Red Flags
The Signs, RED FLAGS, Ages, & Groups
This section of the web site is extremely long and covers 2 parts. We apologise in advance for this but it is important. as we
need to fully explain the significance of the red flags and the consequences when Doctors and Emergency Room personel,
do not know the results of a misdiagnosis of Cauda Equina Syndrome. A misdiagnosis of Cauda Equina is not only
Dangerous but can be very debilitating and life changing for the patient as you will see in this section.
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Adjustment, Rehabilitation, and Compensation.
Cauda Equina Syndrome (CES) is a rare but serious condition. In the majority of cases, it is caused
by a disc herniation in the lower back that causes the Cauda Equina - a bundle of nerveslocated at the
top of the Lumbar Spine - to be compressed.
The symptoms of Cauda Equina Syndrome in some cases can come on slowly, but the worst. kind of
Cauda Equina Syndrome occurs suddenly. Although most disc herniations present with pain, a really
bad disc herniation can cause a Cauda Equina Syndrome within six to 10 hours.
In some severe cases, Degenerative Disc Disease (DDD) can cause nerve problems in the feet. An
intervertebral disc can also herniate and push on the nerves that lead to the feet, causing pain and
sometimes tingling or numbness. The Cauda Equina can be found in the bottom third of the
spinal canal and from the T12/L1 vertebrae to the coccyx, beyond the conus medullaris into the lumbar
region.
This shows the outcome of CES and its problems. Anyone of the symptoms shown can start your journey
to a hideous and painful disorder. This a more detailed breakdown will help you understand more about
CES.
What Nerves and Vertebrae/Discs Affect What Areas
Note: Some of the information may be repeated in earlier Sections/Chapters. We cannot stress enough
that Cauda Equina is dangerous thus we keep hammering home the need for the medical profession to
be alert of the RED FLAGS.
The Cauda Equina Syndrome Association (CESA) is just one of many organisations who are here here for people like
Claude and their families, carers and friends. We aim to embrace people living with CES and by using our collective
voice, we hope we will bring about change and an end to unnecessary suffering. The UK has the highest incidence of
CES. With the help of our members, we hope to change this and empower and support people to continue to live
positive, happy lives.
The charts show the nerves and muscles controlled by the Cauda Equina on the pages following Parathesia is
discussed and what can cause this medical problem. Admittedly we touch on most of these previously but
it requires to bring new medical problems along. (As shown in the chart in Part One Chapter Three of the
Book). Is defined as an abnormal sensation of the body, such as numbness, tingling, or burning. These
sensations may be felt in the fingers, hands, toes, or feet. Depending on the cause, the sensation
of paraesthesia can be short-term and disappear quickly, such as when it occurs due to hyperventilation,
an anxiety attack or from lying on the arm while asleep.
Most people have experienced temporary paraesthesia, a feeling of pins and needles, at some time in their
lives when they have sat with legs crossed for too long, or fallen asleep with an arm crooked under their head.
It happens when sustained pressure is placed on a nerve.
The feeling quickly goes away once the pressure is relieved. Some individuals may experience
chronic paraesthesia. This is usually a symptom of severe underlying conditions. Chronic paraesthesia is
often a symptom of an underlying neurological disease or traumatic nerve damage. Paraesthesia can be
caused by disorders affecting the central nervous system, such as stroke and transient ischemic attacks
(mini-strokes), multiple sclerosis, transverse myelitis, and encephalitis. A tumour or vascular lesion pressed
up against the brain or spinal cord can also cause paraesthesia.
Nerve entrapment syndromes, such as Carpal Tunnel Syndrome, can damage peripheral nerves and because
paraesthesia accompanied by pain. When a person experiences paraesthesia, symptoms from a wide range
of possibilities may occur. There are a number of potential causes as well; multiple sclerosis for
instance. The list below includes many of the potential causes of paraesthesia.
- Migraines :
Migraine headaches can cause throbbing in one particular area that can vary in intensity. Nausea and sensitivity to
light and sound are also common symptoms.
- Alcoholism :
A chronic disease characterised by uncontrolled drinking and preoccupation with alcohol.
- Neuropathy :
Weakness, numbness and pain from nerve damage, usually in the hands and feet.
