Skip to main content
Key Specialties
Cardiology Diabetology Endocrinology Gastroenterology Geriatrics and Gerontology Gynecology and Obstetrics Hematology Infectious Disease Internal Medicine Nephrology Neurology Oncology Pediatrics Respiratory Medicine Rheumatology Surgery
Congress Coverage
2024 ACC Congress 2023 ESMO Congress 2023 EASD Congress 2023 ERS Congress 2023 ESC Congress 2023 EHA Congress 2023 ASCO Annual Meeting
Clinical Collections
Advances in Alzheimer’s

At a glance: The ONWARDS insulin icodec trials

A round-up of the ONWARDS phase 3 clinical trials evaluating the novel weekly insulin icodec in people with diabetes.
ADVANCED SEARCH
Log in
Top
European Spine Journal
Published in: European Spine Journal 9/2016

Open Access 01-09-2016 | Original Article

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

Authors: Arianne P. Verhagen, Aron Downie, Nahid Popal, Chris Maher, Bart W. Koes

Published in: European Spine Journal | Issue 9/2016

Login to get access

Abstract

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.
Literature
1.
Joines JD, McNutt RA, Carey TS, Deyo RA, Rouhani R (2001) Finding cancer in primary care outpatients with low back pain: a comparison of diagnostic strategies. J Gen Intern Med 16(1):14–23CrossRefPubMedPubMedCentral
2.
Henschke N, Maher CG, Refshauge KM, Herbert RD, Cumming RG, Bleasel J, York J, Das A (2008) McAuley JH Prognosis in patients with recent onset low back pain in Australian primary care: inception cohort study. BMJ 337:a171. doi:10.​1136/​bmj.​a171 CrossRefPubMed
3.
Frymoyer JW, Cats-Baril WL (1991) An overview of the incidences and costs of low back pain. Orthop Clin North Am 22:263–271PubMed
4.
van Tulder M, Becker A, Bekkering T, Breen A, del Real MT, Hutchinson A et al (2006) European guidelines for the management of acute nonspecific low back pain in primary care. Eur Spine J 15:S169–S191CrossRefPubMedPubMedCentral
5.
Jarvik JG, Deyo RA (2002) Diagnostic evaluation of low back pain with emphasis on imaging. Ann Intern Med 137(7):586–597CrossRefPubMed
6.
Chou R, Qaseem A, Snow V, Casey D, Cross JT Jr, Shekelle P, Owens DK, Clinical Efficacy Assessment Subcommittee of the American College of Physicians; American College of Physicians; American Pain Society Low Back Pain Guidelines Panel (2007) Diagnosis and treatment of low back pain: a joint clinical practice guideline from the American College of Physicians and the American Pain Society. Ann Intern Med 147(7):478–491CrossRefPubMed
7.
8.
Downie A, Williams CM, Henschke N, Hancock MJ, Ostelo RW, de Vet HC, Macaskill P, Irwig L, van Tulder MW, Koes BW, Maher CG (2013) Red flags to screen for malignancy and fracture in patients with low back pain: systematic review. BMJ 347:f7095. doi:10.​1136/​bmj.​f7095 CrossRefPubMedPubMedCentral
9.
Deyo RA, Rainville J, Kent DL (1992) What can the history and physical examination tell us about low back pain? JAMA 268(6):760–765CrossRefPubMed
10.
Van Goethem J, van den Hauwe L, Ozsarlak O, de Schepper AM, Parizel PM (2004) Spinal tumors. Eur J Radiol 50:159–176CrossRefPubMed
11.
Old JL, Calvert M (2004) Vertebral compression fractures in the elderly. Am Fam Phys 69(1):111–116
12.
Koes B, Tulder M, Wei C, Lin C, Macedo G, McAuley J, Maher C (2010) An updated overview of clinical guidelines for the management of nonspecific low back pain in primary care. Eur Spine J 19:2075–2094CrossRefPubMedPubMedCentral
13.
