title: The reliability of red flags in spinal cord compression.
abstract: BACKGROUND
  Acute low back pain is a common cause for presentation to the emergency department (ED). Since benign etiologies account for 95% of cases, red flags are used to identify sinister causes that require prompt management.
  
  
  OBJECTIVE
  We assessed the effectiveness of red flag signs used in the ED to identify spinal cord and cauda equine compression.
  
  
  METHODS
  It was a retrospective cohort study of 206 patients with acute back pain admitted from the ED. The presence or absence of the red flag symptoms was assessed against evidence of spinal cord or cauda equina compression on magnetic resonance imaging (MRI).
  
  
  RESULTS
  Overall, 32 (15.5%) patients had compression on MRI. Profound lower limb neurologic examination did not demonstrate a statistically significant association with this finding. The likelihood ratio (LR) for bowel and bladder dysfunction (sensitivity of 0.65 and specificity of 0.73) was 2.45. Saddle sensory disturbance (sensitivity of 0.27 and specificity of 0.87) had a LR of 2.11. When both symptoms were taken together (sensitivity of 0.27 and specificity of 0.92), they gave a LR of 3.46.
  
  
  CONCLUSIONS
  The predictive value of the two statistically significant red flags only marginally raises the clinical suspicion of spinal cord or cauda equina compression. Effective risk stratification of patients presenting to the ED with acute back pain is crucial; however, this study did not support the use of these red flags in their current form.
authors.affiliation: Department of Trauma and Orthopaedics, Ashford and St Peter's NHS Trust, London, England.
authors.forename: Nicholas Tobias Johannes
authors.initials: NT
authors.lastname: Raison
authors.affiliation: Department of Trauma and Orthopaedics, Ashford and St Peter's NHS Trust, London, England.
authors.forename: Wisam
authors.initials: W
authors.lastname: Alwan
authors.affiliation: Department of Trauma and Orthopaedics, Ashford and St Peter's NHS Trust, London, England.
authors.forename: Amit
authors.initials: A
authors.lastname: Abbot
authors.affiliation: Department of Trauma and Orthopaedics, Ashford and St Peter's NHS Trust, London, England.
authors.forename: Mohamed
authors.initials: M
authors.lastname: Farook
authors.affiliation: Department of Trauma and Orthopaedics, Ashford and St Peter's NHS Trust, London, England.
authors.forename: Arshad
authors.initials: A
authors.lastname: Khaleel
keywords: Cauda Equina; Low Back Pain; Spinal Cord Compression