[ position statement ]
LAURA M. FINUCANE, MSc, BSc, FCSP, FMACP1 • ARON DOWNIE, MPhil, BSc, MChiro2,3
CHRISTOPHER MERCER, MSc, Grad Dip Phys, PG Cert (Clin Ed), FCSP, FMACP4 • SUSAN M. GREENHALGH, PhD, MA, Phys FCSP5,6
WILLIAM G. BOISSONNAULT, PT, DPT, DHSc7 • ANNELIES L. POOL-GOUDZWAARD, PT, PhD, MT, MSc Psych8
JASON M. BENECIUK, PT, DPT, PhD, MPH9,10 • RACHEL L. LEECH, MSc, BSc6 • JAMES SELFE, DSc, PhD, MA, Grad Dip Phys, FCSP6,11
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International Framework for Red Flags
for Potential Serious Spinal Pathologies
I
dentifying serious pathology as the cause of a person’s musculoskeletal
presentation is complex. Red flags have historically been used to
help clinicians identify serious spinal pathology, and the majority
of guidelines recommend the use of red flags. However, guidelines
are not consistent about which red flags should be considered when
examining people seeking care for musculoskeletal disorders. This
has led to confusion and inconsistency in the management of people
when there is suspicion of serious pathology, and, in some cases, to unnecessary
and worrying medical tests or false reassurance that there is no serious pathology.
We aim to provide clinicians with a
more standardized and consistent approach to identifying people with potential serious spinal pathology. This
framework has been developed by researchers and clinicians to provide a
pragmatic approach for clinicians to
screen for serious spinal pathology that
U SYNOPSIS: The International Federation of Orthopaedic Manipulative Physical Therapists
(IFOMPT) led the development of a framework to
help clinicians assess and manage people who
may have serious spinal pathology. While rare,
serious spinal pathology can have devastating and
life-changing or life-limiting consequences, and
must be identified early and managed appropriately. Red flags (signs and symptoms that might
raise suspicion of serious spinal pathology) have
can masquerade as musculoskeletal spinal conditions. The framework has been
informed by available evidence and augmented by a formal consensus process
that included academics and clinicians
involved in the management of musculoskeletal conditions.
This framework aims to support a
variety of health professionals, irrespective of experience, who provide care for
people with musculoskeletal spinal conditions. Clinicians working in musculohistorically been used by clinicians to identify serious
spinal pathology. Currently, there is an absence of
high-quality evidence for the diagnostic accuracy of
most red flags. This framework is intended to provide
a clinical-reasoning pathway to clarify the role of red
flags.J Orthop Sports Phys Ther 2020;50(7):350372. Epub 21 May 2020. doi:10.2519/jospt.2020.9971
U KEY WORDS: cauda equina syndrome, clinical
reasoning, malignancy, spinal fracture, spinal
infection
skeletal services can play an important
role in early identification of serious pathology, ensuring that people achieve the
best possible outcome. The prevalence of
serious pathology will vary depending on
where in the clinical pathway the clinician has contact with the person. Spinal
surgeons likely see more cases of serious
pathology than general practitioners do,
and physical therapists probably see a
number in between, depending on where
they are on their clinical pathway. Therapists working at an advanced-practice
level are likely to see more serious pathology, as the populations they serve
are likely to have more complex presentations.86 Clinicians must consider the
context within which red flags exist, and
clinically reason the relevance of the information gathered to determine whether any action is required.
Person-Centered Care
Working with people with possible serious pathology can be challenging, and
a collaborative approach is essential. A
possible diagnosis of serious pathology
can be extremely worrying for people in
regard to their families and careers. People must be involved in decision making
Sussex MSK Partnership, Brighton, United Kingdom. 2Department of Chiropractic, Faculty of Science and Engineering, Macquarie University, North Ryde, Australia. 3Institute for
Musculoskeletal Health, School of Public Health, The University of Sydney, Sydney, Australia. 4Western Sussex Hospitals NHS Foundation Trust, Chichester, United Kingdom. 5Bolton
NHS Foundation Trust, Bolton, United Kingdom. 6Department of Health Professions, Manchester Metropolitan University, Manchester, United Kingdom. 7American Physical Therapy
Association, Alexandria, VA. 8Department of Human Movement Sciences, Faculty of Behavioral and Movement Sciences, Vrije Universiteit Amsterdam, Amsterdam, the Netherlands.
9
Department of Physical Therapy, College of Public Health and Health Professions, University of Florida, Gainesville, FL. 10Brooks Rehabilitation, Jacksonville, FL. 11Physical Therapy
Department, Satakunta University of Applied Sciences, Pori, Finland. The following organizations provided financial support for the development and dissemination of this framework:
the Canadian Academy of Manipulative Physiotherapy, Chartered Society of Physiotherapy, International Maitland Teachers Association, Musculoskeletal Association of Chartered
Physiotherapists, Private Physiotherapy Educational Foundation, and Swiss Association for Orthopaedic Manipulative Physiotherapy. The authors certify that they have no affiliations
with or financial involvement in any organization or entity with a direct financial interest in the subject matter or materials discussed in the article. Address correspondence to Laura
Finucane, Sussex MSK Partnership, 177 Preston Road, BN1 6AG Brighton, UK. E-mail: laura.finucane@nhs.net t Copyright ©2020 Journal of Orthopaedic & Sports Physical Therapy®
1
350 | july 2020 | volume 50 | number 7 | journal of orthopaedic & sports physical therapy
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about their care, even when faced with a
serious diagnosis. Shared decision making is essential to ensure that individuals are supported to make decisions that
are right for them. Using a collaborative
process, the clinician should highlight
the treatment options, evidence, risks,
and benefits and, together with the person, seek to understand how these fit
with that person’s circumstances, goals,
values, and beliefs.56
Experts by Experience: How
to Use This Framework
Clear and open communication with
people with potential serious pathology
is vital. People presenting with spinal
pain may have no concept that their
bladder or bowel function might be affected, or that the spinal pain could be
caused by serious pathologies such as infection or malignancy. Providing the reason for the questions in the framework is
an important aspect of the consultation,
as some of these questions may seem irrelevant to a person who presents with
back pain.
Effective communication about red
flags is vital. People can become worried
before an appointment, especially if they
have seen something worrying on television or the internet, heard a story from a
friend or relative, or experienced medical
misdiagnosis.
Provide reassurance about why you
are assessing for red flags, especially
when the person is likely at low risk of
having severe pathology. Consider the
wording of your questions, your body
language, tone of voice, and mannerisms
when asking the questions.
People must feel at ease when answering questions and not judged (eg,
intravenous drug use, poor social and
environmental factors). Ensure people
have sufficient time to consider and communicate their answers about something
that they may never have considered before (eg, their toilet habits and how those
may have changed).
Provide support regarding the emotional impact of being assessed for po-
tentially life-changing conditions and,
in some cases, being sent for further investigations. When asking about subjects
such as previous history of cancer, it is
particularly important to offer appropriate emotional support and, when needed,
help people find other services that can
offer further support.
How an International Framework
Can Help Clinicians
This is an internationally agreed-on
framework to aid early assessment and
initial management of people who pre­
sent with potential serious spinal pathology. These conditions, while considered
rare, can lead to devastating and lifechanging/life-limiting consequences for
people. The neurological function and
quality of life of people with metastatic
spinal cord compression (MSCC) can be
preserved with early diagnosis, by facilitating rapid access to appropriate treatment, reduction in nerve damage, and
maintenance of spinal stability.32 Substantial litigation costs can be incurred
by health care providers if serious spinal pathology is not identified early and
managed appropriately. Litigation relating to cauda equina syndrome (CES)
alone accounted for £25 million ($40
million) in claims against the National
Health Service in the United Kingdom
from 2010 to 2015.54
This international framework has
been developed on behalf of the International Federation of Orthopaedic Manipulative Physical Therapists (IFOMPT)
and has been coordinated by researchers
at Manchester Metropolitan University.
Due to a paucity of primary evidence, the
framework has been developed by expert
clinicians’ interpretation of the highestquality evidence available.
Key Term: Red Flags
Red flags are signs and symptoms that
raise suspicion of serious spinal pathology. Until now, there has been little guidance on their use and they have been left
to individual interpretation. For spinal
pathology, 163 signs and symptoms have
been reported as red flags,32 including 119 symptoms from the individual’s
history and 44 signs from the physical
examination.
The high number of red flags pre­
sents a challenge in terms of their everyday practical utility. Few red flags, when
used in isolation, are informative. Red
flags used in combination have promise,35 but further validation studies are
required. There is a lack of high-quality
evidence for the diagnostic accuracy of
red flag tests,20,34 and the evidence supports only a limited number of red flags
to raise suspicion of serious pathology.
There is no consensus on which red flags
are most useful to identify serious spinal
pathology or how they should be used in
the clinical setting.82
Despite the problems, red flag tests
remain the best tools that health care
practitioners have to raise suspicion of
serious spinal pathology when used in
combination with a thorough patient
Key Clinical Messages
• There is a lack of evidence to support the informativeness of the majority of
red flags commonly used in clinical practice.
• Few red flags, when used in isolation, are informative. Combinations of red
flags demonstrate promise, but this work requires further validation.
• Red flags remain the best tools at the clinician’s disposal to raise suspicion of
serious spinal pathology, when used within the context of a thorough subjective patient history and physical examination.
• Clinicians should consider both the evidence to support red flags and the individual profile of the person’s determinants of health (eg, age, sex) to decide the
level of concern (index of suspicion) for presence of serious spinal pathology.
journal of orthopaedic & sports physical therapy | volume 50 | number 7 | july 2020 | 351
[ position statement ]
history and an appropriate physical examination. Serious spinal pathology is
associated with increasing age, although
serious pathology can affect all ages.33
Populations around the world are aging, which presents challenges, as people with increased medical complexity
and morbidities present more often to
musculoskeletal services. Consequently,
therapists may see more patients with
serious pathology.
TABLE 1): CES, spinal fracture, malignan-
cy, and spinal infection.
The following sections summarize the
red flags for each of the 4 prioritized se-
rious spinal pathologies and outline risk
factors, symptoms, signs, and initial investigations. Each section concludes with
a series of clinical-reasoning scenarios.
Evidence
Prevalence
of pathology
Red flags
(supported by high- versus
quality evidence)
Red flags
(supported by
consensus only)
Red flags
in combination
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Goal of the International Framework
Given the paucity of high-quality evidence to guide practice, we built this
framework on multiple perspectives,
including synthesizing the current research data, expert consensus and opinion, and steering-group consensus, to
reflect an evidence-based practice approach.77 The framework is intended to
provide clinicians with a clear clinicalreasoning pathway to clarify the role of
red flags in identifying serious spinal
pathology.
Decision Tool for Early Identification
of Serious Spinal Pathology
The basis of our framework is a decision
tool to help clinicians identify serious spinal pathology. The tool has 3 steps:
1. Determine your level of concern. Consider the evidence to support red flags
and the individual profile of the person’s health determinants (eg, age, sex)
to decide your level of concern (your index of suspicion) about the presence of
serious pathology (FIGURE 1).
2. Decide on your clinical action, based
on your level of concern determined
in step 1 (FIGURE 2).
3. Consider the pathway for emergency/
urgent referral. Know your local referral pathways and pathways to access
specialist care if indicated (FIGURE 3).
Prioritize Serious Spinal Pathologies
In 2016, the member organizations of IFOMPT, a subgroup of the World Confederation for Physical Therapy, identified 4
priority areas for discussion and research
on red flags (incidence data presented in
Level of concern
Symptom
progression
Repeat visit?
