Recent Study Highlights Red Flags for Major Spinal Conditions

Low back pain is one of the major causes of disability worldwide. In the United States, the lifetime prevalence of low back pain is estimated at 60% to 70% and is the number one cause of limited activity in people younger than 45 years, making it the leading driver of hospital visits and admissions.

Most low back pain cases are nonspecific, but some patients may actually have serious underlying pathology (e.g., infection or malignancy) or neurologic impairments (e.g., spinal stenosis or radiculopathy) that requires accurate and timely diagnosis. While low back pain due to serious pathology is rare, it is essential that the case is appropriately identified to reach an accurate diagnosis.

However, the associated healthcare cost of low back pain can be a burden to many patients. This lead to the utilization of inexpensive and noninvasive screening tools to detect serious disease. Within this context, red flag screening questions were developed.

Red flag symptoms were encouraged for use and have become one of the ways to detect serious spine pathology. Such symptoms drawn from red flag findings are believed to indicate specific underlying pathology. However, the consistency of the guidelines is now being questioned.

In a study published in the December 2018 edition of International Orthopaedics titled “Specific spinal pathologies in adult patients with an acute or subacute atraumatic low back pain in the emergency department,” a group of Finnish researchers, led by Aleksi Reito, M.D., Ph.D, concluded that “the accuracy of red flag symptoms is poor” when it comes to determining if low back pain is actually a serious spinal condition.

In an interview with Orthopedics This Week, Dr. Reito, Resident at the Central Finland Hospital’s Orthopedic Surgery and Traumatology department, says these highly recommended red flag symptoms “work very poorly” due to the fact that the number of patients that have a specific or serious reason for low back pain is extremely low, therefore the accuracy is poor.

Serious medical conditions with low back pain as a symptom, such as cancer, fractures, infection, and cauda equina syndrome, are extremely rare, reaching only 33 cases out 900 patient visits due to atraumatic low back pain. The researchers drew this information using their institutional database, which also showed that out of those visits, 583 cases were due to radicular pain or the compression of a nerve root, and 284 were due to nonspecific low back pain.

According to Dr. Reito, medical professionals assigned in the emergency department and assessing patients with low back pain should not be solely reliant on red flag screening since the occurrence of serious conditions is extremely low.

What should be done instead is to consider each patient individually. The authors of the study also recommend a low threshold for imaging and referral if there is a strong suspicion of a serious and specific condition arising from low back pain. With today’s more advanced imaging technology and better availability than before, there’s a need to tolerate a higher rate of wrong positives for the prevention of wrong negatives, considering that the outcome could be devastating on the individual level.

The researchers further added that due to the poor reliability of red flags due to low serious disease probability, the community should strive to develop better solutions and tools to predict serious conditions marked by the onset of low back pain.

While a positive response to a red flag question may indicate the presence of underlying pathology, a negative response to 1 or 2 questions does not necessarily mean that the likelihood of a serious disease is eliminated. Therefore, clinicians should be more cautious when utilizing red flag questions as tools for screening serious conditions associated with low back pain.