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Table 1 Clinical guidelines regarding red flags

From: Red flags presented in current low back pain guidelines: a review

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)
Past history of malignancy; age >50 years; failure to improve with treatment; unexplained weight loss; pain at multiple sites; pain at rest
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
Fracture: Scavione et al. [51, 52]
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
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
Based on previous guidelines: USA (2008); Europe [4]; Canada (2005); Australia [17] and consensus
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
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
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
Age over 50, unexplained weight loss, history of tumor or failure of symptomatic treatment
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
Old age; history of malignancies; general symptoms: loss of weight, reduced appetite, rapid fatigue; pain, increasing in supine position; intense nocturnal pain
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
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
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
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
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
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
Based on previous guidelines: Italy [32]; UK [33]; Canada (2007); USA (2012) [27]; Chou et al. [6]; Chou et al. [38]
Spain [23]
Primary care; physiotherapy
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 is more common in older people and those with a past history of tumors known to metastasis to bone
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
Nonspecific low back pain Fractures:
Major trauma
Osteoporotic fractures:
Osteoporosis, osteoporosis risk (unspecified)
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
Immunocompromised status, urinary tract infection, intravenous drug use, fever/chills with rest or night pain
New-onset Babinski or sustained clonus, new-onset gait or balance abnormalities, upper motor neuron weakness
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]
Ankylosing spondylitis: Yu et al. [57]; Rajesh and Brent [58]