Urgency
(consequence
of delay)
Response
to care
Comorbidities
Clinical profile
Consider within the context of the patient profile (eg, sex, age, race)
FIGURE 1. Decision tool for early identification of potential serious spinal pathology, step 1. Consider the evidence
to support red flags, together with the clinical and patient profiles, when determining your level of concern for
serious pathology.
Level of Concern
HIGH
LOW
No
concerning
features
Decision:
Begin a trial of
therapy
Revise management if
clinical features
change unexpectedly
Few
concerning
features
Decision:
Begin a trial of
therapy with watchful
waiting
Begin a trial of
therapy
Revise management if
clinical features
change unexpectedly
Some
concerning
features
Some
concerning
features
Decision:
URGENT referral
Decision:
EMERGENCY referral
DO NOT begin a trial
of therapy
DO NOT begin a trial
of therapy
Further investigation
or referral is
warranted
Emergency referral is
warranted
Monitor progress
closely (vigilance)
FIGURE 2. Decision tool for early identification of potential serious spinal pathology, step 2. Decide your clinical
action based on your level of concern.
352 | july 2020 | volume 50 | number 7 | journal of orthopaedic & sports physical therapy
(For all the key definitions used in this
document, see APPENDIX A, available at
www.jospt.org).
Method: Haute Autorité de
Santé Consensus Method
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This framework combines an evidence
synthesis and international expert consensus. We followed the Haute Autorité
de Santé recommendations for the devel-
opment of clinical guidelines.3
Phase 1 We reviewed systematic reviews
and other key papers summarizing available evidence related to red flags in 1 or
more of the 4 key spinal pathologies (see
APPENDIX B, available at www.jospt.org,
for an evidence summary table). This
led to the formulation of 4 international
expert consensus questionnaires, 1 for
each key pathology.
Phase 2 Jisc Online Surveys (Jisc, Bris-
tol, UK) was used to administer the 4
separate questionnaires developed in
phase 1. The international expert group
(100 experts from 19 countries) rated red
flag statements based on the evidence
presented (phase 1) and their own experience. Each section reports separately on
how many experts were involved in the
consensus process for that section. Ano-
Person referred with
musculoskeletal
condition
No concerning
features
Some concerning
features
Few concerning
features
Consider watchful wait
Initiate treatment and
safety neta patient
Treat as planned and
monitor symptoms
Progress as
expected
Consider further investigation/referral
The timing of this will depend on the specific pathology, but may be urgent
Not improving or
new concerning features or same day/emergency. Refer to condition-specific sections for details. If
investigations are negative, consider further referral or restart treatment
Progress as
expected
Treatment proceeds
as expected and
patient is discharged
from care
FIGURE 3. Decision tool for early identification of potential serious spinal pathology, step 3. Consider the pathway for emergency/urgent referral if indicated. aSafety netting is a
management strategy used for people who may present with possible serious pathology. These strategies should include advice on which signs and symptoms to look out for,
which action to take if symptoms deteriorate, and the time frame within which action should be taken.37
TABLE 1
Prevalence Estimates for Key Pathologies When Presenting With Back Pain a
Primary Care
Secondary Care
CES
Estimated incidence (UK): 0.002%31
Back pain: 0.04%17
Fracture: OCF
LBP: 0.7%,35 3.0%,73 4.0%,41 4.1%,80 4.5%16
Fracture: traumatic
LBP: <1%41
Malignancy
LBP: 0.0%,35 0.1%,19 0.2%,43 0.2%,26 0.6%,16 0.7%15
Nonmechanical pain: 0.7%41
Infectionb
Nonmechanical LBP: 0.01%41
Tertiary Care: ED
Tertiary Care: Spine Center
LBP: 0.4%66
Left X-ray: 2.6%69
Back pain: 6.5%29
LBP: 5.6%66
Left X-ray: 7.3%,65 11.0%68
Musculoskeletal pain: 7.0%40
LBP: 0.1%68
LBP: 1.6%66
Lumbar restriction: 6.0%13
LBP: 1.2%66
Postprocedural discitis represents up to 30% of
all cases of pyogenic spondylodiscitis21
Abbreviations: CES, cauda equina syndrome; ED, emergency department; LBP, low back pain; OCF, osteoporotic compression fracture.
a
Values are estimated point prevalence or incidence (where indicated).
b
Infective spondylitis in all settings: 0.0004%21 (in developed countries).
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[ position statement ]
nymized responses were returned online
using a rating scale between 1 and 9 (1 being totally inappropriate, 9 being totally
appropriate). All results were reviewed by
the steering committee.
We calculated the median score for
each statement. Statements with a median score of 7 or above were classed as
consensus appropriate, and those with a
median score of 3.5 or less were classed
as consensus inappropriate.3 Any remaining items that had not gained consensus by this point were reviewed by
the steering committee, and a consensus decision was then taken to either include or exclude these items in the draft
framework.
Phase 3 The draft framework was developed by the steering group based on
a synthesis of the results from phases 1
and 2.
Phase 4 The draft framework was presented to an international peer-review
group (70 individuals) for opinion on
the content, independent of the people
taking part in phase 2. The international
peer-review group was invited to rate
the content via an online questionnaire.
The review group rated each section of
the framework based on the following
criteria:
• Applicability: relevance to the clinical
practice
• Acceptability: clinical usefulness or
helpfulness
• Readability: ease of reading
They were also able to offer suggestions on changes/improvements. This
peer-review group included chiropractors, osteopaths, physical therapists,
experts by experience, and member organization delegates of the IFOMPT. The
response rate of 41% included individuals
from 13 countries. The median score for
each section was calculated. All sections
gained a median score of 7 or above and
were therefore classed as appropriate according to the Haute Autorité de Santé
method. All comments were reviewed
by the steering committee and relevant
changes made to the framework.
Phase 5 Based on the phase 4 feedback,
the steering group developed the final
version of the clinical framework.
Cauda Equina Syndrome
The cauda equina comprises 20 nerve
roots that originate from the conus
medullaris at the base of the spinal cord.
Cauda equina syndrome occurs as a result
of compression of these neural structures.
Cauda equina syndrome is challenging to
diagnose and manage in a timely manner.
It may present in any clinical setting, and
clinicians must effectively and efficiently
reason through their findings to provide
timely management. Timely diagnosis is
essential to avoid life-changing outcomes
such as ongoing bladder, bowel, and sexual dysfunction, along with psychosocial
consequences.31
Literature and International Consensus Three key source papers were used
to formulate the international consensus questionnaire for this section on
CES18,28,31 (APPENDIX B). The questionnaire was sent to 23 international experts and contained 25 items ( TABLES 2
through 6).
Epidemiology The incidence of CES in
the United Kingdom has been estimated
to be 0.002%.31 The overall prevalence of
CES has been estimated to range from 1
in 33 000 to 1 in 100 000 persons.48 Point
prevalence of CES as a cause of low back
pain (LBP) is estimated at 0.04% in primary care17 and 0.4% in tertiary care.66
Cauda equina syndrome is a complication of approximately 2% of all herniated
discs.18 The incidence of postoperative
CES is estimated to be between 0.08%
and 0.2%.42
TABLE 2
Twenty-three percent of litigation
claims for spinal surgery in England relate to CES, according to an assessment
of litigation claims in England between
2013-2015 and 2015-2016.39
Risk Factors Compression of the cauda
equina usually occurs as a result of a disc
prolapse.18 However, any space-occupying lesion could cause cauda equina compression. Relevant symptoms that can be
precursors to CES are unilateral or bilateral radicular pain, dermatomal reduced
sensation, and myotomal weakness.
If symptoms progress from the precursors described above, with any suggestion of changes in bladder or bowel
function or saddle sensory disturbance,
then suspect CES. Clinical cue cards
and credit card–size patient information
handouts can aid communicating sensitive, sometimes subtle but important
symptoms,22 and should form the basis
of your questioning.
Clinical Picture If you suspect CES,
perform a full neurological assessment
to establish dermatome sensory loss,
myotome weakness, or reflex changes.28
A digital rectal examination is no longer considered essential in a primary
care setting in the United Kingdom. It
is necessary in secondary care to evaluate loss of anal sphincter tone. Sensation
to light touch and pinprick throughout
the saddle region, including the buttocks, inner thighs, and perianal region,
is a necessary test in any clinical situation. These intimate objective tests must
only be performed by an appropriately
trained clinician, with a chaperone for
the benefit of both the person and the
Number of Cauda Equina Syndrome
Red Flags Gaining Consensus
Number of Red Flags
Questionnaire sent to 23 25 items reviewed
international experts • 18 items reached consensus as appropriate
• 2 items reached consensus as inappropriate
• 5 items had no consensus
Steering committee
reviewed results
20 items included in the framework (TABLES 3 through 6) (2 items combined)
4 items excluded (APPENDIX C)
354 | july 2020 | volume 50 | number 7 | journal of orthopaedic & sports physical therapy
clinician. Conduct the assessment while
considering cultural sensitivities, local
pathways, medicolegal frameworks, and
state regulations.
People should be sent for emergency
magnetic resonance imaging (MRI)
and surgical opinion. Positive findings
are likely to be accompanied by an ul-
trasound of the bladder. It is important
to know your local care pathway so
that people are managed appropriately.
When a person does not currently have
CES but there is a suspicion that he or
she may later develop CES, it is essential that the person is “safety netted”
(ie, informed about what to look out
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TABLE 3
for and what to do if symptoms of CES
develop).
CES Clinical-Reasoning Scenarios
Case 1
A woman is urgently referred to you with
back pain. Within the wider detailed subjective and objective examination, there
Risk Factors for Cauda Equina Syndrome
Risk Factor/Level
of Evidence
Context
Further Questions
Low Clinical Suspicion
High Clinical Suspicion
Herniated
intervertebral
disc
Low
The most common cause arises from a large
central disc herniation at the L4-5 or L5-S1
level51
Those under 50 y of age carry a higher risk, as
do obese people
Relevant symptoms that can be a precursor
to CES:
• Unilateral or bilateral radicular pain and/or
• Dermatomal reduced sensation and/or
• Myotomal weakness11
How old are you?
Do you have any leg pain?
Where exactly is the pain in your
legs (above or below knees)?
Is the pain down both legs at the
same time?
Do you have any pins and needles
or numbness in your legs, inner
thighs, bottom, or genitals?
Do you feel any weakness in your
legs?
No leg pain, normal
neurology, and no CES
symptoms
• Unilateral or bilateral radicular pain and/
or dermatomal reduced sensation and/or
myotomal weakness
• Reduced saddle sensation (subjective or
objective pinprick)
• Bladder disturbance
• Bowel disturbance
• Reduced anal tone/absent squeeze
• Sexual disturbance31
Presentations that increase the probability of
acute threatened CES:
• Back pain with
- Presence of new saddle anesthesia, bladder or bowel disturbance
- Age, <50 y
- Unilateral onset progressing to bilateral
leg pain
- Alternating leg pain
- Presence of new motor weakness
LSS
Low
The degenerative changes in the lumbar
spine that are responsible for LSS have the
potential to lead to a gradual compromise
of the cauda equina nerve roots. This can
result in slow-onset CES being overlooked or
dismissed in older people11
CES symptoms associated with degenerative
LSS are generally much less clear than with
a herniated disc or claudication. A range of
typical leg symptoms (eg, aching, cramping,
tingling, and heaviness) provoked by walking
and eased by sitting should be considered as
important in LSS27
Can you describe any worsening
Stable or no neuropathic
symptoms, including your level
leg symptoms
of pain or symptoms in your
legs?
