A systematic review identifies five "red flags" to screen for vertebral fracture in patients with low back pain

Nicholas Henschke*, Christopher G. Maher, Kathryn M. Refshauge

*Corresponding author for this work

Research output: Contribution to journalReview articlepeer-review

51 Citations (Scopus)


Objective: To determine the accuracy of clinical features in diagnosing vertebral fracture in low back pain patients and assess the psychometric properties of the Quality Assessment of Studies of Diagnostic Accuracy Included in Systematic Reviews (QUADAS) scale. Study Design and Setting: A diagnostic systematic review was performed on all available records in MEDLINE, CINAHL, and EMBASE. Studies were considered eligible if they investigated clinical features associated with vertebral fracture in a cohort of low back pain patients. All eligible studies were assessed for methodological quality using the QUADAS scale, and two authors extracted true-positive, true-negative, false-positive, and false-negative data for each clinical feature. Results: Twelve studies were identified by the review, investigating 51 clinical features. Five clinical features were useful to raise or lower the probability of vertebral fracture: age >50 years (likelihood ratio [LR]+ = 2.2, LR- = 0.34), female gender (LR+ = 2.3, LR- = 0.67), major trauma (LR+ = 12.8, LR- = 0.37), pain and tenderness (LR+=6.7, LR- = 0.44), and a distracting painful injury (LR+ = 1.7, LR- = 0.78). The QUADAS had low internal consistency, and only three items had high inter-rater reliability. There was inadequate reporting of many methodological quality items. Conclusion: Five clinical features were identified that can be used to screen for vertebral fracture. The psychometric properties of the QUADAS scale raise concerns about its use to rate the quality of low back pain diagnosis studies.

Original languageEnglish
Pages (from-to) 110-118
Number of pages9
JournalJournal of Clinical Epidemiology
Issue number2
Publication statusPublished - Feb 2008
Externally publishedYes


  • Back pain
  • Diagnosis
  • Fracture
  • Red flags
  • Systematic review


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