Low back pain is the most common condition treated by chiropractors. In rare cases, it may be due to underlying serious pathology. The most common serious pathologies that mimic mechanical spinal conditions are fracture, malignancy, spinal infection and cauda equina syndrome.
Early diagnosis of these pathologies is vital, because a missed or delayed diagnosis can lead to permanent harms such as severe, irreversible neurological compromise or death.
Identifying a serious pathology is complex. The majority of guidelines recommend that clinicians use red flags to help identify serious spinal pathology. But despite recommendations for red-flag screening, pathologies are commonly missed.1 Red flags are signs and symptoms that raise suspicion of serious spinal pathology. These can be good tools when used in combination with a thorough patient history and an appropriate physical examination.
Various studies have identified the incidence of serious pathology presenting as low back pain in primary care settings. The incidence of vertebral fracture is between 0.7-4.0 percent; malignancy between 0.0- 0.2 percent; infection 0.01 percent; and cauda equina syndrome 0.04 percent.2-5
Screening Patients With Spinal Pain: A Breakthrough Study
The screening goal for patients with spinal pain is to identify those with high probabilities of having serious medical conditions causing their back pain. A recent study examined the effectiveness of combining red-flag questions as a screening tool for patients presenting with low back pain.6 Researchers conducted a review of 9,940 patients with a chief complaint of low back pain. The patients completed a questionnaire during their first visit that included several red-flag questions. Diagnostic data for the same clinical episode were collected from medical records and were confirmed with imaging reports.
Study findings appear in the Journal of Bone & Joint Surgery. The research team was from the Department of Orthopedic Surgery at Emory University School of Medicine. The table demonstrates the findings. Overall, for fracture, malignancy, infection and cauda equina syndrome, the combination of factors listed yielded very high specificity, but very low sensitivity.
COMBINATIONS OF RED FLAGS ASSOCIATED WITH AN INCREASED PROBABILITY OF UNDERLYING SERIOUS SPINAL PATHOLOGY |
||
Sensitivity |
Specificity |
|
| Fracture (1.7% of patients): trauma and age >70 years | 5.2% | 98.7% |
| Malignancy (1.6% of patients): unexplained weight loss and history of cancer | 2.5% | 99.8% |
| Infection (1.2% of patients): fever, chills or sweating and recent infection | 7.5% | 99.4% |
| Cauda equina syndrome (0.4% of patients): recent loss of bladder and bowel control | 8.3% | 97.2% |
Clinical Application
If combinations of red-flag factors have high specificity, as in this study, and the patient's red-flag factors are positive, you can be fairly certain the patient does have the pathology for which you screened. There are few false positives. An appropriate diagnostic workup would be indicated to investigate the pathology.
However, the low sensitivity of these same red-flag factors means there are many false negative results. If your patients has none of the factors related to serious pathology, you cannot rule out the possibility of any serious pathology, and you should employ watchful waiting. Careful monitoring for changes in symptoms over time is built into an evidence-based approach to health care.
Editor's Note: The research presented in this article is also available in video format at https://chiroevidence.com/research-capsule-240.
References
- Esses SI, McGuire R, Jenkins J, et al. The treatment of symptomatic osteoporotic spinal compression fractures. J Am Acad Orthop Surg, 2011;19:176-182.
- Henschke N, Maher CG, Refshauge KM, et al. Prevalence of and screening for serious spinal pathology in patients presenting to primary care settings with acute low back pain. Arthritis Rheum, 2009;60:3072-3080.
- Jarvik JG, Deyo RA. Diagnostic evaluation of low back pain with emphasis on imaging. Ann Intern Med, 2002;137:586-597.
- Deyo RA, Rainville J, Kent DL. What can the history and physical examination tell us about low back pain? JAMA, 1992;268:760-765.
- Frazier LM, Carey TS, Lyles MF, et al. Selective criteria may increase lumbosacral spine roentgenogram use in acute low-back pain. Arch Intern Med, 1989;149:47-50.
- Premkumar A, Godfrey W, Gottschalk MB, et al. Red flags for low back pain are not always really red: a prospective evaluation of the clinical utility of commonly used screening questions for low back pain. J Bone Joint Surg (U.S.), 2018;100:368-374.
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