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LAURA M. FINUCANE, MSc, BSc, FCSP, FMACP1 • ARON DOWNIE, MPhil, BSc, MChiro2,3
CHRISTOPHER MERCER, MSc, Grad Dip Phys, PG Cert (Clin Ed), FCSP, FMACP4 • SUSAN M. GREENHALGH, PhD, MA, Phys FCSP5,6
WILLIAM G. BOISSONNAULT, PT, DPT, DHSc7 • ANNELIES L. POOL-GOUDZWAARD, PT, PhD, MT, MSc Psych8
JASON M. BENECIUK, PT, DPT, PhD, MPH9,10 • RACHEL L. LEECH, MSc, BSc6 • JAMES SELFE, DSc, PhD, MA, Grad Dip Phys, FCSP6,11
I
dentifying serious pathology as the cause of a person’s musculoskeletal skeletal services can play an important
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presentation is complex. Red flags have historically been used to role in early identification of serious pa-
help clinicians identify serious spinal pathology, and the majority thology, ensuring that people achieve the
best possible outcome. The prevalence of
of guidelines recommend the use of red flags. However, guidelines
serious pathology will vary depending on
are not consistent about which red flags should be considered when
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tential serious spinal pathology. This This framework aims to support a are likely to have more complex presen-
framework has been developed by re- variety of health professionals, irrespec- tations.86 Clinicians must consider the
searchers and clinicians to provide a tive of experience, who provide care for context within which red flags exist, and
pragmatic approach for clinicians to people with musculoskeletal spinal con- clinically reason the relevance of the in-
screen for serious spinal pathology that ditions. Clinicians working in musculo- formation gathered to determine wheth-
er any action is required.
U SYNOPSIS: The International Federation of been used by clinicians to identify serious spinal
Orthopaedic Manipulative Physical Therapists pathology. Currently, there is an absence of high-
quality evidence for the diagnostic accuracy of most
Person-Centered Care
(IFOMPT) led the development of a framework to
help clinicians assess and manage people who may red flags. This framework is intended to provide a Working with people with possible seri-
have serious spinal pathology. While rare, serious clinical-reasoning pathway to clarify the role of red ous pathology can be challenging, and
spinal pathology can have devastating and life- flags.J Orthop Sports Phys Ther 2020;50(7):xxx-xxx. a collaborative approach is essential. A
changing or life-limiting consequences, and must Epub 21 May 2020. doi:10.2519/jospt.2020.9971
possible diagnosis of serious pathology
be identified early and managed appropriately. Red U KEY WORDS: cauda equina syndrome, clinical can be extremely worrying for people in
flags (signs and symptoms that might raise suspi- reasoning, malignancy, spinal fracture, spinal
cion of serious spinal pathology) have historically infection regard to their families and careers. Peo-
ple must be involved in decision making
1
Sussex MSK Partnership, Brighton, United Kingdom. 2Department of Chiropractic, Faculty of Science and Engineering, Macquarie University, North Ryde, Australia. 3Institute for
Musculoskeletal Health, School of Public Health, The University of Sydney, Sydney, Australia. 4Western Sussex Hospitals NHS Foundation Trust, Chichester, United Kingdom. 5Bolton
NHS Foundation Trust, Bolton, United Kingdom. 6Department of Health Professions, Manchester Metropolitan University, Manchester, United Kingdom. 7American Physical Therapy
Association, Alexandria, VA. 8Department of Human Movement Sciences, Faculty of Behavioral and Movement Sciences, Vrije Universiteit Amsterdam, Amsterdam, the Netherlands.
9
Department of Physical Therapy, College of Public Health and Health Professions, University of Florida, Gainesville, FL. 10Brooks Rehabilitation, Jacksonville, FL. 11Physical Therapy
Department, Satakunta University of Applied Sciences, Pori, Finland. The following organizations provided financial support for the development and dissemination of this framework:
the Canadian Academy of Manipulative Physiotherapy, Chartered Society of Physiotherapy, International Maitland Teachers Association, Musculoskeletal Association of Chartered
Physiotherapists, Private Physiotherapy Educational Foundation, and Swiss Association for Orthopaedic Manipulative Physiotherapy. The authors certify that they have no affiliations
with or financial involvement in any organization or entity with a direct financial interest in the subject matter or materials discussed in the article. Address correspondence to Laura
Finucane, Sussex MSK Partnership, 177 Preston Road, BN1 6AG Brighton, UK. E-mail: laura.finucane@nhs.net t Copyright ©2020 Journal of Orthopaedic & Sports Physical Therapy®
Clear and open communication with sent with potential serious spinal pathol- been reported as red flags,32 includ-
people with potential serious pathology ogy. These conditions, while considered ing 119 symptoms from the individual’s
is vital. People presenting with spinal rare, can lead to devastating and life- history and 44 signs from the physical
pain may have no concept that their changing/life-limiting consequences for examination.
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bladder or bowel function might be af- people. The neurological function and The high number of red flags pre
fected, or that the spinal pain could be quality of life of people with metastatic sents a challenge in terms of their every-
caused by serious pathologies such as in- spinal cord compression (MSCC) can be day practical utility. Few red flags, when
fection or malignancy. Providing the rea- preserved with early diagnosis, by facili- used in isolation, are informative. Red
son for the questions in the framework is tating rapid access to appropriate treat- flags used in combination have prom-
an important aspect of the consultation, ment, reduction in nerve damage, and ise,35 but further validation studies are
as some of these questions may seem ir- maintenance of spinal stability.32 Sub- required. There is a lack of high-quality
relevant to a person who presents with stantial litigation costs can be incurred evidence for the diagnostic accuracy of
back pain. by health care providers if serious spi- red flag tests,20,34 and the evidence sup-
Effective communication about red nal pathology is not identified early and ports only a limited number of red flags
Journal of Orthopaedic & Sports Physical Therapy®
flags is vital. People can become worried managed appropriately. Litigation re- to raise suspicion of serious pathology.
before an appointment, especially if they lating to cauda equina syndrome (CES) There is no consensus on which red flags
have seen something worrying on televi- alone accounted for £25 million ($40 are most useful to identify serious spinal
sion or the internet, heard a story from a million) in claims against the National pathology or how they should be used in
friend or relative, or experienced medical Health Service in the United Kingdom the clinical setting.82
misdiagnosis. from 2010 to 2015.54 Despite the problems, red flag tests
Provide reassurance about why you This international framework has remain the best tools that health care
are assessing for red flags, especially been developed on behalf of the Interna- practitioners have to raise suspicion of
when the person is likely at low risk of tional Federation of Orthopaedic Manip- serious spinal pathology when used in
having severe pathology. Consider the ulative Physical Therapists (IFOMPT) combination with a thorough patient
wording of your questions, your body
language, tone of voice, and mannerisms
when asking the questions. Key Clinical Messages
People must feel at ease when an- • There is a lack of evidence to support the informativeness of the majority of
swering questions and not judged (eg, red flags commonly used in clinical practice.
intravenous drug use, poor social and • Few red flags, when used in isolation, are informative. Combinations of red
environmental factors). Ensure patients flags demonstrate promise, but this work requires further validation.
have sufficient time to consider and com- • Red flags remain the best tools at the clinician’s disposal to raise suspicion of
municate their answers about something serious spinal pathology, when used within the context of a thorough subjec-
that they may never have considered be- tive patient history and physical examination.
fore (eg, their toilet habits and how those • Clinicians should consider both the evidence to support red flags and the indi-
may have changed). vidual profile of the person’s determinants of health (eg, age, sex) to decide the
Provide support regarding the emo- level of concern (index of suspicion) for presence of serious spinal pathology.
tional impact of being assessed for po-
Decision Tool for Early Identification FIGURE 1. Decision tool for early identification of potential serious spinal pathology, step 1. Consider the evidence
to support red flags, together with the clinical and patient profiles, when determining your level of concern for
of Serious Spinal Pathology
Journal of Orthopaedic & Sports Physical Therapy®
serious pathology.
The basis of our framework is a decision
tool to help clinicians identify serious spi-
nal pathology. The tool has 3 steps:
1. Determine your level of concern. Con-
Level of Concern
sider the evidence to support red flags
and the individual profile of the per- LOW HIGH
son’s health determinants (eg, age, sex)
to decide your level of concern (your in-
dex of suspicion) about the presence of No Few Some Some
serious pathology (FIGURE 1).
concerning concerning concerning concerning
features features features features
2. Decide on your clinical action, based
on your level of concern determined Decision: Decision: Decision: Decision:
Begin a trial of Begin a trial of URGENT referral EMERGENCY referral
in step 1 (FIGURE 2). therapy therapy with watchful
3. Consider the pathway for emergency/ waiting DO NOT begin a trial DO NOT begin a trial
Revise management if of therapy of therapy
urgent referral. Know your local refer- clinical features Begin a trial of
ral pathways and pathways to access change unexpectedly therapy Further investigation Emergency referral is
or referral is warranted
specialist care if indicated (FIGURE 3). Revise management if warranted
clinical features
Prioritize Serious Spinal Pathologies change unexpectedly
Progress as
expected
Treatment proceeds
Journal of Orthopaedic & Sports Physical Therapy®
as expected and
patient is discharged
from care
FIGURE 3. Decision tool for early identification of potential serious spinal pathology, step 3. Consider the pathway for emergency/urgent referral if indicated. aSafety netting is a
management strategy used for people who may present with possible serious pathology. These strategies should include advice on which signs and symptoms to look out for,
which action to take if symptoms deteriorate, and the time frame within which action should be taken.37
TABLE 1 Prevalence Estimates for Key Pathologies When Presenting With Back Pain a
sus decision was then taken to either in- timely management. Timely diagnosis is cursors described above, with any sug-
clude or exclude these items in the draft essential to avoid life-changing outcomes gestion of changes in bladder or bowel
framework. such as ongoing bladder, bowel, and sex- function or saddle sensory disturbance,
Phase 3 The draft framework was de- ual dysfunction, along with psychosocial then suspect CES. Clinical cue cards
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veloped by the steering group based on consequences.31 and credit card–size patient information
a synthesis of the results from phases 1 Literature and International Consen- handouts can aid communicating sen-
and 2. sus Three key source papers were used sitive, sometimes subtle but important
Phase 4 The draft framework was pre- to formulate the international consen- symptoms,22 and should form the basis
sented to an international peer-review sus questionnaire for this section on of your questioning.