- Malnutrition : Lack of sufficient nutrients in the body.
- Menopause :
A natural decline in reproductive hormones when a woman reaches her 40s or 50s.
- Dehydration :
Dehydration can have causes that aren't due to underlying disease. Examples include heat, excessive activity,
insufficient fluid consumption, excessive sweating or medication side effects.
- Fibromyalgia :
Fibromyalgia is often accompanied by fatigue and altered sleep, memory and mood. Widespread muscle pain and
tenderness are the most common symptoms. Medication, talk therapy and stress reduction may help control
symptom.
- Herpeszoster :
A reactivation of the chickenpox virus in the body, causing a painful rash. Also associated with 'Shingles'.
- Hypoglycaemia :
Low blood sugar, the body's main source of energy. (Diabetes)
- Fabry Disease :
Fabry disease is a rare genetic disease with a deficiency of an enzyme called alpha-galactosidase A.
The disease affects many parts of the body including the skin, eyes, gastrointestinal system, kidney, heart, brain,
and nervous system. Symptoms of Fabry disease include: Episodes of pain and burning sensations.
- Nerve Irritation Atherosclerosis :
Vagus-brain communication in atherosclerosis-related inflammation: a communication
between the immune and central nervous systems.
- Hyperventilation :
Hyperventilation syndrome (HVS) is a name given to a collection of physical and emotional symptoms, largely
brought about by hyperventilation. This happens when we over-breathe. The main signs of this are when we
breathe much more quickly and more shallowly than our bodies needs.
- Multiple Sclerosis :
A disease in which the immune system eats away at the protective covering of nerves.
- Immune Deficiency : Immunodeficiency or immunocompromise is a state in which the immune system's ability to fight infectious
disease and cancer is compromised or entirely absent. Most cases of immunodeficiency are acquired
("secondary") due to extrinsic factors that affect the patient's immune system.
- Anticonvulsant Drugs : Anticonvulsants are a diverse group of pharmacological agents used in the treatment of epileptic
seizures. Anticonvulsants are also increasingly being used in the treatment of bipolar disorder and
borderline personality disorder, since many seem to act as mood stabilizers, and for the treatment of
neuropathic pain.
- Lupus Erythematosus : An inflammatory disease caused when the immune system attacks its own tissues.
- Neurological Disorders :
These disorders include epilepsy, Alzheimer disease and other dementias, cerebrovascular diseases
including stroke, migraine and other headache disorders, multiple sclerosis, Parkinson's disease,
neuroinfections, brain tumours, traumatic disorders of the nervous system.
- Motor Neuron Diseases :
Motor neurone disease is the progressive and fatal degeneration of certain nerve cells that control
muscles, symptoms, diagnosis, management.
- Lyme Disease Infection :
A tick-borne illness caused by the bacterium Borrelia burgdorferi.
- Beta-Alanine Ingestion :
Beta-alanine is a non-essential amino acid. ... Amino acids are the building blocks of proteins. Beta-
alanine is used for improving athletic performance and exercise capacity, building lean muscle mass,
and improving physical functioning in the elderly.
- Autoimmune Disorders :
A disease in which the body's immune system attacks healthy cells.
MOST COMMON TYPES
- Heavy Metal Poisoning :
A toxic heavy metal is any relatively dense metal or metalloid that is noted for its potential toxicity,
especially in environmental contexts. The term has particular application to cadmium, mercury, lead and
arsenic, all of which appear in the World Health Organization's list of 10 chemicals of major public
concern.
- Guillain-Barre Syndrome :
A condition in which the immune system attacks the nerves. The condition may be triggered by an
acute bacterial or viral infection.
(The List above we have showed briefs on what they are, full explanations for each can be found within the
Book/Manual and how they cause Parathesia, and it's effects on CES.)
Symptoms of Paraesthesia
Interestingly, paraesthesia itself is something that can be considered a symptom of certain conditions. The
lack of one of the conditions mentioned in this article does not necessarily mean that a person is not experiencing
some level of paraesthesia. In addition, the paraesthesia a person experiences may be either chronic or transient.
