Introduction
Method
Design
Search strategy
Data extraction
Results
Search results
Guideline | Patient population | Red flags | Cited evidence to support inclusion |
---|---|---|---|
Australia [17] Clinicians and patients | Acute (<3 months) nonspecific low back pain | Fracture: History of (major) trauma Minor trauma (if >50 years, history of osteoporosis and taking corticosteroids) Malignancy: Past history of malignancy; age >50 years; failure to improve with treatment; unexplained weight loss; pain at multiple sites; pain at rest Infection: Symptoms and signs of infection (e.g. fever); risk factors for infection (e.g. underlying disease process, immunosuppression, penetrating wound); bone tenderness over the lumbar spinous process Aortic aneurism: Absence of aggravating features | Malignancy: Deyo and Diehl [41] Infection: Deyo et al. [9] |
Austria [30] Professionals of various disciplines | Nonspecific low back pain | General: Age (<20, >55 years); increasing pain despite treatment; Trauma; history of cancer; osteoporosis; pain in rest; accompanying thoracic pain; pain increase in flexion; use of corticosteroids, immunosuppression use; drug abuse; HIV; neurological signs (neurological claudication); malaise; fever; unexplained weight loss; deformities | Royal College of General Practitioners [53] |
Canada [18] Primary health care providers | Nonspecific low back pain with/without sciatica/radiculopathy | Compression fracture: Severe onset of pain with minor trauma, age >50, prolonged steroid intake or structural deformity Fracture or infection: Significant trauma; use of intravenous drugs or steroids Malignancy: Patient over 50, but particularly over 65, with first episode of severe back pain and other risk factors for malignancy: history of cancer/carcinoma in the last 15 years, unexplained weight loss, failure of conservative care (4 weeks) Malignancy or infection: Severe unremitting (nonmechanical) worsening of pain (at night and pain when laying down); weight loss; fever; history of cancer/HIV; widespread neurological signs; Cauda equina syndrome: Sudden onset of new urinary retention, fecal incontinence, saddle (perineal) anesthesia, radicular (leg) pain often bilateral, loss of voluntary rectal sphincter contraction Ankylosis spondylitis: Younger adults who, in the absence of injury, present with a history of needing to get out of bed at night and reduced side bending | |
Europe COST-13 [4] Patients, health care providers, guideline developers | Acute (<3 months) nonspecific low back pain | General: Age of onset less than 20 years or more than 55 years; recent history of violent trauma; constant progressive, nonmechanical pain (no relief with bed rest); thoracic pain; past medical history of malignant tumor; prolonged use of corticosteroids; drug abuse, immunosuppression, HIV; systemically unwell; unexplained weight loss; widespread neurological symptoms (including cauda equina syndrome); structural deformity; fever Cauda equina syndrome: Likely to be present when patients describe bladder dysfunction (usually urinary retention, occasionally overflow incontinence), sphincter disturbance, saddle anesthesia, global or progressive weakness in the lower limbs, or gait disturbance | Royal College of General Practitioners [53] Malignancy (history (of cancer) and high ESR): van den Hoogen et al. [54] |
Finland [19] Professionals of various disciplines | Adult (>15 years) low back pain patients | Compression fracture: Age over 50 years, fall, use of glucocorticoids, osteoporosis Malignancy: Anamnestic cancer, weight loss without obvious reason, fever, progressing symptoms, night pain, pain over one month, paraparesis Bacterial spondylitis/spondylodiscitis: Previous back surgery; urinary track or skin infection; immunosuppression; intravenous drug use Cauda equina syndrome: Urinary retention and anal sphincter insufficiency, saddle region anesthesia, paresthesia and paresis symptoms in the lower extremities Aneurism: Instant, unbearable pain; age over 50 years; disorder in hemodynamics | Based on Europe guideline [4] |
France [31] General practitioner; Rheumatologist; Orthopedic | Acute LBP (<3 months) with/without sciatica | Fracture: Occurrence of trauma; Corticosteroids use; Age over 70 Malignancy: Age over 50, unexplained weight loss, history of tumor or failure of symptomatic treatment Infection: Fever, pain with recrudescence at night, patient undergoing immunosuppressant therapy, urinary tract infection, IV drug use, prolonged corticosteroid therapy Ankylosing spondylitis Pain which awakened the subject at night and made him leave the bed, pain not relieved by lying down but improved by exercise, 3 months duration of the complaints, morning stiffness lasting >30 min, reduced lateral mobility, flexion (<20°) or extension (<40°) of the lumbar spine Cauda equina syndrome: Sciatica, saddle anesthesia, sphincter problems, incontinence | Malignancy: Deyo et al. [41] Ankylosing spondylitis: Gran [55] |
