Red flags for back pain

I welcome the discussion on red flags in low back pain initiated by Underwood and Buchbinder [1], prompted by the research by Downie et al [2]. It was disappointing, however, not to have any discussion on the presentation of metabolic bone disease with low back pain. I appreciate that the initial research question related only red flags for cancer and fracture, but in at least some parts of the world metabolic bone disease is a much more common issue and treatable!

It is interesting to note that my review in the BMJ [3] specifically mentioned generalised bony pain. This review just preceded the publication of the Clinical Standards Advisory Group report on low back pain [4] (which introduced the concept of red flags to me) which did not mention metabolic bone disease in its list of serious spinal pathology. This may reflect views formed by specialists of different backgrounds. Thus Waddell in a surgical clinic found 2.1% of new referrals from primary care to have cancer and 0.7% to have infection [5]. This contrasts, but not greatly, with a cohort from a rheumatological low back pain clinic with 0.5% cancer and 0% infection respectively [6]. Waddell reported that 3.9% had ‘osteoporotic fractures’ whilst Frank reported ‘metabolic bone disease’ in 2.3% in an area of London where there was a large population of dark skinned vegetarian people.

Frank did not report any missed fracture in his cohort of 657 consecutive referrals with low back pain, although a study of 173 patients presenting with neck pain showed one missed fracture at C1 [7].

Any screening process for patients presenting with low back pain must include the ability to encourage clinicians to remember metabolic bone disease.

Reference List

(1) Underwood M, Buchbinder R. Red flags for back pain. BMJ 2014; 348: 8
(2) Downie A, Williams CM, Henschke N, Hancock MJ, Ostelo RWJG, De HCW et al. Red flags to screen for malignancy and fracture in patients with low back pain: Systematic review. BMJ 2014; 348: 12.
(3) Frank AO. Low back pain - Regular Review. BMJ 1993; 306:901-909.
(4) Clinical Standards Advisory Group - Chairman Prof M Rosen. Back Pain. 1-89. 1994. London, HMSO.
(5) Waddell G. An approach to backache. Br J Hosp Med 1982; September:187-219.
(6) Frank AO, De Souza LH, McAuley JH, Sharma V, Main CJ. A cross-sectional survey of the clinical and psychological features of low back pain and consequent work handicap: use of the Quebec Task Force Classification. Int J Clin Pract 2000; 54(10):639-644.
(7) Frank AO, De Souza LH, Frank CA. Neck pain and disability: a cross-sectional survey of the demographic and clinical characteristics of neck pain seen in a rheumatology clinic. Int J Clin Pract 2005; 59(doi: 10.1111/j.1742-1241.2004.00237.x):173-182.