Sensitivity and specificity of patient-entered red flags for lower back pain

Tsiang, John; Kinzy, Tyler G.; Thompson, Nicolas R.; Tanenbaum, Joseph E.; Thakore, Nitya L.; Khalaf, Tagreed; Katzan, Irene

doi:10.1016/j.spinee.2018.06.342

Cited by 14 publications

(11 citation statements)

References 33 publications

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“…After reviewing the 52 eligible papers, 40 papers met the full eligibility criteria as agreed by the two reviewers (see additional file 1). One paper was excluded from the review because it was a narrative review [26], two papers did not include a description of the testing performed [27, 28] and nine papers were excluded because they did not provide data for red flags/clinical features for SI [11, 12, 28–35].…”

Section: Resultsmentioning

confidence: 99%

“…Based on our initial search there were two potential studies evaluating the diagnostic accuracy of red flags for SI. However, just based on these two studies it was not possible to examine the diagnostic accuracy of red flags for SI, as one study combined the sensitivity and specificity for fever, spine pain, and neurologic deficits (classic triad) [54], while the other study, due to the low prevalence of SI, failed to gauge the sensitivity and specificity of red flags for SI [35]. This is consistent with the findings of Verhagen et al in a recent systematic review looking at the red flags reported in current low back pain guidelines [3].…”

Section: Discussionmentioning

confidence: 99%

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Red flags for the early detection of spinal infection in back pain patients

Yusuf

Finucane

Selfe

2019

BMC Musculoskelet Disord

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BackgroundRed flags are signs and symptoms that are possible indicators of serious spinal pathology. There is limited evidence or guidance on how red flags should be used in practice. Due to the lack of robust evidence for many red flags their use has been questioned. The aim was to conduct a systematic review specifically reporting on studies that evaluated the diagnostic accuracy of red flags for Spinal Infection in patients with low back pain.MethodsSearches were carried out to identify the literature from inception to March 2019. The databases searched were Medline, CINHAL Plus, Web of Science, Embase, Cochrane, Pedro, OpenGrey and Grey Literature Report. Two reviewers screened article texts, one reviewer extracted data and details of each study, a second reviewer independently checked a random sample of the data extracted.ResultsForty papers met the eligibility criteria. A total of 2224 cases of spinal infection were identified, of which 1385 (62%) were men and 773 (38%) were women mean age of 55 (± 8) years. In total there were 46 items, 23 determinants and 23 clinical features. Spinal pain (72%) and fever (55%) were the most common clinical features, Diabetes (18%) and IV drug use (9%) were the most occurring determinants. MRI was the most used radiological test and Staphylococcus aureus (27%), Mycobacterium tuberculosis (12%) were the most common microorganisms detected in cases.ConclusionThe current evidence surrounding red flags for spinal infection remains small, it was not possible to assess the diagnostic accuracy of red flags for spinal infection, as such, a descriptive review reporting the characteristics of those presenting with spinal infection was carried out. In our review, spinal infection was common in those who had conditions associated with immunosuppression. Additionally, the most frequently reported clinical feature was the classic triad of spinal pain, fever and neurological dysfunction.This is an Open Access article distributed in accordance with the Creative Commons Attribution Non-Commercial (CC BY-NC 4.0) license, which permits others to distribute, remix, adapt, build upon this work non-commercially, and license their derivative works on different terms, provided the original work is properly cited and the use is non-commercial. See: http://creativecommons.org/licenses/by-nc/4.0/

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Section: Resultsmentioning

confidence: 99%

Section: Discussionmentioning

confidence: 99%

Red flags for the early detection of spinal infection in back pain patients

Yusuf

Finucane

Selfe

2019

BMC Musculoskelet Disord

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“…Low back pain (LBP) is a major cause of global disease burden, with a lifetime prevalence estimated to be 80% in developed countries [1,2]. Most LBP is non-specific and uncomplicated [1,[3][4][5]; however, pathology causing LBP, such as infection, malignancy, cauda equina syndrome and fracture account for less than 5% of cases in a primary care setting [1,4,[6][7][8][9][10].…”

Section: Introductionmentioning

confidence: 99%

Adherence to spinal imaging guidelines and utilization of lumbar spine diagnostic imaging for low back pain at a Canadian Chiropractic College: a historical clinical cohort study