If 0 is no pain and 10 is the worst
pain you have ever had, how low
does the pain go?
How high does the pain go?
What makes it worse?
What makes it better?
Recurring and insidious but increasing back
pain, with gradual onset of unilateral or
bilateral lower-limb sensory disturbance
and/or motor weakness
Incomplete bladder emptying, urinary hesitancy, incontinence, nocturia, or urinary tract
infections. Bladder and/or bowel dysfunction
may progress gradually over time11
Spinal surgery
Low
CES is a risk with any lumbar spine surgical
intervention
...
Nerve injuries and paralysis can be caused by a
number of problems, including
• Bleeding inside the spinal column (extradural spinal hematoma)
• Leaking of spinal fluid (incidental durotomy)
• Accidental damage to the blood vessels that
supply the spinal cord with blood
• Accidental damage to the nerves when
they’re moved during surgery55
NA
Abbreviations: CES, cauda equina syndrome; LSS, lumbar spinal stenosis; NA, not applicable.
journal of orthopaedic & sports physical therapy | volume 50 | number 7 | july 2020 | 355
[ position statement ]
TABLE 4
Symptoms of Cauda Equina Syndrome
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Symptoms
(subjective)/
Level of Evidence Context
Further Questions
Low Clinical
Suspicion
High Clinical
Suspicion
Sensory change
(lower limbs)
Low
History of symptoms, pattern, progression, and
time scale
Consider existing comorbidities (eg, multiple
sclerosis, diabetes)
When did the sensation problems in your leg(s) start?
Where did they begin and how did those symptoms change as
time went on?
Exactly where in your legs do you feel the symptoms?
Do you have any other medical conditions?
Normal neurology
Sensory change
(lower limbs)
Motor weakness
(lower limbs)
Low
Time scales of perceived weakness and progression are important to establish
Consider existing comorbidities (eg, aortic
aneurysm)
When did the weakness problems in your leg(s) start?
Where did the weakness begin and how did those symptoms
change as time went on?
Do you have any other medical conditions?
As above
Motor weakness
(lower limbs)
Saddle sensory
disturbance
Low
Precise extent of pins and needles and/or numbness (eg, difference between bicycle/horse
saddle)
Previous history
Trauma/surgery
Other potential pudendal nerve compression (eg,
cycling)
See CES cue card
NA
Exactly where do you feel the numbness in your bottom, inner
thighs, or genitals?
Where did it start and how has the numbness and/or pins and
needles changed over time?
Do you have normal sensation when you wipe after toileting?
How long has this been present?
What hobbies do you have?
Were any interventions used during childbirth? (where appropriate)
Have you had any previous surgery?
Saddle sensory
disturbance
Change in
ability to achieve
an erection or
ejaculate
Low
History of symptoms, progression, and time scale
comorbidities (eg, diabetes)
Side effects from pharmacology (neuropathic
medications, codeine)
Age: older people may have spinal stenosis and are
less likely to have acute CES
Functional symptoms: psychosocial presentation
and health care utilization
See CES cue card
When did these symptoms begin?
If it was some time ago, are these symptoms different?
Do you have any other medical conditions?
Have you started any new medication?
Were the symptoms present before you began this medication or
after?
Routine questions related to psychosocial distress
NA
Recent change in
ability to achieve
an erection or
ejaculate
Loss of sensation Previous history of sexual dysfunction?
in genitals
Is this different?
during sexual
intercourse
Low
See CES cue card for relevant questions that need to be asked,
including the following:
• When did these symptoms begin?
• If it was some time ago, are these symptoms different?
• Do you have any other medical conditions?
Ask routine questions related to psychosocial distress
NA
Loss of sensation
in genitals
during sexual
intercourse
Urinary function (eg,
frequency)
Low
Previous history of bladder disturbance
Establish precise change in function, such as
hesitancy, change in stream, loss of sensation
passing urine, inability to feel when the bladder
is full or empty, and sensation of incomplete
voiding
See CES cue card for relevant questions that need to be asked,
including the following:
• When did the changes begin?
• Describe the changes in urine function
• Do you have any other medical conditions?
• Have you started any new medication?
• Were the symptoms present before you began this medication
or after?
NA
Urinary function
(eg, frequency)
Urinary retention
Low
Previous history of bladder disturbance
Most of these people will not have critical cauda
equina compression. However, in the absence
of reliably predictive symptoms and signs, there
should be a low threshold for investigation with
an emergency MRI scan28
Age: older people may have spinal stenosis and are
less likely to have acute CES
Functional symptoms: psychosocial presentation
and health care utilization
Be aware of an increase in health-seeking behavior
See CES cue card for relevant questions that need to be asked,
including the following:
• When did the changes begin?
• When did you last pass urine?
• Have you started any new medication?
• Were the symptoms present before you began this medication
or after?
• Do you have any other medical conditions?
• Have you attended any other health care setting (GP, surgery,
clinic, hospital, etc) because of this problem?
- If so, who did you see and when?
NA
Urinary retention
Table continues on page 357.
356 | july 2020 | volume 50 | number 7 | journal of orthopaedic & sports physical therapy
TABLE 4
Symptoms of Cauda Equina Syndrome (continued)
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Symptoms
(subjective)/
Level of Evidence Context
Further Questions
Low Clinical
Suspicion
High Clinical
Suspicion
Urinary incontinence
Low
Previous history of bladder disturbance
See CES cue card for relevant questions that need to be asked,
including the following:
• When did the changes begin?
• When did you last pass urine?
• Have you started any new medication?
• Were the symptoms present before you began this medication
or after?
• Do you have any other medical conditions?
• Have you attended any other health care setting (GP, surgery,
clinic, hospital, etc) because of this problem?
- If so, who did you see and when?
NA
Urinary incontinence
Bowel incontinence
Low
Previous history of bowel disturbance
See CES cue card for relevant questions that need to be asked,
including the following:
• When did the changes begin?
• When did you last open your bowels?
• Have you started any new medication?
• Were the symptoms present before you began this medication
or after?
• Do you have any other medical conditions?
• Have you attended any other health care setting (GP, surgery,
clinic, hospital, etc) because of this problem?
- If so, who did you see and when?
NA
Bowel incontinence
Constipation
Low
Previous history of bowel disturbance
History of symptoms and time scale
Side effects from pharmacology (neuropathic
medications, codeine)
Age: older people may have spinal stenosis and are
less likely to have acute CES
Functional symptoms: psychosocial presentation
and health care utilization
See CES cue card
...
When did the changes begin?
When did you last pass a stool?
Have you started any new medication?
Were the symptoms present before you began this medication or
after?
Do you have any other medical conditions?
Have you attended any other health care setting (GP, surgery, clinic,
hospital, etc) because of this problem?
• If so, who did you see and when?
Unilateral/bilateral leg pain
Low
Unilateral radicular leg pain progressing to bilateral When did the pain progress from 1 leg to 2?
radicular leg pain is a concerning presentation How far down each leg does the pain go?
The prevalence of bilateral leg pain in primary care Do you have any conditions that affect your heart or circulation?
is not known
Consider other causes of leg pain:
• Smoker
• Cardiovascular disease
Lesion higher in the spine
No CES symptoms
Unilateral/bilateral
leg pain
Low back pain
Low
Presentations that increase the probability of acute
threatened cauda equina
Back pain with:
• Presence of new saddle anesthesia, bladder or
bowel disturbance
• Age, <50 y
• Unilateral onset progressing to bilateral leg pain
• Alternating leg pain
• Presence of new motor weakness
• Obesity
History of symptoms and time scale
See context
Low back pain
When did your back pain begin?
How has it progressed?
Do you have or have you had leg symptoms?
• If so, where exactly is your leg pain?
Consider questions on CES cue card if symptoms progress
Constipation
Abbreviations: CES, cauda equina syndrome; GP, general practitioner; MRI, magnetic resonance imaging; NA, not applicable.
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TABLE 5
Signs of Cauda Equina Syndrome
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Signs (objective)/
Level of Evidence
Context
Physical Assessment
Low Clinical Suspicion
High Clinical Suspicion
Sensory deficit in
Examination in any clinical setting, but only if
saddle to light touch
CES is suspected from the history
and pinprick
Normal examination findings do not exclude
Low
the possibility of CES
Consider previous trauma/surgery to
perineum
Objective light touch and pinprick carNA
ried out by a suitably trained clinician
with a chaperone present
NA
Abnormal lower-limb
neurology
Low
Establish time frame of progression of
neurology
Other causes (eg, upper motor condition,
peripheral neuropathy)
Myotomes, dermatomes, and reflexes
Consider tone, proprioception, and
clonus
Abnormal and progressing neurological
deficit
Management depends on the degree of
neurological deficit: if there is gross
motor weakness (<3/5) or deteriorating neurology
Reduced anal tone
Low
Examination in a secondary care setting, but
only if CES is suspected from the history
Normal examination findings would not
exclude the possibility of CES
Consider previous trauma/surgery to
perineum
Digital rectal examination should be car- NA
ried out by a suitably trained clinician
with a chaperone present
Normal neurology
NA
Abbreviations: CES, cauda equina syndrome; NA, not applicable.
TABLE 6
Initial Investigations for Cauda Equina Syndrome
Modality
Context
MRI
MRI is the gold standard investigation to confirm the diagnosis of CES
Most guidelines recommend that people presenting with any of these key clinical signs and symptoms be referred urgently18
CT scan
If there are contraindications to MRI
Abbreviations: CES, cauda equina syndrome; CT, computed tomography; MRI, magnetic resonance imaging.
are no positive items on the CES cue
card.
• LBP, no leg pain
• No symptoms of CES
• Clinical action: begin a trial of therapy
Level of Concern
LOW
HIGH
• Leg pain worsening
• Signs of bilateral leg pain
• Clinical action: safety net. The important thing in this case is to discuss and document a clear strategy
to follow if symptoms deteriorate
(safety net), ensuring the person is
aware that she needs to act immediately if things get worse
Level of Concern
Level of Concern
Case 2
The woman has back and leg pain. The
pain in her leg is getting worse and is
now radiating distally below the knee,
and she has started to notice pain in the
other leg. Nothing on CES questioning is
positive, and there is no existing neurological deficit.
not since. Neurological examination is
unremarkable.
• Back and bilateral leg pain increasing
• One episode of incontinence 4 weeks
ago
• Clinical action: urgent MRI and discuss
and document a clear strategy to follow
if symptoms deteriorate (safety net)
LOW
LOW
HIGH
HIGH
Case 4
Case 3
The woman now has back and increasing leg pain bilaterally. She reports one
episode of incontinence 4 weeks ago, but
The woman has now developed a 1-week
history of some numbness of the left side
of the vagina.
• Back and bilateral leg pain increasing
358 | july 2020 | volume 50 | number 7 | journal of orthopaedic & sports physical therapy
• One episode of incontinence 4 weeks
ago
• One-week history of vaginal numbness
• Clinical action: emergency MRI/refer
onto emergency pathway
Level of Concern
LOW
HIGH
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Suggested Pathway for Emergency/Urgent Referral Refer to the clinical de-
cision tool for suggested pathways for
emergency/urgent referral (FIGURE 3).
Spinal Fracture
Spinal fractures make up the largest
number of serious pathologies in the
spine. While these are predominantly a
risk for older patients, especially women,
clinicians need to be aware of the risk factors and signs and symptoms of spinal
fractures and to consider what detailed
questions to ask to help with further
management.
Five key source papers were used to
formulate the international consensus
questionnaire for spinal fracture23,50,63,72,85
(APPENDIX B). The questionnaire was sent
to 28 international experts and contained
27 items (TABLES 7 through 11).
