Diagnostic errors in spinal metastases: a systematic review of contributing clinical and systemic factors

Systematic review.

To systematically review diagnostic errors in patients with spinal metastases, focusing on clinical, radiologic, and systemic factors contributing to missed or delayed diagnoses. This review addresses the clinical gap of delayed recognition, clarifies patterns of misdiagnosis, particularly in cases of spinal cord compression, and provides evidence to guide early detection and improve care pathways.

We conducted a comprehensive literature review of 51 peer-reviewed studies reporting diagnostic pathways and clinical outcomes in patients with spinal metastases. Articles were analyzed for documented reasons underlying misdiagnoses, including cognitive bias, missed red flags, imaging misuse or delay, absence of known cancer history, failure to order MRI, and lack of a documented differential diagnosis. Studies were categorized thematically and synthesized based on frequency and context of these contributing factors.

Misdiagnosis of spinal metastases as mechanical back pain occurred frequently. Six studies explicitly reported misdiagnosis rates, with 40-70% of cases initially attributed to benign etiologies. Contributing factors included missed red flags (88.2% of studies), cognitive bias (64.7%), imaging misuse/delay (60.8%), lack of a known cancer history (19.6%), failure to order MRI (23.5%), and absence of a documented differential diagnosis (15.7%).

Misdiagnosis of spinal metastases as mechanical back pain remains common, even in patients presenting with red-flag symptoms. Diagnostic delays are frequently due to cognitive heuristics, inappropriate imaging, or the absence of documented diagnostic reasoning. Early recognition and appropriate imaging are critical to prevent neurologic deterioration. Increased clinical awareness and diagnostic vigilance may improve outcomes for patients with metastatic spinal disease. By addressing the previously under-recognized clinical gap in early detection, this review highlights the need for heightened clinical awareness and systematic diagnostic vigilance to prevent neurologic deterioration.