Review ArticleA systematic review identifies five “red flags” to screen for vertebral fracture in patients with low back pain
Introduction
It is widely agreed that acute low back pain is common, can be seriously disabling, and imposes an enormous social and economic burden on the community. To improve the management of back pain, clinical practice guidelines have been developed in at least 12 countries [1]. A common theme among the guidelines is that acute low back pain should be managed in primary care because it is generally benign, and the few cases of serious disease can be readily detected with a clinical assessment [1]. The exclusion of specific pathologies is one of the primary purposes of the clinical assessment, and the clinical guidelines recommend that the identification of “red flags” is the ideal method to accomplish this purpose [1]. “Red flags” are features of the patient's medical history and clinical examination thought to be associated with a high risk of serious disorders, such as infection, inflammatory disease, cancer, or fracture [2].
Vertebral fracture is associated with significant pain and disability [3] and with increased mortality [4]. The prevalence of vertebral fracture in patients presenting to primary care practitioners with acute low back pain has been estimated to be between 0.5% [5] and 4% [6], yet it is estimated that only 30% of vertebral fractures are diagnosed in clinical practice [7] because the presentation is similar to that of nonspecific low back pain [7], [8]. Vertebral fracture not only requires specific appropriate treatment, but is a contraindication to spinal manipulative therapy, a common treatment that is endorsed in clinical practice guidelines for acute nonspecific low back pain [9]. Therefore, accurate diagnosis in primary care is essential to prevent poor outcomes [10].
As a first step in identifying fracture in patients presenting with acute low back pain, clinical guidelines [11], [12], [13], [14] generally recommend the following red flags: recent history of trauma [12], [13]; prolonged use of corticosteroids [11], [13]; age >50 years [11], [13], [14]; and structural deformity [11], [12], [14] (Table 1). The inclusion of these features in the guidelines is often justified by reference to previous guidelines [14], unpublished data [11], or single studies of questionable methodological quality [12] (Table 1). No study has reviewed the available literature in a systematic manner. Without evaluation of the diagnostic accuracy of the red flags, their usefulness in clinical practice will remain uncertain. This review incorporated a sensitive search strategy and quality assessment of primary studies using a validated tool [15] as recommended in guidelines for performing diagnostic systematic reviews [16], [17].
To determine the accuracy of the clinical examination available to primary care practitioners, we conducted a systematic review of studies evaluating clinical features for diagnosing fracture in low back pain patients [18]. A secondary aim was to determine the psychometric properties of the Quality Assessment of Studies of Diagnostic Accuracy Included in Systematic Reviews (QUADAS) scale [15] when used to rate the quality of retrieved studies.
Section snippets
Data sources
A systematic literature search was performed to identify all relevant original, peer-reviewed articles evaluating vertebral fractures in patients presenting with low back pain. The primary search was performed from the earliest available dates to 5 February 2007, on the MEDLINE, EMBASE, and CINAHL electronic databases. A subject-specific search strategy was used, combining sensitive searches of the diagnostic (index) tests available to primary care practitioners, and the target disease (low
Search results
The electronic database search retrieved 6,027 articles (Fig. 1). After review of the titles, 5,272 articles were excluded because they were clearly outside the scope of the review. The remaining 755 articles were classified into study types to identify those evaluating a cohort of patients [21]. There were 175 review articles, of which four [24], [25], [26], [27] were systematic reviews related to fracture or back pain, but did not focus on diagnosis or clinical features of fracture.
The titles
Discussion
Clinical guidelines for the management of low back pain advocate the use of red flags to raise the index of suspicion concerning serious spinal pathology. This study provides the first diagnostic systematic review of these red flags and other clinical features for identifying vertebral fracture in low back pain patients. It contains a more detailed analysis of the red flags by summarizing the diagnostic accuracy quantitatively and exploring methodological quality of the primary studies. By
Acknowledgments
N.H. is under scholarship awarded by the National Health & Medical Research Council of Australia. C.M. is a senior research fellow funded by the National Health & Medical Research Council of Australia.
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2020, Spine JournalCitation Excerpt :A``s expected, our study found that the incidence of fracture increased with older age, and interestingly, all fractures in the under 35-year-old age group were male and were traumatic, which may reflect the commonly held belief that young males have increased risk-taking behavior and involvement in adventure sport. With respect to gender, other studies [67] have found that fracture risk is higher in females, however our study did not find any overall difference between gender. The prevalence of spinal malignancy has been reported to be low (0%–0.7%) amongst LBP patients presenting to primary care [2,12,15,16,68], and up to 5.9% in a tertiary care spine clinic in America [21].
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2015, Annals of Physical and Rehabilitation MedicineCitation Excerpt :This is why, in case of persistent or recurrent LBP in a worker on long-term sick leave or going on repeated sick leaves, “it is recommended to evaluate prognostic factors, i.e. psychological and behavioral factors (‘yellow flags’) that could influence the progression to chronicity as well as socioeconomic and occupational factors (‘blue’ and ‘black’ flags), which could impact long-term work incapacity and delay the RTW (Grade A) (Fig. 1). This assessment may require several consultations or interviews in complex cases (Grade A) and must be coupled with a thorough search for clinical symptoms of LBP severity (‘red flags’) regardless of the LBP stage: acute, subacute or chronic (Grade A)” [8,19,22–26]. In the literature, psychosocial factors are considered as important factors to identify workers at risk of developing chronic pain and work disability.
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