Intended for healthcare professionals


Red flags for back pain

BMJ 2013; 347 doi: (Published 12 December 2013) Cite this as: BMJ 2013;347:f7432
  1. Martin Underwood, director, Warwick Clinical Trials Unit1,
  2. Rachelle Buchbinder, professor, Department of Epidemiology and Preventive Medicine, School of Public Health and Preventive Medicine, Monash University 2
  1. 1Warwick Medical School, University of Warwick, Coventry CV4 7AL, UK
  2. 2Monash Department of Clinical Epidemiology, Cabrini Hospital, Cabrini Medical Centre, Malvern, VIC 3144, Australia
  1. m.underwood{at}

A popular idea that didn’t work and should be removed from guidelines

Nearly all guidelines on low back pain have stressed the importance of red flag signs—positive answers to key questions about medical history that indicate the possibility of a serious underlying condition—since the publication of influential reports in the United Kingdom and United States in 1994.1 2 In a linked systematic review (doi:10.1136/bmj.f7095), Downie and colleagues challenge this orthodoxy by investigating the accuracy of red flags to screen for fracture or cancer in people presenting with low back pain.3

Although intended to prompt clinicians to think about the possibility of serious conditions such as cancer, infection, or fracture, it is worrying that doctors are advised to investigate or refer patients on the basis of the presence or absence of red flags alone. For example, a BMJ 10 Minute Consultation on chronic back pain advised that “If red flag signs are present refer [patient] to a specialist for further evaluation.”4 NHS clinical knowledge summaries advise “Further investigation and referral with appropriate urgency may be indicated, and should always be considered, if one or more red …

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