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

2018 ◽  
Vol 53 (10) ◽  
pp. 648-654 ◽  
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.

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

2017 ◽  
Vol 52 (8) ◽  
pp. 493-496 ◽  
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.

scholarly journals Low Back Pain in the Emergency Department: Prevalence of Serious Spinal Pathologies and Diagnostic Accuracy of Red Flags

2020 ◽  
Vol 133 (1) ◽  
pp. 60-72.e14 ◽  
Author(s):  
Gabriela Galliker ◽  
Dominique Eva Scherer ◽  
Maurizio Alen Trippolini ◽  
Eva Rasmussen-Barr ◽  
Riccardo LoMartire ◽  
...  
Keyword(s):  
Emergency Department ◽  
Low Back Pain ◽  
Back Pain ◽  
Diagnostic Accuracy ◽  
Low Back ◽  
Red Flags

scholarly journals An Update of the Systematic Assessment of the Diagnostic Accuracy of Lumbar Facet Joint Nerve Blocks

2012 ◽  
Vol 6;15 (6;12) ◽  
pp. E869-E907
Author(s):  
Frank J.E. Falco
Keyword(s):  
Low Back Pain ◽  
Back Pain ◽  
Pain Relief ◽  
Diagnostic Accuracy ◽  
Chronic Low Back Pain ◽  
Facet Joint ◽  
Low Back ◽  
Lumbar Facet Joint ◽  
Nerve Blocks ◽  
Lumbar Facet

Background: Lumbar facet joints are a well recognized source of low back pain and referred pain in the lower extremity in patients with chronic low back pain. Conventional clinical features and other non-invasive diagnostic modalities are unreliable in diagnosing lumbar zygapophysial joint pain. Controlled diagnostic studies with at least 80% pain relief as the criterion standard have shown the prevalence of lumbar facet joint pain to be 16% to 41% of patients with chronic low back pain without disc displacement or radiculitis, with a false-positive rate of 17% to 49% with a single diagnostic block. Study Design: A systematic review of the diagnostic accuracy of lumbar facet joint nerve blocks. Objective: To determine and update the diagnostic accuracy of lumbar facet joint nerve blocks in the assessment of chronic low back pain. Methods: A methodological quality assessment of included studies was performed using Quality Appraisal of Reliability Studies (QAREL). Only diagnostic accuracy studies meeting at least 50% of the designated inclusion criteria were utilized for analysis. Studies scoring less than 50% are presented descriptively and analyzed critically. The level of evidence was classified as good, fair, and limited or poor based on the quality of evidence developed by the United States Preventive Services Task Force (USPSTF). Data sources included relevant literature identified through searches of PubMed and EMBASE from 1966 to June 2012, and manual searches of the bibliographies of known primary and review articles. Outcome Measures: Studies must have been performed utilizing controlled local anesthetic blocks. Pain relief was categorized as at least 50% pain relief from baseline pain and the ability to perform previously painful movements. Results: A total of 25 diagnostic accuracy studies were included. Of these, one study evaluated 50% to 74% relief as criterion standard with a single block with prevalence of 48%, 4 studies evaluated 75% to 100% relief as the criterion standard with a single block with a prevalence of 31% to 61%, 5 studies evaluated 50% to 74% relief as the criterion standard with controlled blocks with a prevalence of 15% to 61%, and 13 studies evaluated 75% to 100% relief as the criterion standard with controlled blocks with a prevalence of 25% to 45% in heterogenous populations. False-positive rates ranged from 17% to 66% in the 50% to 74% pain relief group and 27% to 49% with at least 75% relief as the criterion standard. Based on this evaluation, the evidence showed that there is good evidence for diagnostic facet joint nerve blocks with 75% to 100% pain relief as the criterion standard with dual blocks and fair evidence with 50% to 74% pain relief as the criterion standard with controlled diagnostic blocks; however, the evidence is poor with single diagnostic blocks of 50% to 74%, and limited for 75% or more pain relief as the criterion standard. Limitations: The shortcomings of this systematic review of the accuracy of diagnostic lumbar facet joint nerve blocks include a paucity of literature and continued debate on an appropriate gold standard. Conclusion: There is good evidence for diagnostic facet joint nerve blocks with 75% to 100% pain relief as the criterion standard with dual blocks, with fair evidence with 50% to 74% pain relief. Key words: Chronic low back pain, lumbar facet or zygapophysial joint pain, facet joint nerve blocks, medial branch blocks, controlled comparative local anesthetic blocks

