Department of General Practice, Erasmus Medical Centre University, Rotterdam, the Netherlands.
Musculoskeletal Health Sydney, School of Public Health, The University of Sydney, Sydney, Australia.
Pain. 2017 Oct;158(10):1860-1868. doi: 10.1097/j.pain.0000000000000998.
Clinicians do not want to miss underlying serious pathology, but it is still unclear which red flags are relevant. We aimed to evaluate the origin and evidence on diagnostic accuracy of red flags for malignancy for management of low back pain (LBP) in primary care. We performed a comprehensive overview and searched the literature using snowballing techniques and reference checking for evidence on red flags endorsed in clinical guidelines for identifying patients with higher likelihood of malignancy. We selected studies including people with LBP without any restriction on study design. We extracted data on prevalence and diagnostic accuracy. Furthermore, we assessed the methodological quality of studies evaluating diagnostic accuracy. We identified 13 red flags endorsed in a total of 16 guidelines and 2 extra red flags not endorsed in any guideline. We included 33 publications varying from systematic reviews to case reports. The origin of many red flags was unclear or was sourced from case reports. The incidence of malignancy in patients presenting with LBP in primary care varied between 0% and 0.7%. Seven studies provided diagnostic accuracy data on red flags. We found 5 red flags with accuracy data from 2 or more studies, with 2 ("history of malignancy" and "strong clinical suspicion") considered informative. In conclusion, the origin and diagnostic accuracy of many red flags endorsed in guidelines are unclear. A "history of malignancy" and "strong clinical suspicion" are the only red flags with empirical evidence of acceptably high diagnostic accuracy.
临床医生不想错过潜在的严重病变，但目前仍不清楚哪些危险信号与恶性肿瘤有关。我们旨在评估用于初级保健中腰痛（LBP）管理的恶性肿瘤相关危险信号的起源和诊断准确性证据。我们进行了全面的综述，并使用滚雪球技术和参考文献检查来搜索文献，以寻找临床指南中认可的用于识别恶性肿瘤可能性较高的患者的危险信号的证据。我们选择了研究对象为没有任何研究设计限制的腰痛患者的研究。我们提取了关于患病率和诊断准确性的数据。此外，我们评估了评估诊断准确性的研究的方法学质量。我们确定了 16 项指南中认可的 13 个危险信号和 2 项任何指南中均未认可的额外危险信号。我们纳入了 33 项出版物，从系统评价到病例报告不等。许多危险信号的起源不明确，或者源自病例报告。初级保健中出现腰痛的患者中恶性肿瘤的发生率在 0%至 0.7%之间不等。有 7 项研究提供了危险信号的诊断准确性数据。我们发现了 5 个具有来自 2 项或更多研究的准确性数据的危险信号，其中 2 个（“恶性肿瘤病史”和“强烈的临床怀疑”）被认为是有信息性的。总之，指南中认可的许多危险信号的起源和诊断准确性尚不清楚。“恶性肿瘤病史”和“强烈的临床怀疑”是仅有的具有可接受的高诊断准确性的经验证据的危险信号。