group (70 individuals) for opinion on CES18,28,31 (APPENDIX B). The question- Clinical Picture If you suspect CES,
the content, independent of the people naire was sent to 23 international ex- perform a full neurological assessment
taking part in phase 2. The international perts and contained 25 items ( TABLES 2 to establish dermatome sensory loss,
peer-review group was invited to rate through 6). myotome weakness, or reflex changes.28
the content via an online questionnaire. Epidemiology The incidence of CES in A digital rectal examination is no lon-
Journal of Orthopaedic & Sports Physical Therapy®
The review group rated each section of the United Kingdom has been estimated ger considered essential in a primary
the framework based on the following to be 0.002%.31 The overall prevalence of care setting in the United Kingdom. It
criteria: CES has been estimated to range from 1 is necessary in secondary care to evalu-
• Applicability: relevance to the clinical in 33 000 to 1 in 100 000 persons.48 Point ate loss of anal sphincter tone. Sensation
practice prevalence of CES as a cause of low back to light touch and pinprick throughout
• Acceptability: clinical usefulness or pain (LBP) is estimated at 0.04% in pri- the saddle region, including the but-
helpfulness mary care17 and 0.4% in tertiary care.66 tocks, inner thighs, and perianal region,
• Readability: ease of reading Cauda equina syndrome is a complica- is a necessary test in any clinical situa-
They were also able to offer sugges- tion of approximately 2% of all herniated tion. These intimate objective tests must
tions on changes/improvements. This discs.18 The incidence of postoperative only be performed by an appropriately
peer-review group included chiroprac- CES is estimated to be between 0.08% trained clinician, with a chaperone for
tors, osteopaths, physical therapists, and 0.2%.42 the benefit of both the person and the
experts by experience, and member orga-
nization delegates of the IFOMPT. The
response rate of 41% included individuals Number of Cauda Equina Syndrome
TABLE 2
from 13 countries. The median score for Red Flags Gaining Consensus
each section was calculated. All sections
gained a median score of 7 or above and Number of Red Flags
were therefore classed as appropriate ac- Questionnaire sent to 23 25 items reviewed
cording to the Haute Autorité de Santé international experts • 18 items reached consensus as appropriate
method. All comments were reviewed • 2 items reached consensus as inappropriate
• 5 items had no consensus
by the steering committee and relevant
Steering committee 20 items included in the framework (TABLES 3 through 6) (2 items combined)
changes made to the framework. reviewed results 4 items excluded (APPENDIX C)
Phase 5 Based on the phase 4 feedback,
TABLE 3 Risk Factors for Cauda Equina Syndrome
Risk Factor/Level
of Evidence Context Further Questions Low Clinical Suspicion High Clinical Suspicion
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Herniated The most common cause arises from a large How old are you? No leg pain, normal • Unilateral or bilateral radicular pain and/
intervertebral central disc herniation at the L4-5 or L5-S1 Do you have any leg pain? neurology, and no CES or dermatomal reduced sensation and/or
disc level51 Where exactly is the pain in your symptoms myotomal weakness
Low Those under 50 y of age carry a higher risk, as legs (above or below knees)? • Reduced saddle sensation (subjective or
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do obese people Is the pain down both legs at the objective pinprick)
Relevant symptoms that can be a precursor same time? • Bladder disturbance
to CES: Do you have any pins and needles • Bowel disturbance
• Unilateral or bilateral radicular pain and/or or numbness in your legs, inner • Reduced anal tone/absent squeeze
• Dermatomal reduced sensation and/or thighs, bottom, or genitals? • Sexual disturbance31
• Myotomal weakness11 Do you feel any weakness in your Presentations that increase the probability of
legs? acute threatened CES:
• Back pain with
- Presence of new saddle anesthesia, blad-
der or bowel disturbance
- Age, <50 y
Journal of Orthopaedic & Sports Physical Therapy®
Symptoms
(subjective)/ Low Clinical High Clinical
Level of Evidence Context Further Questions Suspicion Suspicion
Sensory change History of symptoms, pattern, progression, and When did the sensation problems in your leg(s) start? Normal neurology Sensory change
(lower limbs) time scale Where did they begin and how did those symptoms change as (lower limbs)
Low Consider existing comorbidities (eg, multiple time went on?
sclerosis, diabetes) Exactly where in your legs do you feel the symptoms?
Do you have any other medical conditions?
Motor weakness Time scales of perceived weakness and progres- When did the weakness problems in your leg(s) start? As above Motor weakness
(lower limbs) sion are important to establish Where did the weakness begin and how did those symptoms (lower limbs)
Low Consider existing comorbidities (eg, aortic change as time went on?
aneurysm) Do you have any other medical conditions?
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Saddle sensory Precise extent of pins and needles and/or numb- See CES cue card NA Saddle sensory
disturbance ness (eg, difference between bicycle/horse Exactly where do you feel the numbness in your bottom, inner disturbance
Low saddle) thighs, or genitals?
Previous history Where did it start and how has the numbness and/or pins and
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Symptoms
(subjective)/ Low Clinical High Clinical
Level of Evidence Context Further Questions Suspicion Suspicion
Urinary inconti- Previous history of bladder disturbance See CES cue card for relevant questions that need to be asked, NA Urinary inconti-
nence including the following: nence
Low • When did the changes begin?
• When did you last pass urine?
• Have you started any new medication?
• Were the symptoms present before you began this medication
or after?
• Do you have any other medical conditions?
• Have you attended any other health care setting (GP, surgery,
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Signs (objective)/
Level of Evidence Context Physical Assessment Low Clinical Suspicion High Clinical Suspicion
Sensory deficit in Examination in any clinical setting, but only if Objective light touch and pinprick car- NA NA
saddle to light touch CES is suspected from the history ried out by a suitably trained clinician
and pinprick Normal examination findings do not exclude with a chaperone present
Low the possibility of CES
Consider previous trauma/surgery to
perineum
Abnormal lower-limb Establish time frame of progression of Myotomes, dermatomes, and reflexes Normal neurology Abnormal and progressing neurological
neurology neurology Consider tone, proprioception, and deficit
Low Other causes (eg, upper motor condition, clonus Management depends on the degree of
peripheral neuropathy) neurological deficit: if there is gross
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TABLE 6 Initial Investigations for Cauda Equina Syndrome
Journal of Orthopaedic & Sports Physical Therapy®
Modality Context
MRI MRI is the gold standard investigation to confirm the diagnosis of CES
Most guidelines recommend that people presenting with any of these key clinical signs and symptoms be referred urgently18
CT scan If there are contraindications to MRI
Abbreviations: CES, cauda equina syndrome; CT, computed tomography; MRI, magnetic resonance imaging.
are no positive items on the CES cue • Leg pain worsening not since. Neurological examination is
card. • Signs of bilateral leg pain unremarkable.
• LBP, no leg pain • Clinical action: safety net. The im- • Back and bilateral leg pain increasing
• No symptoms of CES portant thing in this case is to dis- • One episode of incontinence 4 weeks
• Clinical action: begin a trial of therapy cuss and document a clear strategy ago
Level of Concern
to follow if symptoms deteriorate • Clinical action: urgent MRI and discuss
(safety net), ensuring the person is and document a clear strategy to follow
LOW HIGH aware that she needs to act immedi- if symptoms deteriorate (safety net)
ately if things get worse Level of Concern
Level of Concern
Case 2 LOW HIGH
The woman has back and leg pain. The LOW HIGH
pain in her leg is getting worse and is
now radiating distally below the knee, Case 4
and she has started to notice pain in the Case 3 The woman has now developed a 1-week
other leg. Nothing on CES questioning is The woman now has back and increas- history of some numbness of the left side
positive, and there is no existing neuro- ing leg pain bilaterally. She reports one of the vagina.
logical deficit. episode of incontinence 4 weeks ago, but • Back and bilateral leg pain increasing
ciency spinal fractures (fractures caused These include metastatic spinal disease
Spinal Fracture by normal stresses on weakened bone), (see the Spinal Malignancy section) and
Spinal fractures make up the largest due to a range of risk factors. These in- multiple myeloma, both of which can
number of serious pathologies in the clude excessive alcohol consumption cause healthy bone to be replaced by tu-
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spine. While these are predominantly a (risk increases when drinking greater mor. In the case of metastatic disease,
risk for older patients, especially women, than 3 units per day), vitamin D deficien- 60% of metastases occur in the anterior
clinicians need to be aware of the risk fac- cy, long-term corticosteroid use (greater half of the vertebral body, thus potential-
tors and signs and symptoms of spinal than 5 or 7.5 mg per day over a 3-month ly weakening this area and leading to a
fractures and to consider what detailed period), rheumatoid arthritis, diabetes, wedge fracture. These fractures may look
questions to ask to help with further smoking (greater than 20 cigarettes per very similar on X-ray. Take a careful his-
management. day61), dietary restriction, eating disor- tory and explore any relevant risk factors
Five key source papers were used to ders, and absorption problems from the for each type of pathology.
