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. 2013 Dec 11:347:f7095.
doi: 10.1136/bmj.f7095.

Red flags to screen for malignancy and fracture in patients with low back pain: systematic review

Aron Downie  1 , Christopher M Williams, Nicholas Henschke, Mark J Hancock, Raymond W J G Ostelo, Henrica C W de Vet, Petra Macaskill, Les Irwig, Maurits W van Tulder, Bart W Koes, Christopher G Maher
Affiliations

Red flags to screen for malignancy and fracture in patients with low back pain: systematic review

Aron Downie et al. BMJ. .

Erratum in

  • BMJ. 2014;348:g7

Abstract

Objective: To review the evidence on diagnostic accuracy of red flag signs and symptoms to screen for fracture or malignancy in patients presenting with low back pain to primary, secondary, or tertiary care.

Design: Systematic review.

Data sources: Medline, OldMedline, Embase, and CINAHL from earliest available up to 1 October 2013.

Inclusion criteria: Primary diagnostic studies comparing red flags for fracture or malignancy to an acceptable reference standard, published in any language.

Review methods: Assessment of study quality and extraction of data was conducted by three independent assessors. Diagnostic accuracy statistics and post-test probabilities were generated for each red flag.

Results: We included 14 studies (eight from primary care, two from secondary care, four from tertiary care) evaluating 53 red flags; only five studies evaluated combinations of red flags. Pooling of data was not possible because of index test heterogeneity. Many red flags in current guidelines provide virtually no change in probability of fracture or malignancy or have untested diagnostic accuracy. The red flags with the highest post-test probability for detection of fracture were older age (9%, 95% confidence interval 3% to 25%), prolonged use of corticosteroid drugs (33%, 10% to 67%), severe trauma (11%, 8% to 16%), and presence of a contusion or abrasion (62%, 49% to 74%). Probability of spinal fracture was higher when multiple red flags were present (90%, 34% to 99%). The red flag with the highest post-test probability for detection of spinal malignancy was history of malignancy (33%, 22% to 46%).

Conclusions: While several red flags are endorsed in guidelines to screen for fracture or malignancy, only a small subset of these have evidence that they are indeed informative. These findings suggest a need for revision of many current guidelines.

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Conflict of interest statement

Competing interests: All authors have completed the ICMJE uniform disclosure form at www.icmje.org/coi_disclosure.pdf and declare: no support from any organisation for the submitted work; no financial relationships with any organisations that might have an interest in the submitted work in the previous three years; no other relationships or activities that could appear to have influenced the submitted work.

Figures

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Fig 1 Flow diagram of search strategies for studies evaluating red flags to screen for spinal fracture and malignancy in patients presenting with low back pain
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Fig 2 Diagnostic accuracy of red flags for spinal fracture included in American College of Physicians (ACP) guideline. Vertical line indicates prevalence of spinal fracture: 1% in primary care, 5% in secondary and tertiary care. *Severe trauma: trauma such as fall from height or motor vehicle crash (Deyo27); trauma which is major in young patients and minor in elderly (Henschke7). †Minor trauma: in elderly women with osteoporosis (Scavone26). ‡Trauma: history of direct trauma (Gibson36); history of trauma (Patrick, Reinus34). §History of osteoporosis not evaluated by any included study
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Fig 3 Diagnostic accuracy of red flags for spinal fracture excluded from American College of Physicians (ACP) guideline. Vertical line indicates prevalence of spinal fracture: 1% in primary care, 5% in secondary and tertiary care. DTR=deep tendon reflex; BMI=body mass index. *Motor deficit: weakness or atrophy. †Henschke index tests: female, age >70, severe trauma, and prolonged use of corticosteroids. ‡Roman index tests: leg or buttock pain, sex, age, BMI, gait abnormality, no regular exercise, sitting pain, osteoarthritis. §Neurological signs or straight leg raise <40º. ¶Neurological deficit: consistent with lumbar plexus distribution
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Fig 4 Diagnostic accuracy of red flags for spinal malignancy included in American College of Physicians (ACP) guideline. Vertical line indicates prevalence of spinal malignancy: 0.5% in primary care, 1.5% in secondary and tertiary care. *Included studies for spinal malignancy did not investigate combination red flags. †Red flag “clinical suspicion” did not meet inclusion criteria of either Cochrane review
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Fig 5 Diagnostic accuracy of red flags for spinal malignancy excluded from American College of Physicians (ACP) guideline. Vertical line indicates prevalence of spinal malignancy: 0.5% in primary care, 1.5% in secondary and tertiary care. *Absence of pain during combined movements of flexion, extension and lateral flexion
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References

    1. Murray CJL, Vos T, Lozano R, Naghavi M, Flaxman AD, Michaud C, et al. Disability-adjusted life years (DALYs) for 291 diseases and injuries in 21 regions, 1990-2010: a systematic analysis for the Global Burden of Disease Study 2010. Lancet 2012;380:2197-223. - PubMed
    1. Hoy D, Brooks P, Blyth F, Buchbinder R. The epidemiology of low back pain. Best Pract Res Clin Rheumatol 2010;24:769-81. - PubMed
    1. Koes BW, van Tulder M, Lin C-WC, Macedo LG, McAuley J, Maher C. An updated overview of clinical guidelines for the management of non-specific low back pain in primary care. Eur Spine J 2010;19:2075-94. - PMC - PubMed
    1. Williams CM, Henschke N, Maher CG, van Tulder MW, Koes BW, Macaskill P, et al. Red flags to screen for vertebral fracture in patients presenting with low-back pain. Cochrane Database Syst Rev 2013;1:CD008643. - PubMed
    1. Henschke N, Maher CG, Ostelo RW, de Vet HCW, Macaskill P, Irwig L. Red flags to screen for malignancy in patients with low-back pain. Cochrane Database Syst Rev 2013;2:CD008686. - PMC - PubMed

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