SynthesisBMJ (Clinical research ed.)2013
Red flags to screen for malignancy and fracture in patients with low back pain: systematic review.
Synthesis in BMJ (Clinical research ed.), 2013. The graph could read no effect estimate from its abstract, so it casts no vote on the map. An erratum has been issued. Cited by 92 papers, 6 of them syntheses that pooled it.
What it found
Each row is one number read from the abstract, on the scale the paper reported it, with its interval. Left of the dashed line favours the treatment, right favours the comparator. Under each row is the sentence it came from. New to these charts? A ten-minute tutorial.
The abstract states no effect estimate the extractor could read, or names no intervention and outcome on the map, so this paper lights no cell and moves no belief. It is still indexed, cited and linked below.
The trial behind it
Trials whose registry record cites this paper, or whose number appears in the abstract. A trial that started after this paper was published is citing it as background, not reporting it.
Neither the registry nor the abstract names a trial number. If this is a trial report, that itself is worth knowing.
Who cites it
92 citing papers in PubMed, 6 syntheses or guidelines pooled it, 300 citations in OpenAlex.
- American Society of Hematology 2026 guidelines on diagnosis of light chain amyloidosis.Blood advances · 2026Guideline
- Tools to Detect Risk of Death by Suicide: A Systematic Review and Meta-Analysis.The Journal of clinical psychiatry · 2022Pooled it
- Defining and measuring imaging appropriateness in low back pain studies: a scoping review.European spine journal : official publication of the European Spine Society, the European Spinal Deformity Society, and the European Section of the Cervical Spine Research Society · 2020Pooled it
- Meta-Analysis of Integrated Therapeutic Methods in Noninvasive Lower Back Pain Therapy (LBP): The Role of Interdisciplinary Functional Diagnostics.Pain research & management · 2020Pooled it
- Red flags for the early detection of spinal infection in back pain patients.BMC musculoskeletal disorders · 2019Pooled it
- Management of neck pain and associated disorders: A clinical practice guideline from the Ontario Protocol for Traffic Injury Management (OPTIMa) Collaboration.European spine journal : official publication of the European Spine Society, the European Spinal Deformity Society, and the European Section of the Cervical Spine Research Society · 2016Guideline
- Trial
- Healthy Lifestyle Care vs Guideline-Based Care for Low Back Pain: A Randomized Clinical Trial.JAMA network open · 2025Trial
- Pain neuroscience education improves post-traumatic stress disorder, disability, and pain self-efficacy in veterans and service members with chronic low back pain: Preliminary results from a randomized controlled trial with 12-month follow-up.Military psychology : the official journal of the Division of Military Psychology, American Psychological Association · 2024Trial
- A Study of 60 Patients with Low Back Pain to Compare Outcomes Following Magnetotherapy, Ultrasound, Laser, and Electrotherapy with and without Lumbosacral Kinesiotherapy.Medical science monitor : international medical journal of experimental and clinical research · 2024Trial
- Effectiveness of patient education plus motor control exercise versus patient education alone versus motor control exercise alone for rural community-dwelling adults with chronic low back pain: a randomised clinical trial.BMC musculoskeletal disorders · 2023Trial
- Analysis of Postural Stability Following the Application of Myofascial Release Techniques for Low Back Pain-A Randomized-Controlled Trial.International journal of environmental research and public health · 2023Trial
- "Blue flags", development of a short clinical questionnaire on work-related psychosocial risk factors - a validation study in primary care.BMC musculoskeletal disorders · 2017Trial
- Appropriateness of Lumbar Spine Magnetic Resonance Imaging Requests: Guideline Concordance, Diagnostic Yield, Artificial-Intelligence Assessment and Derivation of a Simple Clinical Decision Rule.Diagnostics (Basel, Switzerland) · 2026Article
- Rethinking nonspecific low back pain: Evolving from an undifferentiated working diagnosis to precision spine care.Interventional pain medicine · 2026Article
- Emergency surgical management of nontraumatic pathologic spinal pain diagnosed in the emergency department.Ulusal travma ve acil cerrahi dergisi = Turkish journal of trauma & emergency surgery : TJTES · 2026Article
- Article
- Management of older adults consulting in GP surgery practices with back pain in UK Clinical Practice Research Datalink Aurum: population based study.BMC musculoskeletal disorders · 2026Article
- Sensitivity and Specificity of Elliptical Modeling and Sagittal Lumbar Alignment Variables in Normal vs. Acute Low Back Pain Patients: Does Pelvic Morphology Explain Group Lordotic Differences?Healthcare (Basel, Switzerland) · 2025Article
- Diagnostic Utility of Red Flags for Detecting Spinal Malignancies in Patients with Low Back Pain: A Scoping Review.Journal of clinical medicine · 2025Review
32 more citing papers are in PubMed but not listed here.
Corrections and comments
- Commented on by
- Commented on by
- Erratum issued
- Reprinted as
Authors and funding
11 authors at 6 institutions in 3 countries.
Funding
No grant is acknowledged in the PubMed record.
Abstract
objectiveTo review the evidence on diagnostic accuracy of red flag signs and symptoms to screen for fracture or malignancy in patients presenting with low back pain to primary, secondary, or tertiary care.
designSystematic review. DATA SOURCES: Medline, OldMedline, Embase, and CINAHL from earliest available up to 1 October 2013. INCLUSION CRITERIA: Primary diagnostic studies comparing red flags for fracture or malignancy to an acceptable reference standard, published in any language. REVIEW
methodsAssessment of study quality and extraction of data was conducted by three independent assessors. Diagnostic accuracy statistics and post-test probabilities were generated for each red flag.
resultsWe included 14 studies (eight from primary care, two from secondary care, four from tertiary care) evaluating 53 red flags; only five studies evaluated combinations of red flags. Pooling of data was not possible because of index test heterogeneity. Many red flags in current guidelines provide virtually no change in probability of fracture or malignancy or have untested diagnostic accuracy. The red flags with the highest post-test probability for detection of fracture were older age (9%, 95% confidence interval 3% to 25%), prolonged use of corticosteroid drugs (33%, 10% to 67%), severe trauma (11%, 8% to 16%), and presence of a contusion or abrasion (62%, 49% to 74%). Probability of spinal fracture was higher when multiple red flags were present (90%, 34% to 99%). The red flag with the highest post-test probability for detection of spinal malignancy was history of malignancy (33%, 22% to 46%).
conclusionsWhile several red flags are endorsed in guidelines to screen for fracture or malignancy, only a small subset of these have evidence that they are indeed informative. These findings suggest a need for revision of many current guidelines.
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What OpenQuestion holds
Registered trials
Read under generation 80e0d062 · epoch 390. Bibliography from PubMed, PubMed Central and OpenAlex; grants from NIH RePORTER; trial links from ClinicalTrials.gov; estimates, votes and beliefs from the OpenQuestion graph.