SPINE Volume 33, Number 1, pp 68 –73
©2008, Lippincott Williams & Wilkins, Inc.
Clinical Decision Rules for Identification of Low
Back Pain Patients With Neurologic Involvement in
Primary Care
Kate Haswell, BSc, MHSc (Hons), PGDipHSc, John Gilmour, DipMT, DipPhyty,
and Barbara Moore, ADP(MT), DipPhyty, BA
Study Design. Descriptive study.
Objective. To compare clinical decision rules in low back
pain guidelines for identification of neurologic involvement.
Summary of Background Data. Low back pain guidelines have been developed in a number of countries.
Guideline recommendations for assessment of patients
with low back pain in primary care include clinical decision rules for identification of neurologic involvement.
Broad variation in recommended clinical assessments
has previously been identified. More specific investigation
of these clinical assessments seems warranted given that
guidelines have an important role in facilitating accurate
and timely identification of neurologic involvement in patients with low back pain presenting in primary care.
Methods. Guidelines were included that met the following criteria: the guideline included clinical decision
rules for low back pain assessments; recommendations
were for clinical management of low back pain in primary
care; and the guideline was available in English.
Results. Three categories of neurologic involvement
were identified in the guidelines: cauda equina syndrome;
nerve root syndrome; and spinal stenosis. However, only
cauda equina syndrome was included in all guidelines.
Spinal stenosis or both nerve root syndrome and spinal
stenosis categories were omitted from some guidelines.
Decision factors for assignment to categories were: generally consistent for cauda equina syndrome; agreed to
be conduction block in sensory and motor nerves and
pain on straight leg raise for nerve root syndrome; and
agreed to be reduced walking distance resulting from
pseudoclaudication for spinal stenosis. Disagreement related to postural factors for nerve root syndrome and
spinal stenosis categories.
Conclusion. This study has identified differences between the guidelines in the clinical decision rules for identification of neurologic involvement including omission of
categories. Decision-making that employs all 3 categories
of neurologic involvement will arguably facilitate accurate and timely identification of patients with low back
pain so affected in primary care.
Key words: clinical guidelines, low back pain, primary
care, systematic review. Spine 2008;33:68 –73
From the Faculty of Health and Environmental Sciences, Auckland
University of Technology, Akoranga Campus, Auckland, New Zealand.
Acknowledgment date: January 19, 2007. Revision date: May 24,
2007. Acceptance date: June 21, 2007.
The manuscript submitted does not contain information about medical
device(s)/drug(s).
No funds were received in support of this work. No benefits in any
form have been or will be received from a commercial party related
directly or indirectly to the subject of this manuscript.
Address correspondence and reprint requests to Kate Haswell, 28 Winsomere Crescent, Westmere, Auckland 1002, New Zealand; E-mail:
[email protected]
68
Low back pain may signal a significant neurologic disease.1
For this reason, identification of neurologic symptoms
and signs is considered an important responsibility of
first-contact health care providers. Failure to identify
neurologic pathology early in the course of low back
pain, to monitor neurologic findings for deterioration,
and to respond appropriately when neurologic status
worsens can have devastating consequences for the patient with possibility of irreversible paralysis.2
Management of low back pain has been under considerable scrutiny for a number of reasons. Evidence suggests that back pain patients do not necessarily receive
care that is appropriate or optimum for their rehabilitation due in part to the involvement of many different
health care providers who do not necessarily share a
common approach.3 Also of concern is the continued rise
in disability associated with low back problems despite
technological advances and greater expenditure on diagnostic tests and treatment.4
In an attempt to improve clinical management of low
back pain, there has been a focus in a number of countries on the development of recommendations for decision-making in the form of published guidelines. The
first low back pain guideline developed was the Quebec
Task Force Report5 and this reviewed the scientific literature on spinal disorders, with the objective of basing its
recommendations on the scientific evidence available at
that time. A similar approach has been used in more
recent guideline development; however, consensus views
have been accepted for some recommendations while
others are explicitly evidence based.
Guidelines have been developed that include recommendations for assessment and provide clinical decision
rules for identifying patients with low back pain with
neurologic involvement. Detailed clinical decision rules
quantify the individual contributions that various components of the history and physical examination make
towards diagnosis. Clinical decision rules are intended to
increase accuracy of clinician assessments and assist with
the formulation of a diagnosis.6 Low back pain guidelines from different countries have been found to be
broadly similar in that they propose diagnostic triage but
inconsistent in their specific recommendations for clinical assessment.7 In this article, clinical decision rules in
low back pain guidelines are compared regarding recommended decision factors for categorization of patients
with neurologic involvement on the basis of clinical assessment.
