Prevalence of Serious Pathology Among Adults with Low Back Pain Presenting for Chiropractic Care: A Retrospective Chart Review of Integrated Clinics in Hong Kong

Abstract

BACKGROUND There is a limited understanding of the frequency at which chiropractors encounter patients with serious pathology such as malignancy, fracture, and infection. This retrospective study aimed to estimate the prevalence and types of serious pathology among adults with new low back pain presenting to chiropractors in an integrated healthcare organization in Hong Kong, with the hypothesis that such pathology would be found in less than 5% of patients. MATERIAL AND METHODS We identified adults presenting to a chiropractor with new low back pain across 30 clinics with 38 chiropractors, and a subset with previously undiagnosed serious pathology from January 2020 through July 2022. Data were extracted from the electronic medical records, including messaging alerts for serious pathology, notes, radiology reports, and specialist follow-up. Descriptive statistics were utilized to analyze results. RESULTS Among the 7221 identified patients with new-onset low back pain (mean age 61.6±14.3), 35 presented with serious pathology. After excluding 54 cases not meeting inclusion criteria, the prevalence of serious pathology (95% CI) was 35/7221 (0.48%; 0.35-0.67%). Individual condition prevalence included metastasis (0.25%; 0.16-0.39%), fracture (0.12%; 0.07-0.24%), infection (0.04%; 0.01-0.12%), vascular pathology (0.03%; 0.01-0.10%), primary tumor (0.03%; 0.01-0.10%), and gastrointestinal emergency (0.01%; 0.00-0.08%). CONCLUSIONS This study found that serious pathology was uncommon among adults with new low back pain presenting for chiropractic care in Hong Kong, findings which are most consistent with previous research describing the prevalence of serious pathology among low back pain patients in primary care settings.

Figure 1

Identification of patients from the electronic health records. Figure created by RT using Microsoft Word (Version 2206).

Figure 2

Spinal metastasis. This 53-year-old woman with a remote history of breast cancer presented to a chiropractor with a 3-month history of progressively worsening low back pain with radiation into the lower extremities bilaterally and lower extremity weakness. She previously presented to the emergency department and had been referred for physical therapy. Lumbar magnetic resonance imaging showed several findings consistent with bony metastasis, including lesions of the sacrum and ilium (arrows in T2-weighted coronal image), liver, and lumbar spine. The patient was referred to an oncologist for further management. Arrows added by RT using GNU Image Manipulation Program (Version 2.10.30).

Figure 3

Osteoporotic compression fracture. This 72-year-old woman presented with a 1-month history of low back pain with radiation into the left paraspinal region and numbness in the left anterior thigh beginning after a fall from ground level onto her knee. She had been receiving acupuncture and traditional bonesetting therapy and had no previous imaging. The T12 vertebral body shows marrow edema and a hypointense horizontal fracture line is noted in this T2-weighted mid-sagittal image (arrow), which remains hypointense in T1-weighted images (not shown). The patient was referred to an orthopedist but was ultimately treated conservatively. Arrow added by RT using GNU Image Manipulation Program (Version 2.10.30).

Figure 4

Spinal infection. This 50-year-old man who was previously healthy reported acute-onset low back pain which progressively worsened over the prior week, causing him to be unable sleep or stand upright. Lumbar magnetic resonance imaging showed a 3.2×3.1×3.0-centimeter T2-weighted hyperintense lobulated lesion at the left L5/S1 paraspinal region involving the left psoas muscle (arrowhead in axial T2-weighted axial image), with apparent connection with the left side of the intervertebral disc. The chiropractor consulted with an on-site orthopedic surgeon and referred the patient to the emergency department, where he was treated for a psoas abscess and spondylodiscitis. Arrow added by RT using GNU Image Manipulation Program (Version 2.10.30).

Figure 5

Prevalence of serious pathology among patients with new low back pain presenting to a chiropractor. Error bars indicate 95% CI for point estimates. Image created by RT using Microsoft Excel (Version 2206).