Epidemiology Estimates for the point
prevalence of osteoporotic compression
fracture as a cause of LBP range between
0.7% and 4.5% in the primary care setting16,35,41,73,80 and 6.5% in the emergency
care setting.29 Low-impact or nontraumatic fractures are the most common
serious pathology in the spine, with vertebral fractures being the most common
osteoporotic fracture. Approximately
12% of women between 50 and 70 years
of age and up to 20% of those over 70
years of age have vertebral fractures.72 As
much as 70% of these fractures are undiagnosed and found during investigation
for other health conditions.50
It is important to identify people with
vertebral fractures, as they are more likely to sustain later hip fractures, bringing
further health consequences and risk for
the person. Red flags purported to indi-
cate possible fracture are unhelpful in
diagnosing vertebral fracture, with many
false-positive tests accompanied by low
diagnostic accuracy.85 Acting on single
red flags is not recommended. Instead,
consider broader risk factors and differential diagnoses.85 Osteoporotic fractures
have a similar distribution as metastases,
with 70% in the thoracic region, 20% in
the lumbar region, and 10% in the cervical region. Most spinal fractures occur
between the T8 and L4 levels.64
Risk Factors An increasing number of
younger people are affected by insufficiency spinal fractures (fractures caused
by normal stresses on weakened bone),
due to a range of risk factors. These include excessive alcohol consumption
(risk increases when drinking greater
than 3 units per day), vitamin D deficiency, long-term corticosteroid use (greater
than 5 or 7.5 mg per day over a 3-month
period), rheumatoid arthritis, diabetes,
smoking (greater than 20 cigarettes per
day61), dietary restriction, eating disorders, and absorption problems from the
gut (eg, Crohn’s disease5,75). Establish the
presence or absence of these risk factors
with detailed history taking.
Clinical Picture People commonly pre­
sent with sudden onset of pain, mostly
located in the thoracolumbar region, following low-impact trauma such as a slip or
trip or lifting something while in a flexed
position. The pain varies in presentation,
but is often severe and mostly localized to
the area of the fracture.36 Weight-bearing
activities and active movements are restricted and painful, and the person may
require strong analgesia, particularly in
TABLE 7
the early stages. On physical examination, the person may have an increased
prominence of the spinous process at the
affected level, and increased kyphosis.
The person may be tender to percussion
at the affected level, though absence of
this should not reassure the clinician that
there is no fracture.50 People with a suspected fracture should have an X-ray in
the first instance to determine whether a
fracture is present, and to grade and define the nature of the fracture.
Differential Diagnosis Consider possible
differential diagnoses for spinal fracture.
These include metastatic spinal disease
(see the Spinal Malignancy section) and
multiple myeloma, both of which can
cause healthy bone to be replaced by tumor. In the case of metastatic disease,
60% of metastases occur in the anterior
half of the vertebral body, thus potentially weakening this area and leading to a
wedge fracture. These fractures may look
very similar on X-ray. Take a careful history and explore any relevant risk factors
for each type of pathology.
Fractures from myeloma may also look
very similar to osteoporotic fractures on
X-ray, depending on the location. People
with myeloma may present at a slightly
earlier age than those with osteoporosis
and metastases, but further imaging may
be required to establish the cause of a
fracture if there are no clear indications
from the person’s subjective history.
Clinical-Reasoning Scenarios
Case 1
A 35-year-old man presents with sudden
onset of thoracic pain after lifting a heavy
Number of Spinal Fracture Red
Flags Gaining Consensus
Number of Red Flags
Questionnaire was sent
to 28 international
experts
27 items reviewed
• 13 items reached consensus as appropriate
• 14 items had no consensus
• 0 items reached consensus as inappropriate
Steering committee
reviewed results
18 Items included in framework (TABLES 8 through 11)
9 items excluded (APPENDIX C)
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TABLE 8
Risk Factors for Spinal Fracture
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Risk Factor/Level
of Evidence
Context
Further Questions
Low Clinical Suspicion
High Clinical Suspicion
History of osteoporosis
High
History of osteoporosis increases the risk of
fracture
A family history of osteoporosis will also increase
the risk of osteoporosis and fracture in women36
People with known osteoporosis have an increased
risk of fracture, and those with a previous osteoporotic fracture have a 5.4-fold increased risk of
vertebral fracture and a 2.8-fold increased risk
of hip fracture75
Medication for osteoporosis can reduce the risk of
fracture in the following year by 50% to 80%72
Do you have osteoporosis?
Do you have a family history of
osteoporosis?
Have you had previous osteoporotic
fractures?
Are you taking any medication for
your osteoporosis?
• If so, what are you taking?
• If not, have you been prescribed
it, or is there a reason you are not
taking it?
No family history
No other osteoporotic risk
factors
No previous fractures
Previous osteoporotic fractures
Concurrent osteoporotic risk factors
Corticosteroid
use
High
Steroid use of 7.5 mg for >3 mo increases the risk
of osteoporosis.12,58 The effects of inhaled steroids are inconclusive in terms of bone mineral
density, though the clinician should ask about
high-dose inhaled steroid use75
Have you used steroid tablets or
inhaled steroids?
• How long have you used them for,
and what dose did you use?
No steroid use
Steroid use of <5 mg over a
3-mo period in a year
Steroid use of >5 mg over a 3-mo
period
Previous history
of cancer
Low
Metastatic bone disease may decrease bone
density, especially in the thoracic region (70%
of cases)
Do you have a history of cancer?
• Where was the cancer?
• What treatment did you have for
your cancer?
• What stage was the cancer?
No past medical history of
cancer
History of cancer of the
• breast
• prostate
• lung
• kidney
• thyroid
Severe trauma
High
The more significant the amount of trauma, the
higher the likelihood of bony injury (ACR guidelines suggest a fall of 5 stairs or 3 ft)1
The position of the person at the time of injury is
also important (eg, flexed, as this might precipitate a fracture with a seemingly innocuous
activity like coughing)
Have you had a significant injury/fall
from a height?
Did your pain start suddenly after a
particular activity, like coughing or
sneezing?
No immediate bony pain post
injury
Immediate spinal pain post injury
Focal bony tenderness in the midline of
the spine may indicate underlying
bony injury
Female sex
High
19.8/1000 women have osteoporotic fracture
8.4/1000 men have osteoporotic fracture75
Women with late-onset menarche (>16 y)70 or
early menopause (<45 y) are at higher risk of
osteoporosis,81 and therefore spinal fracture
How old were you when you started
your periods?
How old were you when you went
through menopause?
Women with normal
menarche and normal
menopause with no other
risk factors
Women who are postmenopausal, especially those with early menopause
or those with late menarche
Older age
High
Bone density decreases with age in women and
Have you had any investigations for
men
your bones, such as X-rays or
12% of women aged 50-70 y have had a spinal
DEXA scans?
fracture, and 20% of women over 70 y have had
a spinal fracture
70% of these will not know about it72
People under 50 y
Women over 65 y and men over 75
y have a higher risk of vertebral
fracture75
Patients over 80 y have a very high
likelihood of having had an osteoporotic fracture
Previous spinal
fracture
High
If previous fracture due to osteoporosis occurred,
then the person has a 5.4-fold increased risk of
vertebral fracture and a 2.8-fold increased risk
of hip fracture within the year53,75
No previous history of spinal
fracture
Previous history of low-impact spinal
fracture
History of falls
Low
While the trauma of a fall may precipitate a
All people with osteoporosis should
fracture, multiple conditions can cause falls and
be assessed for risk of falls58
immobility, especially in the older patient
All people should have a detailed
Parkinson’s disease, multiple sclerosis, dementia,
past medical history taken
alcoholism, and malnutrition can all increase
the risk of falls61
People with no comorbidities
People with comorbidities: the more
they have, the higher risk they have
of falling
Have you had a previous spinal
fracture?
Abbreviations: ACR, American College of Rheumatology; DEXA, dual-energy X-ray absorptiometry.
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TABLE 9
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Symptoms
(subjective)/
Level of Evidence
Symptoms of Spinal Fracture
Context
Further Questions
Low Clinical Suspicion High Clinical Suspicion
Thoracic pain
High
Most (70%) nontraumatic spinal fractures occur Detailed questioning of the patient is
in the thoracic spine. 70% of metastases ocneeded to assess for risk factors for
cur in the thoracic spine, too, and should be
each of these diseases
considered in the differential diagnosis
Myeloma most commonly affects the thoracic
spine, too, and should also be considered in
the differential diagnosis
Band-like pain should be considered a concern
and may indicate MSCC79
Thoracic pain with no
history of cancer,
osteoporosis, or
myeloma and no
further risk factors
Severe pain
Low
Some people may have a long history of back
pain. It is important to establish whether this
is a new or different pain
If this is a person’s first Describes pain that is unfamiliar and posepisode of back
sibly worsening pain
pain, then conservative management
is the first course of
action
Neurological
symptoms
Low
People with spinal fracture will not usually
Do you have any change in sensation in
develop neurological deficit/signs, but must
your arms or legs?
be carefully examined to exclude neurological Do you have any difficulties with walking
deficit
or coordination?
Do you have any difficulties with your
balance?
Is this a familiar pain to you/does this feel
familiar?
Have you experienced back pain in the
past?
No distally referred
symptoms or subjective neurological
symptoms
Any patient with known cancer, myeloma,
or osteoporosis
People with bilateral/quadrilateral
neurological symptoms, including gait
disturbance and coordination issues/
bladder and bowel disturbance
Abbreviation: MSCC, metastatic spinal cord compression.
TABLE 10
Signs (objective)/
Level of Evidence
Signs of Spinal Fracture
Context
Physical Assessment
Spine tenderness
Low
Patients with midline bony tenderness
should be considered to be at risk of
spinal fracture50
Palpate the spinous processes and consider No spinal tenderness
percussion/vibration with a 128-Hz tuning
fork to examine spinal tenderness or
reproduction of symptoms further
Bony percussion/use of a tuning fork may indicate the presence of bony injury, though
this should be interpreted with caution
Low Clinical Suspicion
Tenderness or reproduction
of symptoms on palpation, percussion, and/or
vibration
Neurological signs
Low
People with a subjective complaint of
neurological symptoms must have a full
neurological examination
Upper- and lower-limb neurology and upper
and lower motor neuron testing should
be performed. Neurological examination
may need to include the upper and/or
lower limbs, including upper and lower
motor neuron clinical tests
People with spinal fracture
and symptoms in the
limbs, or with coordination/gait disturbance, or
changes to bladder/bowel
activity
Spinal deformity
Low
Onset of deformity post trauma
Sudden change in posture associated with
a sudden increase in pain in the person
with known osteoporosis
Bony percussion may indicate bony injury,
No change in spinal posture
as may use of a tuning fork, though these
tests should be treated with some caution
Imaging may be appropriate
Contusion or abrasion
Low
May indicate the site of trauma and should
be considered if associated with a
painful site
...
Localized spinal pain with no distal referral or limb symptoms
High Clinical Suspicion
Sudden change in spinal
shape related to trauma
or in a known osteoporotic
patient
Abrasion with no bony tenderness Abrasion following trauma
associated with central
spinal bony tenderness
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bag of concrete. The man has no previous history of fracture and is generally
in good health. He smokes 5 cigarettes a
day and has done so for 10 years. He has
limited thoracic spine movement into rotation to both sides. He is locally tender
to palpation at T8 and T9 unilaterally on
both sides.
