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Red flags to screen for malignancy and fracture in patients with low back pain: systematic review

BMJ 2013; 347 doi: (Published 11 December 2013) Cite this as: BMJ 2013;347:f7095

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  1. Aron Downie, PhD student12,
  2. Christopher M Williams, honorary research fellow1,
  3. Nicholas Henschke, research fellow13,
  4. Mark J Hancock, senior lecturer4,
  5. Raymond W J G Ostelo, professor5,
  6. Henrica C W de Vet, professor of clinimetrics6,
  7. Petra Macaskill, professor of biostatistics7,
  8. Les Irwig, professor of epidemiology8,
  9. Maurits W van Tulder, professor9,
  10. Bart W Koes, professor10,
  11. Christopher G Maher, director1
  1. 1George Institute for Global Health, University of Sydney, Sydney, NSW, 2050, Australia
  2. 2Faculty of Science, Macquarie University, Sydney, Australia
  3. 3Institute of Public Health, University of Heidelberg, Germany
  4. 4Faculty of Human Sciences, Macquarie University, Sydney, Australia
  5. 5Department of Health Sciences, EMGO Institute for Health and Care Research, VU University, Amsterdam, Netherlands
  6. 6Department of Epidemiology and Biostatistics, EMGO Institute for Health and Care Research, VU University Medical Centre, Amsterdam
  7. 7Screening and Test Evaluation Program (STEP), School of Public Health, Sydney
  8. 8School of Public Health, University of Sydney, Sydney, Australia
  9. 9Department of Health Sciences, Faculty of Earth and Life Sciences, VU University, Amsterdam, Netherlands
  10. 10Department of General Practice, Erasmus Medical Centre, Rotterdam, Netherlands
  1. Correspondence to: A Downie, George Institute for Global Health, University of Sydney, PO Box M201, Camperdown, Sydney, NSW, 2050, Australia adownie{at}
  • Accepted 18 November 2013


Objective To review the evidence on diagnostic accuracy of red flag signs and symptoms to screen for fracture or malignancy in patients presenting with low back pain to primary, secondary, or tertiary care.

Design Systematic review.

Data sources Medline, OldMedline, Embase, and CINAHL from earliest available up to 1 October 2013.

Inclusion criteria Primary diagnostic studies comparing red flags for fracture or malignancy to an acceptable reference standard, published in any language.

Review methods Assessment of study quality and extraction of data was conducted by three independent assessors. Diagnostic accuracy statistics and post-test probabilities were generated for each red flag.

Results We included 14 studies (eight from primary care, two from secondary care, four from tertiary care) evaluating 53 red flags; only five studies evaluated combinations of red flags. Pooling of data was not possible because of index test heterogeneity. Many red flags in current guidelines provide virtually no change in probability of fracture or malignancy or have untested diagnostic accuracy. The red flags with the highest post-test probability for detection of fracture were older age (9%, 95% confidence interval 3% to 25%), prolonged use of corticosteroid drugs (33%, 10% to 67%), severe trauma (11%, 8% to 16%), and presence of a contusion or abrasion (62%, 49% to 74%). Probability of spinal fracture was higher when multiple red flags were present (90%, 34% to 99%). The red flag with the highest post-test probability for detection of spinal malignancy was history of malignancy (33%, 22% to 46%).

Conclusions While several red flags are endorsed in guidelines to screen for fracture or malignancy, only a small subset of these have evidence that they are indeed informative. These findings suggest a need for revision of many current guidelines.


  • This review is adapted from two Cochrane reviews.4 5

  • Contributors: Conception and design: AD, CGM, MJH, CMW, NH. Analysis and interpretation of the data: AD, CGM, MJH, CMW, NH, RWO, HCWdV, PM, LI. Drafting of the article: AD, CGM, MJH, CMW, NH. All authors critically revised the article for important intellectual content and approved the final article. Statistical expertise: RWO, HCWdV, PM, LI, CGM. Administrative, technical, or logistic support: CGM, MJH. Collection and assembly of data: AD, CGM, MJH, CMW, NH. CGM is guarantor.

  • Funding: This research received no specific grant from any funding agency in the public, commercial, or not-for-profit sectors.

  • Competing interests: All authors have completed the ICMJE uniform disclosure form at and declare: no support from any organisation for the submitted work; no financial relationships with any organisations that might have an interest in the submitted work in the previous three years; no other relationships or activities that could appear to have influenced the submitted work.

  • Ethical approval: Not required.

  • Declaration of transparency: The lead author (Aron Downie) affirms that the manuscript is an honest, accurate, and transparent account of the study being reported; that no important aspects of the study have been omitted; and that any discrepancies from the study as planned have been explained.

  • Data sharing: No additional available.

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