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class="bkr_bib"><h1 id="_NBK595822_"><span itemprop="name">Evidence reviews for recognition – spinal metastases</span></h1><div class="subtitle">Spinal metastases and metastatic spinal cord compression</div><p><b>Evidence review D</b></p><p><i>NICE Guideline, No. 234</i></p><div class="half_rhythm">London: <a href="https://www.nice.org.uk" ref="pagearea=meta&targetsite=external&targetcat=link&targettype=publisher"><span itemprop="publisher">National Institute for Health and Care Excellence (NICE)</span></a>; <span itemprop="datePublished">2023 Sep</span>.<div class="small">ISBN-13: <span itemprop="isbn">978-1-4731-5314-1</span></div></div><div><a href="/books/about/copyright/">Copyright</a> © NICE 2023.</div></div><div class="bkr_clear"></div></div><div id="niceng234er4.s1"><h2 id="_niceng234er4_s1_">Recognition - spinal metastases</h2><div id="niceng234er4.s1.1"><h3>Review question</h3><p>What symptoms or signs, individually or in combination, or validated clinical tools, suggest the presence of spinal metastatic malignant disease or direct malignant infiltration of the spine?</p><div id="niceng234er4.s1.1.1"><h4>Introduction</h4><p>Early identification of spinal metastasis or malignant infiltration of the spine may enable treatment or surveillance to prevent spinal cord compression and its consequences. This evidence review addressed whether certain signs or symptoms indicate metastatic spinal disease or direct malignant infiltration of the spine.</p></div><div id="niceng234er4.s1.1.2"><h4>Summary of the protocol</h4><p>See <a class="figpopup" href="/books/NBK595822/table/niceng234er4.tab1/?report=objectonly" target="object" rid-figpopup="figniceng234er4tab1" rid-ob="figobniceng234er4tab1">Table 1</a> for a summary of the Population, Index test, Reference standard, Target Condition and Outcome (PIRTO) characteristics of this review.</p><div class="iconblock whole_rhythm clearfix ten_col table-wrap" id="figniceng234er4tab1"><a href="/books/NBK595822/table/niceng234er4.tab1/?report=objectonly" target="object" title="Table 1" class="img_link icnblk_img figpopup" rid-figpopup="figniceng234er4tab1" rid-ob="figobniceng234er4tab1"><img class="small-thumb" src="/books/NBK595822/table/niceng234er4.tab1/?report=thumb" src-large="/books/NBK595822/table/niceng234er4.tab1/?report=previmg" alt="Table 1. Summary of the PIRTO table." /></a><div class="icnblk_cntnt"><h4 id="niceng234er4.tab1"><a href="/books/NBK595822/table/niceng234er4.tab1/?report=objectonly" target="object" rid-ob="figobniceng234er4tab1">Table 1</a></h4><p class="float-caption no_bottom_margin">Summary of the PIRTO table. </p></div></div><p>For further details see the review protocol in <a href="#niceng234er4.appa">appendix A</a>.</p></div><div id="niceng234er4.s1.1.3"><h4>Methods and process</h4><p>This evidence review was developed using the methods and process described in <a href="https://www.nice.org.uk/process/pmg20/chapter/introduction" ref="pagearea=body&targetsite=external&targetcat=link&targettype=uri">Developing NICE guidelines: the manual</a>. Methods specific to this review question are described in the review protocol in <a href="#niceng234er4.appa">appendix A</a> and the <a href="/books/NBK595822/bin/NG234_Supp_1_Methods_pdf.pdf">methods document</a> (supplementary document 1).</p><p>Declarations of interest were recorded according to <a href="https://www.nice.org.uk/about/who-we-are/policies-and-procedures" ref="pagearea=body&targetsite=external&targetcat=link&targettype=uri">NICE’s conflicts of interest policy</a>.</p></div><div id="niceng234er4.s1.1.4"><h4>Clinical evidence</h4><div id="niceng234er4.s1.1.4.1"><h5>Included studies</h5><p>Eleven studies were included in this review (<a class="bibr" href="#niceng234er4.s1.ref1" rid="niceng234er4.s1.ref1">Bellan 2016</a>, <a class="bibr" href="#niceng234er4.s1.ref2" rid="niceng234er4.s1.ref2">Cook 2012</a>, <a class="bibr" href="#niceng234er4.s1.ref3" rid="niceng234er4.s1.ref3">Donner-Banzhoff 2006</a>, <a class="bibr" href="#niceng234er4.s1.ref4" rid="niceng234er4.s1.ref4">He 2020</a>, <a class="bibr" href="#niceng234er4.s1.ref5" rid="niceng234er4.s1.ref5">Henschke 2009</a>, <a class="bibr" href="#niceng234er4.s1.ref6" rid="niceng234er4.s1.ref6">Khoo 2003</a>, <a class="bibr" href="#niceng234er4.s1.ref7" rid="niceng234er4.s1.ref7">Lingawi 2004</a>, <a class="bibr" href="#niceng234er4.s1.ref8" rid="niceng234er4.s1.ref8">Mijiyawa 2000</a>, <a class="bibr" href="#niceng234er4.s1.ref9" rid="niceng234er4.s1.ref9">Reito 2018</a>, <a class="bibr" href="#niceng234er4.s1.ref10" rid="niceng234er4.s1.ref10">Street 2020</a>, <a class="bibr" href="#niceng234er4.s1.ref11" rid="niceng234er4.s1.ref11">Thiruganasambandamoorthy 2014</a>).</p><p>Eight studies were retrospective cohort studies (<a class="bibr" href="#niceng234er4.s1.ref1" rid="niceng234er4.s1.ref1">Bellan 2016</a>, <a class="bibr" href="#niceng234er4.s1.ref2" rid="niceng234er4.s1.ref2">Cook 2012</a>, <a class="bibr" href="#niceng234er4.s1.ref4" rid="niceng234er4.s1.ref4">He 2020</a>, <a class="bibr" href="#niceng234er4.s1.ref7" rid="niceng234er4.s1.ref7">Lingawi 2004</a>, <a class="bibr" href="#niceng234er4.s1.ref8" rid="niceng234er4.s1.ref8">Mijiyawa 2000</a>, <a class="bibr" href="#niceng234er4.s1.ref9" rid="niceng234er4.s1.ref9">Reito 2018</a>, <a class="bibr" href="#niceng234er4.s1.ref10" rid="niceng234er4.s1.ref10">Street 2020</a> and <a class="bibr" href="#niceng234er4.s1.ref11" rid="niceng234er4.s1.ref11">Thiruganasambandamoorthy 2014</a>), 2 were prospective cohort studies (<a class="bibr" href="#niceng234er4.s1.ref5" rid="niceng234er4.s1.ref5">Henschke 2009</a> and <a class="bibr" href="#niceng234er4.s1.ref6" rid="niceng234er4.s1.ref6">Khoo 2003</a>) and 1 was a cluster randomised controlled trial (<a class="bibr" href="#niceng234er4.s1.ref3" rid="niceng234er4.s1.ref3">Donner-Banzhoff 2006</a>).