Red flags for potential serious spinal pathology

...How should they be monitored in clinical practice?

Although widely present in clinical guidelines as a way of identifying serious spinal pathology, there is a lack of evidence supporting the validity of multiple commonly listed red flags. Moreover, the presence of individual red flags seldom provides reliable information. The combined presence of red flags may provide more valuable information, but further studies are still necessary to confirm this. In order to accurately determine the level of suspicion of serious spinal pathology warranted in each case, clinicians should take into account both the evidence regarding red flags and each patient’s health determinants. This is concluded by an expert panel of the International Federation of Orthopaedic Manipulative Physical Therapists (IFOMPT) that has drawn up a framework on this specific matter.


The complete pathway can be described as follows:

First, to determine the level of concern, the interaction between red flags evidence (prevalence, quality of supporting evidence, red flags present in isolation or combined) and the patient’s profile (age, sex, symptom progression, comorbidities).

Then, the clinical decision (start treatment, treatment with watchful waiting, or urgent/ emergency referral) can be made based on the level of concern.

Finally, according to each decision, the clinician should be ready to take the next step, whether that is just monitoring progress as expected and discharging the patient, having a “safety net” ready (having a list of signs and symptoms to be watched), or being knowledgeable of referral pathways should the clinical situation deteriorate.

> From: Finucane et al., J Orthop Sport Phys Ther 50 (2020) 350-372 . All rights reserved to Journal of Orthopaedic & Sports Physical Therapy. Click here for the online summary.

Expert opinion

This position statement by the International Federation of Orthopaedic Manipulative Physical therapists is an extremely thorough document and is excellent reference material for all physiotherapists dealing with spinal pathology. Given the level of thoroughness, it is impossible to do justice to the manuscript in a short summary; I therefore recommend to give it a full read.

The relevance of this work is related to multiple aspects. First, despite the frequency with which red flags are discussed and its importance is mentioned, there is a surprising lack of evidence for their value in detecting serious spinal pathology, especially when present in isolation. Second, given the potential impact of missing these conditions both for the patient’s health and quality of life and for the clinician’s career, it is paramount that they are identified early and that practitioners have a solid base for clinical decision-making. Finally, this framework may serve as an alert for the need for more robust evidence about the value of red flags.

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