Germany [20] Physicians and nonmedical health care professionals | Nonspecific low back pain | Fracture: Serious trauma (e.g. through a car accident, fall from a great height, sports accident); minor trauma (e.g. coughing, sneezing, heavy lifting in elderly, potential osteoporosis patients); systemic steroid therapy Malignancy: Old age; history of malignancies; general symptoms: loss of weight, reduced appetite, rapid fatigue; pain, increasing in supine position; intense nocturnal pain Infection: General symptoms such as recent fever, chills, reduced appetite, rapid fatigue; previous bacterial infections; intravenous drug abuse; immunosuppression; consuming underlying diseases; very recent spinal infiltration treatment; intense nocturnal pain | Consensus by clinicians and European guidelines [4] |
Italy [32] Primary care and secondary care | Nonspecific low back pain and sciatica | Fracture: Elderly age; female gender; loading pain; significant trauma; osteoporosis; chronically use of steroids; previous fractures Malignancy: Age over 50; history of cancer; loss of weight; no improvement after 4–6 weeks; continuous pain or worsening pain, pain at rest and during the night pain Infection” Fever; infection history; drug addiction; HIV; immunosuppressive therapy; night and rest pain Cauda equina: Urinary retention; saddle anesthesia; anal sphincter reduced tonus; both legs pain; spread sensory deficit Aneurism: Age >60; atherosclerosis; abdominal pulsing mass; night and rest pain; sciatica Inflammatory low back pain/spondylarthropaties: Age <45 years; pain at night/morning; NSAID sensibility; improvement with movement; insidious onset; rigidity duration >3 months; history of enthesitis/mono-oligo arthritis; acute uveitis; family history of spondyloarthritis; ulcerating colitis; Crohn’s disease; psoriasis | Not referenced |
Malaysia [16] | Low back pain | General Onset of pain at age <20 years or >55 years; history of trauma, cancer and osteoporosis; significant weight loss; use of systemic steroids; drug or alcohol abuse; HIV; infection; thoracic pain; unrelenting night pain or pain at rest; fever for 48 h; sudden onset or unexplained changes in bowel or bladder control; sudden onset or otherwise unexplained bilateral leg weakness, or progressive motor weakness in the leg with gait disturbance; saddle numbness or anesthesia; severe restriction of lumbar flexion; structural spinal deformity | Based on: Waddell [56] |
The Netherlands [21] Various health care providers | Nonspecific low back pain | Vertebral fracture: Severe low back pain after trauma Osteoporotic vertebral fracture: Onset of LBP after the age of 60, female gender, low body weight, prolonged corticosteroid use, increased thoracic kyphosis Malignancy: Onset of the low back pain after age 50 years, continuous pain regardless of posture or movement, nocturnal pain, general malaise, history of malignancy, unexplained weight loss, elevated erythrocyte sedimentation rate (ESR) Ankylosing spondylitis: Onset of low back pain before age 20 years, male sex, iridocyclitis, history of unexplained peripheral arthritis or inflammatory bowel disease, pain mostly nocturnal, morning stiffness >1 h, less pain when moving, positive reaction on painkillers (NSAIDs), elevated erythrocyte sedimentation rate (ESR) Severe spondylolisthesis: Onset of low back pain before age 20 years, palpable misalignment of the processi spinosi at the L4–L5 level | Not specifically referenced, only generic references |
New Zealand [34] Physical therapy; general practitioner; osteopath Multidisciplinary | Acute (<3 months) low back pain and recurrent episodes | General: Unremitting night pain, pain worse when lying down; Significant trauma; weight loss, history of cancer, fever; use of intravenous drugs or steroids; patient over 50 years old Cauda equina syndrome: Urinary retention, fecal incontinence, widespread neurological symptoms and signs in the lower limb, including gait abnormality, saddle area numbness and a lax anal sphincter | Not referenced |
Norway [22] Doctors, physiotherapist or chiropractors | Low back pain with/without nerve root affection | General: Age under 20 or above 55 years; constant pain, possibly increasing over time; pain whilst at rest; general feeling of illness and/or loss of weight. Injury or trauma, cancer, use of steroids or immunosuppressant, drug abuse in history; widespread neurological signs. Deformity of the spine. Declared morning stiffness that lasts for more than 1 h. High ESR | Based on European guidelines [4] |