Clinical Decision Rules for Identification of Low Back Pain • Haswell et al 69
Table 1. Primary Care Low Back Pain Guidelines: Recommendations for Categories for Neurologic Syndromes
Low Back Pain Guideline Agencies
Quebec Task Force on Spinal Disorders
Agency for Health Care
Policy and Research, Public Health,
U.S. Department of Health and
Human Services
United Kingdom Royal College of
General Practitioners
Australasian Faculty of
Musculoskeletal Medicine for the
National Health and Medical
Research Council
Danish Institute For Health Technology
Assessment
Swedish Council on Technology
Assessment in Health Care
New Zealand Accident Compensation
Commission
Cauda Equina Syndrome
Nerve Root Syndrome
Spinal Stenosis Syndrome
Other diagnoses
Red flag
Neurologic sign
Nerve root
Spinal stenosis
No recommendation
Red flag
Nerve root
No recommendation
Neurological
Neurological
Neurological
Serious disease
Spinal stenosis
Cauda equina
Radiating symptoms to lower
extremity
Herniated disc
Red flag
No recommendation
No recommendation
Methods
The search for relevant clinical guidelines consisted of a search
in Medline (key words: low back pain, clinical guidelines). The
search was extended to the Internet (key words: back pain,
guideline) in an attempt to capture those guidelines not published in health science journals.
Guidelines included had to meet the following criteria: (1)
the guideline contained clinical decision rules for low back pain
assessments, (2) recommendations were for clinical management of low back pain by primary health care providers, and
(3) the guideline was available in English. The following guidelines (year of publication), prepared by different agencies were
included:
Scientific approach to the assessment and management of
activity-related spinal disorders (1987), Quebec Task Force
on Spinal Disorders5;
Acute Low Back Problems in Adults: Clinical Practice
Guideline No.14 (1994), multidisciplinary panel for the
Agency for Health Care Policy and Research, Public Health
Service, U.S. Department of Health and Human Services8;
Clinical Guidelines for the Management of Acute Low Back
Pain (1996), multidisciplinary group facilitated by the Quality Improvement Group of the United Kingdom Royal College of General Practitioners9;
Draft Evidence-Based Clinical Guidelines for the Management of Acute Low Back Pain (1999), Professor Nikolai
Bogduk on behalf of the Australasian Faculty of Musculoskeletal Medicine for the National Health and Medical Research Council10;
Low Back Pain, Frequency, Management and Prevention
from an HTA Perspective (1999), working group for the
Danish Institute for Health Technology Assessment11;
Neck and Back Pain, The Scientific Evidence of Causes,
Diagnosis and Treatment (2000), multidisciplinary group
for the Swedish Council on Technology Assessment in
Health Care12; and
New Zealand Acute Low Back Pain Guide incorporating
the Guide to Assessing Psychosocial Yellow Flags in Acute
Spinal stenosis
Low Back Pain (2004), multidisciplinary panel for the Accident Compensation Commission.13
Guidelines were excluded if they were not available in
English14,15 and if they were limited to treatment interventions
only.16
Results
Decision Factors
Three categories, cauda equina syndrome, nerve root
syndrome, and spinal stenosis were identified. Table 1
compares recommendations made by the different guidelines regarding categorization of neurologic syndromes.
For each category, the guidelines made recommendations regarding history and physical examination factors
for use in decision-making and these are compared in
Table 2.
Cauda Equina Syndrome
Cauda equina syndrome was categorized along with
other serious spinal pathologies including spinal tumor,
spinal infection, osteoporosis, fractures, and ankylosing
spondylitis in most guidelines.5,8,9,11,13 Cauda equina
syndrome was assigned to its own specific category in
one guideline.12 There was general agreement between
the different guidelines on decision factors for assignment to this category.