scholarly journals LOW BACK PAIN

2021 ◽  
Vol 2 (1) ◽  
pp. 13-17
Author(s):  
Andaru Cahya S ◽  
Widodo Mardi Santoso ◽  
Machlusil Husna ◽  
Badrul Munir ◽  
Shahdevi Nandar Kurniawan
Keyword(s):  
Low Back Pain ◽  
Back Pain ◽  
Multidisciplinary Approach ◽  
World Population ◽  
Common Symptom ◽  
Low Back ◽  
Red Flags ◽  
Pain Attack ◽  
Primary Health ◽  
Clinical Presentations

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.

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

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.

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

2018 ◽  
Vol 30 (3) ◽  
pp. 437-438 ◽  
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

scholarly journals Are general practitioners referring patients with low back pain for CTs appropriately according to the guidelines: a retrospective review of 3609 medical records in Newfoundland using routinely collected data

2020 ◽  
Vol 21 (1) ◽  
Author(s):  
Gabrielle S. Logan ◽  
Russell Eric Dawe ◽  
Kris Aubrey-Bassler ◽  
Danielle Coombs ◽  
Patrick Parfrey ◽  
...  
Keyword(s):  
Low Back Pain ◽  
Back Pain ◽  
Lumbar Spine ◽  
General Practitioners ◽  
Ct Imaging ◽  
Low Back ◽  
Spine Ct ◽  
Red Flag ◽  
Radicular Syndrome ◽  
Record Review

Abstract Background CT Imaging is often requested for patients with low back pain (LBP) by their general practitioners. It is currently unknown what reasons are common for these referrals and if CT images are ordered according to guidelines in one province in Canada, which has high rates of CT imaging. The objective of this study is to categorise lumbar spine CT referrals into serious spinal pathology, radicular syndrome, and non-specific LBP and evaluate the appropriateness of CT imaging referrals from general practitioners for patients with LBP. Methods A retrospective medical record review of electronic health records was performed in one health region in Newfoundland and Labrador, Canada. Inclusion criteria were lumbar spine CT referrals ordered by general practitioners for adults ≥18 years, and performed between January 1st-December 31st, 2016. Each CT referral was identified from linked databases (Meditech and PACS). To the study authors’ knowledge, guidelines regarding when to refer patients with low back pain for CT imaging had not been actively disseminated to general practitioners or implemented at clinics/hospitals during this time period. Data were manually extracted and categorised into three groups: red flag conditions (judged to be an appropriate referral), radicular syndrome (judged be unclear appropriateness), or nonspecific LBP (determined to be inappropriate). Results Three thousand six hundred nine lumbar spine CTs were included from 2016. The mean age of participants was 54.7 (SD 14 years), with females comprising 54.6% of referrals. 1.9% of lumbar CT referrals were missing/unclear, 6.5% of CTs were ordered on a red-flag suspicion, 75.6% for radicular syndromes, and 16.0% for non-specific LBP; only 6.5% of referrals were clearly appropriate. Key information including patient history and clinical exams performed at appointment were often missing from referrals. Conclusion This audit found high proportions of inappropriate or questionable referrals for lumbar spine CT and many were missing information needed to categorise. Further research to understand the drivers of inappropriate imaging and cost to the healthcare system would be beneficial.

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

2016 ◽  
Vol 25 (9) ◽  
pp. 2788-2802 ◽  
Author(s):  
Arianne P. Verhagen ◽  
Aron Downie ◽  
Nahid Popal ◽  
Chris Maher ◽  
Bart W. Koes
Keyword(s):  
Low Back Pain ◽  
Back Pain ◽  
Low Back ◽  
Red Flags

Low back pain – literature review

Ból ◽  
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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