Brox JI, Cedraschi J, Hildebrandt J, Moffett F, KovacIs KI, Mannion AF (2006) European guidelines for the management of chronic nonspecific low back pain. Eur Spine J 15:S192–S300CrossRefPubMedPubMedCentral
14.
Guevara-López U, Covarrubias-Gómez A, Elías-Dib J, Reyes-Sánchez A, Rodríguez-Reyna TS, Consensus Group of Practice Parameters to Manage Low Back Pain (2011) Practice guidelines for the management of low back pain. Consensus Group of Practice Parameters to Manage Low Back Pain. Cir Cir 79(3):264–279, 286–302
15.
16.
17.
18.
19.
Pohjolainen T, Leinonen V, Frantén J, Haanpää M, Jousimaa J, Karppinen J, Kuukkanen T, Luoma K, Salmenkivi J, Osterman H, Malmivaara A, Päivitystiivistelmä (2015) Update on current care guideline: low back pain. Duodecim 131(1):92–94 (Review. Finnish. PubMed PMID: 26245063) PubMed
20.
21.
22.
23.
24.
25.
26.
27.
Goertz M, Thorson D, Bonsell J, Bonte B, Campbell R, Haake B, Johnson K, Kramer C, Mueller B, Peterson S, Setterlund L, Timming R (2012) Adult acute and subacute low back pain. Institute for Clinical Systems Improvement (ICSI), Bloomington
28.
Delitto A, George SZ, van Dillen L, Whitman JM, Sowa G, Shekelle P, Denninger TR, Godges JJ (2012) Low back pain: clinical practice guidelines linked to the International Classification of Functioning, Disability, and Health from the Orthopaedic Section of the American Physical Therapy Association. J Orthop Sports Phys Ther 42(4):A1–A57CrossRefPubMedPubMedCentral
29.
30.
31.
Adorian D, Boureau F, Budowski M, Dietemann L, Guillaumat M, Langlade A (2000) Diagnosis and management acute low back pain with or without sciatica. ANAES/Guidelines Department/February 2000
32.
Negrini S, Giovannoni S, Minozzi S, Barneschi G, Bonaiuti D, Bussotti A, et al. (2006) Diagnostic therapeutic flow-charts for low back pain patients: the Italian clinical guidelines. Eura Medicophys 42(2):151–70. http://​www.​minervamedica.​it/​. Accessed Feb 2016
33.
34.
35.
Dagenais S, Tricco AC, Haldeman S (2010) Synthesis of recommendations for the assessment and management of low back pain from recent clinical practice guidelines. Spine J 10(6):514–529CrossRefPubMed
36.
Hooten WM, Cohen SP (2015) Evaluation and treatment of low back pain: a clinically focused review for primary care specialists. Mayo Clin Proc 90:1699–1718CrossRefPubMed
37.
38.
Chou R, Fu R, Carrino JA, Deyo RA (2009) Imaging strategies for low-back pain:systematic review and meta-analysis. Lancet 373(9662):463–472CrossRefPubMed
39.
40.
Reinus WR, Strome G, Zwemer FL Jr (1998) Use of lumbosacral spine radiographs in a level II emergency department. AJR Am J Roentgenol 170:443–447CrossRefPubMed
41.
Deyo RA, Diehl AK (1988) Cancer as a cause of back pain: frequency, clinical presentation, and diagnostic strategies. J Gen Intern Med 3:230–238CrossRefPubMed
42.
43.
Henschke N, Maher CG, Refshauge KM, Herbert RD, Cumming RG, Bleasel J, York J, Das A, McAuley JH (2009) Prevalence of and screening for serious spinal pathology in patients presenting to primary care settings with acute low back pain. Arthritis Rheum 60(10):3072–3080CrossRefPubMed
44.
Kroenke K (2014) A practical and evidence-based approach to common symptoms: a narrative review. Ann Intern Med 161(8):579–586CrossRefPubMed
45.
Ferguson FC, Morison S, Ryan CG (2015) Physiotherapists’ understanding of red flags for back pain. Musculoskelet Care 13:42–50CrossRef
46.
Underwood M (2009) Diagnosing acute nonspecific low back pain: time to lower the red flags? Arthritis Rheum 60:2855–2857CrossRefPubMed
47.