• Man under 65 years of age
• No family history
• No steroid use
• No previous fractures
• No excessive alcohol use
• Minimal to no smoking
• Clinical action: treat and monitor
symptoms. His age and sex put him at
low risk of osteoporotic fracture and
his smoking habit is below 20 cigarettes per day, which is low risk. No
further investigation is required at
this stage
Level of Concern
LOW
HIGH
Case 2
A 60-year-old woman presents with moderately severe thoracolumbar pain after
bending over and lifting a heavy pot in the
garden 3 weeks ago. Her pain is slightly
improved. She is otherwise well and not
on any medication other than paracetamol
for her pain. She has no history of fracture.
She had an early menopause at age 35. She
smokes 20 cigarettes per day. She has pain
in extension and rotation, some local spinal tenderness, and zygapophyseal (facet)
joint tenderness bilaterally.
TABLE 11
• Age and sex are risk factors (although
she is under 65 years of age)
• Early menopause
• Smokes 20 cigarettes per day
• Clinical action: treat and monitor
symptoms. While there are some risk
factors, her symptoms are recent and
improving, and she is on low-dose
medication for pain. She does not require imaging, and it would be safe to
treat her and monitor progress without further investigation at this stage
Level of Concern
LOW
HIGH
Case 3
A 78-year-old woman presents with upper lumbar pain. No precipitating injury
was reported, but the pain has worsened
over the last 3 months. The pain is
worse when lying supine. She has a history of left radius fractures. She had her
menopause at age 38, having started her
periods at 15 years of age. She is otherwise well and has no family history of
osteoporosis.
• Age and sex are risk factors
• Worsening pain
• Early menopause and a late menarche
• Worse when lying supine
• History of fractures
• Clinical action: urgent thoracic spine
X-ray. The patient has several risk
factors for osteoporosis, including
age, sex, early menopause and late
menarche, and history of radius fractures. An X-ray of her thoracolumbar
region in the first instance would be
appropriate
Level of Concern
LOW
HIGH
Case 4
A 74-year-old man with mid-thoracic and
lumbar pain presents with increasing pain
locally in the spine, but no trauma/injury.
Pain is worse in lying and standing and
eased slightly in sitting. He is taking increasing doses and strengths of analgesia,
which helps a little. He has some shortness
of breath on exertion and pain on deep inspiration. He is a nonsmoker and drinks 3
pints of beer a day. He had a transurethral
resection of the prostate for prostate cancer 10 years ago and has been discharged
from follow-up by the urologist.
• Age and site of pain
• Worsening pain
• Increasing analgesia
• Alcohol intake
• History of prostate cancer
• Breathlessness
• Clinical action: urgent MRI of the
whole spine. The man has several
risk factors for spinal fracture. These
include a history of prostate cancer,
which is one of the cancers most likely
to metastasize to the spine. His pain is
worse in lying, which is more unusual
and may indicate underlying serious
pathology (tumor). His age puts him
at risk of osteoporosis, even though
he is male, as his bone density is likely
to have decreased. His shortness of
Initial Investigations for Spinal Fracture
Modality
Context
X-ray
X-rays are the first-line choice to determine whether there is a fracture present, with lateral views likely to yield the most information.50 X-rays are readily available and relatively low cost. It may be difficult to determine the age of the fracture using X-rays alone
MRI
MRI is the investigation of choice for differentiating osteoporotic fractures from metastatic disease and myeloma. Use MRI if there are multiple fractures identified on X-ray.50 MRI will also help to determine the age of the fracture, as it can identify bone marrow edema from recent/healing fractures61
CT scan
A CT scan is commonly performed for other conditions. Assess the sagittal view for undiagnosed vertebral fractures.72 CT scans may be helpful in evaluating
complex fractures or those with retropulsed fragments, as they give excellent bony definition.61 CT scans may also be used where MRI is contraindicated
Abbreviations: CT, computed tomography; MRI, magnetic resonance imaging.
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breath may be a concern in the absence of a chronic obstructive pulmonary disease or smoking history, given
his prostate cancer. This man would
benefit from further investigation of
his spine with whole-spine MRI to
exclude metastases and fracture. A
chest X-ray would be appropriate to
exclude lung metastases/disease, and
blood tests would be relevant to exclude myeloma and look for signs of
inflammation, infection, or increased
bone turnover. If one is not able to request these medical tests, then urgent
referral would be appropriate
Level of Concern
LOW
HIGH
Suggested Pathway for Emergency/Urgent Referral Refer to the clinical de-
cision tool for suggested pathways for
emergency/urgent referral (FIGURE 3).
Spinal Malignancy
Risk Factors The second most common
Metastases are cancer lesions that have
spread from the primary cancer site to a
new and different site in the body. Spinal
malignancy (TABLES 12 through 16) refers
to metastases that have spread specifically into the spine. Bone is a common
site for metastases, known as metastatic
bone disease (MBD), in a number of
cancers (breast, prostate, lung, kidney,
and thyroid).78 A Cochrane review34 was
the key source paper used to formulate
the international consensus questionnaire for the spinal malignancy section
(APPENDIX B).
Epidemiology Estimates for the point
prevalence of spinal malignancy as a cause
of LBP range between 0.0% and 0.7% in
the primary care setting,15,16,19,26,35,43 0.1%
in the emergency care setting,68 and 1.6%
in the tertiary care setting.66 Malignancy
as a cause of musculoskeletal pain is estimated at 7.0% in the secondary care
setting.40
serious pathology to affect the spine, after fracture, is MBD as a consequence of
a primary cancer.20 More effective medical treatment of primary cancers means
people are living longer, putting them at
greater risk of later developing MBD.7
Cancer can affect all ages, but the risk
of developing malignancy increases with
age.33 The consequences of untreated or
late diagnosis are widespread metastases and visceral involvement. Metastatic
bone disease can lead to significant morbidity and reduction in quality of life due
to MSCC and, in the worst-case scenario, to paralysis and compromise of the
bladder, bowel, and sexual function.78
Clinical Picture The spine is one of the
earliest sites affected by MBD, especially
in those cancers that have a propensity to
metastasize.74 The 5 most common cancers to metastasize are breast, prostate,
lung, kidney, and thyroid.10 Approximately 30% of all people with one of these primary diagnoses of cancer will have their
cancer metastasize, so it is important not
to subject all people with a history of cancer to unnecessary and worrying investigations. In breast cancer, MBD can occur
at any time, with 50% occurring within
the first 5 years after a primary diagnosis
of cancer and the other 50% developing
10 years and later.44
Other primary cancers may metastasize, but have a lower incidence.62 Clinicians should not be reassured by the
Number of Spinal Malignancy Red
Flags Gaining Consensus
TABLE 12
Number of Red Flags
Questionnaire sent to 28 29 items reviewed
international experts • 14 items reached consensus as appropriate
• 6 items reached consensus as inappropriate
• 9 items had no consensus
Steering committee
reviewed results
14 items included in the framework (TABLES 13 through 16)
12 items excluded (APPENDIX C)
TABLE 13
Risk Factor/Level of
Evidence
Past history of
cancer
High
Risk Factors for Spinal Malignancy
Context
Further Questions
Low Clinical Suspicion
High Clinical Suspicion
Not all those cancers with a predilection to bone metastases
will develop them. However,
some will metastasize in the
first 5 y of diagnosis, with
50% doing so 10-20 y later44
Approximately 25% of people
with MSCC have no known
primary diagnosis57
Do you have any concerns
about your symptoms?
How long ago was the primary
diagnosis made?
How big was the primary tumor,
and at which stage?
Was there any lymph node
involvement?
Which treatment did you have?
Cancers with a predilection to
bone metastases but in an
early stage (1 or 2), with no
lymph node involvement62
Cancers that do not have a
predilection to bone metastases (eg, ovarian cancer,
melanoma62)
Cancers that have a predilection to bone metastases (eg,
breast, prostate, lung, kidney, and thyroid10)
In breast cancer grade 3 or 4 (late stage), large tumors
with lymph node involvement62
In prostate cancer, a Gleason score of 9 or 10 (despite
a PSA level greater than 50 ng/mL at diagnosis) is
considered to be an aggressive cancer that is likely to
spread more rapidly4
Abbreviations: MSCC, metastatic spinal cord compression; PSA, prostate-specific antigen.
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TABLE 14
Symptoms of Spinal Malignancy
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Symptoms (subjective)/
Level of Evidence
Context
Further Questions
Low Clinical Suspicion
High Clinical Suspicion
Are your symptoms getting better, the
same, or worse?
Do you have band-like pain?
The person presents with
initial severe pain but reports
improvement with treatment;
it is important to continue to
evaluate, as the person may
be in a good phase
Subjective reports of progressively worsening symptoms,
with possible features of
band-like pain, and inability
to lie flat
Most people with back pain will suffer from
Does your pain wake you at night?
night pain. People who report being
What do you have to do to get back
woken on movement and subsequently
to sleep?
are unable to get comfortable and go back Does your night pain occur in a
to sleep are of less concern than those
particular position?
who describe an inability to get back to
sleep due to the intensity of symptoms
and who report having to get up to relieve
the pain25
The person reports that he or
she is able to get back to
sleep following a change
of position or after taking
medication
People who report having to walk
the floors or sit in a chair or
lie on the floor, with minimal
relief
Systemically unwell
Low
These are often symptoms described in the
Do you feel well?
late stages of the disease and may include • If not, then explore the features of
hypercalcemia
fatigue, nausea, anorexia, and constipation, which are symptoms suggestive of
• Establish whether these symptoms
could be associated with other
hypercalcemia24
Constipation is not necessarily a systemic
causes
complaint
These could appear on their own or as a
cluster of symptoms
Able to associate with another
cause
May describe the features of hypercalcemia, such as fatigue,
nausea, stomach pain, and
fever. These also tend to be
progressive in nature
Thoracic pain
Low
The thoracic spine is the most common site Is the area sensitive to touch?
of MBD
Is it mechanical in presentation?
It is important to note that MBD may not correspond to the sensory level of pain
Appears mechanical, but caution May be painful on percussion
needs to be applied here.
over the area of pain. May not
Often, MBD gives the impresbe a mechanical pain pattern
sion of being mechanical in
nature, appearing to initially
respond to treatment
Neurological symptoms
Low
MBD can cause neurological symptoms and
in some cases cord compression, including UMN signs and CES
Do you have any pins and needles or
numbness?
Have you noticed any weakness in
your legs?
Ask CES questions (see the CES section for more detail)
No distally referred symptoms
or subjective neurological
symptoms
Unexplained weight loss
High
Consider other causes of weight loss, such
as change in diet, increase in exercise,
medication that increases levels of pain,
or other morbidities such as hyperthyroidism or diabetes59
Consider more than 5% of weight loss over a
6-mo period as significant and requiring
further questioning to establish a cause59
Is your weight steady?
Weight loss related to medication The individual has lost 5%-10%
• If the person answers that he or she
or change in diet, or weight
of body weight over a 3- to
has lost weight, ask if the person
loss has stabilized
6-mo period59
knows why he or she has lost
Can be attributed to other
weight
causes
Have you changed your diet?
How much weight loss over the last
3-6 mo have you had?
Unfamiliar back pain
Low
Some people may have a long history of
back pain, so it is important to establish
whether this is a new or different pain
Is this a familiar pain to you?
Have you experienced back pain in
the past?
Does this feel familiar to you?
Severe pain that may
become progressive
and constant
Low
MBD does not have a linear progression and
is more likely to wax and wane, but in the
later stages it becomes more constant
and progressive. People may report
escalating pain, which can increase when
lying flat79
Night pain
Low
If this is a person’s first episode
of back pain, conservative
management is the first
course of action
Abbreviations: CES, cauda equina syndrome; MBD, metastatic bone disease; UMN, upper motor neuron.