When paraesthesia is caused by a particular condition, additional symptoms might become a part of the person's
experience, related to underlying causes. The symptoms of paraesthesia may include: Itching, Tingling, Foot drop,
Dysarthria, Numbness, Muscular atrophy, Ocular Dysmetria Restless leg syndrome, Crawling sensation on the skin,
"Falling asleep" of limbssuch as a hand, foot, arm, leg, etc.
Diagnosing Paraesthesia
Diagnostic evaluation of paraesthesia is based on the determination of the underlying condition that is causing
the person to experience paraesthesia sensations. A person's medical history, in combination with a physical
examination and laboratory testing, are essential for a diagnosis. A doctor might order other tests depending upon the
suspected cause of the paraesthesia the person is experiencing. Paraesthesia can be classified as either transient or
chronic. Transient paraesthesia might be a symptom of hyperventilation or a panic attack. Chronic paraesthesia can be
the result of nerve irritation, poor circulation, neuropathy, or a number of other conditions or causes. There is no form of
long-term physical effect from paraesthesia, although its underlying conditions can have a number of effects.
Treatment of Paraesthesia
Treatment of paraesthesia depends on an accurate diagnosis of the underlying cause. For people with limbs that
have fallen asleep, restoration of their circulation through exercising, stretching, or massaging the affected limb can
rapidly dissipate the tingling and sensations of numbness. If the paraesthesia is due to a chronic disease, such as
diabetes, or occurs as a complication of treatments like chemotherapy, the majority of treatments are aimed at relief of
the person's symptoms. Anti-inflammatory medications such as ibuprofen or aspirin are recommended if the person's
symptoms are mild. People with more difficult paraesthesia might be administered antidepressant medications such as
amitriptyline. Antidepressant medications prescribed for paraesthesia are given at a much lower dosage than they are
for the relief of depression. The medications are believed to help because they alter the person's perception of pain. If
the paraesthesia a person is experiencing is even more severe, opium derivatives such as codeine might be rescribed.
As of the year 1998, trials are being performed in order to determine whether treatment with human nerve growth
factor will be effective in regenerating damaged nerves. There are also a number of alternative treatments available to
assist in relieving the symptoms of paraesthesia. Nutritional therapy can include B complex vitamin supplementation,
particularly vitamin B12. Vitamin supplementation is something that should be pursued with caution; however, because
an overdose of Vitamin B6, for example, is one of the causes of Paraesthesia. People who experience paraesthesia
should avoid the consumption of alcohol. Acupuncture and massage are also believed to provide a level of relief from
the symptoms of paraesthesia. Self-Massage with aromatic oils is sometimes helpful as well. The application of
topical ointments that contain, capsaicin, the substance that makes hot peppers hot, might provide relief from
paraesthesia. It can also be helpful to wear clothes and shoes that are loose-fitting.
Quick Facts on Paraesthesia
Benzodiazepine withdrawal can cause paraesthesia as the drug removal leaves the GABA receptors stripped bare and
possibly malformed. Joint conditions such as rheumatoid arthritis, psoriatic arthritis, and carpal tunnel syndrome are
common sourcesof paraesthesia. Chronic paraesthesia indicates a problem with the functioning of neurons or poor
circulation.Stroke survivors and those with Traumatic Brain Injury (TBI) may experience paraesthesia from damage to
thecentral nervous system. Paraesthesia can also be a symptom of vitamin deficiency and malnutrition, as well
asmetabolic disorders like diabetes, hypothyroidism, and hypoparathyroidism. It can also be a symptom
of mercury poisoning. The herpes zoster disease (shingles) can attack nerves causing numbness instead of
pain commonly associatedwith shingles. Medications offered can include the
immunosuppressant prednisone,intravenous gamma globulin (IVIG),anticonvulsants such as Gabapentin or Gabitril
and Antiviral medication, among others, according to theunderlying cause.
The plate above shows how relevant Cauda Equina Syndrome is connected to paraesthesia.
We have shown you in this chapter what can cause CES. The next chapter Treatments for both ailments.
RED FLAGS & How to Treat Them, Medication
Over-the-counter pain relievers can provide short-term relief from sciatica. Acetaminophen and nonsteroidal
anti- inflammatory drugs (NSAIDs), such as aspirin, ibuprofen, and naproxen are options. Your doctor may
give you a steroid injection to further reduce the inflammation.