formulate the international consensus gut (eg, Crohn’s disease5,75). Establish the Fractures from myeloma may also look
questionnaire for spinal fracture23,50,63,72,85 presence or absence of these risk factors very similar to osteoporotic fractures on
Journal of Orthopaedic & Sports Physical Therapy®
(APPENDIX B). The questionnaire was sent with detailed history taking. X-ray, depending on the location. People
to 28 international experts and contained Clinical Picture People commonly pre with myeloma may present at a slightly
27 items (TABLES 7 through 11). sent with sudden onset of pain, mostly earlier age than those with osteoporosis
Epidemiology Estimates for the point located in the thoracolumbar region, fol- and metastases, but further imaging may
prevalence of osteoporotic compression lowing low-impact trauma such as a slip or be required to establish the cause of a
fracture as a cause of LBP range between trip or lifting something while in a flexed fracture if there are no clear indications
0.7% and 4.5% in the primary care set- position. The pain varies in presentation, from the person’s subjective history.
ting16,35,41,73,80 and 6.5% in the emergency but is often severe and mostly localized to
care setting.29 Low-impact or nontrau- the area of the fracture.36 Weight-bearing Clinical-Reasoning Cases/Scenarios
matic fractures are the most common activities and active movements are re- Case 1
serious pathology in the spine, with ver- stricted and painful, and the person may A 35-year-old man presents with sudden
tebral fractures being the most common require strong analgesia, particularly in onset of thoracic pain after lifting a heavy
osteoporotic fracture. Approximately
12% of women between 50 and 70 years
Number of Spinal Fracture Red
of age and up to 20% of those over 70 TABLE 7
Flags Gaining Consensus
years of age have vertebral fractures.72 As
much as 70% of these fractures are undi-
Number of Red Flags
agnosed and found during investigation
Questionnaire was sent 27 items reviewed
for other health conditions.50
to 28 international • 13 items reached consensus as appropriate
It is important to identify people with experts • 14 items had no consensus
vertebral fractures, as they are more like- • 0 items reached consensus as inappropriate
ly to sustain later hip fractures, bringing Steering committee 18 Items included in framework (TABLES 8 through 11)
further health consequences and risk for reviewed results 9 items excluded (APPENDIX C)
the person. Red flags purported to indi-
Risk Factor/Level
of Evidence Context Further Questions Low Clinical Suspicion High Clinical Suspicion
History of osteo- History of osteoporosis increases the risk of Do you have osteoporosis? No family history Previous osteoporotic fractures
porosis fracture Do you have a family history of No other osteoporotic risk Concurrent osteoporotic risk factors
High A family history of osteoporosis will also increase osteoporosis? factors
the risk of osteoporosis and fracture in women36 Have you had previous osteoporotic No previous fractures
People with known osteoporosis have an increased fractures?
risk of fracture, and those with a previous osteo- Are you taking any medication for
porotic fracture have a 5.4-fold increased risk of your osteoporosis?
vertebral fracture and a 2.8-fold increased risk • If so, what are you taking?
of hip fracture75 • If not, have you been prescribed
Medication for osteoporosis can reduce the risk of it, or is there a reason you are not
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density, though the clinician should ask about and what dose did you use?
high-dose inhaled steroid use75
Previous history Metastatic bone disease may decrease bone Do you have a history of cancer? No past medical history of History of cancer of the
of cancer density, especially in the thoracic region (70% • Where was the cancer? cancer • breast
Low of cases) • What treatment did you have for • prostate
your cancer? • lung
• What stage was the cancer? • kidney
• thyroid
Severe trauma The more significant the amount of trauma, the Have you had a significant injury/fall No immediate bony pain post Immediate spinal pain post injury
High higher the likelihood of bony injury (ACR guide- from a height? injury Focal bony tenderness in the midline of
lines suggest a fall of 5 stairs or 3 ft)1 Did your pain start suddenly after a the spine may indicate underlying
Journal of Orthopaedic & Sports Physical Therapy®
The position of the person at the time of injury is particular activity, like coughing or bony injury
also important (eg, flexed, as this might pre- sneezing?
cipitate a fracture with a seemingly innocuous
activity like coughing)
Female sex 19.8/1000 women have osteoporotic fracture How old were you when you started Women with normal Women who are postmenopausal, es-
High 8.4/1000 men have osteoporotic fracture75 your periods? menarche and normal pecially those with early menopause
Women with late-onset menarche (>16 y)70 or How old were you when you went menopause with no other or those with late menarche
early menopause (<45 y) are at higher risk of through menopause? risk factors
osteoporosis,81 and therefore spinal fracture
Older age Bone density decreases with age in women and Have you had any investigations for People under 50 y Women over 65 y and men over 75
High men your bones, such as X-rays or y have a higher risk of vertebral
12% of women aged 50-70 y have had a spinal DEXA scans? fracture75
fracture, and 20% of women over 70 y have had Patients over 80 y have a very high
a spinal fracture likelihood of having had an osteopo-
70% of these will not know about it72 rotic fracture
Previous spinal If previous fracture due to osteoporosis occurred, Have you had a previous spinal No previous history of spinal Previous history of low-impact spinal
fracture then the person has a 5.4-fold increased risk of fracture? fracture fracture
High vertebral fracture and a 2.8-fold increased risk
of hip fracture within the year53,75
History of falls While the trauma of a fall may precipitate a All people with osteoporosis should People with no comorbidities People with comorbidities: the more
Low fracture, multiple conditions can cause falls and be assessed for risk of falls58 they have, the higher risk they have
immobility, especially in the older patient All people should have a detailed of falling
Parkinson’s disease, multiple sclerosis, dementia, past medical history taken
alcoholism, and malnutrition can all increase
the risk of falls61
Abbreviations: ACR, American College of Rheumatology; DEXA, dual-energy X-ray absorptiometry.
Symptoms
(subjective)/
Level of Evidence Context Further Questions Low Clinical Suspicion High Clinical Suspicion
Thoracic pain Most (70%) nontraumatic spinal fractures occur Detailed questioning of the patient is Thoracic pain with no Any patient with known cancer, myeloma,
High in the thoracic spine. 70% of metastases oc- needed to assess for risk factors for history of cancer, or osteoporosis
cur in the thoracic spine, too, and should be each of these diseases osteoporosis, or
considered in the differential diagnosis myeloma and no
Myeloma most commonly affects the thoracic further risk factors
spine, too, and should also be considered in
the differential diagnosis
Band-like pain should be considered a concern
and may indicate MSCC79
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Severe pain Some people may have a long history of back Is this a familiar pain to you/does this feel If this is a person’s first Describes pain that is unfamiliar and pos-
Low pain. It is important to establish whether this familiar? episode of back sibly worsening pain
is a new or different pain Have you experienced back pain in the pain, then conser-
past? vative management
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TABLE 10 Signs of Spinal Fracture
Signs (objective)/
Level of Evidence Context Physical Assessment Low Clinical Suspicion High Clinical Suspicion
Spine tenderness Patients with midline bony tenderness Palpate the spinous processes and consider No spinal tenderness Tenderness or reproduction
Low should be considered to be at risk of percussion/vibration with a 128-Hz tuning of symptoms on palpa-
spinal fracture50 fork to examine spinal tenderness or tion, percussion, and/or
reproduction of symptoms further vibration
Bony percussion/use of a tuning fork may in-
dicate the presence of bony injury, though
this should be interpreted with caution
Neurological signs People with a subjective complaint of Upper- and lower-limb neurology and upper Localized spinal pain with no dis- People with spinal fracture
Low neurological symptoms must have a full and lower motor neuron testing should tal referral or limb symptoms and symptoms in the
neurological examination be performed. Neurological examination limbs, or with coordina-
may need to include the upper and/or tion/gait disturbance, or
lower limbs, including upper and lower changes to bladder/bowel
motor neuron clinical tests activity
Spinal deformity Onset of deformity post trauma Bony percussion may indicate bony injury, No change in spinal posture Sudden change in spinal
Low Sudden change in posture associated with as may use of a tuning fork, though these shape related to trauma
a sudden increase in pain in the person tests should be treated with some caution or in a known osteoporotic
with known osteoporosis Imaging may be appropriate patient
Contusion or abrasion May indicate the site of trauma and should ... Abrasion with no bony tenderness Abrasion following trauma
Low be considered if associated with a associated with central
painful site spinal bony tenderness
• Clinical action: treat and monitor LOW HIGH which helps a little. He has some shortness
symptoms. His age and sex put him at of breath on exertion and pain on deep in-
low risk of osteoporotic fracture and spiration. He is a nonsmoker and drinks 3
his smoking habit is below 20 ciga- Case 3 pints of beer a day. He had a transurethral
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rettes per day, which is low risk. No A 78-year-old woman presents with up- resection of the prostate for prostate can-
further investigation is required at per lumbar pain. No precipitating injury cer 10 years ago and has been discharged
this stage was reported, but the pain has worsened from follow-up by the urologist.
