Clinical decision rules for identification of low back pain patients with neurol

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Spine. 2008 Jan 1;33(1):68-73.

Clinical decision rules for identification of low back pain patients

with neurologic involvement in primary care.

Haswell K, Gilmour J, B.

Faculty of Health and Environmental Sciences, Auckland University of

Technology, Akoranga Campus, Auckland, New Zealand.

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.