Mike: Hello, I'm Mike Clarke, podcast editor for the Cochrane Library. The Cochrane Library contains many reviews relevant to the management of low back pain, one of the common health problems in the world. This includes reviews of what to look out for when someone presents with low back pain and the review of red flags that would highlight the need to screen for a spinal fracture was updated in August 2023. Here's Chris Han from the Institute for Musculoskeletal Health and the University of Sydney in Australia to describe the latest findings.

Chris: Low back pain is the world's leading cause for years lived with disability. However, it's uncommon for presentations to be due to a serious underlying condition, such as cauda equina syndrome, spinal tumours, or cancer. For example, among 1000 patients presenting to primary care or general practice with low back pain, between 10 and 50 would have serious spinal pathology. In the emergency care setting, these proportions are believed to be 25 to 51 per thousand. In both settings, vertebral fractures are the most common serious pathologies and include vertebral traumatic fractures, vertebral stress fractures, and acute osteoporotic vertebral compression fractures.
Red flags for spinal fractures are signs and symptoms identified by a healthcare professional that suggest a higher likelihood that the low back pain is due to a spinal fracture. Their accuracy is important because if they lead to many false alarms, people without a spinal fracture may undergo unnecessary imaging but, on the other hand, missing a spinal fracture will result in a delay in receiving treatment and may lead to worse outcomes.
We updated the previous Cochrane Review, which was published in 2013, to identify the most informative red flags to screen for spinal fractures. We included studies that compared results of history taking, physical examination or both with results from imaging to identify spinal fractures in people with low back pain.
We found 14 studies that had investigated different red flags, but most of these were not accurate or useful. In the primary care setting, 'trauma' was the most informative red flag to screen for 'unspecified spinal fracture' and 'osteoporotic spinal fracture', while 'older age' was best to screen for 'unspecified spinal fracture'. While 'corticosteroid use' may be useful as a red flag to screen for 'unspecified spinal fracture' and 'osteoporotic spinal fracture'. When used as part of a combination of index tests, red flags are more informative than single tests. For example, 'older age and female gender' is informative to screen for 'unspecified spinal fracture'.
In the secondary care setting, when specialists or consultants would check the patient, 'trauma' as a red flag is best to screen for 'unspecified spinal fracture' and 'older age' for 'osteoporotic spinal fracture'. Once again, red flags as part of a combination of index tests, such as 'older age and trauma', are better than single tests.
Finally, in the tertiary care setting, such as in an emergency department, 'presence of contusion/abrasion' was the best red flag to screen for 'spinal compression fracture'.
In summary, we found that the four most useful red flags were corticosteroid use, person's age, trauma, and a contusion or abrasion; and that combinations seem to be more informative than single red flags. Unfortunately, though, we are not able to definitively solve the challenge of providing clear guidance on which red flags to use routinely because of the limited data available, and further research remains needed.

Mike: If you would like to read this first update of the Cochrane Review and watch for further updates if that research gets done, just go online to Cochrane Library dot com and search 'red flags and low back pain' to find it.