</p><p>Eight studies analysed a population of patients who had low back pain (<a class="bibr" href="#niceng234er4.s1.ref2" rid="niceng234er4.s1.ref2">Cook 2012</a>, <a class="bibr" href="#niceng234er4.s1.ref3" rid="niceng234er4.s1.ref3">Donner-Banzhoff 2006</a>, <a class="bibr" href="#niceng234er4.s1.ref5" rid="niceng234er4.s1.ref5">Henschke 2009</a>, <a class="bibr" href="#niceng234er4.s1.ref7" rid="niceng234er4.s1.ref7">Lingawi 2004</a>, <a class="bibr" href="#niceng234er4.s1.ref8" rid="niceng234er4.s1.ref8">Mijiyawa 2000</a>, <a class="bibr" href="#niceng234er4.s1.ref9" rid="niceng234er4.s1.ref9">Reito 2018</a>, <a class="bibr" href="#niceng234er4.s1.ref10" rid="niceng234er4.s1.ref10">Street 2020</a> and <a class="bibr" href="#niceng234er4.s1.ref11" rid="niceng234er4.s1.ref11">Thiruganasambandamoorthy 2014</a>), 1 study considered cancer patients at presentation (<a class="bibr" href="#niceng234er4.s1.ref4" rid="niceng234er4.s1.ref4">He 2020</a>), 1 study analysed patients with non-traumatic musculoskeletal complaints (<a class="bibr" href="#niceng234er4.s1.ref1" rid="niceng234er4.s1.ref1">Belllan 2016</a>) and 1 study looked at general practice referrals for lumbar spine radiographs (<a class="bibr" href="#niceng234er4.s1.ref6" rid="niceng234er4.s1.ref6">Khoo 2003</a>).</p><p>Six studies were in primary care (GP or emergency department; <a class="bibr" href="#niceng234er4.s1.ref1" rid="niceng234er4.s1.ref1">Bellan 2016</a>, <a class="bibr" href="#niceng234er4.s1.ref3" rid="niceng234er4.s1.ref3">Donner-Banzhoff 2006</a>, <a class="bibr" href="#niceng234er4.s1.ref5" rid="niceng234er4.s1.ref5">Henschke 2009</a>, <a class="bibr" href="#niceng234er4.s1.ref6" rid="niceng234er4.s1.ref6">Khoo 2003</a>, <a class="bibr" href="#niceng234er4.s1.ref9" rid="niceng234er4.s1.ref9">Reito 2018</a>, <a class="bibr" href="#niceng234er4.s1.ref11" rid="niceng234er4.s1.ref11">Thiruganasambanda-moorthy 2014</a>) and 5 studies were in secondary or tertiary care (<a class="bibr" href="#niceng234er4.s1.ref2" rid="niceng234er4.s1.ref2">Cook 2012</a>, <a class="bibr" href="#niceng234er4.s1.ref4" rid="niceng234er4.s1.ref4">He 2020</a>, <a class="bibr" href="#niceng234er4.s1.ref7" rid="niceng234er4.s1.ref7">Lingawi 2004</a>, <a class="bibr" href="#niceng234er4.s1.ref8" rid="niceng234er4.s1.ref8">Mijiyawa 2000</a>, <a class="bibr" href="#niceng234er4.s1.ref10" rid="niceng234er4.s1.ref10">Street 2020</a>).</p><p>All studies related to signs and symptoms, and none addressed clinical prediction tools.</p><p>The included studies are summarised in <a class="figpopup" href="/books/NBK595822/table/niceng234er4.tab2/?report=objectonly" target="object" rid-figpopup="figniceng234er4tab2" rid-ob="figobniceng234er4tab2">Table 2</a>.</p><p>See the literature search strategy in <a href="#niceng234er4.appb">appendix B</a> and study selection flow chart in <a href="#niceng234er4.appc">appendix C</a>.</p></div><div id="niceng234er4.s1.1.4.2"><h5>Excluded studies</h5><p>Studies not included in this review are listed, and reasons for their exclusion are provided in <a href="#niceng234er4.appj">appendix J</a>.</p></div></div><div id="niceng234er4.s1.1.5"><h4>Summary of included studies</h4><p>Summaries of the studies that were included in this review are presented in <a class="figpopup" href="/books/NBK595822/table/niceng234er4.tab2/?report=objectonly" target="object" rid-figpopup="figniceng234er4tab2" rid-ob="figobniceng234er4tab2">Table 2</a>.</p><div class="iconblock whole_rhythm clearfix ten_col table-wrap" id="figniceng234er4tab2"><a href="/books/NBK595822/table/niceng234er4.tab2/?report=objectonly" target="object" title="Table 2" class="img_link icnblk_img figpopup" rid-figpopup="figniceng234er4tab2" rid-ob="figobniceng234er4tab2"><img class="small-thumb" src="/books/NBK595822/table/niceng234er4.tab2/?report=thumb" src-large="/books/NBK595822/table/niceng234er4.tab2/?report=previmg" alt="Table 2. Summary of included studies." /></a><div class="icnblk_cntnt"><h4 id="niceng234er4.tab2"><a href="/books/NBK595822/table/niceng234er4.tab2/?report=objectonly" target="object" rid-ob="figobniceng234er4tab2">Table 2</a></h4><p class="float-caption no_bottom_margin">Summary of included studies. </p></div></div><p>See the full evidence tables in <a href="#niceng234er4.appd">appendix D</a> and the forest plots in <a href="#niceng234er4.appe">appendix E</a>.</p></div><div id="niceng234er4.s1.1.6"><h4>Summary of the evidence</h4><div id="niceng234er4.s1.1.6.1"><h5>Low back pain as a symptom of spinal metastases</h5><p>Low quality evidence from 6 studies in people presenting with low back pain in primary care suggested that around 0.3% would have spinal metastasis (positive predictive value; 95% CI 0.5% to 1.5%). Low quality evidence from 3 studies in people whose low back pain was being investigated in secondary or tertiary care suggested that around 1.3% would have spinal metastasis (positive predictive value; 95% CI 0.8% to 2%). This indicates that low back pain on its own is not a useful indicator of spinal metastasis in primary care (positive predictive values <3%).</p></div><div id="niceng234er4.s1.1.6.2"><h5>Red flag symptoms of spinal metastases in people with low back pain</h5><p>Other studies investigated whether there are additional red-flag signs or symptoms that could help to identify those with spinal metastases amongst people with general low back pain (see <a class="figpopup" href="/books/NBK595822/table/niceng234er4.tab3/?report=objectonly" target="object" rid-figpopup="figniceng234er4tab3" rid-ob="figobniceng234er4tab3">Table 3</a>).</p><p>Moderate quality evidence from a tertiary care study suggested that absence of pain on movement, scoliosis, kyphosis and midline spinal tenderness had positive predictive values of 8.4%, 9.1%, 7.3% and 5.1% respectively for spinal metastasis. However, this was a tertiary care study where patients had a relatively high pre-test probability of spinal metastasis (6%) and the likelihood ratios indicated that these symptoms were not useful predictors of spinal metastasis in people with low back pain (positive likelihood ratio [LR+] <2, negative likelihood ratio [LR−] >0.5).</p><p>High quality evidence from a primary care study suggested that unfamiliar low back pain has a positive predictive value of 0.5% in people with low back pain and is therefore unlikely to be a useful predictor of spinal metastasis in this population.