Relief: Injections into Nerve
In severe cases, a doctor may recommend injecting steroids into the spine area to reduce inflammation.
It delivers the medication directly to the area around the sciatic nerve.
If your sciatica is due to a herniated disk, and it's still causing severe pain after four to six weeks,
surgery may be an option. The surgeon will remove a portion of the herniated disk to relieve the pressure on
the sciatic nerve. About 90% of patients get relief from this type of surgery. Other surgical procedures can
relieve sciatica caused by spinal stenosis.
Last Form 0f Relief:
Rehab
After back surgery, you will generally need to avoid driving, lifting, or bending forward for about a month.
Your doctor may recommend physical therapy to help you strengthen the muscles in the back. Once recovery
is complete, there's an excellent chance you'll be able to get back to all your usual activities. There is evidence that
acupuncture, massage, yoga, and chiropractic adjustments can relieve typical lower back pain. But more research is
needed to determine whether these therapies are helpful for sciatica.
If you've had sciatica once, there's a chance it will return. But there are steps you can take to reduce the
odds:
1) Exercise regularly.Maintain good posture.
2) Bend at the knees to lift heavy objects.
3) These steps can help you avoid back injuries that may lead to sciatica orherniated discs, which could cause
Cauda Equina. Syndrome.
Cauda Equina Syndrome is a rare and dangerous condition in which exposed nerve fibres(as shown below) located
at the bottom of the spinal cord become irritated. The irritation is caused by something with which the exposed
nerves come into contact. The term Cauda Equina means “horse's tail” in Latin it is so named because of the
resemblance. Generally, the sensitive nerve tissue that comprises the spinal cord and nerve roots is encased in the
centre of the spinal column in an area known as the spinal canal. In this way, the highly responsive nervous tissue
is protected from structures that may put pressure on it (which will likely cause symptoms such as pain and/oraltered
functionality).
Most of the time, Cauda Equina Syndrome is caused by a large, centralized herniated disc between the areas of
L4/5 and L5/S1. According to research reviewed by the British Medical Journal, only about 0.12% of all herniated
discs in the U.S. likely cause Cauda Equina. Other, less common causes include trauma or injury to the spine that
leads to fractures and/or subluxations. Tumours or infections that compress the Cauda Equina may also cause
this syndrome. Bone spurs in the spinal canal are another possible cause. Tuberculosis,
Potts' paralysis and Iatrogenic causes (for example spinal manipulation while you're
under anaesthesia or postoperative complications e.g.: Haematomas, ) are also implicated, as are things may
that occupy spinal spaces, such as cysts. You may be predisposed to Cauda Equina Syndrome if you have Spinal
Stenosis (either congenital or acquired). If acquired stenosis underlies your cauda equina syndrome, most likely the
Stenosis comes from disc degeneration and degeneration of your Facet Joints. You may also have a thickened
ligament flavum and a narrowing of your spinal canal.
Cauda Equina Syndrome Symptoms
Cauda Equina Syndrome is roughly categorized into 3 basic types, according to the defining symptom of
urinary retention. Complete CES is accompanied by urinary retention while incomplete is not. With complete
CES, urinary retention has already been diagnosed. With incomplete CES, you may experience reduced
urinary sensation, have a small stream, or similar symptoms, but you're still able to urinate. Urinary
retention can be serious and that's why it's very important to get checked if you notice any changes in this
functionality. Other symptoms of CES include sexual dysfunction, dysfunction of the bowel and/or numbness or other
sensory changes around your anus. (Numbness around the anus is called "saddle anaesthesia.") Of course, back pain
is a symptom, as are sensory or motor changes in your lower limbs (including weakness and/or loss of reflexes and
more.) Back pain is a symptom, as are sensory or motor changes in your lower limbs (including weakness and/or
loss of reflexes and more.) Cauda Equina Syndrome symptoms may present themselves in one of
three general patterns, which are labelled as:
“types.” They are:
Type 1: Symptoms are acute and come on very suddenly and intensely. Symptoms of CES caused by a
herniated disc present in this way.
Type 2: As the final destination after a long journey of chronic back pain, with or without sciatica.