Level of Concern
over the last 3 months. The pain is • Age and site of pain
worse when lying supine. She has a his- • Worsening pain
LOW HIGH tory of left radius fractures. She had her • Increasing analgesia
menopause at age 38, having started her • Alcohol intake
periods at 15 years of age. She is other- • History of prostate cancer
Case 2 wise well and has no family history of • Breathlessness
A 60-year-old woman presents with mod- osteoporosis. • Clinical action: urgent MRI of the
Journal of Orthopaedic & Sports Physical Therapy®
erately severe thoracolumbar pain after • Age and sex are risk factors whole spine. The man has several
bending over and lifting a heavy pot in the • Worsening pain risk factors for spinal fracture. These
garden 3 weeks ago. Her pain is slightly • Early menopause and a late menarche include a history of prostate cancer,
improved. She is otherwise well and not • Worse when lying supine which is one of the cancers most likely
on any medication other than paracetamol • History of fractures to metastasize to the spine. His pain is
for her pain. She has no history of fracture. • Clinical action: urgent thoracic spine worse in lying, which is more unusual
She had an early menopause at age 35. She X-ray. The patient has several risk and may indicate underlying serious
smokes 20 cigarettes per day. She has pain factors for osteoporosis, including pathology (tumor). His age puts him
in extension and rotation, some local spi- age, sex, early menopause and late at risk of osteoporosis, even though
nal tenderness, and zygapophyseal (facet) menarche, and history of radius frac- he is male, as his bone density is likely
joint tenderness bilaterally. tures. An X-ray of her thoracolumbar to have decreased. His shortness of
TABLE 11 Initial Investigations for Spinal Fracture
Modality Context
X-ray X-rays are the first-line choice to determine whether there is a fracture present, with lateral views likely to yield the most information.50 X-rays are readily avail-
able and relatively low cost. It may be difficult to determine the age of the fracture using X-rays alone
MRI MRI is the investigation of choice for differentiating osteoporotic fractures from metastatic disease and myeloma. Use MRI if there are multiple fractures identi-
fied on X-ray.50 MRI will also help to determine the age of the fracture, as it can identify bone marrow edema from recent/healing fractures61
CT scan A CT scan is commonly performed for other conditions. Assess the sagittal view for undiagnosed vertebral fractures.72 CT scans may be helpful in evaluating
complex fractures or those with retropulsed fragments, as they give excellent bony definition.61 CT scans may also be used where MRI is contraindicated
Abbreviations: CT, computed tomography; MRI, magnetic resonance imaging.
referral would be appropriate (APPENDIX B). to MSCC and, in the worst-case scenar-
Level of Concern Epidemiology Estimates for the point io, to paralysis and compromise of the
prevalence of spinal malignancy as a cause bladder, bowel, and sexual function.78
LOW HIGH of LBP range between 0.0% and 0.7% in Clinical Picture The spine is one of the
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the primary care setting,15,16,19,26,35,43 0.1% earliest sites affected by MBD, especially
in the emergency care setting,68 and 1.6% in those cancers that have a propensity to
Suggested Pathway for Emergency/Ur- in the tertiary care setting.66 Malignancy metastasize.74 The 5 most common can-
gent Referral Refer to the clinical de- as a cause of musculoskeletal pain is es- cers to metastasize are breast, prostate,
cision tool for suggested pathways for timated at 7.0% in the secondary care lung, kidney, and thyroid.10 Approximate-
emergency/urgent referral (FIGURE 3). setting.40 ly 30% of all people with one of these pri-
mary diagnoses of cancer will have their
cancer metastasize, so it is important not
Number of Spinal Malignancy Red to subject all people with a history of can-
TABLE 12
Flags Gaining Consensus cer to unnecessary and worrying investi-
Journal of Orthopaedic & Sports Physical Therapy®
TABLE 13 Risk Factors for Spinal Malignancy
Risk Factor/Level of
Evidence Context Further Questions Low Clinical Suspicion High Clinical Suspicion
Past history of Not all those cancers with a pre- Do you have any concerns Cancers with a predilection to Cancers that have a predilection to bone metastases (eg,
cancer dilection to bone metastases about your symptoms? bone metastases but in an breast, prostate, lung, kidney, and thyroid10)
High will develop them. However, How long ago was the primary early stage (1 or 2), with no In breast cancer grade 3 or 4 (late stage), large tumors
some will metastasize in the diagnosis made? lymph node involvement62 with lymph node involvement62
first 5 y of diagnosis, with How big was the primary tumor, Cancers that do not have a In prostate cancer, a Gleason score of 9 or 10 (despite
50% doing so 10-20 y later44 and at which stage? predilection to bone metas- a PSA level greater than 50 ng/mL at diagnosis) is
Approximately 25% of people Was there any lymph node tases (eg, ovarian cancer, considered to be an aggressive cancer that is likely to
with MSCC have no known involvement? melanoma62) spread more rapidly4
primary diagnosis57 Which treatment did you have?
Abbreviations: MSCC, metastatic spinal cord compression; PSA, prostate-specific antigen.
Symptoms (subjective)/
Level of Evidence Context Further Questions Low Clinical Suspicion High Clinical Suspicion
Severe pain that may MBD does not have a linear progression and Are your symptoms getting better, the The person presents with Subjective reports of progres-
become progressive is more likely to wax and wane, but in the same, or worse? initial severe pain but reports sively worsening symptoms,
and constant later stages it becomes more constant Do you have band-like pain? improvement with treatment; with possible features of
Low and progressive. People may report it is important to continue to band-like pain, and inability
escalating pain, which can increase when evaluate, as the person may to lie flat
lying flat79 be in a good phase
Night pain Most people with back pain will suffer from Does your pain wake you at night? The person reports that he or People who report having to walk
Low night pain. People who report being What do you have to do to get back she is able to get back to the floors or sit in a chair or
woken on movement and subsequently to sleep? sleep following a change lie on the floor, with minimal
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are unable to get comfortable and go back Does your night pain occur in a of position or after taking relief
to sleep are of less concern than those particular position? medication
who describe an inability to get back to
sleep due to the intensity of symptoms
and who report having to get up to relieve
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the pain25
Systemically unwell These are often symptoms described in the Do you feel well? Able to associate with another May describe the features of hy-
Low late stages of the disease and may include • If not, then explore the features of cause percalcemia, such as fatigue,
fatigue, nausea, anorexia, and constipa- hypercalcemia nausea, stomach pain, and
tion, which are symptoms suggestive of • Establish whether these symptoms fever. These also tend to be
hypercalcemia24 could be associated with other progressive in nature
Constipation is not necessarily a systemic causes
complaint
These could appear on their own or as a
cluster of symptoms
Journal of Orthopaedic & Sports Physical Therapy®
Thoracic pain The thoracic spine is the most common site Is the area sensitive to touch? Appears mechanical, but caution May be painful on percussion
Low of MBD Is it mechanical in presentation? needs to be applied here. over the area of pain. May not
It is important to note that MBD may not cor- Often, MBD gives the impres- be a mechanical pain pattern
respond to the sensory level of pain sion of being mechanical in
nature, appearing to initially
respond to treatment
Neurological symptoms MBD can cause neurological symptoms and Do you have any pins and needles or No distally referred symptoms People with bilateral/quadrilat-
Low in some cases cord compression, includ- numbness? or subjective neurological eral neurological symptoms,
ing UMN signs and CES Have you noticed any weakness in symptoms including gait disturbance and
your legs? coordination issues/bladder
Ask CES questions (see the CES sec- and bowel disturbance
tion for more detail)
Unexplained weight loss Consider other causes of weight loss, such Is your weight steady? Weight loss related to medication The individual has lost 5%-10%
High as change in diet, increase in exercise, • If the person answers that he or she or change in diet, or weight of body weight over a 3- to
medication that increases levels of pain, has lost weight, ask if the person loss has stabilized 6-mo period59
or other morbidities such as hyperthyroid- knows why he or she has lost Can be attributed to other
ism or diabetes59 weight causes
Consider more than 5% of weight loss over a Have you changed your diet?
6-mo period as significant and requiring How much weight loss over the last
further questioning to establish a cause59 3-6 mo have you had?
Unfamiliar back pain Some people may have a long history of Is this a familiar pain to you? If this is a person’s first episode Describes pain that is unfamiliar
Low back pain, so it is important to establish Have you experienced back pain in of back pain, conservative and possibly worsening
whether this is a new or different pain the past? management is the first
Does this feel familiar to you? course of action
Abbreviations: CES, cauda equina syndrome; MBD, metastatic bone disease; UMN, upper motor neuron.
Signs (objective)/
Level of Evidence Context Physical Assessment Low Clinical Suspicion High Clinical Suspicion
Altered sensation People might report altered sensation that Neurological examination testing Normal neurology and no objective Objective signs and reduced
from trunk down is nondermatomal and describe strange Sensation throughout the area change in sensation sensation
Low feelings in the legs (often a vague and non- described by the patient
specific, difficult-to-describe sensation).