</p><p>One prospective primary care study evaluated red flag symptoms of serious spinal pathology in people presenting with low back pain. Although no cases of spinal metastatic disease were encountered, some of the proposed red flag symptoms (such as age > 50 years, insidious onset of pain, or tried bed rest but no relief) were relatively common and would likely have poor positive predictive value to identify spinal metastases in those with low back pain in primary care.</p></div><div id="niceng234er4.s1.1.6.3"><h5>Symptoms of spinal metastases in people presenting with cancer</h5><p>There was high quality evidence from a single study in people presenting with cancer that several signs and symptoms had relatively high PPV for spinal metastases. These included local pain (PPV 56%), radicular pain (53.6%), night-aggravating pain (92.4%), limb numbness (52.1%), limb weakness (29.9%), unstable gait (39%), claudication (32.3%), loss of sphincter control (24.5%), weight loss (23.7%) and all symptoms pooled (25%). The likelihood ratios indicated that several of the symptoms were useful indicators for spinal metastasis (LR+ > 5): local pain, radicular pain, night-aggravating pain and limb numbness (see <a class="figpopup" href="/books/NBK595822/table/niceng234er4.tab4/?report=objectonly" target="object" rid-figpopup="figniceng234er4tab4" rid-ob="figobniceng234er4tab4">Table 4</a>). Other symptoms were potentially useful indicators (LR+ between 2 and 5): limb weakness, unstable gait, claudication, loss of sphincter control and weight loss. Absence of the individual symptoms local pain or night-aggravating pain was also potentially useful at identifying those without spinal metastases (LR− between 0.2 and 0.5). Absence of any of the symptoms was a useful way of identifying those without spinal metastases (LR− < 0.2).</p><p>See <a href="#niceng234er4.appf">appendix F</a> for full GRADE tables.</p><div class="iconblock whole_rhythm clearfix ten_col table-wrap" id="figniceng234er4tab3"><a href="/books/NBK595822/table/niceng234er4.tab3/?report=objectonly" target="object" title="Table 3" class="img_link icnblk_img figpopup" rid-figpopup="figniceng234er4tab3" rid-ob="figobniceng234er4tab3"><img class="small-thumb" src="/books/NBK595822/table/niceng234er4.tab3/?report=thumb" src-large="/books/NBK595822/table/niceng234er4.tab3/?report=previmg" alt="Table 3. Signs or symptoms of spinal metastasis in people presenting with low back pain." /></a><div class="icnblk_cntnt"><h4 id="niceng234er4.tab3"><a href="/books/NBK595822/table/niceng234er4.tab3/?report=objectonly" target="object" rid-ob="figobniceng234er4tab3">Table 3</a></h4><p class="float-caption no_bottom_margin">Signs or symptoms of spinal metastasis in people presenting with low back pain. </p></div></div><div class="iconblock whole_rhythm clearfix ten_col table-wrap" id="figniceng234er4tab4"><a href="/books/NBK595822/table/niceng234er4.tab4/?report=objectonly" target="object" title="Table 4" class="img_link icnblk_img figpopup" rid-figpopup="figniceng234er4tab4" rid-ob="figobniceng234er4tab4"><img class="small-thumb" src="/books/NBK595822/table/niceng234er4.tab4/?report=thumb" src-large="/books/NBK595822/table/niceng234er4.tab4/?report=previmg" alt="Table 4. Signs or symptoms of spinal metastasis in people presenting with cancer." /></a><div class="icnblk_cntnt"><h4 id="niceng234er4.tab4"><a href="/books/NBK595822/table/niceng234er4.tab4/?report=objectonly" target="object" rid-ob="figobniceng234er4tab4">Table 4</a></h4><p class="float-caption no_bottom_margin">Signs or symptoms of spinal metastasis in people presenting with cancer. </p></div></div></div></div><div id="niceng234er4.s1.1.7"><h4>Economic evidence</h4><div id="niceng234er4.s1.1.7.1"><h5>Included studies</h5><p>A systematic review of the economic literature was conducted but no economic studies were identified which were applicable to this review question.</p><p>A single economic search was undertaken for all topics included in the scope of this guideline. See <a href="/books/NBK595822/bin/NG234_Supp_2_Health_economics_pdf.pdf">supplement 2</a> for details.</p></div><div id="niceng234er4.s1.1.7.2"><h5>Excluded studies</h5><p>Economic studies not included in this review are listed, and reasons for their exclusion are provided in <a href="/books/NBK595822/bin/NG234_Supp_2_Health_economics_pdf.pdf">supplement 2</a>.</p></div></div><div id="niceng234er4.s1.1.8"><h4>Economic model</h4><p>No economic modelling was undertaken for this review because the committee agreed that other topics were higher priorities for economic evaluation.</p></div><div id="niceng234er4.s1.1.9"><h4>The committee’s discussion and interpretation of the evidence</h4><div id="niceng234er4.s1.1.9.1"><h5>The outcomes that matter most</h5><p>The committee prioritised diagnostic accuracy outcomes as critical for this evidence review. This was because accurately classifying malignant versus non-malignant spinal disease would allow early treatment for people with undiagnosed metastatic spinal disease and avoid sending those with benign disease for unnecessary investigations.</p><p>The committee recognised that assessment of signs or symptoms (such as pain with movement) may be uncomfortable and this was an important outcome. Signs and symptoms if positive would typically lead to definitive tests (such as imaging or biopsy) which can have adverse effects. Inappropriate treatment or investigations due to false positive results are also a potential harm. Both these outcomes were considered important for decision making.</p></div><div id="niceng234er4.s1.1.9.2"><h5>The quality of the evidence</h5><p>The quality of the evidence was assessed using GRADE and ranged from low to high quality, with most of the evidence being of a moderate or high quality. Evidence was downgraded due to risk of bias. There was also very serious heterogeneity in the estimate of the positive predictive value of low back pain for spinal metastasis when combining all studies. Subgroup analysis according to setting (primary care verses secondary or tertiary care) reduced heterogeneity but it remained serious.</p><p>No evidence was identified about clinical prediction rules, adverse effects of assessment itself or due to false positive results. As a result of these limitations in the evidence the guideline committee also drew on their own experience and expertise when drafting the recommendations.