Guidelines reported limited evidence for validity of
decision factors for the categorization of cauda equina
syndrome.8 A literature review17 that reported that urinary retention has a sensitivity of 0.90, while unilateral
or bilateral sciatica, sensory and motor deficits have a
sensitivity of 0.80 was cited by one guideline.8 In support
of early identification of cauda equina syndrome, a nonsystematic review of 322 patients with this syndrome
found that patients operated on after 48 hours seemed to
have much less chance of resolution of severe neurologic
loss.12
70 Spine • Volume 33 • Number 1 • 2008
Table 2. Primary Care Low Back Pain Guidelines: Recommendations for Decision Factors From History and Physical
Examination for Neurologic Assessment
Low Back Pain Guideline Agencies
Cauda Equina Syndrome
Nerve Root Syndrome
Quebec Task Force on Spinal
Disorders
Loss of intestinal bladder or
sexual function
Muscular weakness
Focal muscular weakness
Assymetry of reflexes
Sensory loss in a dermatome
Agency for Health Care Policy and
Research, Public Health, U.S.
Department of Health and Human
Services
Urinary retention
overflow incontinence
Saddle anaesthesia about anus
perineum and genitals
Unilateral or bilateral
leg pain and weakness
global or progressive motor
weakness in lower limbs
United Kingdom Group of Royal
College of General Practitioners
Sphincter disturbance
Saddle anaesthesia
Gait disturbance
Australasian Faculty of Musculoskeletal
Medicine for National Health and
Medical Research Council
Danish Institute for Health Technology
Assessment
No specific recommendation
Age 30–50 yr
Overweight
Pain radiating below knee
Leg pain worse than back pain
Persistent numbness weakness
Ankle and knee reflexes
Ankle and great toe dorsiflexion
strength
Straight leg raise and crossed
straight leg raise
Sensory complaints
Unilateral leg pain worse than
low back pain to feet or toes
Numbness or paraesthesia in
the same distribution
SLR reproduces leg pain
Localized neurological signs
No specific recommendation
Swedish Council on Technology
Assessment in Health Care
New Zealand Accident
Compensation Commission
Inability to control bladder
function
Sensation loss groin
Decreased strength legs
Urinary retention
Loss of anal sphincter tone
Faecal incontinence
Saddle anaestheria around
anus, perineum and genitals
Progressive motor weakness in
legs
Gait disturbance
Urinary retention
Lax anal sphincter
Faecal incontinence
Saddle area numbness
Widespread neurological
symptoms and signs in lower
limb
Gait abnormality
Nerve Root Syndrome
Nerve root syndrome was categorized to a specific category in most guidelines.5,8,9,11,12 There was disagreement on the timing of assessment for this category. Identification of nerve root syndrome at first assessment9 or
after 4 weeks treatment8 was variously recommended.
Guidelines5,8 –12 agreed regarding decision factors indicative of conduction block in motor or sensory nerves
and reproduction of pain on straight leg raise. However,
loss of lordosis and/or sciatic scoliosis and severe lumbar
Radiating pain to leg
Weakness of foot
Sensory, Reflex, Muscle
changes
Tall men ⬎180 cm
Unilateral leg pain worse than
low back pain
Severe radicular pain
Pain causing awakening at
night
Severe lumbar motion
restriction
Loss of lordosis and/or sciatic
scoliosis
Crossed straight leg raise and
straight leg raise ⬍60
degrees
Sensory loss, pins and needles,
paraesthesia
Impaired reflexes
Muscle weakness
No specific recommendation
Spinal Stenosis Syndrome
⬎50 yr
Lumbar pain increased during day
Pain in legs
Paraesthesias triggered and
increased by walking
No specific recommendation
No specific recommendation
No specific recommendation
Pain and decreased strength in
the legs
⬎65 yr
Pseudoclaudication numbness,
weakness leg pain usually
diffuse and often bilateral
SLR usually negative
No specific recommendation
motion restriction were recommended decision factors
of only 1 guideline.12
There was supporting evidence for recording results of
straight leg raise in the assessment of sciatica and for performing a neurologic examination emphasizing ankle and
great toe dorsiflexion strength, ankle and knee reflexes, and
distribution of sensory complaints.8 Crossed straight leg
raising reproducing pain in the symptomatic leg was argued
to have the most predictive value for finding a disc hernia at
neuroradiographic examination.12 Severe radicular pain,
Clinical Decision Rules for Identification of Low Back Pain • Haswell et al 71
pain causing awakening at night, severe lumbar motion
restriction, loss of lordosis and/or sciatic scoliosis, and unilateral leg pain worse than back pain were also argued to
have good predictive strength.12
Spinal Stenosis
