Low Back Pain in the Emergency Department: Prevalence of Serious Spinal Pathologies and Diagnostic Accuracy of Red Flags

doi:10.1016/j.amjmed.2019.06.005

The American Journal of Medicine

Volume 133, Issue 1, January 2020, Pages 60-72.e14

https://doi.org/10.1016/j.amjmed.2019.06.005 Get rights and content

Abstract

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 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 or history of cancer (spinal cancer); intravenous drug use, indwelling vascular catheter, and 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.

Introduction

Low back pain is one of the leading complaints in US emergency departments (ED),1., 2. accounting for 4.4% of all ED visits between 2000 and 2016.1., 2. The primary goal is to detect a serious pathology that requires urgent treatment.³ In the primary-care setting, the prevalence of serious pathologies was found to be less than 1%.⁴ The prevalence in the ED setting is unclear, and it is reasonable to assume it to be higher compared to the primary-care setting.⁵

Red flags are signs or symptoms that help to identify patients at risk for a serious underlying disease.⁶ However, there is no consensus on which red flags should be screened for: 16 guidelines recommended 46 different red flags.⁶ For example, to identify underlying malignancy, 14 different red flags were suggested, and only 2 red flags were included in all guidelines.⁶ Further, the predictive utility of red flags is unclear. According to 2 systematic reviews, the only helpful red flag in the primary-care setting to detect spinal cancer was a history of cancer,⁷ and the only relevant red flags to detect vertebral fractures were older age, prolonged steroid use, contusion or abrasion, and a history of trauma.⁸

The aim of this systematic review was to summarize the evidence on the prevalence of serious spinal pathologies in patients with low back pain presenting to the ED. We hypothesized that serious conditions are more prevalent in ED compared to primary-care settings. Further, we aimed to assess the diagnostic accuracy of red flags to identify patients with a serious spinal pathology in the ED setting.

Section snippets

Study Design

We conducted a systematic review following the recommendation of the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA).⁹ The development process of the study protocol was described previously.¹⁰

Literature Search

We searched the following databases from the inception until January 12, 2019: Medline (Ovid), Embase (Elsevier), Pubmed, Cochrane Library, and Scopus (Elsevier). The search was developed with the help of an experienced librarian (Appendix 1, available online). No language

Study Selection

Out of 2290 references (Figure 1), 208 records were read in full text, and 22 studies were included (21 assessed the prevalence and 10 the diagnostic accuracy of red flags).

Study Characteristics

Three studies (13.6%, Table 1) used a prospective observational, 3 studies (13.6%) a cross-sectional, and 15 studies (68.2%) a retrospective design (1 case-control study, 14 chart reviews). One study used mixed methods (retrospective chart review followed by a cross-sectional study).¹⁹ The aggregate number of patients

Discussion

This systematic review showed a higher prevalence of serious spinal pathologies in patients with low back pain presenting to the ED compared to the prevalence in primary-care settings that was reported to be < 1%.⁴ A multicenter cohort study conducted in primary care in Australia reported that less than 1% of the patients presenting with low back pain to their general practitioner were diagnosed with a serious spinal pathology over a follow-up of 12 months.⁴ The main pathology identified in the

Conclusions

We found a substantially higher prevalence of serious spinal pathologies in the ED compared to that of primary-care settings. Red flags may be useful in the clinical assessment. However, their diagnostic accuracy needs to be interpreted with caution because few studies were of high quality, and for most red flags, only a single study was available. High-quality, prospective studies should validate the diagnostic accuracy of red flags in patients with low back pain presenting to the ED.

Acknowledgment

We thank Dr. Sabine Klein, University of Zurich, for conducting the literature search.

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: Funding: None.

: Conflicts of Interest: None.

: Authorship: All authors had access to the data and a role in writing this manuscript. GG and DES shared first authorship and contributed equally to this work.

View full text

Clinical Research StudyLow Back Pain in the Emergency Department: Prevalence of Serious Spinal Pathologies and Diagnostic Accuracy of Red Flags

Abstract

Background

Methods

Results

Conclusion

Introduction

Section snippets

Study Design

Literature Search

Study Selection

Study Characteristics

Discussion

Conclusions

Acknowledgment

Emerg Med Clin North Am

Int J Surg

J Clin Epidemiol

J Emerg Med.

Acad Radiol

J Emerg Med.

J Emerg Med.

J Am Coll Radiol

J Emerg Med.

Ann Emerg Med

J Emerg Med

Osteoarthr Cartil

Radiol Clin N Am

Prevalence of low back pain in emergency settings: a systematic review and meta-analysis

BMC Musculoskelet Disord

National trends in use of computed tomography in the emergency department

Ann Emerg Med

Prevalence of and screening for serious spinal pathology in patients presenting to primary care settings with acute low back pain

Arthritis Rheum

Clinical predictors of the medical interventions provided to patients with low back pain in the emergency department

J Back Musculoskelet Rehabil

Red flags presented in current low back pain guidelines: a review

Eur Spine J

Red flags to screen for malignancy in patients with low-back pain

Cochrane Database Syst Rev

Red flags to screen for vertebral fracture in patients presenting with low-back pain

Cochrane Database Syst Rev

Preferred reporting items for systematic reviews and meta-analyses: the PRISMA statement

PLoS Med

Prevalence of serious spinal pathologies and red flags in patients presenting with low back pain to the emergency department. Protocol for a systematic review [master's thesis]

SIGN 50 - A guideline developer’s handbook. Vol 2017. Scottish Intercollegiate Guidelines Network (SIGN) website: Scottish Intercollegiate Guidelines Network (SIGN)

Evidence-based medicine: how to read an article about a diagnostic test

Heart Drug

Users' guides to the medical literature. III. How to use an article about a diagnostic test. B. What are the results and will they help me in caring for my patients? The Evidence-Based Medicine Working Group

JAMA

Clinical Research Study
Low Back Pain in the Emergency Department: Prevalence of Serious Spinal Pathologies and Diagnostic Accuracy of Red Flags