et al. 2022

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Background: Diagnostic imaging is useful for assessing low back pain (LBP) when a clinician suspects a specific underlying pathology. Evidence-based imaging guidelines assist clinicians in appropriately determining the need for imaging when assessing LBP. A previous study reported high adherence to three clinical guidelines, with utilization rate of 12.3% in imaging of LBP patients attending a chiropractic teaching clinic. A new imaging guideline for spinal disorders has been published and used in teaching. Thus, the aims of our study were to assess the adherence to the new guideline and X-ray utilization in new episodes of LBP. Methods:We conducted a historical clinical cohort study using patient electronic health record audits at seven teaching clinics over a period of 20 months. Records of patients who were at least 18 years of age, presented with a new onset of LBP, and consented to data collection were included. Abstracted data included patient demographics, the number and type of red flags, and the decision to image. Rate of guideline adherence (proportion of those not recommended for imaging, given no red flags) and rate of image utilization were descriptively analyzed. Results:We included 498 patients in this study. At least 81% of included patients had one or more red flags reported. The most commonly reported individual red flag was age ≥ 50 (43.8%) followed by pain at rest (15.7%). In those referred for imaging, age ≥ 50 (93.3%) was the most frequently reported red flag. No red flag(s) were identified in 93 patient records, and none were referred for imaging of their LBP, yielding an adherence rate of 100% (95% CI 96, 100%). A total of 17 of 498 patients were recommended for imaging for their low back pain, resulting in an imaging utilization rate of 3.4% (95% CI 1.8, 5.0%). Conclusion:The imaging utilization rate was 3.4%, lower than 12.3% previously reported at a chiropractic teaching clinic. None without red flags were referred for imaging, yielding a 100%, adherence rate to current LBP imaging guidelines. Future research should consider currency of guideline, accuracy of red flags and factors influencing clinicians' decision, when assessing imaging adherence rates.

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“…Even though rare, malignancy and infection should be included in the differential diagnoses of back pain as well . Clarifying the possibility of all the red‐flag signs that are potential clinical risk factors for VFs, including older age, night pain, a history of trauma, a history of cancer, prolonged use of glucocorticosteroids, absence of leg pain, and body mass index (BMI) ≤22, is a great challenge for general practitioners . A combination of the above risk factors has been proposed to increase the diagnostic accuracy, but unfortunately, this combination produces suboptimal diagnostic accuracy in clinical practice .…”

Section: Introductionmentioning

confidence: 99%

“…(13)(14)(15)(16)(17)(18) Clarifying the possibility of all the red-flag signs that are potential clinical risk factors for VFs, including older age, night pain, a history of trauma, a history of cancer, prolonged use of glucocorticosteroids, absence of leg pain, and body mass index (BMI) ≤22, is a great challenge for general practitioners. (14)(15)(16)(17)(18)(19) A combination of the above risk factors has been proposed to increase the diagnostic accuracy, but unfortunately, this combination produces suboptimal diagnostic accuracy in clinical practice. (14,16,19,20) Thus, a simple and efficient physical examination for VFs is warranted.…”

Section: Introductionmentioning

confidence: 99%

Back Pain-Inducing Test, a Novel and Sensitive Screening Test for Painful Osteoporotic Vertebral Fractures: A Prospective Clinical Study

Jin

Liu

et al. 2019

Journal of Bone and Mineral Research

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To detect painful vertebral fractures (VFs) in back pain populations at risk of osteoporosis, we designed a physical examination test (the Back Pain‐Inducing Test [BPIT]) that included three movements: lying supine, rolling over, and sitting up. If back pain is induced during any of these movements, the result is defined as positive, thereby establishing a presumptive diagnosis of painful VFs. Pain severity is quantified using a self‐reported numerical rating scale (NRS). The presence or absence of painful VFs is verified by whole‐spine magnetic resonance imaging (MRI), the gold standard for final diagnosis. According to the standards for reporting diagnostic accuracy, a real‐world, prospective, and observational study was performed on 510 back pain patients (enrolled from a single institute) at risk of osteoporosis. The sensitivity, specificity, and accuracy of the BPIT for identifying painful VFs were 99.1% (95% CI, 97.5% to 99.8%), 67.9% (95% CI, 60.4% to 74.5%), and 89.0%, respectively. The positive and negative predictive values were 86.6% (95% CI, 82.9% to 89.6%) and 97.4% (95% CI, 92.6% to 99.3%), respectively. Cutoff NRS scores for lying supine, rolling over, and sitting up were 3, 0, and 2, respectively. The corresponding area under the receiver operating characteristic curves (AUROCs) of each movement was 0.898 (95% CI, 0.868 to 0.922), 0.884 (95% CI, 0.854 to 0.911), and 0.910 (95% CI, 0.882 to 0.933), respectively. Although the high prevalence of VFs in the enrolled cohort partially limits the external validity of the predictive value in the general population, we conclude that the BPIT is potentially effective for detecting painful VFs in back pain populations at risk of osteoporosis. This test may be used as a stratification tool in decision‐making on subsequent imaging procedures: a negative BPIT rules out painful VFs and indicates that an MRI should be spared, whereas a positive BPIT means that an MRI is necessary and is likely to identify painful VFs. © 2019 American Society for Bone and Mineral Research.

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Sensitivity and specificity of patient-entered red flags for lower back pain

Cited by 14 publications

References 33 publications

Red flags for the early detection of spinal infection in back pain patients

Red flags for the early detection of spinal infection in back pain patients

Adherence to spinal imaging guidelines and utilization of lumbar spine diagnostic imaging for low back pain at a Canadian Chiropractic College: a historical clinical cohort study

Back Pain-Inducing Test, a Novel and Sensitive Screening Test for Painful Osteoporotic Vertebral Fractures: A Prospective Clinical Study

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