Spinal stenosis was assigned a specific category in 3
guidelines.5,11,12 There was agreement with the decision
factor of reduced walking distance resulting from
pseudoclaudication and disagreement about patient age
which was variously described as ⬎50 years5 and ⬎65
years.12
Further decision factors reported to have moderate
predictive value for spinal stenosis were bilateral nonradicular pain, treadmill test total time ⬍5 minutes and
relief from sitting down or squatting.12
stenosis with the ageing of the population emphasize the
relevance of this category.18
Agreement and disagreement occurred in relation to
when assessments for neurologic involvement should occur. Although all guidelines agreed that prompt identification of cauda equina syndrome was imperative, not all
emphasized the importance of early identification of
nerve root syndrome and spinal stenosis. For example,
one recommendation was to defer identification of nerve
root syndrome for the first month.8 The recommendation is possibly based on the view that the natural history
of nerve root compromise is favorable in some disc herniations.19 However, the guidelines that recommended
early identification argued that nerve root syndrome and
spinal stenosis were likely to be overlooked as a cause of
recurrence and chronicity if not part of the decisionmaking from the beginning.11,12
Discussion
Recognition of Neurologic Involvement
Although less common than nonspecific low back pain,
cauda equina syndrome, nerve root syndrome, and spinal stenosis are potentially more serious. It is known that
patients with low back pain with neurologic involvement
are those most likely to: present for surgery; have slower
recovery rates; and higher recurrence rates.12 As a consequence, timely and adequate evaluation for neurologic
involvement is considered essential.12 It is especially important in the current health care environment where the
label “nonspecific” low back pain dominates that those
patients with neurologic involvement are identified.
Whereas guideline recommendations for identification of cauda equina syndrome were generally consistent, variation was evident in recommendations for identification of nerve root syndrome and spinal stenosis. An
obvious difference was that some guidelines omitted categories for the latter syndromes whereas others included
them.
“The New Zealand Acute Low Back Pain Guide,”13
for example, does not recommend categories for nerve
root syndrome or spinal stenosis. The influence of psychological and social factors on the continuation of low
back pain toward a chronic phase receives considerable
emphasis in the guideline, as illustrated by the incorporation of the “Guide to Assessing Psychosocial Yellow
Flags in Acute Low Back Pain.”13 While some patients
will likely benefit from this approach it is inevitable
that neurologic involvement will be overlooked both
in the initial management of low back pain and on
recurrence because of the absence of recommendations for these categories.
The absence of a category for spinal stenosis in several
guidelines8,9,13 is not in line with evidence. Surgery rates
for spinal stenosis have increased dramatically since the
1970s with lumbar spinal stenosis being the most common diagnosis for individuals older than the age of 65
undergoing spinal surgery.18 Further to this, projections
of rapid expansion in surgical rates for lumbar spinal
Decision Factors for Diagnosis of
Neurologic Involvement
History and physical examination factors for categorization of patients with neurologic disease have not been
thoroughly investigated.20 Studies investigating the diagnostic value of the various factors have been biased in
their selection as they have included only those patients
with severe neurologic disease awaiting surgery or those
with symptoms severe enough to justify bed rest for 14
days.20,21 Improved understanding of decision factors
that are valid for identification of patients in the early
stages of neurologic disease is required.
Predictors of the 3 syndromes are not fully understood
with evidence for cauda equina syndrome the most limited. Significant predictors of nerve root syndrome have
been identified as focal muscle weakness and increased
finger to floor distance.20 Further validated predictors
are findings of pain worse in the leg than the back, a
dermatomal distribution of pain, paroxysmal pain, and
pain worse on coughing, sneezing, or straining.20 Evidence also suggests that reproduction of symptoms on
crossed straight leg raise, and decreased reflexes rules in
nerve root syndrome while the absence of symptoms on
straight leg can be used to rule out the diagnosis.21
Guideline recommendations are generally in line with
these findings.