</p></div><div id="niceng234er4.s1.1.9.3"><h5>Benefits and harms</h5><p>The committee agreed that early identification of spinal metastases, direct malignant infiltration of the spine and metastatic spinal cord compression is essential in order to maximise the effectiveness of treatments and prevent disease progression.</p><p>The committee reviewed evidence which compared the presence of signs and symptoms of metastatic disease in people with cancer and those without; for example in people with low back pain resulting from other causes, as well as symptoms of spinal metastases which were reported in people with undiagnosed cancers.</p><p>On the basis of the evidence, as well as their own experience, the committee agreed to draft a recommendation listing certain symptoms that practitioners should be aware of that could be suggestive of spinal metastases or direct malignant infiltration of the spine (see box 1 in the guideline).</p><p>The committee agreed that in primary care relevant signs or symptoms in people without a history of cancer should have a positive predictive value of at least 3% - so that at least 3 in every 100 people presenting with that sign or symptom would turn out to have spinal metastasis. This could mean a lot of false positives, however the evidence did not identify any symptoms that would require urgent referral for investigation of spinal metastases in people without a history of cancer or without suspected cancer. For people with a known history of cancer or with suspected cancer the evidence suggested that the positive predictive value of symptoms of spinal metastasis (listed in box 1 of the guideline) was much higher. While there still may be some false positives the committee agreed that these are serious symptoms (such as severe pain) which require further investigation regardless of the cause. The committee recognised that false positive classifications can cause anxiety and distress, but they agreed that it is better to have further investigations so that false positives can be corrected (with the reassurance this would bring) rather than missing people.</p><p>A personal history of cancer was identified by the committee an important factor, based on their experience, because spinal metastases are a consequence of disease progression in some patients. They also identified suspected diagnosis of cancer as an important factor, based on both their experience and evidence which indicates some people already have spinal metastases at their initial presentation with cancer.</p><p>While the evidence suggested low back pain on its own was unlikely to indicate spinal metastases, the committee agreed that back pain combined with a personal history of cancer should raise suspicion of spinal metastases. In particular, the committee agreed that, based on their experience, back pain that is severe, progressive or aggravated by movement or straining is characteristic of spinal metastases. There was also evidence to support night-time back pain, localised tenderness and claudication as potential indicators of spinal metastases.</p><p>The evidence and committee’s experience supported the list of cord compression symptoms including bladder or bowel dysfunction, gait disturbance or difficulty walking, limb weakness, numbness, paraesthesia or sensory loss and radicular pain. The committee added neurological signs of spinal cord or cauda equina compression to the list based on their experience.</p><p>While the evidence suggested that weight loss was weakly associated with spinal metastases the committee agreed that it is a general symptom of cancer, and that investigations for spinal metastases would not be the most appropriate first step in patients presenting with cancer and unexplained weight loss.</p><p>If cord compression is suspected the committee agreed that the MSCC coordinator should be contacted immediately (see evidence report E) as this is an oncological emergency.</p><p>If spinal metastases or direct malignant infiltration are suspected (but without symptoms of spinal cord compression), prompt action is still needed so that the person can be assessed and where appropriate treatment is provided. All of this involves several specialties and therefore requires coordinated care. The committee agreed to recommend, based on their own experiences, that advice should be sought through the MSCC coordinator (within 24 hours), when people with a past or current diagnosis of cancer present with back pain suggestive of spinal metastasis or direct malignant infiltration of the spine. The committee discussed that this would not necessarily mean that a referral would be made within 24 hours, for example suspected spinal metastases would usually lead to less urgent referral than suspected MSCC. Usually, this contact would be made to initiate oncological assessments but also to organise ongoing care to ensure that appropriate investigations are made and treatment can be given and coordinated in a timely manner.</p><p>The committee also agreed that in their experience it is common for people without known cancer to present with signs or symptoms that are suggestive of spinal metastases or direct malignant infiltration of the spine. They agreed that in these cases it was most appropriate to make an urgent oncology referral to ensure that appropriate investigations and treatments can be arranged.</p><p>The committee emphasised the importance of early identification of spinal metastases, direct malignant infiltration of the spine and/or cord compression and noted that it is especially important in people with a known history of cancer, in order to ensure that appropriate treatment can be provided. They therefore agreed to recommend that practitioners should explain to people with a current or past diagnosis of cancer presenting with back pain (but no clinical evidence of metastases, direct malignant infiltration, or cord compression in the spine) the signs that they should be aware of that suggest their risk of these conditions has increased. The committee also agreed that practitioners should emphasise to patients the importance of contacting their healthcare professional if these symptoms occur.