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.

COVID-19 & Remote Consultations

Coronavirus disease (COVID-19) is an infectious respiratory disease which spreads primarily through saliva and respiratory droplets when an infected person sneezes or coughs. Although the majority of people infected will only experience mild to moderate respiratory illness, the elderly and those with underlying health conditions are more likely to suffer from severe illness. There has been over 4.5 million confirmed cases which has resulted in over 300,000 deaths globally (WHO, 2020).

The R value is estimated to be between 1.4 and 2.5 which makes this disease more contagious than the influenza virus (Liu et al., 2020). This has forced healthcare services to rapidly implement alternative models of care to avoid face-to-face contact between patient and clinician (Greenhalgh et al., 2020). Therefore, guidelines have been released for remote consultations based on current evidence evaluating its effectiveness (CSP, 2020; NHS, 2020).

A systematic review (SR) by Cottrell et al (2017) compared the effectiveness of telerehabilitation (defined by phone call and/or video consultations) and face-to-face consultations within a physiotherapy musculoskeletal (MSK) setting. The results were equally effective on the physical function of patients (SMD MD 0.14, 95% CI -0.10-0.37) which is similar to the findings of another SR by Shukla et al (2016).

Qualitative studies have also provided an insight into patient and clinician experiences during remote consultations. Positive feedback included, time convenience, cost efficient, easy to use technology, home environments, empowering self-management and taking away the stigmatisation of ‘hands on’ therapy for treating low back pain (Hinman et al., 2017; Synott et al., 2015).

The evidence greatly supports the use of remote consultations therefore, it is important to discuss how MSK physiotherapists can successfully identify and screen patients for red flags when presenting with low back pain during remote consultations. 

Low Back Pain Red Flag

Back pain is common in the UK with a lifetime chance of occurrence of 59% (GP online, 2008.) The majority of back pain clears up quite quickly; however, back pain experienced along with ‘red flag’ symptoms may have a serious underlying cause.

This page discusses the clinical indicators for:

·       Cauda Equina Syndrome

·       Malignancy (Cancer)

·       Vertebral Fractures

·       Infection 

Cauda Equina

Cauda equina syndrome (CES) is a rare but potentially devastating neurological condition affecting the bundle of nerve roots at the lower end of the spinal cord called the cauda equina (CE). The CE is responsible for the innervation of the lower limbs, control of the sphincter, regulation and function of the bladder and distal bowel and sensation to the skin around the bottom and back passage (Shim, Park and Lee, 2009).

There is large debate over CES, consequently there is no agreed definition, however, the British Association of Spinal Surgeons (BASS) present a definition that is useful in clinical practice.Tsiang et al. (2019)

'A patient presenting with acute back pain and/or leg pain with a suggestion of a disturbance of their bladder or bowel function and/or saddle sensory disturbance should be suspected of having a CES. Most of these patients will not have critical compression of the cauda equina. However, in the absence of reliably predictive symptoms and signs, there should be a low threshold for investigation with an emergency scan’ (Germon et al., 2015).

Epidemiology

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). Cauda equina 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 cauda equina.

Published estimates of the incidence for CES are fewer than one per 100 000 population (Hurme et al., 1984; Podnar, 2007). However, in 2010–2011 in England, 981 surgical decompressions were performed for CES (The National Spinal Taskforce, 2013) and the population was estimated at 52 234 000 (Office for National Statistics, 2011) giving an incidence of 1.9 per 100 000. Therefore, there may be over 1000 patients managed for CES in the UK each year.

In a primary care setting, ‘Table 1’ highlights the incidence of diagnosed patients with CES in the UK 2018/19 (Barnes, 2019).

Condition	Number of primary diagnoses	% of total cases
Low Back Pain	45,520	0.04%
Cauda Equina Syndrome	170	0.0%
Malignant Neoplasm: Cauda Equina	58	0.0%

Prognosis

The prognosis for complete recovery is dependent upon many factors. The most important of these is the severity and duration of compression upon the damaged nerve(s). Generally, the longer the time before intervention to remove the compression causing nerve damage, the greater the damage caused to the nerve(s). Similarly, Kennedy et al. (1999), describes the most important factor identified in this series as predictors of a favourable outcome in CES was an early diagnosis, This highlights to importance of understanding and identifying red flags. 

Clinical Indicators

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, however, there is variation in which red flags are endorsed, and there exists heterogeneity in precise definitions of the red flags.