The postural component overlooked by all guidelines
except one12 has been found to have potential in differential diagnosis of nerve root syndrome in addition to its
more widely recognized role in diagnosis of spinal stenosis. With regards to the latter, lower extremity pain exacerbated by walking, with longer walking time during
inclined treadmill walking, and improvement of symptoms when sitting are validated predictors of spinal
stenosis.18,22 In support of the former, direct measurement of nerve root pressure in disc surgery patients has
found very high pressures in patients with trunk list as
well as in those with severe paralysis such as foot drop.23
72 Spine • Volume 33 • Number 1 • 2008
Impact of Guideline Recommendations
The value of clinical decision rules is ultimately determined by their impact on patient outcomes, patient satisfaction, and costs of care.6 In fact, a major reason for
the development and implementation of low back pain
guidelines was to halt the increasing expenditure on low
back pain. According to the Swedish Council on Technology Assessment in Heath Care,12 10% to 15% of
patients with unresolved low back pain account for 80%
to 90% of the total costs for spinal disorders, and the 1%
to 2% of patients who undergo surgery for disc disorders
and spinal stenosis are the most costly. A more specific
intention of the guidelines was therefore to manage the
group of patients likely to progress to surgical care more
effectively, a group dominated by those with neurologic
involvement. Evidence suggests that this has not been
achieved.24,25
With regard to surgery, there are troubling reports of
a rapidly increasing use of spinal fusion surgery in the
United States.25,26 Detailed characteristics of patients
undergoing surgery in the United States are not easily
obtained, however, it has been inferred that decisionmaking for spinal fusion cannot be optimal, given large
variation in surgery rates across different regions.26 Recent analysis identified that the annual number of spinalfusion operations rose by 77% in the United States
between 1996 and 2001.27 Concerned analysts have advised a shift in emphasis away from considerations of
how to perform spinal fusion operations to critical analysis of decision factors that lead to surgical intervention.27 One part of this analysis arguably demands scrutiny of the quality and impact of decisions made in
primary care on patients with low back pain with neurologic involvement who subsequently require surgical
care. Further analysis could also consider the consistency
of primary and secondary care low back pain guidelines
in their recommendations for identification of neurologic
involvement.
Other trends that are of concern have been revealed in
a recent analysis of musculoskeletal pain visits in the
United States, the majority of which were for low back
pain and ostearthrosis.24 In a comparison 1980 versus
2000, a notable increase in the use of strong opioids and
specialist visits for chronic pain and nonsteroidal antiinflammatory drugs for acute pain was identified while
referrals for less costly physiotherapy services decreased.24 Costs extend beyond that of direct expenditure on low back pain care. The societal impact of activity limitation, time lost from work and chronic disability
consequent to low back pain disorders is enormous in the
Western world.4,28,29
Guideline Review
First editions of guidelines studied were published 19,5
12,8 11,9 9,13 7,10,11 and 612 years ago, respectively.
There has been a recent focus on evaluation of the low
back pain guidelines. Implementation of the guidelines has
been investigated,30 –32 usefulness of mono-disciplinary
versus multidisciplinary guidelines considered,3 quality of
guidelines assessed,33,34 regional analysis of guidelines
conducted35 and as in this study guideline recommendations compared.7
This study has identified differences in the clinical decision rules for neurologic involvement. Guidelines from
different countries are expected to be similar because the
scientific evidence informing guideline development is
common to all. It is therefore difficult to explain why
categories of neurologic involvement have been omitted
from some guidelines. One suggestion is that different
approaches were used in the development of guidelines
some relying more on consensus of opinion rather than
evidence. Another reason for the differences could be the
different dates of issue.
Identification of patients with low back pain with neurologic involvement is arguably enhanced by guidelines
with relevant comprehensive clinical decision rules. For
this reason, review of primary care low back pain guidelines is recommended with the aim of considering inclusion of clinical decision rules for identification of all 3
categories, cauda equina syndrome, nerve root syndrome, and spinal stenosis. In addition, further investigations that seek to improve understanding and determine validity of decision factors for assignment to the 3
categories are recommended. Possible benefits of accurate and timely identification of neurologic involvement
in primary care are yet to be investigated and this is also
a recommended area for future study.
Key Points
● Three categories of neurologic involvement were
identified: cauda equina syndrome; nerve root syndrome; and spinal stenosis; however, nerve root
syndrome and spinal stenosis categories were omitted from some low back pain guidelines.
● Recommendations for identification of cauda
equine syndrome were generally consistent.
● Identification of patients with low back pain in
primary care with neurologic involvement is arguably enhanced by guidelines with comprehensive
clinical decision rules that recommend all 3 categories for clinical decision-making.
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