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Back pain “red flags”: which are most predictive of serious pathology in the Emergency Department?

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Abstract

Purpose

To determine the frequency of red flag signs and symptoms in patients presenting with back pain to the Emergency Department (ED) and association with serious pathologies and investigations performed.

Methods

This retrospective observational study evaluated consecutive patients presenting with back pain to a Melbourne ED over a 14-month period. Data regarding red flags, patient characteristics, ED-initiated investigations, and diagnoses were extracted from medical records. Prevalence of each red flag and sensitivity, specificity, and likelihood ratios for diagnosing serious spinal or non-spinal pathology were calculated.

Results

Analysis was undertaken on 1000 eligible participants with back pain. 69% had red flags. Participants were categorised into diagnostic groups: musculoskeletal (80.6%), serious spinal (3.3%), and serious non-spinal (14.6%) pathologies. A number of red flags had positive likelihood ratios (LR) > 5, indicating a higher probability of serious pathology (spinal/non-spinal) including fever (LR + 68.8), tuberculosis history (LR + 13.8), known nephrolithiasis/abdominal aortic aneurysm (LR + 10.2), unexplained weight-loss (LR + 9.2), writhing in pain (LR + 6.9), urinary symptoms (LR + 5.4), and flank pain (LR + 5.2). Red flags with positive LR > 5 indicating a higher probability of serious spinal pathology were saddle anaesthesia (LR + 11.0), tuberculosis history (LR + 9.8), intravenous drug-use (LR + 6.9), acute-onset urinary retention (LR + 6.4), and anal tone loss (LR + 6.3).

Conclusion

The majority of this study cohort had back pain of benign cause. Some red flags were associated with greater risk of serious pathology, others were not. Further evidence regarding red flags and their association with serious pathology is required, to better inform clinical guidelines.

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Acknowledgements

This study was supported by a St Vincent’s Hospital Melbourne Research Endowment Fund (Grant no. 35.2013). The authors wish to express their gratitude to Dr Neil Cunningham, ED Physician, who generously provided advice in refinement of the red flag definition decision guide (Supplementary File 1).

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Correspondence to Bridget Shaw.

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Supplementary file1 (DOCX 26 kb)

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Shaw, B., Kinsella, R., Henschke, N. et al. Back pain “red flags”: which are most predictive of serious pathology in the Emergency Department?. Eur Spine J 29, 1870–1878 (2020). https://doi.org/10.1007/s00586-020-06452-1

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  • DOI: https://doi.org/10.1007/s00586-020-06452-1

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