</p></div><div id="niceng234er4.s1.1.9.4"><h5>Cost effectiveness and resource use</h5><p>No economic evidence was identified for this topic from the systematic search of previously published evidence. The committee considered cost effectiveness based on their own experience and knowledge.</p><p>Improving recognition of spinal metastases or direct malignant infiltration of the spine will be cost saving because it will mean that people can have the necessary investigations and treatments promptly improving outcomes and reducing outcomes associated with large costs and detriments to quality of life such as becoming non-ambulatory. Improved recognition will also prevent large downstream costs of more specialised and expensive treatment such as emergency surgery.</p></div><div id="niceng234er4.s1.1.9.5"><h5>Other factors the committee took into account</h5><p>The committee were aware of tools that are used for risk assessment in people presenting with low back pain in current practice so they cross referred to recommendations in the NICE guideline on <a href="https://www.nice.org.uk/guidance/ng59/chapter/Recommendations#assessment-of-low-back-pain-and-sciatica" ref="pagearea=body&targetsite=external&targetcat=link&targettype=uri">low back pain and sciatica in over 16s</a>. They were also aware that when there is a suspicion of cancer healthcare professionals should refer to the <a href="https://www.nice.org.uk/guidance/ng12" ref="pagearea=body&targetsite=external&targetcat=link&targettype=uri">NICE guideline on suspected cancer</a> so that they can take the appropriate action.</p></div></div><div id="niceng234er4.s1.1.10"><h4>Recommendations supported by this evidence review</h4><p>This evidence review supports recommendations Evidence reviews underpinning recommendations 1.3.1 and 1.3.3, 1.3.5 and to 1.3.6 (as well as parts of box 1 – cancer or suspected cancer and pain characteristics) in the NICE guideline.</p></div></div><div id="niceng234er4.s1.rl.r1"><h3>References – included studies</h3><ul class="simple-list"><div id="niceng234er4.s1.rl.r1.1"><h4>Diagnostic</h4><ul class="simple-list"><li class="half_rhythm"><p><div class="bk_ref" id="niceng234er4.s1.ref1"><p id="p-248">
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<strong>Bellan 2016</strong>
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</p>Bellan
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M, Molinari
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R, Castello
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L, et al. Profiling the patients visiting the emergency room for musculoskeletal complaints: characteristics and outcomes. Clinical Rheumatology, 35, 2835–2839x, 2016 [<a href="https://pubmed.ncbi.nlm.nih.gov/27315242" ref="pagearea=cite-ref&targetsite=entrez&targetcat=link&targettype=pubmed">PubMed<span class="bk_prnt">: 27315242</span></a>]</div></p></li><li class="half_rhythm"><p><div class="bk_ref" id="niceng234er4.s1.ref2"><p id="p-249">
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<strong>Cook 2012</strong>
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</p>Cook
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C, Ross
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M, Isaacs
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R, et al. Investigation of nonmechanical findings during spinal movement screening for identifying and/or ruling out metastatic cancer. Pain Practice, 12, 426–33, 2012 [<a href="https://pubmed.ncbi.nlm.nih.gov/22103245" ref="pagearea=cite-ref&targetsite=entrez&targetcat=link&targettype=pubmed">PubMed<span class="bk_prnt">: 22103245</span></a>]</div></p></li><li class="half_rhythm"><p><div class="bk_ref" id="niceng234er4.s1.ref3"><p id="p-250">
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|
<strong>Donner-Banzhoff 2006</strong>
|
|
</p>Donner-Banzhoff
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N, Roth
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|
T, Sönnichsen
|
|
A, et al. Evaluating the accuracy of a simple heuristic to identify serious causes of low back pain. Family Practice, 23, 682–686, 2006 [<a href="https://pubmed.ncbi.nlm.nih.gov/17046973" ref="pagearea=cite-ref&targetsite=entrez&targetcat=link&targettype=pubmed">PubMed<span class="bk_prnt">: 17046973</span></a>]</div></p></li><li class="half_rhythm"><p><div class="bk_ref" id="niceng234er4.s1.ref4"><p id="p-251">
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|
<strong>He 2020</strong>
|
|
</p>He
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|
S, Ye
|
|
C, Gao
|
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X, et al. Distribution and predictive value of initial presenting symptoms in spinal metastases from primary cancer patients. European Spine Journal, 29, 3148–3156, 2020 [<a href="https://pubmed.ncbi.nlm.nih.gov/32377894" ref="pagearea=cite-ref&targetsite=entrez&targetcat=link&targettype=pubmed">PubMed<span class="bk_prnt">: 32377894</span></a>]</div></p></li><li class="half_rhythm"><p><div class="bk_ref" id="niceng234er4.s1.ref5"><p id="p-252">
|
|
<strong>Henschke 2009</strong>
|
|
</p>Henschke
|
|
N, Maher
|
|
C, Refshauge
|
|
K, et al. Prevalence of and screening for serious spinal pathology in patients presenting to primary care settings with acute low back pain. Arthritis and Rheumatism, 60, 3072–80, 2009 [<a href="https://pubmed.ncbi.nlm.nih.gov/19790051" ref="pagearea=cite-ref&targetsite=entrez&targetcat=link&targettype=pubmed">PubMed<span class="bk_prnt">: 19790051</span></a>]</div></p></li><li class="half_rhythm"><p><div class="bk_ref" id="niceng234er4.s1.ref6"><p id="p-253">
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|
<strong>Khoo 2003</strong>
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|
</p>Khoo
|
|
L, Heron
|
|
C, Patel
|
|
U, et al. The diagnostic contribution of the frontal lumbar spine radiograph in community referred low back pain–a prospective study of 1030 patients. Clinical Radiology
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|
58, 606–609, 2003 [<a href="https://pubmed.ncbi.nlm.nih.gov/12887953" ref="pagearea=cite-ref&targetsite=entrez&targetcat=link&targettype=pubmed">PubMed<span class="bk_prnt">: 12887953</span></a>]</div></p></li><li class="half_rhythm"><p><div class="bk_ref" id="niceng234er4.s1.ref7"><p id="p-254">