Type 3: Insidiously, where you've slowly been experiencing more and more numbness, as well as
urinary symptoms.
Diagnosing Cauda Equina Syndrome
Cauda Equina Syndrome is a result of an interruption or dysfunction of the nerves associated with the +
lumbar and sacral vertebrae. However, such disruption is only diagnosed as cauda equina when your bladder,
bowel and/or sexual function is impaired. This includes the symptom of saddle numbness or
saddle anaesthesia, discussed briefly earlier, which is loss of feeling around the anus.
CES is diagnosed with MRI, myelogram, specialized nerve testing such as nerve conduction velocity
tests and/or electromyography, CT scans. If your doctor suspects you have cauda equina, you'll be subjected
to a physical exam that uses palpation (touch) to determine the degree of feeling and response around
your anus and rectum.
Treatments
Most of the time, CES is due to a herniated disc; therefore, the treatment of choice will likely be spinal
decompression surgery, probably a discectomy. Once your CES diagnosis is confirmed by your doctor, and if your MRI
shows that the cause of the pressure on the CES is reversible, at that point, surgery may make the most sense as an
immediate treatment option. With that said, sometimes emergency surgery is required to enable you to
avoid permanent dysfunction of your lower extremity (or extremities) as well as your bladder, bowel or sexual
functioning, the time gap for these functions to start to fail is uniquely small, 12 - 24 hours in some patients. Longer
than 36 Hours and the patient is in real danger of losing all functionality. The effects of untreated Cauda Equina
Syndrome can be devastating; the same is true for Cauda Equina Syndrome that is treated too late, time is the biggest
healer in the treatment of CES. Do not delay in speaking with your doctor about your treatment options. If something
other than a herniated disc is creating the pressure on your Cauda Equina, you'll likely need to work with a specialist or
team of specialists to address that problem, as well.
When in Doubt, Get It Checked Out!
The controversies around diagnosis and treatment of CES can easily complicate
decision making. However, this condition is potentially life-threatening, especially so if you do not heed your
symptoms. If you notice symptoms, speak with your doctor as soon as you can. When it comes to Cauda
Equina Syndrome, it's only natural to feel embarrassed about discussing what you notice, or apprehensive
about getting checked. But remember, doing so in a timely way may save your life or at the very least, your
quality of life. The purpose of the survey and study we undertook was to identify and descriptively compare
the RED FLAGS endorsed in guidelines for the detection of serious pathology in patients presenting with low
back pain to primary care.
CES GUIDELINES for PRIMARY CARE
& CLINICAL DIAGNOSIS
We searched databases, the World Wide Web and contacted experts aiming to find the
multidisciplinary clinical guideline in low back pain in primary care, and selected the most recent one per country. We
extracted data on the number and type of red flags for identifying patients with a higher likelihood of serious pathology.
Furthermore, we extracted data on whether or not accuracy data (sensitivity/specificity, predictive values, etc.)
were presented to support the endorsement of specific RED FLAGS.
We found discrete guidelines all published between 2000 and 2015. One guideline could not be
retrieved and after selecting one guideline per country we included 16 guidelines in our analysis from 15 different
countries and one for Europe as a whole. All guidelines focused on the management of patients with low back pain
in primary care or multidisciplinary care setting. Five guidelines presented red flags in general, i.e., not related to any
specific disease. Overall, we found 4 to 6 discrete RED FLAGS related to the four main categories of serious
pathology the main being Cauda Equina Syndrome.
The majority of guidelines presented for SEVEN RED FLAGS for Cauda Equina Syndrome. Quite often
pain at night or at rest was considered as a RED FLAG for various underlying pathologies. We based our choice
of RED FLAGS on consensus or previous guidelines; five did not provide any reference to support the choice
of RED FLAGS, three guidelines presented a reference in general, and data on diagnostic accuracy was
rarely provided. A wide variety of red flags was presented in questions for low back pain, with a lack of consensus
between guidelines for which RED FLAGS to endorse. Evidence for the accuracy of the recommended RED
FLAGS was lacking. Low back pain remains a common condition among primary care patients with an
estimated lifetime prevalence of 13.8 % for chronic pain and 80 % for an episode of pain on a scale of
1 - 5. European guidelines for the management of low back pain in primary care define low back pain as
‘‘pain and discomfort’’ localized below the costal margin and above the inferior gluteal folds, with or without
leg pain.