364 | july 2020 | volume 50 | number 7 | journal of orthopaedic & sports physical therapy
People with bilateral/quadrilateral neurological symptoms,
including gait disturbance and
coordination issues/bladder
and bowel disturbance
Describes pain that is unfamiliar
and possibly worsening
TABLE 15
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Signs (objective)/
Level of Evidence
Signs of Spinal Malignancy
Context
Physical Assessment
Low Clinical Suspicion
High Clinical Suspicion
Altered sensation
from trunk down
Low
People might report altered sensation that
is nondermatomal and describe strange
feelings in the legs (often a vague and nonspecific, difficult-to-describe sensation).
People may report decreased mobility79
Neurological examination testing
Sensation throughout the area
described by the patient
Normal neurology and no objective
change in sensation
Objective signs and reduced
sensation
Neurological signs
Low
People who present with a subjective comNeurological examination that may Localized spinal pain with no distal
plaint of neurological symptoms must have
need to include the upper and/or
referral or limb symptoms
a full neurological examination
lower limbs, including upper and
lower motor neuron clinical tests
People with symptoms in the limbs
and/or with coordination/gait
disturbance, or changes to bladder/bowel activity
Spine tenderness
Low
Sometimes, the spine can be tender on percussion. However, lack of tenderness does
not rule out the possibility of metastases
It is important to percuss the whole spine, as
the area of pain reported may not be the
area of metastasis
Tenderness or reproduction of
symptoms on palpation or
percussion/vibration
TABLE 16
The clinician should palpate the
spinous processes and may
use percussion/vibration with
a 128-Hz tuning fork to further
examine spinal tenderness or
reproduction of symptoms
No tenderness on palpation or
percussion/vibration
Initial Investigations for Spinal Malignancy
Modality
Context
MRI
MRI is the gold standard for diagnosing MBD78
Because the sensory level does not always correspond to the level of metastases if MBD is suspected, MRI of the whole spine is required46
CT scan
If there are contraindications to MRI
Blood tests
There is no combination of inflammatory markers that can be used as a reliable rule-in or rule-out test strategy. The decision to test must be made in the
context of other clinical findings84
Abbreviations: CT, computed tomography; MBD, metastatic bone disease; MRI, magnetic resonance imaging.
absence of a history of cancer, as MSCC
can be the first sign of metastases in approximately 25% of people who do not
have a primary diagnosis of cancer and
are subsequently diagnosed with MSCC.57
Metastatic spinal cord compression can
occur as a consequence of MBD when
there is pathological vertebral-body collapse or where direct tumor growth causes
compression of the spinal cord, leading to
irreversible neurological damage.46
A high index of suspicion, early diagnosis with referral for urgent investigation, and prompt treatment can result in
better outcomes in terms of function and
prognosis.79 Careful questioning using
good communication skills is essential
in early identification. The use of credit
card–size patient information handouts
can aid in communication between cli-
nicians and patients (eg, https://www.
christie.nhs.uk/media/1125/legacymedia-1201-mscc-service_education_msccresources_red-flag-card.pdf ).
Metastases can affect any region
of the spine, most commonly the thoracic spine (70%), but also the cervical
spine (10%) and lumbar spine (20%).73
Primary tumors that are at high risk of
metastasizing are those that were large
at diagnosis, diagnosed at a late stage of
the disease (stage 3 or 4), or had lymph
node involvement with radical treatment, including surgery, chemotherapy,
and/or radiotherapy.62
Clinical-Reasoning Scenarios
Case 1
A 58-year-old woman with a 42-year
history of chronic LBP and history of
breast cancer 5 years ago presents with
an exacerbation of LBP. No other red
flags or signs and symptoms suggestive
of a mechanical problem are present on
examination.
• History of breast cancer 5 years ago
• Clinical action: treat and monitor
symptoms
Level of Concern
LOW
HIGH
Case 2
The woman reports that her pain
is not responding to usual medication and that she has been prescribed
stronger medication, which is helping.
She describes her symptoms as different from her usual back pain, which
journal of orthopaedic & sports physical therapy | volume 50 | number 7 | july 2020 | 365
[ position statement ]
has had some relief from conservative
treatment.
• History of breast cancer 5 years ago
• Using stronger painkillers
• Some relief with conservative
management
• Describes unfamiliar pain
• Clinical action: treat, monitor symptoms, and discuss and document a
clear strategy to follow if symptoms
deteriorate (safety net)
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HIGH
Case 3
The woman’s pain has become progressively worse and she now complains of
symptoms waking her at night. She is
having difficulty getting back to sleep because the pain is so intense.
• History of breast cancer 5 years ago
• Using stronger painkillers
• Describes unfamiliar pain
• Night pain with worsening symptoms
• Clinical action: refer for urgent MRI,
discuss and document a clear strategy to follow if symptoms deteriorate
(safety net). Some concerning features
suggest malignancy. An MRI scan of
the whole spine should be carried out
urgently
Level of Concern
LOW
Level of Concern
LOW
Level of Concern
LOW
• Clinical action: emergency MRI scan.
Some concerning features may suggest MSCC. Provide information that
describes the symptoms of MSCC
and what to do if symptoms develop79
(see also https://www.christie.nhs.uk/
media/1125/legacymedia-1201-msccservice_education_mscc-resources_
red-flag-card.pdf ).
HIGH
Case 4
A 75-year-old man presents with a past
history of prostate cancer 2 years ago,
and he describes band-like pain and
states that his legs feel odd and heavy. He
reports occasionally tripping and stumbling. He says he has lost weight but has
put it down to a loss of appetite due to
the pain.
• History of prostate cancer
• Balance issues
• Odd sensations in legs
• Band-like pain
• Weight loss
HIGH
Suggested Pathway for Emergency/Urgent Referral Refer to the clinical de-
cision tool for suggested pathways for
emergency/urgent referral (FIGURE 3).
Spinal Infection
Spinal infection is an infectious disease
that affects the spinal structures, including the vertebrae, intervertebral discs,
and adjacent paraspinal tissues.60 In
high-income and upper middle–income
countries, spinal infection has steadily
increased over recent years, possibly due
to an aging population and an increase in
intravenous drug abuse.52 In lower middle–income and lower-income countries,
spinal infection has increased due to the
dual epidemic of HIV/AIDS and tuberculosis (TB).
For further country-specific information on TB, see https://www.wwl.nhs.
uk/library/general_docs/specialties/a_
to_z/t/tb-service-who-estimates-oftuberculosis-incidence-by-country.pdf,67
and for further information on the global
burden of the dual epidemic of HIV/AIDS
TABLE 17
and TB, see the World Health Organization.87 Staphylococcus aureus and Brucella are the other main bacteria that are
identified in reports on spinal infection.88
Two key source papers were used to
formulate the international consensus
questionnaire for this section on spinal
infection67,88 (APPENDIX B). The questionnaire was sent to 21 international experts and contained 56 items (TABLES 17
through 21).
Epidemiology Spinal infections, such
as TB, discitis, and spinal abscesses, are
uncommon. The incidence is 0.2 to 2.4
cases per 100 000 annually in Western
societies.9,30 Spinal infection represents
2% to 7% of all musculoskeletal infections.45 The point prevalence of spinal
infection in developed countries is estimated at 0.0004% (across all settings).21
The point prevalence of infection presenting as nonmechanical LBP is estimated at 0.01% in primary care41 and
1.2% in a tertiary setting,66 where postprocedural discitis represents up to 30%
of all cases.21
Discitis mostly affects the lumbar spine
(58%), followed by the thoracic spine
(30%) and cervical spine (11%),30 whereas TB lesions mainly affect the thoracic
spine, and often at more than 2 levels.8
The frequency of spinal infections
presenting in a clinical setting depends
on the demographics of where you work.
Due to the rarity of spinal infection in
high-income countries, the diagnosis of
spinal infection is often delayed, because
clinicians fail to recognize the relevant
red flags and consider spinal infection as
a potential differential diagnosis.6
Number of Spinal Infection Red
Flags Gaining Consensus
Number of Red Flags
Questionnaire sent to 21 56 items reviewed
international experts • 30 items reached consensus as appropriate
• 0 items reached consensus as inappropriate
• 26 items had no consensus
Steering committee
reviewed results
17 items included in the framework (TABLES 18 through 21)
24 items excluded (APPENDIX C) (16 items were combined)
366 | july 2020 | volume 50 | number 7 | journal of orthopaedic & sports physical therapy
TABLE 18
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Risk Factor/Level of
Evidence
Risk Factors for Spinal Infection
Context
Further Questions
Immunosuppression
Low
Comorbidities that cause immunosuppression can increase the risk of SI
(eg, diabetes, HIV/AIDS, rheumatoid
arthritis, pre-existing infections,
alcohol abuse, and long-term use of
steroids)
Do you have any health issues I need Well-controlled comorbidities with
to be aware of?
no history of infections attributed
Is your diabetes well controlled?
to their condition
How long have you been taking steroid
medication?
Have you had a recent infection?
Do you drink alcohol?
• How many units a week do you
drink?
Low Clinical Suspicion
High Clinical Suspicion
Uncontrolled morbidities with previous evidence of infections
Surgery: invasive
Low
Long duration of surgery, in particular,
the type of surgery (more commonly,
lumbar and posterior approaches),
and multiple revisions are significant
risk factors for SI45
Any previous spinal or abdominal
surgery?
No previous surgical intervention
The person has undergone surgery,
particularly of the spine, with
repeated revisions
Intravenous drug use
Low
An increase in IVDA is thought to be associated with increased risk of SI89
People with a history of intravenous
drug use may present late and may
not see the relevance of drug use to
their condition. Know the incidence
of drug abuse in the community
within which you work
Questions must be in the context of
the suspicion of SI
I want to make sure you do not have
an infection, so I am going to ask
you some questions that will help
me. Do you take, or have you ever
taken, recreational drugs?
• If yes, how were these drugs
administered (orally or intravenously)?
No evidence of IVDA
Known intravenous drug user
Social and environmen- There is a strong association with social
tal factors (eg, mideprivation and TB. Consider a
grant, occupational
patient’s social history and whether
exposure, homelesshis or her situation might include the
ness, prisoner,
following: alcohol abuse, migrant,
contact with infected
homelessness, and imprisonment.47
animals)
Consider working and living condiLow
tions (eg, contact with TB-infected
cattle)88
What are the conditions like where you Appears well kempt (well dressed
live, in the workplace, or places you
with a clean and tidy appearfrequently visit?
ance) and does not report social
Do you drink alcohol?
conditions that raise concern
• How many units a week do you
drink?
Is unkempt (an untidy appearance
and unwashed hair and clothes),
raising concerns for poor living
and social conditions
History of TB (born
in TB-endemic
country)
Low
The majority of TB cases are a result
of reactivation of latent infection
acquired some years before47
However, transmission of TB needs to
be considered where individuals
are born in TB-endemic countries
or where an individual has been
exposed to TB sufferers47
Have you ever been diagnosed with
TB?
• Where was the TB?
Have you been abroad recently?
• If yes, consider whether this
country has a high burden of TB
• If it is a country with high burden,
has the person had an inoculation
for TB?
Have you been in contact with someone who has a history of TB?
No evidence of TB or contact with
TB
No inoculation and has been
exposed to TB via an endemic
country or persons known to
have TB
Recent pre-existing
infection
Low
New local back pain following a recent
episode of sepsis or infection52
Have you recently had an infection?
