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

Diagnosis Value of Patient Evaluation Components Applicable in Primary Care Settings for the Diagnosis of Low Back Pain: A Scoping Review of Systematic Reviews

Low back pain ranks as the leading cause of years lived with disability worldwide. Although best practice guidelines share a consistent diagnostic approach for the evaluation of patients with low back pain, confusion remains as to what extent patient history and physical examination findings can inform management strategies. The aim of this study was to summarize evidence investigating the diagnostic value of patient evaluation components applicable in primary care settings for the diagnosis of low back pain. To this end, peer-reviewed systematic reviews were searched in MEDLINE, CINAHL, PsycINFO and Cochrane databases from 1 January 2000 to 10 April 2023. Paired reviewers independently reviewed all citations and articles using a two-phase screening process and independently extracted the data. Of the 2077 articles identified, 27 met the inclusion criteria, focusing on the diagnosis of lumbar spinal stenosis, radicular syndrome, non- specific low back pain and specific low back pain. Most patient evaluation components lack diagnostic accuracy for the diagnosis of low back pain when considered in isolation. Further research is needed to develop evidence-based and standardized evaluation procedures, especially for primary care settings where evidence is still scarce.

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

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.

Emergency department evaluation, treatment, and functional outcomes among patients presenting with low back pain

OBJECTIVES

Low back pain (LBP) leads to more than 4.3 million emergency department (ED) visits annually. Despite the number of ED visits for LBP, emergency medicine societies have not established clear guidelines for the evaluation and care of these patients. This study aims to describe patterns in the evaluation, treatment, and outcomes of patients presenting to an urban, academic ED for atraumatic LBP.

METHODS

We prospectively identified a convenience sample of patients presenting with LBP to the University of Utah Hospital ED between January 2017 and June 2018. We collected baseline demographic information and calculated the Patient-Reported Outcomes Measurement Information System Physical Function Short Form 12a (PROMIS PFSF-12a) score to assess patient function and mobility (50 = average PROMIS PFSF-12a score, with higher scores indicating better function). We contacted patients 6 weeks after the ED visit to assess outpatient follow-up and functional outcomes.

RESULTS

Over the 18-month study period, 103 patients presented with a chief complaint of LBP and agreed to participate in the study. Average age of the cohort was 48.5 years (SD = 18.3) and 55 (53.4%) were female. Notably, 61 patients (59.2%) had been seen previously in the ED for LBP and 32 (31.1%) had received an opioid for LBP in the preceding 3 months. In the ED, 35.9% of patient received an opioid while 18.5% had an opioid prescription at discharge. While in the ED, 37 (35.9%) had an x-ray and 47 (45.6%) underwent computed tomography or magnetic resonance imaging. At 6-week follow-up, 22 of 68 (32.4%) patients reported having missed work due to pain. PROMIS PFSF-12a score improved from 32.2 ("low" range) at time of ED visit to 42.0 ("low-average" range) at the 6-week follow up. Regarding outpatient follow-up after the ED visit, 22 patients (21.4%) saw a primary care provider, 12 patients (17.8%) saw orthopedics or neurosurgery, and 8 patients (11.8%) attended physical therapy.

CONCLUSIONS

Patients receiving ED care for LBP had a significant improvement in PROMIS PFSF-12a scores 6 weeks after the ED but return to function continued to lag despite interventions. Imaging patterns, medication prescriptions, and outpatient follow-up varied widely, emphasizing the needs for clear guidelines and treatment pathways for ED patients with LBP.

The diagnostic value of Red Flags in thoracolumbar pain: a systematic review

PURPOSE

Red Flags (RFs) are signs and symptoms related to the screening of serious underlying pathologies mimicking a musculoskeletal pain. The current literature wonders about the usefulness of RFs, due to high false-positive rates and low diagnostic accuracy. The aims of this systematic review are: (a) to identify and (b) to evaluate the most important RFs that could be found by a health care professional during the assessment of patients with low and upper back pain (named as thoracolumbar pain (TLP)) to screen serious pathologies.

MATERIALS AND METHODS

A systematic review of the literature was conducted. Searches were performed on seven databases (Pubmed, Web of Science, Cochrane Library, Pedro, Scielo, CINAHL, and Google Scholar) between March 2019 and June 2020, using a search string which included synonyms of low back pain (LBP), chest pain (CP), differential diagnosis, RF, and serious disease. Only observational studies enrolling patients with LBP or CP were included. Risk of bias was assessed with the Newcastle Ottawa Scale and inter-rater agreement between authors for full-text selection was evaluated with Cohen's Kappa. Where possible the diagnostic accuracy was recorded for sensitivity (Sn), specificity (Sp), and positive/negative likelihood ratio (LR+/LR-).