Non-specific low back pain is commonly defined as low back pain without any known pathology. Although nonspecific
low back pain accounts for about 85–90% of back pain, which could be Sciatica, herniated disc, fracture of vertebrae or
tearing of tendons and muscles supporting the spine or a Sacral injury. remaining patients may have neurologic
impairments (e.g., spinal stenosis, radiculopathy) or serious underlying diseases (e.g., fractures), of which the latter
necessitates timely and accurate diagnosis. Serious pathology in patients presenting with low back pain includes
Cauda Equina Syndrome (CES), infection or aortic aneurysms. Spinal malignancy and vertebral fracture are the most
frequent serious pathologies of the spine. However, the absolute magnitude of occurrence may be regarded as rare.
Among patients with low back pain presenting in primary care less than 1 % will have spinal malignancy (primary
vertebral tumour or vertebral metastasis) and about 4 % will have a spinal fracture. CES or spinal infections are even
rarer, with an estimated prevalence of 0.04% and 0.01 %, respectively, among patients with low back pain but the
outcome of the survey was inconclusive as to exactly what the cause was. This being CES or an infection. It was hard
to dissimilate between the data so the assumptions were taken into account that the resultant low back pain was the
prelude to CES and further evidence supported this assumption.
The spine is the most common bony site for musculoskeletal tumours. The majority of spinal malignancies are
the result of metastases of other tumours in the body, mainly from breast, lung or prostate cancer. Vertebral
compression fractures occur in almost 25 % of all postmenopausal women and the prevalence of compression
fractures linearly increases with advancing age, up to 40 % in women 80 years of age. Clinicians are advised
by guidelines to evaluate serious underlying pathology by checking for Red Flags (or alarm signals) during the
history taking and physical examination. The presence of red flags may indicate underlying serious
pathology in patients with low back pain.
Current guidelines often present a list of red flags, which are considered to be associated with an increased
risk of the presence of underlying serious pathology in the spine, often without consideration given to the
diagnostic accuracy of the RED FLAG (test).
Here we have to note the main seven RED FLAGS that we were looking for from the guidelines but have
included (Twelve) 12 in total.:
1. Bladder Incontinence can be permanent with a Super Pubic Catheter with BOTOX injections six or twelve monthly
for spasms.
2. Bowel and Faecal Incontinence.
3. Permanent or partial Sexual Dysfunction.
4. Radiated pain down one or both legs.
5. Unable to Stand, Sit, Or Lie flat for long periods, require a bed that gives a "0" Gravity effect taking the
pressure of the spine.
6. Walking without an aid, mobile walker or walking stick/s is impossible and some CES sufferers require
wheelchairs.
7. Major depression, Anxiety, Stress (bordering on PTSD - Post Traumatic Stress Disorder) and Panic Attacks, even
nightmares due to some of the medications and the shock of the diagnosis
The above 7 (seven) are the main characteristics Doctors should be looking for. Any 3 (three) of them could
lead to a diagnosis of CES. The next 5 (five) are not to be discarded either and could be linked with any of the
above to put doubt in the mind of the Doctor, BUT, there must be two of the above and linked with one
of the following five the question must be asked, Is It CES or Not ?
8. If Nerves in the upper part L1 or TH 12, cause problems in the Lower Diaghram not allowing the
patient to take deepbreathes, would eventually cause Chronic Obstructive Pulmonary Disease
(C.O.P.D.)
9. Reduced appetite
10. Rapid fatigue and general malaise.
11. Fever.
12. Paraparesis, and progressive symptoms.
While most guidelines recommend screening for RED FLAGS, there is variation in which red flags are endorsed,
and there exists heterogeneity in precise definitions of the RED FLAGS (e.g. ‘trauma’, ‘severe trauma’, ‘major
trauma’).
An overview of recommended RED FLAGS in the guidelines is lacking. So, therefore, CES can be broken down
into three categories.
Please Note: there is actually four main categories which will be shown further on.
CES – R: Restricted which may involve any 3 of the above,
CES – T: Trauma, this involves at least 4+ of the above and
CES – MT: Involves all Twelve of the above.