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|
<strong>Lingawi 2004</strong>
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|
</p>Lingawi
|
|
S. How often is low back pain or sciatica not due to lumbar disc disease?
|
|
Neurosciences
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9, 94–97, 2004 [<a href="https://pubmed.ncbi.nlm.nih.gov/23377359" ref="pagearea=cite-ref&targetsite=entrez&targetcat=link&targettype=pubmed">PubMed<span class="bk_prnt">: 23377359</span></a>]</div></p></li><li class="half_rhythm"><p><div class="bk_ref" id="niceng234er4.s1.ref8"><p id="p-255">
|
|
<strong>Mijiyawa 2000</strong>
|
|
</p>Mijiyawa
|
|
M, Oniankitan
|
|
O, Kolani
|
|
B
|
|
et al. Low back pain in hospital outpatients in Lomé (Togo). Joint Bone Spine
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67, 533–8, 2000 [<a href="https://pubmed.ncbi.nlm.nih.gov/11195317" ref="pagearea=cite-ref&targetsite=entrez&targetcat=link&targettype=pubmed">PubMed<span class="bk_prnt">: 11195317</span></a>]</div></p></li><li class="half_rhythm"><p><div class="bk_ref" id="niceng234er4.s1.ref9"><p id="p-256">
|
|
<strong>Reito 2018</strong>
|
|
</p>Reito
|
|
A, Kyrola
|
|
K, Pekkanen
|
|
L, et al. Specific spinal pathologies in adult patients with an acute or subacute atraumatic low back pain in the emergency department. International Orthopaedics
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42, 2843–2849, 2018 [<a href="https://pubmed.ncbi.nlm.nih.gov/29845368" ref="pagearea=cite-ref&targetsite=entrez&targetcat=link&targettype=pubmed">PubMed<span class="bk_prnt">: 29845368</span></a>]</div></p></li><li class="half_rhythm"><p><div class="bk_ref" id="niceng234er4.s1.ref10"><p id="p-257">
|
|
<strong>Street 2020</strong>
|
|
</p>Street
|
|
K, White
|
|
S, Vandal
|
|
A. Clinical prevalence and population incidence of serious pathologies among patients undergoing magnetic resonance imaging for low back pain. Spine Journal, 20, 101–111, 2020 [<a href="https://pubmed.ncbi.nlm.nih.gov/31518682" ref="pagearea=cite-ref&targetsite=entrez&targetcat=link&targettype=pubmed">PubMed<span class="bk_prnt">: 31518682</span></a>]</div></p></li><li class="half_rhythm"><p><div class="bk_ref" id="niceng234er4.s1.ref11"><p id="p-258">
|
|
<strong>Thiruganasambandamoorthy 2014</strong>
|
|
</p>Thiruganasambandamoorthy
|
|
V, Turko
|
|
E, Ansell
|
|
D, et al. Risk factors for serious underlying pathology in adult emergency department nontraumatic low back pain patients. Journal of Emergency Medicine
|
|
47, 1–11, 2014 [<a href="https://pubmed.ncbi.nlm.nih.gov/24725822" ref="pagearea=cite-ref&targetsite=entrez&targetcat=link&targettype=pubmed">PubMed<span class="bk_prnt">: 24725822</span></a>]</div></p></li></ul></div></ul></div></div><div id="appendixesappgroup1"><h2 id="_appendixesappgroup1_">Appendices</h2><div id="niceng234er4.appa"><h3>Appendix A. Review protocols</h3><p id="niceng234er4.appa.et1"><a href="/books/NBK595822/bin/niceng234er4-appa-et1.pdf" class="bk_dwnld_icn bk_dwnld_pdf">Review protocol for review question: What symptoms or signs, individually or in combination, or validated clinical tools, suggest the presence of spinal metastatic malignant disease or direct malignant infiltration of the spine?</a><span class="small"> (PDF, 217K)</span></p></div><div id="niceng234er4.appb"><h3>Appendix B. Search strategy (clinical / economic)</h3><p id="niceng234er4.appb.et1"><a href="/books/NBK595822/bin/niceng234er4-appb-et1.pdf" class="bk_dwnld_icn bk_dwnld_pdf">Literature search strategies for review question: What symptoms or signs, individually or in combination, or validated clinical tools, suggest the presence of spinal metastatic malignant disease or direct malignant infiltration of the spine?</a><span class="small"> (PDF, 125K)</span></p></div><div id="niceng234er4.appc"><h3>Appendix C. Clinical evidence study selection</h3><p id="niceng234er4.appc.et1"><a href="/books/NBK595822/bin/niceng234er4-appc-et1.pdf" class="bk_dwnld_icn bk_dwnld_pdf">Study selection for: What symptoms or signs, individually or in combination, or validated clinical tools, suggest the presence of spinal metastatic malignant disease or direct malignant infiltration of the spine?</a><span class="small"> (PDF, 103K)</span></p></div><div id="niceng234er4.appd"><h3>Appendix D. Evidence tables</h3><p id="niceng234er4.appd.et1"><a href="/books/NBK595822/bin/niceng234er4-appd-et1.pdf" class="bk_dwnld_icn bk_dwnld_pdf">Evidence tables for review question: What symptoms or signs, individually or in combination, or validated clinical tools, suggest the presence of spinal metastatic malignant disease or direct malignant infiltration of the spine?</a><span class="small"> (PDF, 401K)</span></p></div><div id="niceng234er4.appe"><h3>Appendix E. Forest plots</h3><p id="niceng234er4.appe.et1"><a href="/books/NBK595822/bin/niceng234er4-appe-et1.pdf" class="bk_dwnld_icn bk_dwnld_pdf">Forest plots for review question: What symptoms or signs, individually or in combination, or validated clinical tools, suggest the presence of spinal metastatic malignant disease or direct malignant infiltration of the spine?</a><span class="small"> (PDF, 162K)</span></p></div><div id="niceng234er4.appf"><h3>Appendix F. Modified GRADE tables</h3><p id="niceng234er4.appf.et1"><a href="/books/NBK595822/bin/niceng234er4-appf-et1.pdf" class="bk_dwnld_icn bk_dwnld_pdf">GRADE tables for review question: What symptoms or signs, individually or in combination, or validated clinical tools, suggest the presence of spinal metastatic malignant disease or direct malignant infiltration of the spine?</a><span class="small"> (PDF, 210K)</span></p></div><div id="niceng234er4.appg"><h3>Appendix G. Economic evidence study selection</h3><div id="niceng234er4.appg.s1"><h4>Study selection for: What symptoms or signs, individually or in combination, or validated clinical tools, suggest the presence of spinal metastatic malignant disease or direct malignant infiltration of the spine?</h4><p>No economic evidence was identified which was applicable to this review question.