Background: Very little evidence is available on the prevalence of serious spinal pathologies and the diagnostic accuracy of red flags in patients presenting to the emergency department (ED). This systematic review aims to investigate the prevalence of serious spinal pathologies and the diagnostic accuracy of red flags in patients presenting with low back pain to the ED. Methods: We systematically searched MEDLINE, PUBMED, EMBASE, Cochrane Library, and SCOPUS from inception to January 2019. Two reviewers independently reviewed the references and evaluated methodological quality. Results: We analyzed 22 studies with a total of 41'320 patients. The prevalence of any serious spinal pathology requiring immediate/urgent treatment was 2.5-5.1% in prospective and 0.7-7.4% in retrospective studies (0.0-7.2% for vertebral fractures, 0.0-2.1% for spinal cancer, 0.0-1.9% for infectious disorders, 0.1-1.9% for pathologies with spinal cord/cauda equina compression, 0.0-0.9% for vascular pathologies). Examples of red flags which increased the likelihood for a serious condition were: suspicion and/or history of cancer (spinal cancer); intravenous drug use, indwelling vascular catheter, other infection site (epidural abscess). Conclusion: We found a higher prevalence of serious spinal pathologies in the ED compared to the reported prevalence in primary care settings. As the diagnostic accuracy of most red flags was reported only by a single study, further validation in high quality prospective studies is needed.

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