Red & Yellow Flags

Low Back Pain
David Murphy, MD

The differential diagnosis of Low Back Pain (LBP) can be divided into three categories:
            1) mechanical LBP
            2) non mechanical spinal conditions
            3) visceral disease

Mechanical LBP represents about 97% of of all LBP and includes lumbar strain, degenerative disc disease, compression fracture, spondylolisthesis, traumatic fracture and others.

Non mechanical LBP (1%) includes neoplasia, infection and spondyloarthropathies.

Visceral disease (2%) includes prostatitis, PID, aortic aneurism, perforated ulcer, etc.

Determining the cause of LBP can present a significant clinical challenge. Pain receptors are present in bone, Z-joints, muscle, connective tissue, periosteum, intervertebral discs and perivascular tissue. These receptors can be activated by mechanical strain or dysfunction, metabolites or inflammation.

Current evidence shows that no particular constellation of physical signs allows a valid or reliable diagnosis to be made in anatomic or pathological terms. Therefore the diagnostic algarhythm regarding patients with LBP focuses initially on the exclusion of serious pathology, which represents less than 3% of LBP.

The Red Flag
David Murphy, MD

Defined as a clinical sign or symptom that may indicate sinister pathology as the source of LBP, most red flags can be identified during a careful history.

The following is a list of sinister conditions and their associated red flags:

Malignancy (<1%): elderly, pain worse at night and not relieved by recumbancy, weight loss, chills, fever, night sweats

Infection (.01%): chills, fever, night seats, compromised host (diabetic, chronically ill ), IV drug use, previous UTI, skin infection or spinal procedure

Spinal fracture (<1%): history of trauma or osteoporosis

Cauda equina syndrome: saddle anesthesia, incontinence of urine/stool

Spondyloarthropathies (<1%) (Rieter’s Syndrome, ankylosing spondylitis): inflammatory bowel disease, am stiffness, age < 40, improvement with exercise

Visceral disease (2%): include abdomenal aneurism, PID, peptic ulcer disease, endometriosis, ectopic pregnancy, tenderness or mass on abdomenal exam

The Yellow Flag
Lonnie Johnson, DC

Sometimes we make the right diagnosis and provide appropriate treatment but the lower back pain doesn’t significantly decrease. Yellow flags are items in case presentation that can alert us to the possibility of delayed healing. These factors need to be considered in order to avoid chronicity. Some need to be addressed before treatment begins.
 
Yellow Flags in History and Examination:
            • Non-localized pain
            • Previous episodes of low back pain
            • Delay in getting treatment
            • Symptoms lasting more than three months
            • Pain intensity of greater than 8/10 three weeks or more after onset
            • Positive findings on neurological exam
            • Positive findings on orthopedic exam
            • Poor sleep(less than six hours/night)

Non-organic yellow flags:
            • Anxiety
            • Depression
            • Three or more positive Waddell signs
            • Negative family life
            • Negative work environment
            • Receiving compensation
            • Anticipation of future disability
            • Litigation
            • Prior work disability

Occasionally I am referred a patient because everything else has failed. It is unlikely at this point that chiropractic work is going to provide more than partial pain relief. I firmly believe that anyone with lower back pain deserves timely and aggressive care. Functional evaluation to prevent the perpetuation of chronic pain patterns is the logical choice.