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

Low back pain is the most common symptom found in the primary health care and is the number one cause of disability throughout worldwide. It is estimated that around 60 – 80% the world population will experience back pain during their lifespan. There are three different source of pain in the spine: axial-lumbosacral, radicular and reffered pain. All of these source brings different clinical presentations. Low back pain could be classified as acute, subacute and chronic low back pain. The pain could be nociceptive or neuropathic, the most common symptoms reported are “pressure pain” and “pain attack”. The physician should be aware of “red flags” symptoms that lead into more serious condition beside back pain and, therefore the patient has to be investigated to further examination whenever these symptoms present. The management of low back pain consist of severe modalities, both therapeutic and rehabilitative procedure. Oftentimes, the management needed multidisciplinary approach. It is important to general practitioners to identify and treat low back pain appropriately to reduce the burden of the disease and to prevent the disabilties caused by this condition.

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Clinical principles for the diagnosis and treatment of musculoskeletal (non-specific) lower back pain

Neurology neuropsychiatry Psychosomatics ◽

10.14412/2074-2711-2021-3-107-112 ◽

2021 ◽

Vol 13 (3) ◽

pp. 107-112

Author(s):

V. A. Golovacheva ◽

A. A. Golovacheva ◽

T. G. Fateyeva

Keyword(s):

Low Back Pain ◽

Back Pain ◽

Combination Therapy ◽

Interdisciplinary Approach ◽

Interventional Treatment ◽

Low Back ◽

Lumbar Stenosis ◽

Red Flags ◽

Lower Back ◽

Symptoms And Signs

Low back pain (LBP) is one of the most common reasons for a neurologist visit. In 90–95% of cases, LBP is nonspecific (musculoskeletal). The diagnosis of nonspecific LBP based on symptoms, somatic and neurological examination data, the absence of «red flags» (symptoms and signs characteristic of specific causes of back pain, discogenic radiculopathy, or lumbar stenosis). We review the modern principles of acute, subacute, and chronic nonspecific LBP treatment. We also discuss interventional and non-interventional treatment approaches, emphasizing the importance of combination therapy and an interdisciplinary approach.

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Re: Limited evidence for screening for serious pathologies using red flags in patients with low back pain presenting to the emergency department

Emergency Medicine Australasia ◽

10.1111/1742-6723.13096 ◽

2018 ◽

Vol 30 (3) ◽

pp. 437-438 ◽

Cited By ~ 1

Author(s):

Kirsten Strudwick ◽

Megan McPhee ◽

Anthony Bell ◽

Melinda Martin-Khan ◽

Trevor Russell

Keyword(s):

Emergency Department ◽

Low Back Pain ◽

Back Pain ◽

Low Back ◽

Red Flags ◽

Limited Evidence

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Evaluation of guideline-endorsed red flags to screen for fracture in patients presenting with low back pain

British Journal of Sports Medicine ◽

10.1136/bjsports-2018-099525 ◽

2018 ◽

Vol 53 (10) ◽

pp. 648-654 ◽

Cited By ~ 3

Author(s):

Patricia C S Parreira ◽

Christopher G Maher ◽

Adrian C Traeger ◽

Mark J Hancock ◽

Aron Downie ◽

...

Keyword(s):

Low Back Pain ◽

Back Pain ◽

Diagnostic Accuracy ◽

Older Age ◽

Diagnostic Study ◽

Low Back ◽

Red Flags ◽

Eligibility Criteria ◽

Red Flag ◽

Accuracy Data

Objectives(1) Describe the evolution of guideline-endorsed red flags for fracture in patients presenting with low back pain; (2) evaluate agreement between guidelines; and (3) evaluate the extent to which recommendations are accompanied by information on diagnostic accuracy of endorsed red flags.DesignSystematic review.Data sourcesMEDLINE and PubMed, PEDro, CINAHL and EMBASE electronic databases. We also searched in guideline databases, including the National Guideline Clearinghouse and Canadian Medical Association Infobase.Eligibility criteria for selecting studiesEvidence-based clinical practice guidelines.Data extractionTwo review authors independently extracted the following data: health professional association or society producing guideline, year of publication, the precise wording of endorsed red flag for vertebral fracture, recommendations for diagnostic workup if fracture is suspected, if the guidelines substantiate the recommendation with citation to a primary diagnostic study or diagnostic review, if the guideline provides any diagnostic accuracy data.Results78 guidelines from 28 countries were included. A total of 12 discrete red flags were reported. The most commonly recommended red flags were older age, use of steroids, trauma and osteoporosis. Regarding the evolution of red flags, older age, trauma and osteoporosis were the first red flags endorsed (in 1994); and previous fracture was the last red flag endorsed (in 2003). Agreement between guidelines in endorsing red flags was only fair; kappa=0.32. Only 9 of the 78 guidelines substantiated their red flag recommendations by research and only nine provided information on diagnostic accuracy.Summary/conclusionThe number of red flags endorsed in guidelines to screen for fracture has risen over time; most guidelines do not endorse the same set of red flags and most recommendations are not supported by research or accompanied by diagnostic accuracy data.

