Red flags for potential serious pathologies in people with neck pain: a systematic review of clinical practice guidelines

Daniel Feller; Alessandro Chiarotto; Bart Koes; Filippo Maselli; Firas Mourad

doi:10.33393/aop.2024.3245

Authors

Daniel Feller Provincial Agency for Health of the Autonomous Province of Trento, Trento - Italy and Department of General Practice, Erasmus MC, University Medical Centre, Rotterdam - The Netherlands https://orcid.org/0000-0001-9853-3486
Alessandro Chiarotto Department of General Practice, Erasmus MC, University Medical Centre, Rotterdam - The Netherlands https://orcid.org/0000-0003-2350-9945
Bart Koes Department of General Practice, Erasmus MC, University Medical Centre, Rotterdam - The Netherlands and Research Unit of General Practice, Department of Public Health and Center for Muscle and Joint Health, University of Southern Denmark, Odense - Denmark https://orcid.org/0000-0002-0450-9969
Filippo Maselli Department of Human Neurosciences, Sapienza University of Rome, Rome - Italy and Sovrintendenza Sanitaria Regionale Puglia, INAIL, Bari - Italy https://orcid.org/0000-0001-9683-9975
Firas Mourad Department of Health, LUNEX University of Applied Sciences, Differdange - Luxembourg and Luxembourg Health and Sport Sciences Research Institute A.s.b.l., Differdange - Luxembourg

DOI:

https://doi.org/10.33393/aop.2024.3245

Keywords:

Differential diagnosis, Guidelines, Neck pain, Red flags

Abstract

Introduction: We conducted a systematic review of clinical practice guidelines to identify red flags for serious pathologies in neck pain mentioned in clinical practice guidelines, to evaluate agreement in red flag recommendations across guidelines, and to investigate the level of evidence including what study type the recommendations are based on.

Methods: We searched for guidelines focusing on specific and nonspecific neck pain in MEDLINE, EMBASE, and PEDro up to June 9, 2023. Additionally, we searched for guidelines through citation tracking strategies, by consulting experts in the field, and by checking guideline organization databases.

Results: We included 29 guidelines, 12 of which provided a total of 114 red flags for fracture (n = 17), cancer (n = 21), spinal infection (n = 14), myelopathy (n = 15), injury to the spinal cord (n = 1), artery dissection (n = 7), intracranial pathology (n = 3), inflammatory arthritis (n = 2), other systemic disease (n = 6), or unrelated to a specific condition (n = 19). Overall, there is very little agreement (median Fleiss’ kappa of 0) between guidelines on the red flags to screen for serious pathologies.

Conclusion: Red flags were mainly supported by expert opinions. We also observed a general lack of consensus among guidelines regarding which red flags to endorse. Considering the current limitations of the evidence, specific recommendations on which red flags to use cannot be provided, except for using the Canadian C-Spine rule for screening posttraumatic fractures.

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