People may report decreased mobility79
Neurological signs People who present with a subjective com- Neurological examination that may Localized spinal pain with no distal People with symptoms in the limbs
Low plaint of neurological symptoms must have need to include the upper and/or referral or limb symptoms and/or with coordination/gait
a full neurological examination lower limbs, including upper and disturbance, or changes to blad-
lower motor neuron clinical tests der/bowel activity
Spine tenderness Sometimes, the spine can be tender on per- The clinician should palpate the No tenderness on palpation or Tenderness or reproduction of
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Low cussion. However, lack of tenderness does spinous processes and may percussion/vibration symptoms on palpation or
not rule out the possibility of metastases use percussion/vibration with percussion/vibration
It is important to percuss the whole spine, as a 128-Hz tuning fork to further
the area of pain reported may not be the examine spinal tenderness or
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TABLE 16 Initial Investigations for Spinal Malignancy
Modality Context
MRI MRI is the gold standard for diagnosing MBD78
Because the sensory level does not always correspond to the level of metastases if MBD is suspected, MRI of the whole spine is required46
CT scan If there are contraindications to MRI
Journal of Orthopaedic & Sports Physical Therapy®
Blood tests There is no combination of inflammatory markers that can be used as a reliable rule-in or rule-out test strategy. The decision to test must be made in the
context of other clinical findings84
Abbreviations: CT, computed tomography; MBD, metastatic bone disease; MRI, magnetic resonance imaging.
absence of a history of cancer, as MSCC nicians and patients (eg, https://www. breast cancer 5 years ago presents with
can be the first sign of metastases in ap- christie.nhs.uk/media/1125/legacyme- an exacerbation of LBP. No other red
proximately 25% of people who do not dia-1201-mscc-service_education_mscc- flags or signs and symptoms suggestive
have a primary diagnosis of cancer and resources_red-flag-card.pdf ). of a mechanical problem are present on
are subsequently diagnosed with MSCC.57 Metastases can affect any region examination.
Metastatic spinal cord compression can of the spine, most commonly the tho- • History of breast cancer 5 years ago
occur as a consequence of MBD when racic spine (70%), but also the cervical • Clinical action: treat and monitor
there is pathological vertebral-body col- spine (10%) and lumbar spine (20%).73 symptoms
lapse or where direct tumor growth causes Primary tumors that are at high risk of Level of Concern
compression of the spinal cord, leading to metastasizing are those that were large
irreversible neurological damage.46 at diagnosis, diagnosed at a late stage of LOW HIGH
A high index of suspicion, early diag- the disease (stage 3 or 4), or had lymph
nosis with referral for urgent investiga- node involvement with radical treat-
tion, and prompt treatment can result in ment, including surgery, chemotherapy, Case 2
better outcomes in terms of function and and/or radiotherapy.62 The woman reports that her pain
prognosis.79 Careful questioning using is not responding to usual medica-
good communication skills is essential Clinical-Reasoning Cases/Scenarios tion and that she has been prescribed
in early identification. The use of credit Case 1 stronger medication, which is helping.
card–size patient information handouts A 58-year-old woman with a 42-year She describes her symptoms as differ-
can aid in communication between cli- history of chronic LBP and history of ent from her usual back pain, which
Suggested Pathway for Emergency/Ur- cases per 100 000 annually in Western
gent Referral Refer to the clinical de- societies.9,30 Spinal infection represents
Case 3 cision tool for suggested pathways for 2% to 7% of all musculoskeletal infec-
The woman’s pain has become progres- emergency/urgent referral (FIGURE 3). tions.45 The point prevalence of spinal
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sively worse and she now complains of infection in developed countries is esti-
symptoms waking her at night. She is Spinal Infection mated at 0.0004% (across all settings).21
having difficulty getting back to sleep be- Spinal infection is an infectious disease The point prevalence of infection pre-
cause the pain is so intense. that affects the spinal structures, includ- senting as nonmechanical LBP is esti-
• History of breast cancer 5 years ago ing the vertebrae, intervertebral discs, mated at 0.01% in primary care41 and
• Using stronger painkillers and adjacent paraspinal tissues.60 In 1.2% in a tertiary setting,66 where post-
• Describes unfamiliar pain high-income and upper middle–income procedural discitis represents up to 30%
• Night pain with worsening symptoms countries, spinal infection has steadily of all cases.21
• Clinical action: refer for urgent MRI, increased over recent years, possibly due Discitis mostly affects the lumbar spine
discuss and document a clear strat- to an aging population and an increase in (58%), followed by the thoracic spine
Journal of Orthopaedic & Sports Physical Therapy®
egy to follow if symptoms deteriorate intravenous drug abuse.52 In lower mid- (30%) and cervical spine (11%),30 where-
(safety net). Some concerning features dle–income and lower-income countries, as TB lesions mainly affect the thoracic
suggest malignancy. An MRI scan of spinal infection has increased due to the spine, and often at more than 2 levels.8
the whole spine should be carried out dual epidemic of HIV/AIDS and tuber- The frequency of spinal infections
urgently culosis (TB). presenting in a clinical setting depends
Level of Concern
For further country-specific informa- on the demographics of where you work.
tion on TB, see https://www.wwl.nhs. Due to the rarity of spinal infection in
LOW HIGH uk/library/general_docs/specialties/a_ high-income countries, the diagnosis of
to_z/t/tb-service-who-estimates-of- spinal infection is often delayed, because
tuberculosis-incidence-by-country.pdf,67 clinicians fail to recognize the relevant
Case 4 and for further information on the global red flags and consider spinal infection as
A 75-year-old man presents with a past burden of the dual epidemic of HIV/AIDS a potential differential diagnosis.6
history of prostate cancer 2 years ago,
and he describes band-like pain and
states that his legs feel odd and heavy. He Number of Spinal Infection Red
TABLE 17
reports occasionally tripping and stum- Flags Gaining Consensus
bling. He says he has lost weight but has
put it down to a loss of appetite due to Number of Red Flags
the pain. Questionnaire sent to 21 56 items reviewed
• History of prostate cancer international experts • 30 items reached consensus as appropriate
• 0 items reached consensus as inappropriate
• Balance issues
• 26 items had no consensus
• Odd sensations in legs
Steering committee 17 items included in the framework (TABLES 18 through 21)
• Band-like pain reviewed results 24 items excluded (APPENDIX C) (16 items were combined)
• Weight loss
Risk Factor/Level of
Evidence Context Further Questions Low Clinical Suspicion High Clinical Suspicion
Immunosuppression Comorbidities that cause immunosup- Do you have any health issues I need Well-controlled comorbidities with Uncontrolled morbidities with previ-
Low pression can increase the risk of SI to be aware of? no history of infections attributed ous evidence of infections
(eg, diabetes, HIV/AIDS, rheumatoid Is your diabetes well controlled? to their condition
arthritis, pre-existing infections, How long have you been taking steroid
alcohol abuse, and long-term use of medication?
steroids) Have you had a recent infection?
Do you drink alcohol?
• How many units a week do you
drink?
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Surgery: invasive Long duration of surgery, in particular, Any previous spinal or abdominal No previous surgical intervention The person has undergone surgery,
Low the type of surgery (more commonly, surgery? particularly of the spine, with
lumbar and posterior approaches), repeated revisions
and multiple revisions are significant
risk factors for SI45
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Intravenous drug use An increase in IVDA is thought to be as- Questions must be in the context of No evidence of IVDA Known intravenous drug user
Low sociated with increased risk of SI89 the suspicion of SI
People with a history of intravenous I want to make sure you do not have
drug use may present late and may an infection, so I am going to ask
not see the relevance of drug use to you some questions that will help
their condition. Know the incidence me. Do you take, or have you ever
of drug abuse in the community taken, recreational drugs?
within which you work • If yes, how were these drugs
administered (orally or intrave-
nously)?
Journal of Orthopaedic & Sports Physical Therapy®
Social and environmen- There is a strong association with social What are the conditions like where you Appears well kempt (well dressed Is unkempt (an untidy appearance
tal factors (eg, mi- deprivation and TB. Consider a live, in the workplace, or places you with a clean and tidy appear- and unwashed hair and clothes),
grant, occupational patient’s social history and whether frequently visit? ance) and does not report social raising concerns for poor living
exposure, homeless- his or her situation might include the Do you drink alcohol? conditions that raise concern and social conditions
ness, prisoner, following: alcohol abuse, migrant, • How many units a week do you
contact with infected homelessness, and imprisonment.47 drink?
animals) Consider working and living condi-
Low tions (eg, contact with TB-infected
cattle)88
History of TB (born The majority of TB cases are a result Have you ever been diagnosed with No evidence of TB or contact with No inoculation and has been
in TB-endemic of reactivation of latent infection TB? TB exposed to TB via an endemic
country) acquired some years before47 • Where was the TB? country or persons known to
Low However, transmission of TB needs to Have you been abroad recently? have TB
be considered where individuals • If yes, consider whether this
are born in TB-endemic countries country has a high burden of TB
or where an individual has been • If it is a country with high burden,
exposed to TB sufferers47 has the person had an inoculation
for TB?
Have you been in contact with some-
one who has a history of TB?
Recent pre-existing New local back pain following a recent Have you recently had an infection? The person’s infection has respond- Progressively worsening symptoms
infection episode of sepsis or infection52 Consider other causes, such as ed to treatment (eg, antibiotics)
Low urinary tract infections, and ask and back pain symptoms have
questions related to the condition improved
Abbreviations: IVDA, intravenous drug abuse; SI, spinal infection; TB, tuberculosis.
