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Review
. 2023 Aug 24;8(8):CD014461.
doi: 10.1002/14651858.CD014461.pub2.

Red flags to screen for vertebral fracture in people presenting with low back pain

Christopher S Han  1 , Mark J Hancock  2 , Aron Downie  1   3 , Jeffrey G Jarvik  4 , Bart W Koes  5   6 , Gustavo C Machado  1 , Arianne P Verhagen  7 , Christopher M Williams  8 , Qiuzhe Chen  1 , Christopher G Maher  1
Affiliations
Review

Red flags to screen for vertebral fracture in people presenting with low back pain

Christopher S Han et al. Cochrane Database Syst Rev. .

Abstract

Background: Low back pain is a common presentation across different healthcare settings. Clinicians need to confidently be able to screen and identify people presenting with low back pain with a high suspicion of serious or specific pathology (e.g. vertebral fracture). Patients identified with an increased likelihood of having a serious pathology will likely require additional investigations and specific treatment. Guidelines recommend a thorough history and clinical assessment to screen for serious pathology as a cause of low back pain. However, the diagnostic accuracy of recommended red flags (e.g. older age, trauma, corticosteroid use) remains unclear, particularly those used to screen for vertebral fracture.

Objectives: To assess the diagnostic accuracy of red flags used to screen for vertebral fracture in people presenting with low back pain. Where possible, we reported results of red flags separately for different types of vertebral fracture (i.e. acute osteoporotic vertebral compression fracture, vertebral traumatic fracture, vertebral stress fracture, unspecified vertebral fracture).

Search methods: We used standard, extensive Cochrane search methods. The latest search date was 26 July 2022.

Selection criteria: We considered primary diagnostic studies if they compared results of history taking or physical examination (or both) findings (index test) with a reference standard test (e.g. X-ray, magnetic resonance imaging (MRI), computed tomography (CT), single-photon emission computerised tomography (SPECT)) for the identification of vertebral fracture in people presenting with low back pain. We included index tests that were presented individually or as part of a combination of tests.

Data collection and analysis: Two review authors independently extracted data for diagnostic two-by-two tables from the publications or reconstructed them using information from relevant parameters to calculate sensitivity, specificity, and positive (+LR) and negative (-LR) likelihood ratios with 95% confidence intervals (CIs). We extracted aspects of study design, characteristics of the population, index test, reference standard, and type of vertebral fracture. Meta-analysis was not possible due to heterogeneity of studies and index tests, therefore the analysis was descriptive. We calculated sensitivity, specificity, and LRs for each test and used these as an indication of clinical usefulness. Two review authors independently conducted risk of bias and applicability assessment using the QUADAS-2 tool.

Main results: This review is an update of a previous Cochrane Review of red flags to screen for vertebral fracture in people with low back pain. We included 14 studies in this review, six based in primary care, five in secondary care, and three in tertiary care. Four studies reported on 'osteoporotic vertebral fractures', two studies reported on 'vertebral compression fracture', one study reported on 'osteoporotic and traumatic vertebral fracture', two studies reported on 'vertebral stress fracture', and five studies reported on 'unspecified vertebral fracture'. Risk of bias was only rated as low in one study for the domains reference standard and flow and timing. The domain patient selection had three studies and the domain index test had six studies rated at low risk of bias. Meta-analysis was not possible due to heterogeneity of the data. Results from single studies suggest only a small number of the red flags investigated may be informative. In the primary healthcare setting, results from single studies suggest 'trauma' demonstrated informative +LRs (range: 1.93 to 12.85) for 'unspecified vertebral fracture' and 'osteoporotic vertebral fracture' (+LR: 6.42, 95% CI 2.94 to 14.02). Results from single studies suggest 'older age' demonstrated informative +LRs for studies in primary care for 'unspecified vertebral fracture' (older age greater than 70 years: 11.19, 95% CI 5.33 to 23.51). Results from single studies suggest 'corticosteroid use' may be an informative red flag in primary care for 'unspecified vertebral fracture' (+LR range: 3.97, 95% CI 0.20 to 79.15 to 48.50, 95% CI 11.48 to 204.98) and 'osteoporotic vertebral fracture' (+LR: 2.46, 95% CI 1.13 to 5.34); however, diagnostic values varied and CIs were imprecise. Results from a single study suggest red flags as part of a combination of index tests such as 'older age and female gender' in primary care demonstrated informative +LRs for 'unspecified vertebral fracture' (16.17, 95% CI 4.47 to 58.43). In the secondary healthcare setting, results from a single study suggest 'trauma' demonstrated informative +LRs for 'unspecified vertebral fracture' (+LR: 2.18, 95% CI 1.86 to 2.54) and 'older age' demonstrated informative +LRs for 'osteoporotic vertebral fracture' (older age greater than 75 years: 2.51, 95% CI 1.48 to 4.27). Results from a single study suggest red flags as part of a combination of index tests such as 'older age and trauma' in secondary care demonstrated informative +LRs for 'unspecified vertebral fracture' (+LR: 4.35, 95% CI 2.92 to 6.48). Results from a single study suggest when '4 of 5 tests' were positive in secondary care, they demonstrated informative +LRs for 'osteoporotic vertebral fracture' (+LR: 9.62, 95% CI 5.88 to 15.73). In the tertiary care setting, results from a single study suggest 'presence of contusion/abrasion' was informative for 'vertebral compression fracture' (+LR: 31.09, 95% CI 18.25 to 52.96).

