Prevalence of and screening for serious spinal pathology in patients presenting to primary care settings with acute low back pain

Henschke, Nicholas; Maher, Christopher G.; Refshauge, Kathryn M.; Herbert, Robert D.; Cumming, Robert G.; Bleasel, Jane; York, John R.; Das, Arpita; McAuley, James H.

doi:10.1002/art.24853

Cited by 393 publications

(327 citation statements)

References 75 publications

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“…In the vast majority of patients with low back pain, symptoms can be attributed to non-specific mechanical factors. However, in a much smaller percentage of patients, the cause of back pain may be something more serious, such as cancer, 79 cauda equina syndrome, 81 spinal infection, 303 spinal compression fractures, 142 spinal stress fractures, 143 ankylosing spondylitis, 125 or aneurysm. 94 Clinical findings that increase the level of suspicion that there is a serious medical condition presenting as common, non-serious, musculoskeletal conditions, are commonly described as “red flags.” Table 4 lists serious medical conditions that can cause low back pain and their associated red flags.…”

Section: Clinical Guidelines: Impairment/function-based Diagnosismentioning

confidence: 99%

Low Back Pain

Delitto¹,

George²,

Dillen³

et al. 2012

Journal of Orthopaedic & Sports Physical Therapy

803

352

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Section: Clinical Guidelines: Impairment/function-based Diagnosismentioning

confidence: 99%

Low Back Pain

Delitto¹,

George²,

Dillen³

et al. 2012

Journal of Orthopaedic & Sports Physical Therapy

803

352

View full text Add to dashboard Cite

“…An Australian population-based prospective cohort study of 1172 consecutive patients presenting to primary care for low back pain calculated the increased probability of fracture when a combination of red flags were positive [43]. When any three of the red flags 'female', 'age [70', 'severe trauma', and 'prolonged use of corticosteroids' were present, the probability of fracture increased from 4 % (pre-test) to 90 % (95 % CI 34-99 %).…”

Section: Comparison With the Literaturementioning

confidence: 99%

“…Nevertheless, the majority of guidelines inferred that the presence of a red flag was absolute by recommending further diagnostic workup (e.g., advanced imaging). Given that up to 80 % of patients presenting to primary care may have at least one positive red flag [43], when combined with weak evidence in support of many red flags, this advice may cause harm to many patients through unnecessary imaging (increased radiation and health care costs), unnecessary alarming the patients (resulting in reduction of quality of life) and unnecessary treatment (including unnecessary surgery) [42,44].…”

Section: Comparison With the Literaturementioning

confidence: 99%

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Red flags presented in current low back pain guidelines: a review

et al. 2016

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Objective The purpose of this study was to identify and descriptively compare the red flags endorsed in guidelines for the detection of serious pathology in patients presenting with low back pain to primary care. Method We searched databases, the World Wide Web and contacted experts aiming to find the multidisciplinary clinical guideline in low back pain in primary care, and selected the most recent one per country. We extracted data on the number and type of red flags for identifying patients with higher likelihood of serious pathology. Furthermore, we extracted data on whether or not accuracy data (sensitivity/specificity, predictive values, etc.) were presented to support the endorsement of specific red flags. Results We found 21 discrete guidelines all published between 2000 and 2015. One guideline could not be retrieved and after selecting one guideline per country we included 16 guidelines in our analysis from 15 different countries and one for Europe as a whole. All guidelines focused on the management of patients with low back pain in a primary care or multidisciplinary care setting. Five guidelines presented red flags in general, i.e., not related to any specific disease. Overall, we found 46 discrete red flags related to the four main categories of serious pathology: malignancy, fracture, cauda equina syndrome and infection. The majority of guidelines presented two red flags for fracture ('major or significant trauma' and 'use of steroids or immunosuppressors') and two for malignancy ('history of cancer' and 'unintentional weight loss'). Most often pain at night or at rest was also considered as a red flag for various underlying pathologies. Eight guidelines based their choice of red flags on consensus or previous guidelines; five did not provide any reference to support the choice of red flags, three guidelines presented a reference in general, and data on diagnostic accuracy was rarely provided. Conclusion A wide variety of red flags was presented in guidelines for low back pain, with a lack of consensus between guidelines for which red flags to endorse. Evidence for the accuracy of recommended red flags was lacking.

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“…Osteoporotic fractures of the spine are a relatively common presentation in primary care but represent Ͻ1% of the presentations in the study by Henschke and colleagues (6). Clinician judgment, however, has a positive predictive value similar to that of the formulaic red flag-based diagnostic rule (6).…”

Section: Martin Underwoodmentioning

confidence: 93%

Diagnosing acute nonspecific low back pain: Time to lower the red flags?

Underwood¹

2009

Arthritis & Rheumatism

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Episodes of acute low back pain are a universal human experience (1). Usually, this is a benign, selflimiting disorder that does not require professional advice or specific treatment (2). Once someone with acute low back pain presents for care, a plethora of management guidelines are available to treating clinicians. These guidelines typically recommend that serious disorders (cauda equina syndrome, fracture, infection, inflammatory disorders, malignancy) should be excluded, using a number of "red flag" questions, before making a diagnosis of nonspecific low back pain (3). In contrast to the high-quality data available for at least some treatments of nonspecific low back pain, systematic reviews of the use of red flag questions to identify malignancy and fractures show that the strength of the evidence underpinning these screening questions is weak (4,5). Furthermore, few of the data that are available were collected in a primary care setting, where most consultations for back pain take place.In this issue of Arthritis & Rheumatism, Henscke and colleagues report on the performance of commonly recommended red flags in a prospective study of 1,172 consecutive patients presenting to a primary care setting because of acute low back pain (duration of Ͼ24 hours but Ͻ6 weeks) (6). After careful followup over 1 year, a serious cause for back pain was identified in only 11 patients (0.9%; 95% confidence interval [95% CI] 0.5-1.7%). The incidence of spinal fractures (8 [0.7%] of 1,172 patients [95% CI 0.4-1.3%]) and malignancy (none of 1,172 patients [95% CI 0-0.3%]) was much lower than the commonly quoted values for osteoporotic fractures and malignancy (ϳ4% and ϳ0.7%, respectively) (7).An important strength of this study is that data were collected from members of different health professions who provide first-contact care for acute back pain in a primary care setting. This approach also results in an important weakness of the study: only first presentations for a new episode of low back pain were considered. Serious disorders causing low back pain are likely to be more common in some other patient groups. Persons in such groups include those presenting for a second, third, or subsequent primary care consultation because of pain that is not resolving, those presenting to an emergency room, and those who had been referred for specialist care. Thus, even though the incidence of serious disease is very low at the time of first consultations for new episodes of acute low back pain, clinicians do need to keep their diagnosis of nonspecific low back pain under review during the subacute and early chronic phases of low back pain (8). Indeed, these serious disorders can develop in patients with established disabling chronic low back pain and thus cannot be disregarded regardless of how long the patient has been experiencing low back pain. With this extremely low incidence of serious disease identified following a first consultation for a new episode of acute low back pain, the large number of patients with 1 or more red flag sy...

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Prevalence of and screening for serious spinal pathology in patients presenting to primary care settings with acute low back pain

Cited by 393 publications

References 75 publications

Low Back Pain

Low Back Pain

Red flags presented in current low back pain guidelines: a review

Diagnosing acute nonspecific low back pain: Time to lower the red flags?

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