Symptoms (subjective)/
Level of Evidence Context Further Questions Low Clinical Suspicion High Clinical Suspicion
Spinal pain Back pain is the most common presenting How did your back pain start? No evidence of progressive symp- Localized progressive pain
Low symptom. Neurological symptoms may be Are your symptoms getting better, toms and the person is not able to that limits movement
present. Usually, symptoms are nonspecific, worse, or remaining the same? pinpoint symptoms significantly
with an insidious onset. Range of motion of Can you point to where your symp-
the spine is often limited due to localized toms are?
spinal pain and muscle spasm52
Neurological symptoms Neurological symptoms make up part of the Do you have any pins or needles or No distally referred symptoms or People with bilateral/
Low classic triad for SI numbness? subjective neurological symptoms quadrilateral neurological
Have you noticed any weakness in If the person does not describe any symptoms, including gait
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Low activities that they would normally be able Have you noticed any changes in that is abnormal for them
to carry out38 your ability to carry out activities when carrying out their
that normally you manage easily? usual tasks
Fever (consider sepsis/ Fever makes up one of the classic triad symp- Have you experienced a fever or chills The absence of fever should not be Person reports fever within
septic shock) toms. Recognize signs of sepsis, as it can since the onset of your back pain? reassuring; it should be monitored the time frame since on-
Low develop rapidly71 set of back pain. Concern
Fever can be absent in approximately 50% of that person might be
people with SI88 developing sepsis
Unexplained weight loss Consider other causes of weight loss, such Is your weight steady? Weight loss related to medication or Person has lost more than
Low as change in diet, increase in exercise or • If the person answers that he or change in diet 5% of body weight over a
medication, increasing levels of pain, or she has lost weight: Weight loss has stabilized 3- to 6-mo period59
other morbidities such as hyperthyroidism - Do you know why you might Can be attributed to other causes
Journal of Orthopaedic & Sports Physical Therapy®
Clinical Picture In cases of spinal infec- that suppress a patient’s immune sys- 50% of people report fever as a symp-
tion, the time between onset and diagnosis tem, such as diabetes, HIV, long-term tom.45 Absence of fever cannot rule out
is often prolonged. People can remain rel- steroid use, and smoking, put the person spinal infection.
atively healthy until symptoms manifest in at risk of infection. Consider social and
the later stages of the disease.83 Unlike ma- environmental factors like intravenous Clinical-Reasoning Cases/Scenarios
lignancy, where symptoms wax and wane, drug use, obesity, birth in a TB-endemic Case 1
spinal infection has a more linear pro- country, family history of TB, and living A 47-year-old ex-heroin addict presents
gression, with back pain being the most conditions (overcrowded living, home- with recurrent episodes of LBP and a pre-
common presenting symptom, which can lessness, imprisonment, or rural envi- vious history of back pain. He describes
progress to neurological symptoms. If not ronment). Spinal surgery is a key risk symptoms that are intermittent. He is
treated in a timely manner, the condition factor for spinal infection, in particular very inactive and usually self-treats the
can progress with serious complications multiple revision surgery of the lumbar problem with rest.
such as paralysis or instability of the spine, spine, with an added increased risk for • Male
and can ultimately be fatal. obese people.88 • Ex-drug addict
Diagnosis The subjective history should The classic triad of clinical features • No other concerning features
consider determinants that can be di- comprises back pain, fever, and neurologi- • Clinical action: treat and monitor
vided into comorbidities, environmental cal dysfunction.14 However, many people symptoms, discuss and document a
factors, and social factors. Comorbidities do not present with all 3 features. Only clear strategy to follow if symptoms
Signs (objective)/
Level of Evidence Context Physical Assessment Low Clinical Suspicion High Clinical Suspicion
Neurological signs People with a subjective complaint of Neurological examination may need to include Localized spinal pain with People with symptoms in the
Low neurological symptoms must have a full the upper and/or lower limbs, including up- no distal referral or limb limbs, or with coordination/gait
neurological examination per and lower motor neuron clinical tests symptoms disturbance, or with changes to
bladder/bowel activity
Radiculopathy SI can cause radiculopathy, which com- A full neurological examination, including Normal neurological Abnormal and progressing neuro-
Low monly presents with leg pain that usually dermatomes, myotomes, and reflexes examination logical deficit
radiates to the part of the body that is Management depends on the degree
supplied by that specific nerve of neurological deficit (gross
The person may present with weakness or motor weakness of <3/5 or
pins and needles/numbness deteriorating neurology)
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Spine tenderness The spine can be tender and reproduce Palpate the spinous processes and consider No significant tenderness Tenderness or reproduction of symp-
on palpation symptoms on percussion using percussion/vibration with a 128-Hz on palpation toms on palpation, percussion,
Low Lack of tenderness or reproduction of tuning fork to further examine spinal tender- and/or vibration
symptoms does not rule out SI ness or reproduction of symptoms
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Percuss the whole spine, as the area of pain Bony percussion/use of a tuning fork may
reported may not be the area of infection indicate the presence of bony injury, but
interpret with caution
Abbreviation: SI, spinal infection.
TABLE 21 Initial Investigations for Spinal Infection
Modality Context
Journal of Orthopaedic & Sports Physical Therapy®
MRI MRI is the imaging of choice. Findings on MRI can be observed 3-5 d after the onset of infection, with high sensitivity (96%), specificity (92%), and accuracy
(94%)2,9,49,76
Blood tests There is no single diagnostic blood test. Inflammatory markers are routinely used to assess for infection. The white blood cell count is less useful than erythro-
cyte sedimentation rate and C-reactive protein, as a normal white blood cell count does not exclude spinal infection45
X-ray Chest X-ray if there is suspicion of tuberculosis
Abbreviation: MRI, magnetic resonance imaging.
deteriorate (safety net). Utilize a pe- • Clinical action: treat and monitor ment is normal.
riod of watchful waiting, with advice symptoms, discuss and document a • Born in TB-endemic country
about being more physically active clear strategy to follow if symptoms • Smoker
Level of Concern
deteriorate (safety net). Consider MRI • Feels unwell
if there is an increased suspicion of • Night pain, worsening symptoms
LOW HIGH pathology • Clinical action: urgent MRI and re-
Level of Concern
quest blood tests, discuss and docu-
ment a clear strategy to follow if
Case 2 LOW HIGH symptoms deteriorate (safety net)
A 43-year-old man reports a 3-month Level of Concern
history of LBP that is intermittent and
mechanical in nature. He was born in So- Case 3 LOW HIGH
malia and smokes 20 cigarettes per day. The man now feels unwell and has had a
He is neurologically intact and exhibits fever and chills in the last few days. He
normal function. reports pain at night and is unable to Case 4
• Born in TB-endemic country settle. His pain has now become constant The man has now developed neurologi-
• Smoker and more intense. Neurological assess- cal signs and symptoms, with back and
searchers, clinicians, member organization cauda equina symptoms in older adults with
lumbar spinal stenosis. Musculoskelet Sci Pract.
LOW HIGH delegates of the IFOMPT, Sussex MSK Part-
2020;45:102049. https://doi.org/10.1016/j.
nership patient partners, and experts by msksp.2019.102049
experience for generously giving their time to 12. Compston J, Cooper A, Cooper C, et al. UK clini-
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Suggested Pathway for Emergency/Ur- review the document, respond to our surveys, cal guideline for the prevention and treatment
of osteoporosis. Arch Osteoporos. 2017;12:43.
gent Referral Refer to the clinical de- and participate in the consensus-building
https://doi.org/10.1007/s11657-017-0324-5
cision tool for suggested pathways for process. 13. Cook C, Ross MD, Isaacs R, Hegedus E.
emergency/urgent referral (FIGURE 3). t Investigation of nonmechanical findings
during spinal movement screening for iden-
STUDY DETAILS REFERENCES tifying and/or ruling out metastatic cancer.
Pain Pract. 2012;12:426-433. https://doi.
AUTHOR CONTRIBUTIONS: All authors pro- org/10.1111/j.1533-2500.2011.00519.x
1. American College of Rheumatology Ad
vided substantial intellectual content Hoc Committee on Glucocorticoid‐Induced 14. Davis DP, Wold RM, Patel RJ, et al. The clinical
contributions to the conception and de- Osteoporosis. Recommendations for the presentation and impact of diagnostic delays on
prevention and treatment of glucocorticoid- emergency department patients with spinal epi-
velopment of the framework document
Journal of Orthopaedic & Sports Physical Therapy®
induced osteoporosis: 2001 update. Arthritis dural abscess. J Emerg Med. 2004;26:285-291.
during early draft and revision stages. https://doi.org/10.1016/j.jemermed.2003.11.013
Rheum. 2001;44:1496-1503. https://doi.
All authors provided final approval of org/10.1002/1529-0131(200107)44:7<1496::AID- 15. Deyo RA, Diehl AK. Cancer as a cause of back
the manuscript to be published and ART271>3.0.CO;2-5 pain: frequency, clinical presentation, and diag-
2. An HS, Seldomridge JA. Spinal infections: nostic strategies. J Gen Intern Med. 1988;3:230-
have agreed to be accountable for all
diagnostic tests and imaging studies. Clin 238. https://doi.org/10.1007/bf02596337
aspects of the work to ensure that ques- 16. Deyo RA, Diehl AK. Lumbar spine films in pri-
Orthop Relat Res. 2006;444:27-33. https://doi.
tions related to the accuracy or integrity org/10.1097/01.blo.0000203452.36522.97 mary care: current use and effects of selective
of any part of the work are appropriately 3. André-Vert J, Dhénain M. Development of ordering criteria. J Gen Intern Med. 1986;1:20-25.
Good Practice Guidelines: “Formal Consensus” https://doi.org/10.1007/bf02596320
investigated and resolved.
