During the nominal groups and the experts meetings, the need to disseminate this list of red flags to clinicians involved in the management of low back and radicular pain was broadly emphasised. Clinicians asked a standardized tool for triage (for example, a questionnaire to be included in the electronic medical record). It is also felt that some students in medicine have a real lack of skills in clinical examination, maybe because some academic curricula have minimised propaedeutic training in the past and until recently.
KCE Report 295 Low back pain and radicular pain: development of a clinical pathway 83 Table 8 – List of red flags, grouped by cluster (based on expert opinion) Urgent (immediate) Red flags Action Neurological emergencies • Widespread (e.g. in the arms, cranial nerves or bilateral) neurological symptoms (pyramidal signs, coordination problems, motor or sensory disturbances…) • Progressive neurological symptoms • Saddle anaesthesia /hypoesthesia, urinary retention, faecal or urinary incontinence, isolated sexual dysfunction (cauda equina syndrome) • Severe motor deficit (MRC score ≤3/5) <48 h Refer the patient to the emergency department Traumatic fracture • Severe low back pain following significant/high-energy trauma • Back pain following trauma with ankylosing spondylitis Refer the patient to the emergency department Vascular problems • Vascular signs (cold foot, reduced peripheral arterial pulsation) that could indicate a torn aneurysm of the aorta if paired with low back pain or even with shock Echography & vascular surgery consult Semi-urgent (within 48h) Red flags Action Pathological fracture : Low back pain following minor trauma or even without awareness of trauma with: • History/risk of osteoporosis • Chronic corticoid use • Thoracic pain • Older age • Unexplained weight loss, fatigue • History of cancer 1/ X-ray (or CT) 2/ Spine surgery consult Infection • Objective signs (e.g. nocturnal sweating, fever, chills) • Intravenous drug use • Immunocompromised patient • Unexplained weight loss • Known previous or concurrent systemic infection or risk of infection • Recent surgical intervention • Urinary or cutaneous infection 1/ MRI & Lab (e.g. leukocyte count, CRP, sedimentation) 2/ Spine surgery consult & Internist/infection specialist consult
84 Low back pain and radicular pain: development of a clinical pathway KCE Report 295 Moins urgent Drapeau rouge Action Tumor • New onset back pain at age <18 and >55 • History of cancer • Unexplained weight loss, fatigue • Severe nocturnal pain 1/ MRI 2/ Oncology/radiotherapy consult & Spine surgery consult Inflammatory disease • Constant progressive non-mechanical pain • (Improvement in back pain with exercise but not with rest) • Severe nocturnal pain • Morning stiffness > 30 min or nocturnal awakening in younger patients Rheumatology consult Miscellaneous • Increasing postoperative pain • Excruciating and therapy-resistant low back pain (>6 weeks) • Unilateral pyramidal signs 1/ MRI 2/ Spine specialist consult (specialist in physical medicine