Red Flags For Low Back Pain, Or Clinical Decision Making?
It’s only happened a couple of times in my career.
You know that feeling you get when something just isn’t right? You’re not quite sure what it is, but something just seems off?
Twice I’ve had people come in where their pain and limited mobility had me questioning if they needed a trip to the emergency room. In one instance I called a family member who took the patient in, and everything checked out fine.
The other instance, the persons low back pain was so extreme, it just didn’t add up. There was no history of trauma or anything else that suggested the hospital was necessary, but I could barely touch the patient during the treatment because their low back was so sensitive. Afterward, I recommended seeing a doctor, or emergency room, but they refused. I never saw them again, so I’m not sure what the outcome was.
So how do we know when low back pain is an emergency, or just really painful?
Traumatic Injuries And The RTC
In old First Aid terms, there were criteria we would use at the scene of an accident to quickly decide if a patient had to have spinal immobilization used and if they needed to be immediately sent to the hospital.
It was called the RTC (Rapid Transport Category), and it was a simple list which made it easier to decide how to provide the appropriate care to a patient. While this isn’t as useful in a clinical setting, it could be invaluable in a sport, or outreach setting if some type of emergency were to happen and you are required to provide care. In a clinical setting, it would be helpful during your patient interview in case you weren’t quite sure why a patient is having the issues they are presenting with.
The RTC criteria include quite an extensive list of things to watch for. Not all of them would be applicable to us, but here are some that would be:
- Mechanism of injury
- Fall from greater than 20ft
- High-speed accident
- Pedestrian struck at speeds higher than 30 km/hour
- Broken windshield damaged steering wheel, or airbags deployed
- A rollover accident
- Severe crush injuries
- Any other people involved in the accident that result in a fatality
- Electrical injuries (we always assume spinal damage with electrocution)
- Anatomy of injury
- Severe brain injury
- Penetrating injuries to anything but the limbs
- Depressed skull fracture
- Pregnant woman with fairly moderate trauma
- Findings in the Primary Survey
- Decreased level of consciousness
- Cardiac arrest
- Suspected heart attack
- Status Epilepticus
Particularly for us in the clinical setting the mechanism of injury should be one category to take note of. Hopefully, if someone has been through an accident that traumatic, they have already been to the emergency room, or at least a doctor to be checked out, but this doesn’t always happen. Sometimes a patient may play it off and just think they need to see a chiro, physio, or massage therapist and book in with you before ever seeing a doctor, or even calling 9-1-1 after an accident.
I’m sure we all see patients on a regular basis who have been in a car accident. Knowing those above criteria and being able to ask some of those specific questions in your interview may give you a better idea as to how severe their injuries could be. Or, if they played it off and haven’t been checked out, you may want to refer them to a doctor just to be safe.
Whenever I teach a first aid course we talk about the signs and symptoms of a heart attack. This is where there could be a bit of a red flag, as it is quite common for women to experience back pain associated with a heart attack. However, it would be back pain combined with other symptoms like chest pain, nausea and vomiting, sweating, and shortness of breath.
This is certainly part of our role as healthcare professionals to recognize and help our patients if this is happening.
The Red Flags Of Low Back Pain
There seems to be a wide array of information on the red flags of acute low back pain.
Most of the concern is driven toward four issues:
- Cauda Equina Syndrome
One red flag that is unrelated to specific disease was the onset of pain in patients under 20 years old. However, one study actually calls this a “dubious distinction” and shows that age alone combined with pain is not enough to be considered a red flag, as most of the participants in the study were diagnosed with non-specific mechanical spinal pain.
When we look at the risk factors associated with spinal fractures, most information cites major or significant trauma, age, a history of osteoporosis, and the use of corticosteroids as the red flags to look out for. A systematic review showed that all of the above combined with the presence of a contusion brought the probability of a fracture up from 4% to a range between 9 and 62%. An Australian study showed that when three red flags (female, over 7o years of age, severe trauma, and use of corticosteroids) were all present, the chance of a fracture went from 4% to 90%. So, when looking at red flags for fractures, one red flag alone is not likely an issue, but a combination of the red flags is more likely to result in a fracture.
The commonly used red flags for infection were:
- Use of corticosteroids or immunosuppressant therapy
- IV drug use
- Pain worse at night
- Night and rest pain
- Tenderness over the spinous process
But the same systematic review showed that there is a lack of standardization with these red flags, and the risk of serious disease in patients with low back pain is less than 0.1%.
The same can be said for malignancy, as the one big red flag, in this case, is a history of cancer. Yet “history of cancer” isn’t clear enough as it doesn’t specify how long ago the person was diagnosed or the type of cancer they had. There are several cancer types that apparently put a person at greater risk for spreading to the spine, but if the person didn’t have one of those types, or had it 20 years ago, the likelihood of spinal malignancy is probably a lot less than someone diagnosed recently.
The two most common red flags with Cauda Equina were saddle anesthesia (perineal numbness) and sudden onset of bladder dysfunction. Either way, I’d be referring out for that!
One thing that came out of most of the studies I could find was one resonating point. Clinical decision making and judgment of the therapist to determine if the patient needs to be referred out is more reliable than the list of red flags. So in other words, when in doubt, refer out! There are some other things to take into account with this whole red flag discussion and one review makes a great point as to why screening for red flags isn’t reliable. As practitioners, we don’t actually screen, we manage low back conditions. They actually encourage watchful waiting for changes in symptoms, as evidence is showing that early intervention with low back pain may actually be more harmful.
One thing I hadn’t ever heard of was “yellow flags,” however, I found it encouraging that it was mentioned in a paper from rheumatologists. They listed these yellow flags as:
- A belief that back pain is harmful or disabling
- Fear of pain and movement avoidance
- Tendency to low mood and withdrawal from social interaction
- Expectation of passive treatments rather than believing active participation helps
Biopsychosocial approach anyone? It’s great to see these “yellow flags” being mentioned with the same importance as the dreaded red flags.
Overall, it is probably good to be aware of those red flags to help guide your clinical decision making, but they aren’t the be all end all like we once thought they were. The valuable thing will be your judgment call and also making sure to monitor your patients progress. If your spidey senses start tingling, and something doesn’t seem right, don’t hesitate to refer out, it’s better safe than sorry.