Method. Seine-Saint-Denis, France: Haute 17. Deyo RA, Rainville J, Kent DL. What can the his-
DATA SHARING: Data are from anonymous tory and physical examination tell us about low
Autorité de Santé; 2015.
questionnaire responses and available 4. Association of Directors of Anatomic and Surgical back pain? JAMA. 1992;268:760-765. https://doi.
on request from Dr Rachel Leech at Pathology. Understanding your pathology report: org/10.1001/jama.1992.03490060092030
prostate cancer. Available at: https://www.cancer. 18. Dionne N, Adefolarin A, Kunzelman D, et al.
R.Leech@mmu.ac.u. These data, with
org/treatment/understanding-your-diagnosis/ What is the diagnostic accuracy of red flags
an appropriate citation, may be inte- tests/understanding-your-pathology-report/ related to Cauda Equina Syndrome (CES), when
grated with other datasets obtained prostate-pathology/prostate-cancer-pathology. compared to Magnetic Resonance Imaging
from repositories, or other sources. html. Accessed April 16, 2020. (MRI)? A systematic review. Musculoskelet Sci
5. Berg KM, Kunins HV, Jackson JL, et al. Pract. 2019;42:125-133. https://doi.org/10.1016/j.
PATIENT AND PUBLIC INVOLVEMENT: Patient
Association between alcohol consumption and msksp.2019.05.004
partners (n = 4) with previous schol- both osteoporotic fracture and bone density. 19. Donner-Banzhoff N, Roth T, Sönnichse AC, et
arly review experience were identified Am J Med. 2008;121:406-418. https://doi. al. Evaluating the accuracy of a simple heuristic
through the Sussex MSK Partnership. org/10.1016/j.amjmed.2007.12.012 to identify serious causes of low back pain.
6. Bhise V, Meyer AND, Singh H, et al. Errors in Fam Pract. 2006;23:682-686. https://doi.
Patient partners were engaged to par-
diagnosis of spinal epidural abscesses in the org/10.1093/fampra/cml049
ticipate in a web-based survey during era of electronic health records. Am J Med. 20. Downie A, Williams CM, Henschke N, et al. Red
phase 4 to provide opinions about the 2017;130:975-981. https://doi.org/10.1016/j. flags to screen for malignancy and fracture in
applicability, acceptability, and read- amjmed.2017.03.009 patients with low back pain: systematic review.
7. Biermann JS, Holt GE, Lewis VO, Schwartz HS, BMJ. 2013;347:f7095. https://doi.org/10.1136/
ability of the framework. Individual
Nurs. 2013;22:S4, S6, S8-S11. https://doi. patient accounts of their pathways to diagno- Assessing the Risk of Fragility Fracture. NICE
org/10.12968/bjon.2013.22.Sup7.S4 sis. PLoS One. 2018;13:e0194788. https://doi. Short Clinical Guideline. London, UK: National
25. Finucane L, Greenhalgh S, Selfe J. Which red org/10.1371/journal.pone.0194788 Clinical Guideline Centre; 2012.
flags aid the early detection of metastatic 39. Hutton M. Spinal Services: GIRFT Programme 54. National Health Service. Did you know – Cauda
bone disease in back pain? Physiother Pract National Specialty Report. London, UK: Getting It Equina Syndrome. Available at: https://webar-
Copyright © ${year} Journal of Orthopaedic & Sports Physical Therapy®. All rights reserved.
British Association of Spine Surgeons standards org/10.3171/foc.2004.16.6.6 Manchester, UK: National Institute for Health and
of care for cauda equina syndrome. Spine 43. Khoo LA, Heron C, Patel U, et al. The diagnostic Care Excellence; 2008.
J. 2015;15:S2-S4. https://doi.org/10.1016/j. contribution of the frontal lumbar spine radio- 58. National Institute for Health and Care Excellence.
spinee.2015.01.006 graph in community referred low back pain—a Osteoporosis - prevention of fragility fractures.
29. Gibson M, Zoltie N. Radiography for back pain prospective study of 1030 patients. Clin Radiol. Available at: https://www.nice.org.uk/cks-uk-
presenting to accident and emergency depart- 2003;58:606-609. https://doi.org/10.1016/ only#!scenario:1. Accessed April 17, 2020.
ments. Arch Emerg Med. 1992;9:28-31. https:// s0009-9260(03)00173-9 59. Nicholson BD, Aveyard P, Hamilton W, Hobbs
doi.org/10.1136/emj.9.1.28 44. Lee SJ, Park S, Ahn HK, et al. Implications of FDR. When should unexpected weight loss war-
30. Gouliouris T, Aliyu SH, Brown NM. bone-only metastases in breast cancer: favorable rant further investigation to exclude cancer? BMJ.
Spondylodiscitis: update on diagnosis and preference with excellent outcomes of hormone 2019;366:l5271. https://doi.org/10.1136/bmj.l5271
management. J Antimicrob Chemother. 2010;65 receptor positive breast cancer. Cancer Res 60. Nickerson EK, Sinha R. Vertebral osteomyelitis in
suppl 3:iii11-iii24. https://doi.org/10.1093/jac/ Treat. 2011;43:89-95. https://doi.org/10.4143/ adults: an update. Br Med Bull. 2016;117:121-138.
dkq303 crt.2011.43.2.89 https://doi.org/10.1093/bmb/ldw003
31. Greenhalgh S, Finucane L, Mercer C, Selfe J. 45. Lener S, Hartmann S, Barbagallo GMV, Certo 61. Nuti R, Brandi ML, Checchia G, et al. Guidelines
Assessment and management of cauda equina F, Thomé C, Tschugg A. Management of spi- for the management of osteoporosis and fragility
syndrome. Musculoskelet Sci Pract. 2018;37:69- nal infection: a review of the literature. Acta fractures. Intern Emerg Med. 2019;14:85-102.
74. https://doi.org/10.1016/j.msksp.2018.06.002 Neurochir (Wien). 2018;160:487-496. https://doi. https://doi.org/10.1007/s11739-018-1874-2
32. Greenhalgh S, Selfe J. Red Flags and Blue Lights: org/10.1007/s00701-018-3467-2 62. Oliver TB, Bhat R, Kellett CF, Adamson DJ.
Managing Serious Spinal Pathology. 2nd ed. 46. Levack P, Graham J, Collie D, et al. Don’t wait Diagnosis and management of bone metastases.
Edinburgh, UK: Elsevier; 2019. for a sensory level – listen to the symptoms: J R Coll Physicians Edinb. 2011;41:330-338.
33. Harel R, Angelov L. Spine metastases: current a prospective audit of the delays in diagnosis 63. Parreira PCS, Maher CG, Megale RZ, March L,
treatments and future directions. Eur J Cancer. of malignant cord compression. Clin Oncol Ferreira ML. An overview of clinical guidelines for
2010;46:2696-2707. https://doi.org/10.1016/j. (R Coll Radiol). 2002;14:472-480. https://doi. the management of vertebral compression frac-
ejca.2010.04.025 org/10.1053/clon.2002.0098 ture: a systematic review. Spine J. 2017;17:1932-
34. Henschke N, Maher CG, Ostelo RW, de Vet HC, 47. Lipman M, White J. Collaborative tuberculosis 1938. https://doi.org/10.1016/j.spinee.2017.07.174
Macaskill P, Irwig L. Red flags to screen for malig- strategy for England. BMJ. 2015;350:h810. 64. Patel U, Skingle S, Campbell GA, Crisp AJ, Boyle
nancy in patients with low-back pain. Cochrane https://doi.org/10.1136/bmj.h810 IT. Clinical profile of acute vertebral compres-
Database Syst Rev. 2013:CD008686. https://doi. 48. Long B, Koyfman A, Gottlieb M. Evaluation and sion fractures in osteoporosis. Br J Rheumatol.
org/10.1002/14651858.CD008686.pub2 management of cauda equina syndrome in 1991;30:418-421. https://doi.org/10.1093/
35. Henschke N, Maher CG, Refshauge KM, et al. the emergency department. Am J Emerg Med. rheumatology/30.6.418
tion of osteoporotic vertebral compression history and technologies for identifying patients
17, 2020.
fracture or wedge deformity. J Man Manip Ther. at high risk of vertebral fracture and spinal cord 87. World Health Organization. TB and HIV, and other
2010;18:44-49. https://doi.org/10.1179/10669811 compression. Health Technol Assess. 2013;17:1- comorbidities. Available at: https://www.who.int/
0X12595770849641 274. https://doi.org/10.3310/hta17420 tb/areas-of-work/tb-hiv/en/. Accessed April 16,
70. Roy DK, O’Neill TW, Finn JD, et al. Determinants 79. Turnpenney J, Greenhalgh S, Richards L, 2020.
of incident vertebral fracture in men and Crabtree A, Selfe J. Developing an early alert 88. Yusuf M, Finucane L, Selfe J. Red flags for
women: results from the European Prospective system for metastatic spinal cord compression the early detection of spinal infection in back
Osteoporosis Study (EPOS). Osteoporos (MSCC): Red Flag credit cards. Prim Health Care pain patients. BMC Musculoskelet Disord.
Int. 2003;14:19-26. https://doi.org/10.1007/ Res Dev. 2015;16:14-20. https://doi.org/10.1017/ 2019;20:606. https://doi.org/10.1186/
s00198-002-1317-8 S1463423613000376 s12891-019-2949-6
71. Royal College of Physicians. National Early 80. van den Bosch MA, Hollingworth W, Kinmonth 89. Ziu M, Dengler B, Cordell D, Bartanusz V.
