Remote Screening for Lumbar Spine Red Flags
Introduction
Clinical findings that increase the level of suspicion that there is a serious medical condition described as red flags (Finucane L. 2020), They are key for patient safety so often a component of clinical guidelines for the assessment and management of people with low back pain (Ferguson, Morison and Ryan, 2015). Red flags are features from a patient's subjective and objective assessment which are thought to put them at a higher risk of serious pathology and warrant referral for further diagnostic testing (Delitto, George, and Godges. 2012).
Physiotherapists understanding of red flags for low back pain
The role of physiotherapists as primary identifiers of red flags has grown owing to the spread of self‐referral services (Holdsworth et al., 2006). Physiotherapists often exists without any medical input or review (Kersten et al., 2007; McPherson et al., 2006). Therefore, there is a need to ensure that physiotherapists have a good understanding of individual red flags, understand their importance, and can ask these questions in a clear and unambiguous manner. Similarly, physiotherapists must have a clear understanding and agreed pathways of care dependent on these findings. Failure to do so raises issues around patient safety and professional reputation.
Epidemiology of Red flags
One study aimed to investigate which red flags do physiotherapists routinely record; which red flags do they consider to be most important; how would they define each red flag; and how they would ask each red‐flag question to a person with back pain (Ferguson, Morison and Ryan, 2015). 98 physiotherapists responded to the survey, 84% worked exclusively in the National Health Service (NHS). They recorded that ‘Previous history of cancer’, ‘saddle anaesthesia’ and ‘difficulty with micturition’ were the red flags with the highest level of importance attached to them to rise suspicion to serious pathologies. Definitions of were as follows, history of cancer: ‘an individual who has previously been diagnosed with cancer’. And Saddle anaesthesia: Since your symptoms commenced, have you noticed any pins and needles or numbness around your back passage or genital area’. Finally, limited consensus was found in how physiotherapists asked patients about red flags. However, one theme in ponticular emerged, which is the use of nebulous terminology - for example, the terms recent, weight loss and prolonged period.
Cauda Equina
Cauda Equina Syndrome (CES) is a challenging condition to diagnose and manage. It may present at any time or in any setting and it is imperative that clinicians are able to quickly reason through their findings to manage the patient effectively. There are many causes of CES, but the most common cause is that of a lumbar spine disc herniation and it occurs most frequently between the ages of 31–50 (Fuso et al., 2013). CES compression usually occurs as a result of a disc prolapse, often at the L4/5 level (Fraser et al., 2009). However, any space-occupying lesion, such as spinal stenosis, tumour, cysts, infection, or bony ingress can narrow the spinal canal and cause compression of the CES.
In 1994, The Clinical Standards Advisory Group suggested that serious pathology comprised just 1% of all back pain, with CES being just one of the many serious conditions that can lead to back pain (Verhagen et al., 2016). Despite CES being estimated to have a very low prevalence, it is considered to be a major problem internationally and multiple National Guidelines for the management of low back pain refer to the importance of screening for CES (Verhagen et al., 2016). CES red flags
The presence of red flags may indicate underlying CES in patients with low back pain. Current guidelines often present a list of red flags, which are considered to be associated with an increased risk of the presence of CES, often without consideration given to the diagnostic accuracy of the red flag. While most guidelines recommend screening for red flags, there is variation in which red flags are endorsed, and there exists heterogeneity in precise definitions of the red flags.
References
Delitto, A., George, S. and Godges. J, 2012. Low Back Pain Clinical Practice Guidelines Linked to the International Classification of Functioning, Disability, and Health from the Orthopaedic Section of the American Physical Therapy Association. Journal of orthopaedics and sports physical therapy. 42(4), pp. 57
Ferguson, F.C., Morison, S. and Ryan, C.G., 2015. Physiotherapists' understanding of red flags for back pain. Musculoskeletal care, 13(1), pp.42-50.
Finucane L. 2020. An Introduction to Red Flags in Serious Pathology. Fraser, S., Roberts, L. and Murphy, E., 2009. Cauda equina syndrome: a literature review of its definition and clinical presentation. Archives of physical medicine and rehabilitation, 90(11), pp.1964-1968.
Fuso, F.A.F., Dias, A.L.N., Letaif, O.B., Cristante, A.F., Marcon, R.M. and de Barros Filho, T.E.P., 2013. Epidemiological study of cauda equina syndrome. Acta ortopedica brasileira, 21(3), p.159.
Holdsworth, L.K., Webster, V.S., McFadyen, A.K. and Scottish Physiotherapy Self-Referral Study Group, 2006. Self-referral to physiotherapy: deprivation and geographical setting: is there a relationship? Results of a national trial. Physiotherapy, 92(1), pp.16-25.
Kersten, P., McPherson, K., Lattimer, V., George, S., Breton, A. and Ellis, B., 2007. Physiotherapy extended scope of practice–who is doing what and why?. Physiotherapy, 93(4), pp.235-242.
McPherson, K., Kersten, P., George, S., Lattimer, V., Breton, A., Ellis, B., Kaur, D. and Frampton, G., 2006. A systematic review of evidence about extended roles for allied health professionals. Journal of health services research & policy, 11(4), pp.240-247.
Todd, N.V., 2017. Guidelines for cauda equina syndrome. Red flags and white flags. Systematic review and implications for triage. British journal of neurosurgery, 31(3), pp.336-339.
Verhagen, A.P., Downie, A., Popal, N., Maher, C. and Koes, B.W., 2016. Red flags presented in current low back pain guidelines: a review. European Spine Journal, 25(9), pp.2788-2802.
