Clinical Decision Rules for Identification of Low Back Pain Patients with Neurologic Involvement in Primary Care

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.