Premkumar et al. (2018) and Tsiang et al. (2019) identified various clinical indicators of CES that should be screened for during the assessment of these patients. Premkumar et al. (2018) reported the combination of recent loss of bladder control and recent loss of bowel control produced a specificity of 97.4%. both studies highlighted, while although these indicators were relatively specific, all of red flag questions were poorly sensitive in identifying their diagnoses of interest.  

Premkumar et al. (2018). 

Indicator	Sensitivity (%)	Specificity (%)
Recent loss of bladder control	22.2	90.4
Recent loss of bowel control	13.9	95
Combination: Recent loss of bladder and bowel control	8.3	97.2

Tsiang et al. (2019) 

Indicator	Sensitivity (%)	Specificity (%)
Urinary retention	30.3	96.2
Incontinence	50	86.5
Saddle numbness	0	94.7
Weakness in limbs	67.7	53.2

Malignancy

The spinal cord may be compressed due to tumours occupying space within the vertebral canal (Gilbert et al. 1978). This may then affect the neural function of the spinal cord causing unremitting pain, muscle power and sensation alteration, sexual dysfunction, bladder/bowel dysfunction and sleep disturbances (cancerresearchuk.org, 2020).

Epidemiology

Tumours are classified as primary, originating in the spine, and secondary, originating elsewhere in the body and spreading to the spine (cancerresearchuk.org). Secondary tumours are much more prevalent than primary tumours. They occur in approximately 70% of cancer patients (Ciftdemir et al. 2016) whereas primary tumours occur in approximately 0.07% of healthy people (Schellinger et al. 2008). The most common types of primary tumours are meningiomas (29%), nerve-sheath tumours (24%) and ependymomas (23%) (Schellinger et al. 2008).  Secondary tumours can metastasise from many different areas of the body; most commonly they may spread from breast, lung and prostate primary tumours (John Hopkins Medicine, 2020).

In a primary care setting, malignancy is extremely rare. ‘Table 1’ highlights the incidence primary diagnoses given that may result in low back pain within NHS primary care settings in the UK in 2018/19. 96,420,114 patients were seen in total (Barnes, 2019).

Condition	Number of primary diagnoses	% of total cases
Low back pain	45,520	0.04%
Malignant neoplasm: Vertebral column	136	0.00%
Malignant neoplasm: Connective and soft tissue of trunk	85	0.00%
Malignant neoplasm: Spinal meninges	1	0.00%
Malignant neoplasm: CNS unspecified	233	0.00%
Malignant neoplasm of other and ill-defined sites: Lower limb	74	0.00%
Secondary malignant neoplasm of other unspecified parts of the nervous system	158	0.00%
Secondary malignant neoplasm of bone and bone marrow	17,629	0.02%

Prognosis

Around 10-20% of patients diagnosed with spinal metastasis live for longer than two years after this diagnosis (Delank et al. 2011). Better prognoses and longer survival rates have been associated with earlier detection of the tumour (Ruckdeschel, 2005). Therefore, it is important to screen patients with low back pain for red flags associated spinal malignancy.

Clinical Indicators

When assessing patients with low back pain, there are a number of ‘red flags’ which may increase suspicion of spinal malignancy. Large scale studies by Henschke et al. (2013), Premkumar et al. (2018) and Tsiang et al. (2019) have identified numerous clinical indicators of malignancy that should be screened for during the assessment of these patients.

These studies accept that no single ‘red flag’ can be used in isolation to give a diagnosis of spinal malignancy. Instead, a combination may increase a clinician’s index of suspicion. The literature stated that patient-reported history of cancer, alongside low back pain, was identified as the most significant sign of spinal malignancy. Interestingly, Premkumar et al. (2018) reported that a past medical history of cancer, combined with unexplained weight loss, produced a specificity of 99.8%. The summary of findings from these studies is detailed in table X below.

Indicator	Sensitivity (%)	Specificity (%)
Age >50	71.7	32.6
Age >70	22.6	79.5
Night pain	54.2-55.4	41.8-49.6
Unexplained weight loss	8.2	95.6
Pain at rest	25	69.8
Urinary retention	4.2	95.8
History of cancer	32-75	78.7-95.6
History of cancer + Unexplained weight loss	2.5	99.8

A Cochrane review carried out by Henschke et al. (2013) examining studies containing over 6000 patients emphasised the need for an affective diagnostic test to assist in the identification of spinal malignancy in patients with low back pain.