Consider other causes, such as
urinary tract infections, and ask
questions related to the condition
The person’s infection has responded to treatment (eg, antibiotics)
and back pain symptoms have
improved
Progressively worsening symptoms
Abbreviations: IVDA, intravenous drug abuse; SI, spinal infection; TB, tuberculosis.
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[ position statement ]
TABLE 19
Symptoms of Spinal Infection
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Symptoms (subjective)/
Level of Evidence
Context
Further Questions
Low Clinical Suspicion
High Clinical Suspicion
Spinal pain
Low
Back pain is the most common presenting
How did your back pain start?
symptom. Neurological symptoms may be Are your symptoms getting better,
present. Usually, symptoms are nonspecific,
worse, or remaining the same?
with an insidious onset. Range of motion of Can you point to where your sympthe spine is often limited due to localized
toms are?
spinal pain and muscle spasm52
No evidence of progressive sympLocalized progressive pain
toms and the person is not able to
that limits movement
pinpoint symptoms
significantly
Neurological symptoms
Low
Neurological symptoms make up part of the
classic triad for SI
Do you have any pins or needles or
numbness?
Have you noticed any weakness in
your legs?
No distally referred symptoms or
People with bilateral/
subjective neurological symptoms
quadrilateral neurological
If the person does not describe any
symptoms, including gait
neurological symptoms, continue
disturbance and coorto evaluate for possible change
dination issues/bladder
and bowel disturbance
Fatigue
Low
People might describe “underperforming”
activities that they would normally be able
to carry out38
Do you feel fit and well?
Have you noticed any changes in
your ability to carry out activities
that normally you manage easily?
No evidence of fatigue
Fever (consider sepsis/
septic shock)
Low
Fever makes up one of the classic triad symptoms. Recognize signs of sepsis, as it can
develop rapidly71
Fever can be absent in approximately 50% of
people with SI88
Have you experienced a fever or chills The absence of fever should not be
Person reports fever within
since the onset of your back pain?
reassuring; it should be monitored
the time frame since onset of back pain. Concern
that person might be
developing sepsis
Unexplained weight loss
Low
Consider other causes of weight loss, such
as change in diet, increase in exercise or
medication, increasing levels of pain, or
other morbidities such as hyperthyroidism
or diabetes59
Consider more than a 5% weight loss over a
6-month period as significant; this requires
further questioning to establish a cause59
Is your weight steady?
Weight loss related to medication or
• If the person answers that he or
change in diet
she has lost weight:
Weight loss has stabilized
- Do you know why you might
Can be attributed to other causes
have lost weight?
- Have you changed your diet?
- How much weight loss over the
last 3-6 months have you had?
Describes a level of fatigue
that is abnormal for them
when carrying out their
usual tasks
Person has lost more than
5% of body weight over a
3- to 6-month period59
Abbreviation: SI, spinal infection.
Clinical Picture In cases of spinal infec-
tion, the time between onset and diagnosis
is often prolonged. People can remain relatively healthy until symptoms manifest in
the later stages of the disease.83 Unlike malignancy, where symptoms wax and wane,
spinal infection has a more linear progression, with back pain being the most
common presenting symptom, which can
progress to neurological symptoms. If not
treated in a timely manner, the condition
can progress with serious complications
such as paralysis or instability of the spine,
and can ultimately be fatal.
Diagnosis The subjective history should
consider determinants that can be divided into comorbidities, environmental
factors, and social factors. Comorbidities
that suppress a patient’s immune system, such as diabetes, HIV, long-term
steroid use, and smoking, put the person
at risk of infection. Consider social and
environmental factors like intravenous
drug use, obesity, birth in a TB-endemic
country, family history of TB, and living
conditions (overcrowded living, homelessness, imprisonment, or rural environment). Spinal surgery is a key risk
factor for spinal infection, in particular
multiple revision surgery of the lumbar
spine, with an added increased risk for
obese people.88
The classic triad of clinical features
comprises back pain, fever, and neurological dysfunction.14 However, many people
do not present with all 3 features. Only
50% of people report fever as a symptom.45 Absence of fever cannot rule out
spinal infection.
Clinical-Reasoning Scenarios
Case 1
A 47-year-old ex-heroin addict presents
with recurrent episodes of LBP and a previous history of back pain. He describes
symptoms that are intermittent. He is
very inactive and usually self-treats the
problem with rest.
• Male
• Ex-drug addict
• No other concerning features
• Clinical action: treat and monitor
symptoms, discuss and document a
clear strategy to follow if symptoms
368 | july 2020 | volume 50 | number 7 | journal of orthopaedic & sports physical therapy
TABLE 20
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Signs (objective)/
Level of Evidence
Signs of Spinal Infection
Context
Physical Assessment
Low Clinical Suspicion
High Clinical Suspicion
Neurological signs
Low
People with a subjective complaint of
neurological symptoms must have a full
neurological examination
Neurological examination may need to include
the upper and/or lower limbs, including upper and lower motor neuron clinical tests
Localized spinal pain with
no distal referral or limb
symptoms
People with symptoms in the
limbs, or with coordination/gait
disturbance, or with changes to
bladder/bowel activity
Radiculopathy
Low
SI can cause radiculopathy, which commonly presents with leg pain that usually
radiates to the part of the body that is
supplied by that specific nerve
The person may present with weakness or
pins and needles/numbness
A full neurological examination, including
dermatomes, myotomes, and reflexes
Normal neurological
examination
Abnormal and progressing neurological deficit
Management depends on the degree
of neurological deficit (gross
motor weakness of <3/5 or
deteriorating neurology)
Spine tenderness
on palpation
Low
The spine can be tender and reproduce
symptoms on percussion
Lack of tenderness or reproduction of
symptoms does not rule out SI
Percuss the whole spine, as the area of pain
reported may not be the area of infection
Palpate the spinous processes and consider
No significant tenderness
using percussion/vibration with a 128-Hz
on palpation
tuning fork to further examine spinal tenderness or reproduction of symptoms
Bony percussion/use of a tuning fork may
indicate the presence of bony injury, but
interpret with caution
Tenderness or reproduction of symptoms on palpation, percussion,
and/or vibration
Abbreviation: SI, spinal infection.
TABLE 21
Initial Investigations for Spinal Infection
Modality
Context
MRI
MRI is the imaging of choice. Findings on MRI can be observed 3-5 d after the onset of infection, with high sensitivity (96%), specificity (92%), and accuracy
(94%)2,9,49,76
Blood tests
There is no single diagnostic blood test. Inflammatory markers are routinely used to assess for infection. The white blood cell count is less useful than erythrocyte sedimentation rate and C-reactive protein, as a normal white blood cell count does not exclude spinal infection45
X-ray
Chest X-ray if there is suspicion of tuberculosis
Abbreviation: MRI, magnetic resonance imaging.
deteriorate (safety net). Utilize a period of watchful waiting, with advice
about being more physically active
Level of Concern
LOW
HIGH
• Clinical action: treat and monitor
symptoms, discuss and document a
clear strategy to follow if symptoms
deteriorate (safety net). Consider MRI
if there is an increased suspicion of
pathology
Level of Concern
Case 2
A 43-year-old man reports a 3-month
history of LBP that is intermittent and
mechanical in nature. He was born in Somalia and smokes 20 cigarettes per day.
He is neurologically intact and exhibits
normal function.
• Born in TB-endemic country
• Smoker
LOW
HIGH
ment is normal.
• Born in TB-endemic country
• Smoker
• Feels unwell
• Night pain, worsening symptoms
• Clinical action: urgent MRI and request blood tests, discuss and document a clear strategy to follow if
symptoms deteriorate (safety net)
Level of Concern
Case 3
The man now feels unwell and has had a
fever and chills in the last few days. He
reports pain at night and is unable to
settle. His pain has now become constant
and more intense. Neurological assess-
LOW
HIGH
Case 4
The man has now developed neurological signs and symptoms, with back and
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left leg pain to the dorsum of the foot. He
scored 3/5 (Oxford strength scale) for
left dorsiflexion. He has been up all night
with leg pain.
• Born in TB-endemic country
• Smoker
• Systemically unwell
• Night pain, worsening symptoms
• Neurological signs and symptoms
• Clinical action: emergency medical
assessment is required. As per local
pathway, consider/discuss whether
hospital admission is required
Level of Concern
LOW
HIGH
Suggested Pathway for Emergency/Urgent Referral Refer to the clinical de-
cision tool for suggested pathways for
emergency/urgent referral (FIGURE 3). t
STUDY DETAILS
perspectives about patient-provider
communication in regard to red flag
findings and opportunities for dissemination approaches to positively impact
clinical practice were also provided. The
steering committee reviewed all comments, and the red flag framework was
modified accordingly.
ACKNOWLEDGMENTS: This clinical framework
for identifying red flags for serious spinal
pathologies is endorsed by the IFOMPT, a
subgroup of the World Confederation for
Physical Therapy. Thanks to all the researchers, clinicians, member organization
delegates of the IFOMPT, Sussex MSK Partnership patient partners, and experts by
experience for generously giving their time to
review the document, respond to our surveys,
and participate in the consensus-building
process. Thanks to Sussex MSK Partnership
Patient Partners, Fleur Goff-Beardsley, Abby
King and Iris Keppler for their time and
contribution.
AUTHOR CONTRIBUTIONS: All authors pro-
vided substantial intellectual content
contributions to the conception and development of the framework document
during early draft and revision stages.
All authors provided final approval of
the manuscript to be published and
have agreed to be accountable for all
aspects of the work to ensure that questions related to the accuracy or integrity
of any part of the work are appropriately
investigated and resolved.
DATA SHARING: Data are from anonymous
questionnaire responses and available
on request from Dr Rachel Leech at
R.Leech@mmu.ac.u. These data, with
an appropriate citation, may be integrated with other datasets obtained
from repositories, or other sources.
PATIENT AND PUBLIC INVOLVEMENT: Patient
partners (n = 4) with previous scholarly review experience were identified
through the Sussex MSK Partnership.
Patient partners were engaged to participate in a web-based survey during
phase 4 to provide opinions about the
applicability, acceptability, and readability of the framework. Individual
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APPENDIX A
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DEFINITIONS
• Clinical risk/index of suspicion: relates to clinical risk factors and presenting clinical features. Once the index of suspicion passes a critical threshold, the therapist will become concerned about the underlying cause of the person’s complaint3
• Emergency referral: this needs to reflect local pathways, but, as a guide, on the same day
• Experts by experience: patient representatives
• General practitioner review: follow-up by medical practitioner; onward medical management to be carried out by the general practitioner
• High level of evidence: evidence supported by the literature
• Investigations: refers to requesting imaging or ordering blood tests to aid diagnosis
• Low level of evidence: evidence supported by consensus and the steering group
• Red flag: Goodman and Snyder2 define red flags as features of the individual’s medical history and clinical examination thought to be associated
with a high risk of serious disorders such as infection, inflammation, cancer, or fracture. Red flags are clinical prediction guides—they are not diagnostic tests, and they are not necessarily predictors of diagnosis or prognosis. The main role of red flags is that, when combined, they help to raise
the clinician’s index of suspicion. Unfortunately, with a few exceptions, the prognostic strength of individual red flags or combinations of red flags is
not known3
• Safety netting: safety netting is a management strategy used for people who may present with possible serious pathology. These strategies should
include advice on which signs and symptoms to look out for, which action to take, and the time frame within which that action needs to be taken 4
• Shared decision making: the conversation that happens between a patient and a clinician to reach a health care choice together
• Urgent referral: this needs to reflect local pathways, but, as a guide, within 5 days
• Watchful waiting: the act of close surveillance while undergoing treatment as required, but allowing time to pass before medical intervention or
therapy is used1
REFERENCES
1. Cook CE, George SZ, Reiman MP. Red flag screening for low back pain: nothing to see here, move along: a narrative review. Br J Sports Med. 2018;52:493-496. https://doi.
org/10.1136/bjsports-2017-098352
2. Goodman CC, Snyder TEK. Screening for immunologic disease. In: Differential Diagnosis for Physical Therapists: Screening for Referral. 5th ed. St Louis, MO: Elsevier/
Saunders; 2013:ch 12.