RESULTS

Forty full-texts were included. Most of the included observational studies were judged as low risk of bias, and Cohen's Kappa was good (=0.78). The identified RFs were: advanced age; neurological signs; history of trauma; malignancy; female gender; corticosteroids use; night pain; unintentional weight loss; bladder or bowel dysfunction; loss of anal sphincter tone; saddle anaesthesia; constant pain; recent infection; family or personal history of heart or pulmonary diseases; dyspnoea; fever; postprandial CP; typical reflux symptoms; haemoptysis; sweating; pain radiated to upper limbs; hypotension; retrosternal pain; exertional pain; diaphoresis; and tachycardia. The diagnostic accuracy of RFs as self-contained screening tool was low, while the combination of multiple RFs showed to increase the probability to identify serious pathologies.

CONCLUSIONS

Despite the use of single RF should not be recommended for the screening process in clinical practice, the combination of multiple RFs to enhance diagnostic accuracy is promising. Moreover, the identified RFs could be a baseline to develop a screening tool for patients with TLP.Implications for rehabilitationDifferential diagnosis and screening for referral are mandatory skills for each healthcare professional in direct access clinical settings, and should be the primary step for an appropriate management of a patient with signs and symptoms mimicking serious pathologies in thoracolumbar region.Clinical reasoning and decision-making processes are essential throughout all phases of a patient's pathway of care. By which, the use of single Red Flag (RF) as a self-contained screening tool should not be recommended. The combination of multiple RFs promises to increase diagnostic accuracy and could grow into an excellent screening tool for thoracolumbar pain.

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

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.

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

BACKGROUND

Red 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.

METHODS

Searches 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.

RESULTS

Forty 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.

CONCLUSION

The 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/.

The ambiguity of sciatica as a clinical diagnosis: A case series

Sciatica as a clinical diagnosis is nonspecific. A diagnosis of sciatica is typically used as a synonym for lumbosacral radiculopathy. However, the differential for combined low back and leg pain is broad, and the etiology can be one several different conditions. The lifetime prevalence of sciatica ranges from 12.2% to 43%, and nonsuccessful outcomes of treatment are prevalent. Nurse practitioners and other primary care clinicians often have minimal training in differential diagnosis of the complex causes of lower back and leg pain, and many lack adequate time per patient encounter to work up these conditions. Differentiating causes of low back and leg pain proves challenging, and inadequate or incomplete diagnoses result in suboptimal outcomes. Chiropractic care availability may lessen demands of primary care with respect to spinal complaints, while simultaneously improving patient outcomes. The authors describe three patients referred from primary care with a clinical diagnosis of sciatica despite differing underlying pathologies. More precise clinical terminology should be used when diagnosing patients with combined low back and leg pain. Nurse practitioners and other clinicians' triage, treat, and determine appropriate referrals for low back and leg pain. Multidisciplinary care including chiropractic may add value in settings where patients with lower back and leg pain are treated.

Study protocol for targeted interventions to prevent chronic low back pain in high-risk patients: A multi-site pragmatic cluster randomized controlled trial (TARGET Trial)

BACKGROUND

Low back pain (LBP) is one of the most prevalent and potentially disabling conditions for which people seek health care. Patients, providers, and payers agree that greater effort is needed to prevent acute LBP from transitioning to chronic LBP.

METHODS AND STUDY DESIGN

The TARGET (Targeted Interventions to Prevent Chronic Low Back Pain in High-Risk Patients) Trial is a primary care-based, multisite, cluster randomized, pragmatic trial comparing guideline-based care (GBC) to GBC + referral to Psychologically Informed Physical Therapy (PIPT) for patients presenting with acute LBP and identified as high risk for persistent disabling symptoms. Study sites include primary care clinics within each of five geographical regions in the United States, with clinics randomized to either GBC or GBC + PIPT. Acute LBP patients at all clinics are risk stratified (high, medium, low) using the STarT Back Tool. The primary outcomes are the presence of chronic LBP and LBP-related functional disability determined by the Oswestry Disability Index at 6 months. Secondary outcomes are LBP-related processes of health care and utilization of services over 12 months, determined through electronic medical records. Study enrollment began in May 2016 and concluded in June 2018. The trial was powered to include at least 1860 high-risk patients in the randomized controlled trial cohort. A prospective observational cohort of approximately 6900 low and medium-risk acute LBP patients was enrolled concurrently.

DISCUSSION

The TARGET pragmatic trial aims to establish the effectiveness of the stratified approach to acute LBP intervention targeting high-risk patients with GBC and PIPT.

TRIAL REGISTRATION

ClinicalTrials.govNCT02647658 Registered Jan. 6, 2016.