Vertebral fractures

Of the 96,420,114 patients who were assessed in an NHS primary care setting in 2019, only 524 were diagnosed as having a Lumbar vertebral fracture. There were 498 diagnosed with a Fracture of other and unspecified parts of lumbar spine and pelvis, and 10 diagnosed with Multiple fractures of Lumbar spine and pelvis (NHS digital, 2019).

The actual incidence of vertebral fractures is likely much greater given the large number of vertebral fractures that go undetected. More than two-thirds of patients with Vertebral fractures are asymptomatic, and are diagnosed incidentally (Fink, 2005). Symptomatic patients may report abrupt onset of pain with position changes, coughing, sneezing, or lifting. Physical examination findings are often normal but may demonstrate kyphosis and midline spine tenderness.

A vertebral fracture not only requires specific appropriate treatment, but is a contraindication to spinal manipulative therapy, a common treatment that is endorsed in clinical practice guidelines for acute nonspecific low back pain. Therefore, accurate diagnosis in primary care is essential to prevent poor outcome

Epidemiology

Ballane (2017) investigated the prevalence and incidence of vertebral fractures worldwide using a total of 62 articles of fair to good quality and comparable methods for vertebral fracture identification were considered. Graphs A and B display age-standardized incidence rates in men and women combining hospitalized and ambulatory vertebral fractures, ranked by descending incidence. Standardization to 2010 UN population (a) and 2015 UN population (b).

(Ballane,. 2017)

Rates partially depend on the definition of vertebral fracture, clinical versus morphometric. The morphometric definition is not universal; at least seven methods have been used in different studies (included in Graphs A and B). Within the same method, varying decision thresholds (fracture grade or standard deviation from means) make the definition of vertebral fracture even more difficult. Different definitions include of vertebral fracture include: - Morphometric method - McCloskey method - Eastell method - Genant Method - Davies method - Melton method - Denis Classification

Diagnosis

In the primary care setting, between 1% and 5% of all patients who present with LBP will have a serious spinal pathology which requires further assessment and often specific treatment (Deyo 1992; Henschke 2009). The most common of these serious spinal pathologies which initially manifests as LBP is vertebral fracture, followed by malignancy, infection, and inflammatory disease. The presence of a "red flag" should alert clinicians to the need for further examination and in most cases, specific management (Waddell 2004). With respect to vertebral fractures, the typical “red flags” include >50 years of age, prolonged corticosteroid use, trauma and Osteoporosis. High quality evidence investigating the efficacy of these “red flags” correctly identifying serious pathologies has been investigated in studies such as Premkumar et al. (2018) and Tsiang et al. (2019).

Osteoporosis	Steroid Use	Trauma	Sensitivity (95% CI)	Specificity (95% CI)	TP (%)	FP (%)	FN (%)	TN (%)
X			.415 (.281-.559)	.762 (.719-.802)	4.6	21.1	6.5	67.7
	X		.283 (.168-.423)	.867 (.831-.898)	3.2	11.8	8.0	77.0
		X	.226 (.123-.362)	.938 (.911-.959)	2.5	5.5	8.6	83.3
X	X		.528 (.386-.667)	.694 (.647-.737)	5.9	27.2	5.3	61.6
X		X	.509 (.368-.649)	.713 (.667-.755)	5.7	25.5	5.5	63.3
	X	X	.415 (.281-.559)	.815 (.774-.851)	4.6	16.5	6.5	72.4
X	X	X	.585 (.441-.719)	.648 (.601-.694)	6.5	31.2	4.6	57.6

Tsiang et al. (2019).

Premkumar et al. (2018)

Premkumar et al. (2018)

The presence of both recent trauma and an age of >50 years carries a 13.1% probability of a vertebral fracture in the setting of low back pain; Tsiang et al. (2019). The presence of both recent trauma and an age of >70 years carries a 20.5% probability of vertebral fracture in the setting of low back pain. Tsiang et al. (2019).

Clinical implications

There is agreement in the current literature the findings give rise to a weak recommendation that a combination of a small subset of red flags may be useful to screen for vertebral fracture. It should also be noted that many red flags have high false positive rates; and if acted upon uncritically there would be consequences for the cost of management and outcomes of patients with LBP.

Infection

Infections can often masquerade as MSK conditions of the lower back. Specifically, spinal infection (SI) is a term used to describe infectious diseases of the intervertebral discs, vertebral body and the paraspinal tissues (Nickerson and Sinha, 2016). SI can develop through open trauma, surrounding areas which are infected and through bacteria entering the blood circulation spreading throughout the body (Calhoun and Manring, 2005). Evidence has shown that infections can cause redness of the skin, swelling, pain, heat, raised temperature and raised vital signs (NICE, 2020).