The purpose of our survey and the results was to identify and compare the RED FLAG recommendations in
current guidelines for the detection of medically serious pathology in patients presenting with low back pain.
Overview of RED FLAG screening in low back pain. We searched for clinical guidelines in primary health care
concerning adults with low back pain date of the last search was from January to April 2018. Our starting point was a
previously published review article including many guidelines we settled on 10 National and International guidelines.
For diagnosis and treatment of low back pain. First, we checked for updates of these 10 guidelines.
Additionally, we searched for other clinical practice guidelines using electronic databases: Medline, Pedro,
MEDeD, Healthline and Rare Disorders (NORD), using the keywords: low back pain, practice guidelines,
clinical guidelines, National Guideline For Low Back Pain, and Government Ministries of Health for registered
Cauda Equina Syndrome patients or Low Back Pain and Sciatica and The National Institute for Health and
Clinical Excellence (UK) as well as The John Hopkins Research Centre along with the Mayo Clinic Research
Department on Lower Back Disorders, Universities, and as mentioned earlier London School of Spinal
Surgery. To use a Gene Rodenberry term the creator of "Star Trek" "We basically went where no-man has gone
before" looking for data.
Furthermore, we performed searches via Google, performed snowballing and citation tracking on
publications that consulting experts with peer reviews in the fields of Spinal Surgery and Neurology fields.
The search was aimed at finding all the clinical guidelines that exist. No language or date restriction was
applied. Health care practitioners and patients were asked to make decisions about appropriate health care for
low back pain under the auspices of a medical specialty associated with further problems, and the survey
results further on in this area are from relevant professional societies public or private organizations.
When one country had more than one guideline, we selected the most recent multidisciplinary guideline.
Data Extraction
We extracted data on the number and types of red flags for serious pathology for each guideline using a
standardized form for both individuals and medical associations. For each red flag, we scored if the
RED FLAGS was supported by the literature presenting its accuracy on sensitivity, predictive values, etc. if it was
supported by the consensus of the guidelines set out in the survey cover introduction. No information was
given to support the endorsement of any red flags. We only required a summary.
First, of the original 10 guidelines of previously published review articles, we found and used we excluded the
European guideline for chronic low back pain. The reason for this was given that RED FLAGS were presented in
the European guideline for acute only low back pain which defeated what we were really trying to discover.
Eight countries updated their guidelines they being Austria, Canada, Finland, Germany, Netherlands, Norway,
Spain, United States, and Australia. New Zealand and Asia failed to reply, but we had some information from
New Zealand already and included it within the data.
Of the reply countries three, we found more than one updated guideline Austria, Netherlands, and the United
States. Austria including an update of a multidisciplinary guideline from 2017 and one specifically for
radiologists of which we selected the multidisciplinary one. The updated guidelines from The Netherlands
included a multidisciplinary guideline and one specifically for physiotherapists and Osteopaths of which we selected the
multidisciplinary one. The United States had two multidisciplinary guidelines and one specifically for
physiotherapists, of which we selected for this overview of the latest multidisciplinary guideline linked to a
website. The guidelines of Finland and Norway were not available in English, so colleagues were contacted to
extract the relevant data and translate for us. Their data was for Physios, Osteopaths and Chiropractors. Our next step
in carrying out this survey was to perform a broad search aiming to identify additional guidelines. In total, we identified
21 guidelines, of which eleven were excluded. As we selected one guideline per country. We found three new
guidelines Philippines, Malaysia, and Mexico, of which one guideline Mexico could not be retrieved Finally, 10 discrete
guidelines were included in this review.
Description of the guidelines to suit our survey
The guidelines were published between 2016 (France) and 2018 (Finland), with the publication date of one
guideline unknown (Malaysia) but appear it may have been 2017. The target population was mostly adults (25
to 70 years of age) with low back pain. Seven RED FLAGS used the term specific low back pain, three also
included people with radiculopathy, four guidelines specifically focused on patients with acute low back pain
defined as a duration less than 3 months, and one guideline included patients with acute and/or recurrent low
back pain New Zealand finally submitted information on this matter.
Click On Image To Go To Section 2 Of RED FLAGS
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