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

Area of Science:

• Medical Diagnostics
• Oncology
• Orthopedics

Background:

• Identifying serious pathologies like spinal malignancy is crucial in low-back pain (LBP) assessment.
• Clinical guidelines suggest using
• red flag
• features from history and physical examination.
• Empirical data on the diagnostic accuracy and clinical utility of these features are limited.

Purpose of the Study:

• To evaluate the diagnostic performance of clinical history and physical examination (
• red flags
• ) for screening spinal malignancy in LBP patients.

Main Methods:

• Systematic search of electronic databases (MEDLINE, EMBASE, CINAHL) and systematic reviews (PubMed, Medion) up to April 2012.
• Included studies compared LBP patient history/examination findings with diagnostic imaging (MRI, CT, myelography).
• Quality assessment using QUality Assessment of Diagnostic Accuracy Studies (QUADAS) tool and data extraction on study characteristics and diagnostic accuracy (sensitivity, specificity).

Main Results:

• Eight cohort studies were included (total n=7361), with most studies conducted in primary care.
• Prevalence of spinal malignancy in primary care settings ranged from 0% to 0.66%.
• Previous cancer history showed potential for increasing malignancy probability, but most individual "red flags" (e.g., insidious onset, age >50) had high false positive rates. No study evaluated combinations of tests.

Conclusions:

• Insufficient evidence exists to recommend most "red flags" for diagnosing spinal malignancy in LBP patients.
• A diagnosis of spinal malignancy should not rely on a single "red flag" finding.
• Further research is recommended to assess the diagnostic performance of combined clinical tests.