Philippine [15] Physiatrists [Rehabilitation Medicine Specialist’s (Physiatrists)] | Nonspecific low back pain | General: Age under 20 or over 55 of age; violent trauma; constant, progressive, nonmechanical pain; thoracic or abdominal pain; pain at night that is not eased by a prone position; history of or suspected cancer, HIV or other pathologies that can cause back pain; chronic corticosteroid consumption; unexplained weight loss, chills or fever; significant limitation of lumbar flexion; loss of feeling in the perineum; Recent onset of urinary incontinence | |
Spain [23] Primary care; physiotherapy Monodisciplinary | Nonspecific low back pain | General: Pain <20 or >50 age; thoracic spine pain; deficit neurologic; deformity, not flexion of 5th; bad general state, fever; trauma or neoplasms; use of corticosteroids; addictions; immunodeficiency, AIDS | Based on: European guideline (COST B13 working group) [3] |
United Kingdom (NCC-PC/NICE) [33] General practitioners and patients | Nonspecific low back pain | Fracture: Osteoporotic fractures typically affect older people (women more than men) and those with other chronic illnesses; particularly if they have used long-term oral steroids Malignancy: Malignancy is more common in older people and those with a past history of tumors known to metastasis to bone Infection: Infection should be considered in those who may have an impaired immune system, e.g. people living with HIV, or who are systemically unwell Pain that continues for longer than 6 weeks or who further deteriorate between 6 weeks and 1 year, the possibility of a specific cause needs to be re-considered | Not referenced |
United States [24] Primary care providers Multidisciplinary | Nonspecific low back pain | Fractures: Major trauma Osteoporotic fractures: Osteoporosis, osteoporosis risk (unspecified) Malignancy: History of cancer, multiple cancer risk factors (unspecified), strong clinical suspicion Cauda equina syndrome (CES): New bowel or bladder dysfunction, perineal numbness or saddle anesthesia, persistent/increasing lower motor neuron weakness Infection: Immunocompromised status, urinary tract infection, intravenous drug use, fever/chills with rest or night pain Myelopathy: New-onset Babinski or sustained clonus, new-onset gait or balance abnormalities, upper motor neuron weakness Spondylarthropaties:
Ankylosing spondylitis at least 4 of the following: age of pain onset <40, years; insidious onset; improvement with exercise; no improvement with rest; pain at night (with improvement upon rising); morning stiffness
Reactive arthritis/reiter’s syndrome recent history of genitourinary or gastrointestinal tract infection; acute onset; asymmetrically painful and swollen joints; weight loss; high temperatures
Spondyloarthropathy associated with inflammatory bowel disease (IBD) abrupt onset; asymmetric, affecting lower limbs; generally subsides in 6–8 weeks; other symptoms: uveitis, chronic skin lesions, dactylitis, enthesitis Psoriatic arthritis: asymmetric, affecting distal joints; morning stiffness; pain accentuated by prolonged immobility, alleviated by physical activity; psoriatic lesions | Based on previous guidelines: European guideline (COST B13 working group) [4]; NICE [33]; Koes et al. [12]; Institute for Clinical Systems Improvement (ICSI) [27]; Malignancy: Chou et al. [50] |
Description of the guidelines
Red flags
Condition | Red flag | Endorsed by guideline |
---|---|---|
Malignancy | History of malignancies/cancer | Australia, Canada, Finland, France, Germany, Italy, Netherlands, United Kingdom, United States |
(Unexplained/unintentional) Weight loss | Australia, Canada, Finland, France, Germany, Italy, Netherlands | |
Pain | ||
(Increasing) Pain at night | Finland, Germany, Italy, Netherlands | |
(Continuous) Pain at rest | Australia, Italy, Netherlands | |
At multiple sites | Australia | |
Over 1 month (duration) | Finland | |
Pain at night that is not eased by a prone position (or increasing in supine position) | Germany | |
Failure to improve with treatment (>4–6 weeks) | Australia, Canada, France, Italy | |
Age | ||
Age over 50 years | Australia, France, Italy, Netherlands | |
Old age | Germany, United Kingdom | |
Elevated erythrocyte sedimentation (ESR) | Netherlands | |
General malaise | Netherlands | |
Multiple cancer risk factors | United States | |
Strong clinical suspicion | United States | |
Reduced appetite | Germany | |
Rapid fatigue | Germany | |
Progressive symptoms | Finland | |
Fever | Finland | |
Paraparesis | Finland | |
Age over 50 (over 65), first episode of severe back pain [and history of cancer/carcinoma in the last 15 years, unexplained weight loss, failure of conservative care (4 weeks)] | Canada | |
Fracture | (History of) Major/significant trauma | Australia, Canada, Finland, France, Germany, Italy, Netherlands, United States |