3. Greenhalgh S, Selfe J. Red Flags II: A Guide to Solving Serious Pathology of the Spine. Edinburgh, UK: Elsevier/Churchill Livingstone; 2010.
4. Hirst Y, Lim AWW. Acceptability of text messages for safety netting patients with low-risk cancer symptoms: a qualitative study. Br J Gen Pract. 2018;68:e333-e341. https://
doi.org/10.3399/bjgp18X695741
journal of orthopaedic & sports physical therapy | volume 50 | number 7 | july 2020 | a1
[ position statement ]
APPENDIX B
KEY PAPERS: EVIDENCE STATEMENTS
Journal of Orthopaedic & Sports Physical Therapy®
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Pathology
CES1
Papers Reviewed, n
7
Patients, n
569
CES4
NA
NA
CES5
NA
NA
Fracture13
8
7378
Fracture11
Fracture9
NA
4 guidelines
NA
NA
Fracture3
Fracture8
Malignancy6
NA
NA
8
NA
NA
7361
Infection14
41
2058
Infection10
NA
NA
Evidence Statement
Red flags commonly used to screen for CES are not robust enough to diagnose CES on their own, as their
diagnostic accuracy is poor. That being said, red flags still remain important clinical markers for the
suspicion of CES, as presently they are the best tools that general health care practitioners have to screen
for this serious condition
Policy document outlining best standards of care
In patients with symptoms suggestive of CES, with confirmed cauda equina compression on MRI, the recommended treatment of choice is urgent surgical decompression
Nothing is to be gained by delaying surgery, and potentially there is much to be lost. Decompressive surgery
should be undertaken at the earliest opportunity, taking into consideration the duration of pre-existing
symptoms and the potential for increased morbidity, while operating in the small hours. We do not
consider that there is anything in the literature that justifies contravention of this principle. We recommend
that reasons for any delay in surgery be documented
A number of authors, including Henschke et al,7 Downie et al,2 and Verhagen et al,12 have published highquality review papers demonstrating that red flags have a weak evidence base
The available evidence does not support the use of many red flags to specifically screen for vertebral fracture
in patients presenting with LBP. From the limited evidence, 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
NA
Overall, none of the guidelines was of satisfactory quality. The domains with the lowest scores were rigor of
development and applicability
NA
Evidence rating: C—consensus, disease-oriented evidence, usual practice, expert opinion, or case series
For most “red flags,” there is insufficient evidence to provide recommendations regarding their diagnostic
accuracy or usefulness for detecting spinal malignancy
The current evidence surrounding red flags for SI remains of low quality, and clinical features alone should
not be relied on to identify SI
NA
Abbreviations: CES, cauda equina syndrome; LBP, low back pain; MRI, magnetic resonance imaging; NA, not applicable; SI, spinal infection.
REFERENCES
1. Dionne N, Adefolarin A, Kunzelman D, et al. What is the diagnostic accuracy of red flags related to Cauda Equina Syndrome (CES), when compared to Magnetic Resonance
Imaging (MRI)? A systematic review. Musculoskelet Sci Pract. 2019;42:125-133. https://doi.org/10.1016/j.msksp.2019.05.004
2. Downie A, Williams CM, Henschke N, et al. Red flags to screen for malignancy and fracture in patients with low back pain: systematic review. BMJ. 2013;347:f7095. https://
doi.org/10.1136/bmj.f7095
3. Esses SI, McGuire R, Jenkins J, et al. The treatment of symptomatic osteoporotic spinal compression fractures. J Am Acad Orthop Surg. 2011;19:176-182. https://doi.
org/10.5435/00124635-201103000-00007
4. Germon T, Ahuja S, Casey ATH, Todd NV, Rai A. British Association of Spine Surgeons standards of care for cauda equina syndrome. Spine J. 2015;15:S2-S4. https://doi.
org/10.1016/j.spinee.2015.01.006
5. Greenhalgh S, Finucane L, Mercer C, Selfe J. Assessment and management of cauda equina syndrome. Musculoskelet Sci Pract. 2018;37:69-74. https://doi.org/10.1016/j.
msksp.2018.06.002
6. Henschke N, Maher CG, Ostelo RW, de Vet HC, Macaskill P, Irwig L. Red flags to screen for malignancy in patients with low-back pain. Cochrane Database Syst Rev.
2013:CD008686. https://doi.org/10.1002/14651858.CD008686.pub2
7. Henschke N, Maher CG, Refshauge KM, et al. Prevalence of and screening for serious spinal pathology in patients presenting to primary care settings with acute low back
pain. Arthritis Rheum. 2009;60:3072-3080. https://doi.org/10.1002/art.24853
8. McCarthy J, Davis A. Diagnosis and management of vertebral compression fractures. Am Fam Physician. 2016;94:44-50.
9. Parreira PCS, Maher CG, Megale RZ, March L, Ferreira ML. An overview of clinical guidelines for the management of vertebral compression fracture: a systematic review.
Spine J. 2017;17:1932-1938. https://doi.org/10.1016/j.spinee.2017.07.174
10. Public Health England. Tuberculosis in England: 2019 Report (presenting data to end of 2018). London, UK: Public Health England; 2019.
11. Royal Osteoporosis Society. Clinical guidance for the effective identification of vertebral fractures. Available at: https://www.guidelines.co.uk/musculoskeletal-and-joints-/
ros-guideline-identification-of-vertebral-fractures/454148.article. Accessed April 16, 2020.
12. Verhagen AP, Downie A, Popal N, Maher C, Koes BW. Red flags presented in current low back pain guidelines: a review. Eur Spine J. 2016;25:2788-2802. https://doi.
org/10.1007/s00586-016-4684-0
13. Williams CM, Henschke N, Maher CG, et al. Red flags to screen for vertebral fracture in patients presenting with low-back pain. Cochrane Database Syst Rev.
2013:CD008643. https://doi.org/10.1002/14651858.CD008643.pub2
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s12891-019-2949-6
a2 | july 2020 | volume 50 | number 7 | journal of orthopaedic & sports physical therapy
APPENDIX C
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RED FLAGS THAT GAINED CONSENSUS AS INAPPROPRIATE
Pathology
Risk Factors
Signs
Symptoms
Investigations
CES
...
• Absent bulbocavernosus reflex
• Saddle anesthesia
• X-ray
• Bladder ultrasound
Fracture
• BMI, <23 kg/m2
• Recent back injury
• No regular exercise
• Family history of spinal fracture
• Smoking
• Alcohol intake, >14 units/wk
• Muscle spasm
• Muscle spasm
• Leg pain
...
Malignancy
• Failure to improve after 1 mo with
conservative therapy
• Duration of episode, >1 mo
• Age, >50 y
• Muscle spasm
• Fever recorded via thermometer (temperature, >100°F/37.8°C)
• Muscle spasm
• X-ray
• Insidious onset
• Patient reports symptoms of fever
• Patient reports neurological symptoms
• Patient reports having tried bed rest,
with no relief
• Patient reports gradual onset before
age 40
Infection
• Older age
• Spinal trauma
• Male sex
• Lives in rural area
• Ingestion of unpasteurized dairy
product
• Blood pressure dysfunction
• Abscess
• Paralysis
• Active bacterial/fungal infection
• Sepsis/septic shock
• Weight loss (at least 4 kg)
• Observed spinal deformity
• Anorexia (BMI, ≤19 kg/m2)
• Hepatosplenomegaly (liver and spleen
enlargement)
• Patient reports stiffness
• Patient reports feeling of tenderness
• Patient reports radiculopathy
• Patient reports bladder/bowel dysfunction
• Patient reports urinary incontinence
• Weakness/extreme weakness
• Arthralgia
• Myalgia
• Anorexia
• CT scan
Abbreviations: BMI, body mass index; CES, cauda equina syndrome; CT, computed tomography.
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70. Kelli Wrolstad, John J Mischke, Audrey RC Elias. 202⒊ Desmoid fibromatosis presenting as lateral hip pain in an
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71. I.V. Sarvilina, A.B. Danilov. 202⒊ Comparative analysis of the use of symptomatic slow acting drugs for osteoarthritis
containing chondroitin sulfate or affecting its biosynthesis in patients with non-specific low back pain. Zhurnal nevrologii
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202⒊ Bacteria in human lumbar discs – subclinical infection or contamination? Metabolomic evidence for colonization,
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Anne Courbalay. 202⒊ Effects of an acute Mindfulness-based intervention on exercise tolerance, maximal strength,
pain and effort-related experiences in individuals with primary chronic low back pain: a pilot study. Movement & Sport
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Ethiopia, 20⒛ BMC Medical Imaging 22:1. . [Crossref]
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Adherence to spinal imaging guidelines and utilization of lumbar spine diagnostic imaging for low back pain at a Canadian
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8⒎ Seth Peterson. 2022. Why Rush to Surgery? A Case Report of Safety Netting and Management of Suspected Cauda
Equina Syndrome. JOSPT Cases 2:4, 208-2⒚ [Abstract] [Full Text] [PDF] [Supplementary Material]
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United States. Journal of Manipulative and Physiological Therapeutics 45:8, 551-56⒌ [Crossref]
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Determination of potential risk characteristics for cauda equina compression in emergency department patients presenting
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Research 6:5, 512-5⒘ [Crossref]
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Environmental Research and Public Health 19:17, 1065⒎ [Crossref]
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Francis Fatoye. 2022. Red flags for spinal pain in patients diagnosed with spinal infection in Nigeria: A 10-year medical
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2022. Orthopedic Asynchronous Teleconsultation for Primary Care Patients by a Large-Scale Telemedicine Service in
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Dyspareunia: A Cross-Sectional Study. Diagnostics 12:8, 182⒎ [Crossref]
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for the management of lower back pain in the emergency department: A narrative review. Emergency Care Journal 18:2. .
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101. Cecilie Rud Budtz, Helle Rønn-Smidt, Janus Nikolaj Laust Thomsen, Rikke Pilegaard Hansen, David Høyrup
Christiansen. 2022. Primary Care Physical Therapists’ Experiences When Screening for Serious Pathologies Among
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during the active straight leg raise test. European Journal of Clinical Investigation 52:⒌ . [Crossref]
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10⒋ Yan Gao, Min Wang, Guogang Zhang, Lingjun Zhou, Jingming Luo, Lijue Liu. 2022. Cluster-Based Ensemble
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[Crossref]
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responses following joint mobilisation and manipulation in people with persistent neck pain: a protocol for a randomised
placebo-controlled trial. BMJ Open 12:3, e05574⒏ [Crossref]
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Mathon. 2022. Chronic low back pain during COVID-19 lockdown: is there a paradox effect?. European Spine Journal
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acute myocardial infarction in physiotherapy direct access: findings from a case report. Archives of Physiotherapy 11:1. .
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12⒋ Ahmed S Alhowimel, Mazyad A Alotaibi, Dalyah M Alamam, Faris A Alodaibi, Julie M Fritz. 2021. Attitudes and
Beliefs of Primary Care Physicians Working in Saudi Arabia Regarding the Management of Low Back Pain: A CrossSectional Study. International Journal of General Medicine Volume 14, 10225-1023⒊ [Crossref]
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