</p></div></div><div id="niceng234er4.apph"><h3>Appendix H. Economic evidence tables</h3><div id="niceng234er4.apph.s1"><h4>Economic evidence tables for review question: What symptoms or signs, individually or in combination, or validated clinical tools, suggest the presence of spinal metastatic malignant disease or direct malignant infiltration of the spine?</h4><p>No evidence was identified which was applicable to this review question.</p></div></div><div id="niceng234er4.appi"><h3>Appendix I. Economic model</h3><div id="niceng234er4.appi.s1"><h4>Economic model for review question: What symptoms or signs, individually or in combination, or validated clinical tools, suggest the presence of spinal metastatic malignant disease or direct malignant infiltration of the spine?</h4><p>No economic analysis was conducted for this review question.</p></div></div><div id="niceng234er4.appj"><h3>Appendix J. Excluded studies</h3><div id="niceng234er4.appj.s1"><h4>Excluded studies for review question: What symptoms or signs, individually or in combination, or validated clinical tools, suggest the presence of spinal metastatic malignant disease or direct malignant infiltration of the spine?</h4></div><div id="niceng234er4.appj.s2"><h4>Excluded effectiveness/ qualitative/diagnostic/prognostic/epidemiological/service delivery studies</h4><div class="iconblock whole_rhythm clearfix ten_col table-wrap" id="figniceng234er4appjtab1"><a href="/books/NBK595822/table/niceng234er4.appj.tab1/?report=objectonly" target="object" title="Table 10" class="img_link icnblk_img figpopup" rid-figpopup="figniceng234er4appjtab1" rid-ob="figobniceng234er4appjtab1"><img class="small-thumb" src="/books/NBK595822/table/niceng234er4.appj.tab1/?report=thumb" src-large="/books/NBK595822/table/niceng234er4.appj.tab1/?report=previmg" alt="Table 10. Excluded studies and reasons for their exclusion." /></a><div class="icnblk_cntnt"><h4 id="niceng234er4.appj.tab1"><a href="/books/NBK595822/table/niceng234er4.appj.tab1/?report=objectonly" target="object" rid-ob="figobniceng234er4appjtab1">Table 10</a></h4><p class="float-caption no_bottom_margin">Excluded studies and reasons for their exclusion. </p></div></div></div><div id="niceng234er4.appj.s3"><h4>Excluded economic studies</h4><p>No economic evidence was identified for this review.</p></div></div><div id="niceng234er4.appk"><h3>Appendix K. Research recommendations – full details</h3><div id="niceng234er4.appk.s1"><h4>Research recommendations for review question: What symptoms or signs, individually or in combination, or validated clinical tools, suggest the presence of spinal metastatic malignant disease or direct malignant infiltration of the spine?</h4><p>No research recommendations were made for this review question.</p></div></div></div></div><div class="fm-sec"><div><p>Final</p></div><div><p>Evidence reviews underpinning recommendations 1.3.1 and 1.3.3, 1.3.5 and 1.3.6 (as well as parts of box 1 – cancer or suspected cancer and pain characteristics) in the NICE guideline</p><p>These evidence reviews were developed by NICE</p></div><div><p><b>Disclaimer</b>: The recommendations in this guideline represent the view of NICE, arrived at after careful consideration of the evidence available. When exercising their judgement, professionals are expected to take this guideline fully into account, alongside the individual needs, preferences and values of their patients or service users. The recommendations in this guideline are not mandatory and the guideline does not override the responsibility of healthcare professionals to make decisions appropriate to the circumstances of the individual patient, in consultation with the patient and/or their carer or guardian.</p><p>Local commissioners and/or providers have a responsibility to enable the guideline to be applied when individual health professionals and their patients or service users wish to use it. They should do so in the context of local and national priorities for funding and developing services, and in light of their duties to have due regard to the need to eliminate unlawful discrimination, to advance equality of opportunity and to reduce health inequalities. Nothing in this guideline should be interpreted in a way that would be inconsistent with compliance with those duties.</p><p>NICE guidelines cover health and care in England. Decisions on how they apply in other UK countries are made by ministers in the <a href="https://www.gov.wales/" ref="pagearea=body&targetsite=external&targetcat=link&targettype=uri">Welsh Government</a>, <a href="http://www.scotland.gov.uk/" ref="pagearea=body&targetsite=external&targetcat=link&targettype=uri">Scottish Government</a>, and <a href="http://www.northernireland.gov.uk/" ref="pagearea=body&targetsite=external&targetcat=link&targettype=uri">Northern Ireland Executive</a>. All NICE guidance is subject to regular review and may be updated or withdrawn.</p></div><div class="half_rhythm"><a href="/books/about/copyright/">Copyright</a> © NICE 2023.</div><div class="small"><span class="label">Bookshelf ID: NBK595822</span><span class="label">PMID: <a href="https://pubmed.ncbi.nlm.nih.gov/37824692" title="PubMed record of this title" ref="pagearea=meta&targetsite=entrez&targetcat=link&targettype=pubmed">37824692</a></span></div></div><div class="small-screen-prev"></div><div class="small-screen-next"></div></article><article data-type="table-wrap" id="figobniceng234er4tab1"><div id="niceng234er4.tab1" class="table"><h3><span class="label">Table 1</span><span class="title">Summary of the PIRTO table</span></h3><p class="large-table-link" style="display:none"><span class="right"><a href="/books/NBK595822/table/niceng234er4.tab1/?report=objectonly" target="object">View in own window</a></span></p><div class="large_tbl" id="__niceng234er4.tab1_lrgtbl__"><table class="no_bottom_margin"><tbody><tr><th id="hd_b_niceng234er4.tab1_1_1_1_1" rowspan="1" colspan="1" style="text-align:left;vertical-align:top;">Population</th><td headers="hd_b_niceng234er4.tab1_1_1_1_1" rowspan="1" colspan="1" style="text-align:left;vertical-align:bottom;">Adults presenting with back pain or other signs/symptoms consistent with metastatic spinal disease or direct malignant infiltration of the spine</td></tr><tr><th id="hd_b_niceng234er4.tab1_1_1_2_1" rowspan="1" colspan="1" style="text-align:left;vertical-align:top;">Index test (presence of sign or symptom)</th><td headers="hd_b_niceng234er4.tab1_1_1_2_1" rowspan="1" colspan="1" style="text-align:left;vertical-align:bottom;">Symptoms alone or in combination:
