags for malignancy in low back pain guidelines lack empirical support: a systematic review

Abstract

Clinicians do not want to miss underlying serious pathology, but it is still unclear which red flags are relevant. We aimed to evaluate the origin and evidence on diagnostic accuracy of red flags for malignancy for management of low back pain (LBP) in primary care. We performed a comprehensive overview and searched the literature using snowballing techniques and reference checking for evidence on red flags endorsed in clinical guidelines for identifying patients with higher likelihood of malignancy. We selected studies including people with LBP without any restriction on study design. We extracted data on prevalence and diagnostic accuracy. Furthermore, we assessed the methodological quality of studies evaluating diagnostic accuracy. We identified 13 red flags endorsed in a total of 16 guidelines and 2 extra red flags not endorsed in any guideline. We included 33 publications varying from systematic reviews to case reports. The origin of many red flags was unclear or was sourced from case reports. The incidence of malignancy in patients presenting with LBP in primary care varied between 0% and 0.7%. Seven studies provided diagnostic accuracy data on red flags. We found 5 red flags with accuracy data from 2 or more studies, with 2 ("history of malignancy" and "strong clinical suspicion") considered informative. In conclusion, the origin and diagnostic accuracy of many red flags endorsed in guidelines are unclear. A "history of malignancy" and "strong clinical suspicion" are the only red flags with empirical evidence of acceptably high diagnostic accuracy.

Informed appropriate imaging for low back pain management: A narrative review

“…The very low specificity of most “red flags” contributes to unnecessary specialist referrals and imaging [30] , [31] . The “red flag” with the highest post-test probability for detection of spinal malignancy is the history of malignancy, and it has been noted that a “history of malignancy” and “strong clinical suspicion” are the only red flags with empirical evidence of acceptably high diagnostic accuracy [32] , [33] .…”

Experience with bruxism in the everyday oral implantology practice in the Netherlands: a qualitative study

“… 42 In low back pain literature, a “strong clinical suspicion” has recently been reported as having acceptably high diagnostic accuracy as a red flag for malignancy. 43 We were not able to retrieve literature mentioning such a specific manner to diagnose bruxism. Therefore, we suggest that the extent of using this approach in bruxism diagnostics, and its validity be further researched.…”

When Is Imaging Appropriate for a Patient With Low Back Pain?

“…A 2017 systematic review of 33 publications that included 13 different red flags endorsed by 16 guidelines found that a history of malignancy and high clinical suspicion were the only 2 red flags of 7 with acceptable diagnostic accuracy for malignancy. 6 Of the 33 publications, the studies that evaluated the 7 signs and symptoms with the most acceptable diagnostic accuracy showed moderate quality evidence. The positive likelihood ratios for diagnostic accuracy of malignancy were reported to range from 6.4 to 15.3 for history of malignancy and 12 to 54.2 for high clinical suspicion.…”