Epidemiology

According to Duarte and Vaccaro (2013), SI accounts for 2-7% of all MSK infections. A Japanese national figure database estimated the incidence of vertebral osteomyelitis to range from 5.3/100,000 to 7.4/100,000 population per year between 2007 and 2010 (Akiyama et al., 2013). Postoperative SI is a common complication following spinal surgery. The incidence of SI post spinal surgery is reported to be between 0.1% to 6.7% (Dessy et al., 2017).

Similarly to CES and malignancy, spinal infections are exceptionally rare within the primary care setting. This is highlighted in Table … which demonstrates the incidence primary diagnoses of infections which can lead to low back pain within an NHS primary care setting in the UK in 2018/2019 (ref…).

Condition	Number of primary diagnoses	% of total cases
Low back pain	45,520	0.00%
Osteomyelitis of vertebra	63	0.00%
Osteomyelitis, unspecified	1558	0.00%
Infection of intervertebral disc (pyogenic)	6	0.00%
Discitis, unspecified	175	0.00%
Infective myositis	65	0.00%
Pyogenic arthritis, unspecified	359	0.00%
Meningitis, unspecified	75	0.00%
Infection following a procedure, not elsewhere classified	398	0.00%
Intraspinal abscess and granuloma	13	0.00%

Prognosis

Untreated infections can cause serious life changing implications including severe neurological deficits (Lam and Webb, 2004; Inoue et al., 2013). Numerous studies have reported successful treatment rates of 50% to 91% when administered antibiotics however, mortality rate depends on the severity of co-morbidities and age (Kwon et al., 2017). By recognising the seriousness of implications if left untreated, it is of high importance that MSK physiotherapist are able to successfully screen patients for red flags associated with infection.

Clinical Indicators

It is vital for clinicians to be aware of the ‘red flags’ when assessing patients presenting with low back pain. Awareness of the clinical signs and symptoms of serious pathologies such as infections, will allow the clinician to ask the right questions. This will help rule out serious and sinister pathologies and aid your clinical decision for the most appropriate pathway for further investigation.

Large retrospective studies identified various ‘red flags’ for SI and evaluated their diagnostic accuracy in low back pain patients (Galliker et al., 2020; Premkumar et al., 2018; Tsiang et al., 2019). These studies came to the same conclusions for SI as they did malignancy, fractures and CES. They concluded that due to the low sensitivity and specificity of ‘red flags’ it would be inappropriate to base your treatment decision on a singular ‘red flag’ in isolation. However, a combination should increase the clinicians index of suspicion and be used to probe further questioning or clinically reason further investigation. Premkumar et al (2018) provided further evidence to support the dismissal of using ‘red flags’ in isolation. Other results showed that negative responses to ’red flag’ questions did not decrease the likelihood of ‘red flag’ diagnoses.

Due to the low prevalence of infection, it was difficult to assess the diagnostic accuracy of their associated ‘red flags’ (Tsiang et al., 2019). In the Premkumar et al (2018) study, ‘red flag’ indicators for infection were based on published guidelines which included fever, chills, or sweating, recent infection, pain awakens from sleep and persistent sweating at night. Fever, chills, or sweating and recent infection all significantly increase the probability of SI. A summary of the findings from these studies are detailed in table… below.

Indicator	Sensitivity (%)	Specificity (%)
Fever, chills, or sweating	11.7	93.2
Pain awakens from sleep	57.5	41.8
Persistent sweating at night	17.5	86.1
Recent infection	24.2	97.4
Night pain	37.5	49.1
Pain at rest	12.5	69.7
Fever	25.0	97.6

Yusuf et al (2019) conducted a descriptive review reporting on the characteristics of 2224 patients with SI. Interestingly, the most common clinical features were spinal pain (72%), fever (55%) and neurological dysfunction (33%). It was also found that SI was common in immunosuppressed patients due to other health conditions. The most common determinants were identified as diabetes (18%), IV drug use (9%) and recent surgery (6%). Although the diagnostic accuracy could not be tested, these findings within a large cohort are important to acknowledge to support your clinical reasoning and increase your index of suspicion.

Ultimately, screening for ‘red flag’ indicators for SI does not change when assessing patients remotely. These screening questions are part of a subjective assessment therefore, can be conducted over a number of remote models of care. Finally, an accumulation of ‘red flags’ should lead the clinicians management of these patients and prompt further questioning and investigation when needed.

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