Warning Score (NEWS) 2: Standardising the AL, Dixon AK. Evidence against the use of lum- Diagnosis and management of primary pyogenic
Journal of Orthopaedic & Sports Physical Therapy®
Assessment of Acute-Illness Severity in the NHS. bar spine radiography for low back pain. Clin spinal infections in intravenous recreational drug
London, UK: Royal College of Physicians; 2017. Radiol. 2004;59:69-76. https://doi.org/10.1016/j. users. Neurosurg Focus. 2014;37:E3. https://doi.
72. Royal Osteoporosis Society. Clinical guidance for crad.2003.08.012 org/10.3171/2014.6.FOCUS14148
the effective identification of vertebral fractures. 81. van der Voort DJ, van der Weijer PH, Barentsen R.
Available at: https://www.guidelines.co.uk/ Early menopause: increased fracture risk at older
@ MORE INFORMATION
musculoskeletal-and-joints-/ros-guideline-iden- age. Osteoporos Int. 2003;14:525-530. https://
tification-of-vertebral-fractures/454148.article. doi.org/10.1007/s00198-003-1408-1
Accessed April 16, 2020. 82. Verhagen AP, Downie A, Popal N, Maher C, WWW.JOSPT.ORG
DEFINITIONS
• Clinical risk/index of suspicion: relates to clinical risk factors and presenting clinical features. Once the index of suspicion passes a critical thresh-
old, the therapist will become concerned about the underlying cause of the person’s complaint3
• Emergency referral: this needs to reflect local pathways, but, as a guide, on the same day
• Experts by experience: patient representatives
• General practitioner review: follow-up by medical practitioner; onward medical management to be carried out by the general practitioner
• High level of evidence: evidence supported by the literature
• Investigations: refers to requesting imaging or ordering blood tests to aid diagnosis
• Low level of evidence: evidence supported by consensus and the steering group
• Red flag: Goodman and Snyder2 define red flags as features of the individual’s medical history and clinical examination thought to be associated
with a high risk of serious disorders such as infection, inflammation, cancer, or fracture. Red flags are clinical prediction guides—they are not diag-
Downloaded from www.jospt.org at on June 4, 2020. For personal use only. No other uses without permission.
nostic tests, and they are not necessarily predictors of diagnosis or prognosis. The main role of red flags is that, when combined, they help to raise
the clinician’s index of suspicion. Unfortunately, with a few exceptions, the prognostic strength of individual red flags or combinations of red flags is
not known3
• Safety netting: safety netting is a management strategy used for people who may present with possible serious pathology. These strategies should
Copyright © ${year} Journal of Orthopaedic & Sports Physical Therapy®. All rights reserved.
include advice on which signs and symptoms to look out for, which action to take, and the time frame within which that action needs to be taken 4
• Shared decision making: the conversation that happens between a patient and a clinician to reach a health care choice together
• Urgent referral: this needs to reflect local pathways, but, as a guide, within 5 days
• Watchful waiting: the act of close surveillance while undergoing treatment as required, but allowing time to pass before medical intervention or
therapy is used1
REFERENCES
1. Cook CE, George SZ, Reiman MP. Red flag screening for low back pain: nothing to see here, move along: a narrative review. Br J Sports Med. 2018;52:493-496. https://doi.
org/10.1136/bjsports-2017-098352
2. Goodman CC, Snyder TEK. Screening for immunologic disease. In: Differential Diagnosis for Physical Therapists: Screening for Referral. 5th ed. St Louis, MO: Elsevier/
Saunders; 2013:ch 12.
3. Greenhalgh S, Selfe J. Red Flags II: A Guide to Solving Serious Pathology of the Spine. Edinburgh, UK: Elsevier/Churchill Livingstone; 2010.
Journal of Orthopaedic & Sports Physical Therapy®
4. Hirst Y, Lim AWW. Acceptability of text messages for safety netting patients with low-risk cancer symptoms: a qualitative study. Br J Gen Pract. 2018;68:e333-e341. https://
doi.org/10.3399/bjgp18X695741
consider that there is anything in the literature that justifies contravention of this principle. We recommend
that reasons for any delay in surgery be documented
CES5 NA NA A number of authors, including Henschke et al,7 Downie et al,2 and Verhagen et al,12 have published high-
quality review papers demonstrating that red flags have a weak evidence base
Copyright © ${year} Journal of Orthopaedic & Sports Physical Therapy®. All rights reserved.
Fracture13 8 7378 The available evidence does not support the use of many red flags to specifically screen for vertebral fracture
in patients presenting with LBP. From the limited evidence, the findings give rise to a weak recommenda-
tion that a combination of a small subset of red flags may be useful to screen for vertebral fracture
Fracture11 NA NA NA
Fracture9 4 guidelines NA Overall, none of the guidelines was of satisfactory quality. The domains with the lowest scores were rigor of
development and applicability
Fracture3 NA NA NA
Fracture8 NA NA Evidence rating: C—consensus, disease-oriented evidence, usual practice, expert opinion, or case series
Malignancy6 8 7361 For most “red flags,” there is insufficient evidence to provide recommendations regarding their diagnostic
accuracy or usefulness for detecting spinal malignancy
Infection14 41 2058 The current evidence surrounding red flags for SI remains of low quality, and clinical features alone should
not be relied on to identify SI
Journal of Orthopaedic & Sports Physical Therapy®
Infection10 NA NA NA
Abbreviations: CES, cauda equina syndrome; LBP, low back pain; MRI, magnetic resonance imaging; NA, not applicable; SI, spinal infection.
REFERENCES
1. Dionne N, Adefolarin A, Kunzelman D, et al. What is the diagnostic accuracy of red flags related to Cauda Equina Syndrome (CES), when compared to Magnetic Resonance
Imaging (MRI)? A systematic review. Musculoskelet Sci Pract. 2019;42:125-133. https://doi.org/10.1016/j.msksp.2019.05.004
2. Downie A, Williams CM, Henschke N, et al. Red flags to screen for malignancy and fracture in patients with low back pain: systematic review. BMJ. 2013;347:f7095. https://
doi.org/10.1136/bmj.f7095
3. Esses SI, McGuire R, Jenkins J, et al. The treatment of symptomatic osteoporotic spinal compression fractures. J Am Acad Orthop Surg. 2011;19:176-182. https://doi.
org/10.5435/00124635-201103000-00007
4. Germon T, Ahuja S, Casey ATH, Todd NV, Rai A. British Association of Spine Surgeons standards of care for cauda equina syndrome. Spine J. 2015;15:S2-S4. https://doi.
org/10.1016/j.spinee.2015.01.006
5. Greenhalgh S, Finucane L, Mercer C, Selfe J. Assessment and management of cauda equina syndrome. Musculoskelet Sci Pract. 2018;37:69-74. https://doi.org/10.1016/j.
msksp.2018.06.002
6. Henschke N, Maher CG, Ostelo RW, de Vet HC, Macaskill P, Irwig L. Red flags to screen for malignancy in patients with low-back pain. Cochrane Database Syst Rev.
2013:CD008686. https://doi.org/10.1002/14651858.CD008686.pub2
7. Henschke N, Maher CG, Refshauge KM, et al. Prevalence of and screening for serious spinal pathology in patients presenting to primary care settings with acute low back
pain. Arthritis Rheum. 2009;60:3072-3080. https://doi.org/10.1002/art.24853
8. McCarthy J, Davis A. Diagnosis and management of vertebral compression fractures. Am Fam Physician. 2016;94:44-50.
9. Parreira PCS, Maher CG, Megale RZ, March L, Ferreira ML. An overview of clinical guidelines for the management of vertebral compression fracture: a systematic review.
Spine J. 2017;17:1932-1938. https://doi.org/10.1016/j.spinee.2017.07.174
10. Public Health England. Tuberculosis in England: 2019 Report (presenting data to end of 2018). London, UK: Public Health England; 2019.
11. Royal Osteoporosis Society. Clinical guidance for the effective identification of vertebral fractures. Available at: https://www.guidelines.co.uk/musculoskeletal-and-joints-/
ros-guideline-identification-of-vertebral-fractures/454148.article. Accessed April 16, 2020.
12. Verhagen AP, Downie A, Popal N, Maher C, Koes BW. Red flags presented in current low back pain guidelines: a review. Eur Spine J. 2016;25:2788-2802. https://doi.
org/10.1007/s00586-016-4684-0
13. Williams CM, Henschke N, Maher CG, et al. Red flags to screen for vertebral fracture in patients presenting with low-back pain. Cochrane Database Syst Rev.
2013:CD008643. https://doi.org/10.1002/14651858.CD008643.pub2
14. Yusuf M, Finucane L, Selfe J. Red flags for the early detection of spinal infection in back pain patients. BMC Musculoskelet Disord. 2019;20:606. https://doi.org/10.1186/
s12891-019-2949-6
with no relief
• Patient reports gradual onset before
age 40
Infection • Older age • Abscess • Patient reports stiffness • CT scan
• Spinal trauma • Paralysis • Patient reports feeling of tenderness
• Male sex • Active bacterial/fungal infection • Patient reports radiculopathy
• Lives in rural area • Sepsis/septic shock • Patient reports bladder/bowel dys-
• Ingestion of unpasteurized dairy • Weight loss (at least 4 kg) function
product • Observed spinal deformity • Patient reports urinary incontinence
• Blood pressure dysfunction • Anorexia (BMI, ≤19 kg/m2) • Weakness/extreme weakness
• Hepatosplenomegaly (liver and spleen • Arthralgia
enlargement) • Myalgia
Journal of Orthopaedic & Sports Physical Therapy®
• Anorexia
Abbreviations: BMI, body mass index; CES, cauda equina syndrome; CT, computed tomography.