Stiell IG, Greenberg GH, McKnight RD, Nair RC, McDowell I, Reardon M, Stewart JP, Maloney J (1993) Decision rules for the use of radiography in acute ankle injuries. Refinement and prospective validation. JAMA 269(9):1127–1132CrossRefPubMed
48.
Bachmann LM, Kolb E, Koller MT, Steurer J, ter Riet G (2003) Accuracy of Ottawa ankle rules to exclude fractures of the ankle and mid-foot: systematic review. BMJ 326(7386):417CrossRefPubMedPubMedCentral
49.
Roman M, Brown C, Richardson W, Isaacs R, Howes C, Cook C (2010) The development of a clinical decision making algorithm for detection of osteoporotic vertebral compression fracture or wedge deformity. J Man Manip Ther 18(1):44–49CrossRefPubMedPubMedCentral
50.
Chou R, Qaseem A, Owens DK, Shekelle P (2011) Diagnostic imaging for low back pain advice for high-value health care from the American College of Physicians. Ann Intern Med 154:181–189CrossRefPubMed
51.
Scavone JG, Latshaw RF, Weidner WA (1981) AP and lateral radiographs: an adequate lumbar spine examination. AJR 136:715–717CrossRefPubMed
52.
Scavone JG, Latshaw RF, Rohrer V (1981) Use of lumbar spine films: statistical evaluation at a university teaching hospital. JAMA 246:1105–1108CrossRefPubMed
53.
Waddell G, McIntosh A, Hutchinson A, Feder G, Lewis M (1999) Low Back Pain Evidence Review. Royal College of General Practitioners, London
54.
Van den Hoogen HJ, Koes BW, Van Eijk JT, Bouter LM (1995) On the diagnostic accuracy of history, physical examination, and erythrocyte sedimentation rate in diagnosing low back pain in general practice; a criteria based review of the literature. Spine 20:318–327CrossRefPubMed
55.
Gran JT (1985) An epidemiological survey of the signs and symptoms of ankylosing spondylitis. Clin Rheumatol 4:161–169CrossRefPubMed
56.
Waddell G (ed) (2004) The back pain revolution. Churchill Livingstone, London, pp 10–11
57.
58.
Metadata
Title
Red flags presented in current low back pain guidelines: a review
Authors
Arianne P. Verhagen
Aron Downie
Nahid Popal
Chris Maher
Bart W. Koes
Publication date
01-09-2016
Publisher
Springer Berlin Heidelberg
Published in
European Spine Journal / Issue 9/2016
Print ISSN: 0940-6719
Electronic ISSN: 1432-0932
DOI
https://doi.org/10.1007/s00586-016-4684-0

Other articles of this Issue 9/2016

European Spine Journal 9/2016 Go to the issue

Letter to the Editor

Comments on Ren et al.: Is duration of preoperative anti-tuberculosis treatment a risk factor for postoperative relapse or non-healing of spinal tuberculosis?

Authors Reply

Answer to the Letter to the Editor of M. D. Sewell et al. concerning “Virtually bloodless posterior midline exposure of the lumbar spine using the ‘para-midline’ fatty plane” by Moghimi MH, Leonard DA, Cho CH, Schoenfeld AJ, Phan P, Harris MB, Bono CM: Eur Spine J (2016) 25;956–962

Original Article

Chronic low back pain in relation to Modic changes, bony endplate lesions, and disc degeneration in a prospective MRI study

Original Article

Validity and responsiveness of the French version of the Örebro Musculoskeletal Pain Screening Questionnaire in chronic low back pain

Letter to the Editor

Letter to the Editor concerning “Virtually bloodless posterior midline exposure of the lumbar spine using the ‘paramidline’ fatty plane” by Moghimi MH, Leonard DA, Cho CH, et al. (Eur Spine J (2016) 25;956–962)

Original Article

Axial loading during MRI influences T2-mapping values of lumbar discs: a feasibility study on patients with low back pain