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

Key Points

1. Healthcare providers should know the strength of the red flags they are using for their patients presenting with low back pain.
2. The four best red flags that would indicate a fracture is likely found, according to this review, were corticosteroid use, person’s age (>70 years of age), trauma, and a contusion or abrasion.

BACKGROUND & OBJECTIVE

Low back pain (LBP) is a very common clinical diagnosis across all healthcare settings. Many professions have long utilized red flags to identify people who present with LBP who may have a more serious pathology that would need further investigation. Malignancy and spinal fractures are two common pathologies that red flags have been used to identify.

The objective of this review was to assess the diagnostic accuracy of red flags used to screen for vertebral fracture in people presenting with LBP.

Malignancy and spinal fractures are two common pathologies that red flags have been used to identify.

“Screening for red flags” is a part of most healthcare professional training but are often presented without being questioned as to their accuracy.

METHODS

• This Cochrane Review is an update of a previous review and follows the standard Cochrane search methods.

• The standard Cochrane Review methods include the identification of relevant studies from a number of different sources, the selection of studies for inclusion, and the evaluation of their strengths and limitations on the basis of clear, predefined criteria.

• Data were systematically collected, and finally, the data are synthesized (1).

• The latest search for new articles to include was performed on 26 July 2022.

• The data considered for inclusion came from primary diagnostic studies if they compared results of history taking or physical examination findings with a reference standard (such as some sort of imaging) for the identification of vertebral fractures in people presenting with LBP.

• Two review authors independently extracted data, and calculated sensitivity, specificity, and positive (+LR) and negative (-LR) likelihood ratios with 95% confidence intervals (CI).

RESULTS

• Only six additional studies were added to the previous review (2).

• Trauma and older age were found to be informative when screening for fractures in people presenting with LBP.

• Corticosteroid use and abrasions/contusions were also found to be informative.

• A combination of red flags was more informative than red flags used in isolation.

LIMITATIONS

As with most reviews, the heterogeneity of the studies included in the review impact the final findings of the review. The included studies had significant variations in healthcare settings, utilized different study designs, or presented data for different types of spinal fractures. Many red flags investigated were from single studies with varying degrees of quality.

CLINICAL IMPLICATIONS

LBP continues to be one of the most common issues seen across healthcare settings. It is understandable that when initially evaluating a patient with any condition, a quality healthcare provider would like to accurately diagnose the condition and provide the most effective treatment for that condition.

Red flags have been used for decades to identify serious pathologies that would warrant additional investigation or referral to a specialist. “Screening for red flags” is a part of most healthcare professional training but are often presented without being questioned as to their accuracy. There have been calls to not use red flags, as they lack the negative likelihood ratio to truly act as a screen (3). Lack of clarity has also been found in the red flags e.g. corticosteroid use is listed as a red flag and has been found to be useful in screening people with LBP for fractures, but how long or at what dose the corticosteroids were used has not been examined.

The use of red flags for patients with low back pain has been under review for both fractures and malignancy (4), which will hopefully assist clinicians in utilizing red flags appropriately and limit the use of unnecessary imaging, testing, or worrying of people with LBP.

+STUDY REFERENCE

Han C, Hancock M, Downie A, Jarvik J, Koes B, Machado G, Verhagen A, Williams C, Chen Q, Maher C (2023) ‘Red flags to screen for vertebral fracture in people presenting with low back pain’, The Cochrane Library, 8(8).

SUPPORTING REFERENCE

1. Cochrane Library n.d., About Cochrane Reviews | Cochrane Library, cochranelibrary.com.
2. Williams, CM, Henschke, N, Maher, CG, van Tulder, MW, Koes, BW, Macaskill, P & Irwig, L 2013, ‘Red Flags to Screen for Vertebral Fracture in Patients Presenting with low-back Pain’, Cochrane Database of Systematic Reviews.
3. Cook, CE, George, SZ & Reiman, MP 2017, ‘Red Flag Screening for Low Back pain: Nothing to See here, Move along: a Narrative Review’, British Journal of Sports Medicine, vol. 52, no. 8, pp. 493–496.
4. Henschke, N, Maher, CG, Ostelo, RW, de Vet, HC, Macaskill, P & Irwig, L 2013, ‘Red Flags to Screen for Malignancy in Patients with low-back Pain’, Cochrane Database of Systematic Reviews.