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Red flag screening for low back pain: nothing to see here, move along: a narrative review

British Journal of Sports Medicine ◽

10.1136/bjsports-2017-098352 ◽

2017 ◽

Vol 52 (8) ◽

pp. 493-496 ◽

Cited By ~ 15

Author(s):

Chad E Cook ◽

Steven Z George ◽

Michael P Reiman

Keyword(s):

Low Back Pain ◽

Back Pain ◽

Clinical Practice ◽

Clinical Practice Guidelines ◽

Practice Guidelines ◽

Best Practice ◽

Negative Likelihood Ratio ◽

Low Back ◽

Red Flags ◽

Red Flag

Screening for red flags in individuals with low back pain (LBP) has been a historical hallmark of musculoskeletal management. Red flag screening is endorsed by most LBP clinical practice guidelines, despite a lack of support for their diagnostic capacity. We share four major reasons why red flag screening is not consistent with best practice in LBP management: (1) clinicians do not actually screen for red flags, they manage the findings; (2) red flag symptomology negates the utility of clinical findings; (3) the tests lack the negative likelihood ratio to serve as a screen; and (4) clinical practice guidelines do not include specific processes that aid decision-making. Based on these findings, we propose that clinicians consider: (1) the importance of watchful waiting; (2) the value-based care does not support clinical examination driven by red flag symptoms; and (3) the recognition that red flag symptoms may have a stronger relationship with prognosis than diagnosis.

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Psychosocial Yellow Flags for acute low back pain: ‘Yellow Flags'; as an analogue to ‘Red Flags';

European Journal of Pain ◽

10.1016/s1090-3801(98)90050-7 ◽

1998 ◽

Vol 2 (1) ◽

pp. 87-89 ◽

Cited By ~ 15

Author(s):

N.A.S. Kendall ◽

S.J. Linton ◽

C. Main

Keyword(s):

Low Back Pain ◽

Back Pain ◽

Low Back ◽

Red Flags ◽

Acute Low Back Pain ◽

Yellow Flags

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Low back pain – literature review

Ból ◽

10.5604/01.3001.0013.7395 ◽

2020 ◽

Vol 20 (3) ◽

pp. 51-59

Author(s):

Marcin Kopka

Keyword(s):

Low Back Pain ◽

Back Pain ◽

Intervertebral Discs ◽

Prior History ◽

Low Back ◽

Red Flags ◽

Recurrence Rates ◽

Reduction Of Pain ◽

History Of ◽

Optimal Visualization

Low back pain (LBP) is the third most common disorder presenting in the neurology outpatient clinic. It is usually defined as acute (less than 4 weeks), subacute (4–8 weeks) and chronic (more than 12 weeks). It is estimated that lifetime prevalence of up to 84 %. LBP is the most common cause of disability. LBP is divided into musculoskeletal and neurologic low back pain. In 90% of patients under the age of 65 the cause of pain is nerve root compression caused by disk herniation. Although serious spinal pathology is rare (less than 1%), the identification of red flags remains key in the evaluation of patients with LBP. A prior history of cancer, even in the absence of other red flags, has the highest predictive value for detection of malignancy. In conjunction with the history, a careful neurologic examination can help establish the presence and localize the lesion. According to guidelines imaging studies should not be obtained in patients with LBP of less than 6 weeks duration in the absence of red flags. Magnetic resonance imaging is the study of choice in patients with LBP. It allows for optimal visualization of the spinal cord, nerve roots and intervertebral discs. The results of MRI should be interpreted with caution because incidental degenerative spine changes unrelated to the pain are commonly seen in MRI. The main goals of treatment the patients presenting with acute LBP are reduction of pain and preservation of sensory and motor function. In the absence of red flags, for most cases conservative management will be appropriate. Prognosis are favorable, although recurrence rates range from 23% to 80%.

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Most red flags for malignancy in low back pain guidelines lack empirical support

Pain ◽

10.1097/j.pain.0000000000000998 ◽

2017 ◽

Vol 158 (10) ◽

pp. 1860-1868 ◽

Cited By ~ 20

Author(s):

Arianne P. Verhagen ◽

Aron Downie ◽

Chris G. Maher ◽

Bart W. Koes

Keyword(s):

Low Back Pain ◽

Back Pain ◽

Empirical Support ◽

Low Back ◽

Red Flags

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Knowledge and Utilization of Red Flags by Physiotherapists in the Assessment and Management of Patients with Low Back Pain

African Journal of Physiotherapy and Rehabilitation Sciences ◽

10.4314/ajprs.v5i1-2.6 ◽

2014 ◽

Vol 5 (1-2) ◽

pp. 35

Author(s):

B Bello ◽

BD Ibosiola

Keyword(s):

Low Back Pain ◽

Back Pain ◽

Low Back ◽

Red Flags

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Clinical evaluation and red flags of acute low back pain in primary care

International Journal of Community Medicine and Public Health ◽

10.18203/2394-6040.ijcmph20220006 ◽

2022 ◽

Author(s):

Marwah Y. Abdullah ◽

Reem A. Bana ◽

Seham O. Aldogil ◽

Mutlaq A. Alsolami ◽

Reem A. Alshihri ◽

...

Keyword(s):

Primary Care ◽

Low Back Pain ◽

Back Pain ◽

Physical Examination ◽

Clinical Evaluation ◽

Low Back ◽

Red Flags ◽

Acute Low Back Pain ◽

Primary Care Settings

Back pain has been reported as a common cause for various patients to present in an emergency or primary care settings. Besides, the management of back pain has been associated with a huge economic burden and remarkably impacts the quality of life of the affected patients. The diagnosis of acute low-back pain can be adequately achieved by conducting proper clinical evaluation and knowing the characteristics of each condition. The present review discusses the clinical evaluation and red flags for diagnosing patients presenting with acute low-back pain. An adequate examination of patients is conducted by obtaining a thorough history and successful physical examination. It should be noted that obtaining an adequate history might not be enough in some cases, and physical examination might not show any diagnostic clues. However, we also reported various red flags for detecting serious conditions, including malignancy, infections, inflammation, and others. These might help establish a further assessment of these patients, including imaging and laboratory studies. Therefore, these cases should be managed as early as possible to enhance the prognosis and intervene against any potential complications.

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