(Systemic) Use of steroids | Canada, Finland, France, Germany, Italy, Netherlands, United Kingdom | |
Osteoporosis | Finland, Italy, United States | |
Female gender | Italy, Netherlands, United Kingdom | |
Age | ||
Age >50 | Canada, Finland | |
Age >60 | Netherlands | |
Older age (over 70) | France, Italy, United Kingdom | |
Pain | ||
Sudden onset | Canada | |
Loading pain | Italy | |
Minor trauma | Germany | |
Fracture in history/previous fractures | Italy | |
Low body weight | Netherlands | |
Increased thoracic kyphosis | Netherlands | |
Structural deformity | Canada | |
Minor trauma (if age >50, history of osteoporosis and taking corticosteroids) | Australia | |
Severe onset of pain (with minor trauma, age >50, prolonged steroid intake or structural deformity) | Canada | |
Infection | Fever ≥38 °C | Australia, France, Germany, Italy, United States |
Use of corticosteroids or immunosuppressant therapy | Australia, Finland, France, Germany, Italy, United States | |
Intravenous drug abuse/drug addiction | Finland, France, Germany, Italy, United States | |
Immunodeficiency/AIDS | Italy, United Kingdom | |
Urinary tract infection | Finland, France, United States | |
Pain | ||
Pain with recrudescence at night | France | |
Intense night pain (and rest pain) | Germany, Italy, United States | |
Bone tenderness over the lumbar spinous process | Australia | |
Previous back surgery | Finland, Germany | |
Previous bacterial infections | Germany, Italy | |
Penetrating wound | Australia | |
Reduced appetite | Germany | |
Rapid fatigue | Germany | |
Impaired immune system | United Kingdom | |
Underlying disease process | Australia | |
Cauda equina syndrome (CES) | Saddle anesthesia/perineal numbness | Canada, Europe, Finland, France, Italy, New Zealand, United States |
(Sudden onset) Bladder dysfunction (e.g. urinary retention, overflow incontinence) | Canada, Europe, Finland, France, Italy, New Zealand, United States | |
Sphincter disturbance/reduced tonus | Canada, Europe, Finland, France, Italy, New Zealand | |
Progressive weakness in lower limbs/lower motor neuron weakness | Europe, Finland, United States | |
(Wide) Spread sensory deficit (in lower limbs) | Italy, New Zealand | |
Gait disturbance/abnormality | Europe, New Zealand | |
Fecal incontinence | Canada, New Zealand | |
Pain (radiating) in both legs | Canada, Italy | |
Sciatica | France |
Malignancy
Fracture
Infection
Cauda equina syndrome
Red flags unrelated to specific disease
Red flag | Endorsed by guideline |
---|---|
Pain | |
Onset of pain <20 or >50 years old | Austria, Europe, Malaysia, Norway, Philippine, Spain |
Constant, progressive, nonmechanical pain | Canada, Europe, Philippine |
No pain relief with bed rest | Europe |
Thoracic (or abdominal) pain | Austria, Europe, Malaysia, Philippine, Spain |
(Continuous) Pain at resta
| Austria, Canada, Malaysia, New Zealand, Norway |
(Increasing) Pain at nighta,c
| Canada, Malaysia, New Zealand |
Pain increase in flexion | Austria |
Increasing pain despite treatment | Austria |
Pain at night that is not eased by a prone position (or increasing in supine position)a
| Philippine |
History of malignancies/cancera
| Austria, Canada, Europe, Malaysia, New Zealand, Norway, Philippine, Spain |
(Unexplained/unintentional) Weight lossa
| Austria, Canada, Europe, Malaysia, New Zealand, Norway, Philippine |
Fever ≥38 °Ca,c
| Austria, Canada, Europe, Malaysia, New Zealand, Philippine, Spain |
General malaisea
| Austria, Norway, Spain |
Elevated erythrocyte sedimentation (ESR)a
| Norway |
Age over 50 yearsa
| New Zealand |
(History of) Major/significant traumab
| Austria, Europe, Malaysia, New Zealand, Norway, Philippine, Spain |
(Structural spinal) deformityb
| Austria, Europe, Malaysia, Norway, Spain |
(Systemic) Use of steroidsb
| Malaysia, New Zealand, |
Osteoporosisb
| Austria, Malaysia |
Intravenous drug abuse/drug addictionc
| Austria, Europe, Malaysia, New Zealand, Norway, Spain |
Use of corticosteroids or immunosuppressant therapyc
| Austria, Europe, Norway, Philippine, Spain |
Immunodeficiency/HIV/AIDSc
| Austria, Europe, Malaysia, Philippine, Spain |
Saddle anesthesia/perineal numbnessd
| Malaysia, Philippine |
(Sudden onset) Bladder dysfunction (e.g. urinary retention, overflow incontinence)d
| Malaysia, Philippine |
(Wide) Spread sensory deficit (in lower limbs)d
| Austria, Canada, Europe, Norway, Spain |
Progressive weakness in lower limbs/lower motor neuron weaknessd
| Malaysia |
Gait disturbance/abnormalityd
| Malaysia |
Progressive weakness in lower limbs/lower motor neuron weaknessd
| Malaysia |
Significant limitation of lumbar flexion | Malaysia, Philippine |
Not flexion of 5th lumbar spine | Spain |
Morning stiffness | Norway |