Authors' conclusions: The available evidence suggests that only a few red flags are potentially useful in guiding clinical decisions to further investigate people suspected to have a vertebral fracture. Most red flags were not useful as screening tools to identify vertebral fracture in people with low back pain. In primary care, 'older age' was informative for 'unspecified vertebral fracture', and 'trauma' and 'corticosteroid use' were both informative for 'unspecified vertebral fracture' and 'osteoporotic vertebral fracture'. In secondary care, 'older age' was informative for 'osteoporotic vertebral fracture' and 'trauma' was informative for 'unspecified vertebral fracture'. In tertiary care, 'presence of contusion/abrasion' was informative for 'vertebral compression fracture'. Combinations of red flags were also informative and may be more useful than individual tests alone. Unfortunately, the challenge to provide clear guidance on which red flags should be used routinely in clinical practice remains. Further research with primary studies is needed to improve and consolidate our current recommendations for screening for vertebral fractures to guide clinical care.

PubMed Disclaimer

Conflict of interest statement

CSH: none.

MJH: none.

AD: none.

JGJ declares the following: Association of University Radiologists (Fiduciary Officer), Wolters Klewer Health, Inc. (Independent Contractor – Consultant), Springer Publishing (Independent Contractor – Other), GE Healthcare (travel)

BWK: none.

GCM: none.

APV: none.

CMW: none.

QC: none.

CGM is a Senior Editor for Cochrane Musculoskeletal. Editors are required to conduct at least one Cochrane Review, which ensures that they are aware of the processes and commitment needed to conduct reviews.

Figures

1
1
Study flow diagram.
2
2
Risk of bias and applicability concerns summary: review authors' judgements about each domain for each included study
1
1. Test
Age > 50 years
2
2. Test
Age > 54 years
3
3. Test
Age > 52 years
4
4. Test
Age > 64 years
5
5. Test
Age > 70 years
6
6. Test
Age > 74 years
7
7. Test
Female gender
8
8. Test
Female > 54 years
9
9. Test
Female > 64 years
10
10. Test
Female > 74 years
11
11. Test
Trauma
12
12. Test
Corticosteroid use
13
13. Test
OA
14
14. Test
No regular exercise
15
15. Test
Sensation change
16
16. Test
Motor deficit
17
17. Test
DTR abnormality
18
18. Test
Neurological signs
19
19. Test
SLR
20
20. Test
Tenderness
21
21. Test
Spasm
22
22. Test
Contusion/abrasion
23
23. Test
Sciatica
24
24. Test
Hip/leg pain
25
25. Test
Absence of buttock/leg pain
26
26. Test
BMI < 23
27
27. Test
Decreased pain on sitting
28
28. Test
No gait abnormality
29
29. Test
Trauma and neurological signs
30
30. Test
Multiple findings
31
31. Test
Henschke rule 1 sign positive
32
32. Test
Henschke rule 2 positive signs
33
33. Test
Henschke rule 3 positive signs
34
34. Test
1 of 5 positive ‐ Roman Cluster
35
35. Test
2 of 5 positive ‐ Roman Cluster
36
36. Test
3 of 5 positive ‐ Roman Cluster
37
37. Test
4 of 5 positive ‐ Roman Cluster
38
38. Test
5 of 5 positive ‐ Roman Cluster
39
39. Test
Age ≥ 75 years
40
40. Test
Osteoporosis
41
41. Test
Percussion tenderness of spine
42
42. Test
Sudden decrease in height
43
43. Test
Severe disability
44
44. Test
Acute onset of pain
45
45. Test
Back pain score ≥ 7
46
46. Test
Thoracic back pain
47
47. Test
BPIT
48
48. Test
Age 65–75 years
49
49. Test
Participation in sports
50
50. Test
Hyperextension
51
51. Test
Hyperflexion
52
52. Test
Sharp pain
53
53. Test
Pain extent (fingertip size)
54
54. Test
Pain location
55
55. Test
Previous history of LBP
56
56. Test
Waking night pain
57
57. Test
Lumbar rotation
58
58. Test
Lumbar lateral flexion
59
59. Test
Single leg hyperextension
60
60. Test
2 of 3 negative ‐ Therriault cluster
61
61. Test
2 of 3 positive ‐ Therriault cluster
62
62. Test
3 of 3 negative ‐ Therriault cluster
See this image and copyright information in PMC

Update of

  • doi: 10.1002/14651858.CD014461

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References to other published versions of this review

Henschke 2010b
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