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<ul><li class="half_rhythm"><div>Pain location:
|
|
<ul class="circle"><li class="half_rhythm"><div>in the middle (thoracic) spine</div></li><li class="half_rhythm"><div>upper (cervical) spine</div></li><li class="half_rhythm"><div>lower (lumbar) spinal</div></li><li class="half_rhythm"><div>bone pain elsewhere</div></li></ul></div></li><li class="half_rhythm"><div>Pain dynamics:
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|
<ul class="circle"><li class="half_rhythm"><div>New onset spinal pain</div></li><li class="half_rhythm"><div>Progressive spinal pain</div></li></ul></div></li><li class="half_rhythm"><div>Severe unremitting lower spinal pain</div></li><li class="half_rhythm"><div>Spinal pain aggravated by straining (for example, at stool, or when coughing or sneezing) or weight bearing</div></li><li class="half_rhythm"><div>Localised spinal tenderness</div></li><li class="half_rhythm"><div>Nocturnal spinal pain preventing sleep.</div></li><li class="half_rhythm"><div>Spinal deformity</div></li><li class="half_rhythm"><div>Vertebral compression fractures</div></li><li class="half_rhythm"><div>Neurological symptoms including:
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|
<ul class="circle"><li class="half_rhythm"><div>radicular pain,</div></li><li class="half_rhythm"><div>any limb weakness,</div></li><li class="half_rhythm"><div>difficulty in walking</div></li><li class="half_rhythm"><div>inability to stand</div></li><li class="half_rhythm"><div>unsteadiness (ataxia)</div></li><li class="half_rhythm"><div>sensory loss or disturbance (for example tingling)</div></li><li class="half_rhythm"><div>bladder, bowel or sexual dysfunction</div></li></ul></div></li><li class="half_rhythm"><div>Neurological signs of spinal cord or cauda equina compression.</div></li></ul>
|
|
Any of the above in combination with potential symptoms of advanced cancer such as:
|
|
<ul><li class="half_rhythm"><div>Weight loss</div></li><li class="half_rhythm"><div>Loss of appetite</div></li><li class="half_rhythm"><div>Fatigue</div></li><li class="half_rhythm"><div>Change in bowel habit</div></li><li class="half_rhythm"><div>New and unexplained lumps</div></li><li class="half_rhythm"><div>Frequent infections</div></li><li class="half_rhythm"><div>Cough or hoarseness</div></li></ul></td></tr><tr><th id="hd_b_niceng234er4.tab1_1_1_3_1" rowspan="1" colspan="1" style="text-align:left;vertical-align:top;">Reference standard</th><td headers="hd_b_niceng234er4.tab1_1_1_3_1" rowspan="1" colspan="1" style="text-align:left;vertical-align:top;">Radiological diagnosis of metastases, for example:
|
|
<ul><li class="half_rhythm"><div>MRI</div></li><li class="half_rhythm"><div>CT</div></li><li class="half_rhythm"><div>PET-CT (particularly for haematological cancers)</div></li><li class="half_rhythm"><div>Isotope bone scans</div></li><li class="half_rhythm"><div>X-ray</div></li></ul></td></tr><tr><th id="hd_b_niceng234er4.tab1_1_1_4_1" rowspan="1" colspan="1" style="text-align:left;vertical-align:top;">Target conditions</th><td headers="hd_b_niceng234er4.tab1_1_1_4_1" rowspan="1" colspan="1" style="text-align:left;vertical-align:top;">
|
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<ul><li class="half_rhythm"><div>Metastatic spinal disease</div></li><li class="half_rhythm"><div>Direct malignant infiltration of the spine</div></li></ul>
|
|
</td></tr><tr><th id="hd_b_niceng234er4.tab1_1_1_5_1" rowspan="1" colspan="1" style="text-align:left;vertical-align:top;">Outcomes</th><td headers="hd_b_niceng234er4.tab1_1_1_5_1" rowspan="1" colspan="1" style="text-align:left;vertical-align:top;">
|
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<p>
|
|
<b>Critical</b>
|
|
</p>
|
|
<p>Diagnostic accuracy:
|
|
<ul><li class="half_rhythm"><div>Sensitivity, specificity</div></li><li class="half_rhythm"><div>Positive and negative predictive value</div></li><li class="half_rhythm"><div>Likelihood ratios</div></li></ul>
|
|
For clinical prediction tools:
|
|
<ul><li class="half_rhythm"><div>Calibration</div></li><li class="half_rhythm"><div>Discrimination</div></li></ul>
|
|
<b>Important</b>
|
|
<ul><li class="half_rhythm"><div>Adverse events associated with measurement of the symptom or sign</div></li><li class="half_rhythm"><div>Adverse events associated with radiology:
|
|
<ul class="circle"><li class="half_rhythm"><div>Contrast related</div></li></ul></div></li><li class="half_rhythm"><div>False positive / biopsy related adverse events</div></li></ul></p>
|
|
</td></tr></tbody></table></div><div class="tblwrap-foot"><div><dl class="temp-labeled-list small"><dl class="bkr_refwrap"><dt></dt><dd><div><p class="no_margin">CT: computed tomography; MRI: magnetic resonance imaging; PET-CT: positron emission tomography–computed tomography</p></div></dd></dl></dl></div></div></div></article><article data-type="table-wrap" id="figobniceng234er4tab2"><div id="niceng234er4.tab2" class="table"><h3><span class="label">Table 2</span><span class="title">Summary of included studies</span></h3><p class="large-table-link" style="display:none"><span class="right"><a href="/books/NBK595822/table/niceng234er4.tab2/?report=objectonly" target="object">View in own window</a></span></p><div class="large_tbl" id="__niceng234er4.tab2_lrgtbl__"><table class="no_bottom_margin"><thead><tr><th id="hd_h_niceng234er4.tab2_1_1_1_1" rowspan="1" colspan="1" style="text-align:left;vertical-align:top;">Study</th><th id="hd_h_niceng234er4.tab2_1_1_1_2" rowspan="1" colspan="1" style="text-align:left;vertical-align:top;">Population</th><th id="hd_h_niceng234er4.tab2_1_1_1_3" rowspan="1" colspan="1" style="text-align:left;vertical-align:top;">Sign or symptom</th><th id="hd_h_niceng234er4.tab2_1_1_1_4" rowspan="1" colspan="1" style="text-align:left;vertical-align:top;">Outcomes</th></tr></thead><tbody><tr><td headers="hd_h_niceng234er4.tab2_1_1_1_1" rowspan="1" colspan="1" style="text-align:left;vertical-align:top;">
|
|
<p>
|
|
<a class="bibr" href="#niceng234er4.s1.ref1" rid="niceng234er4.s1.ref1">Bellan 2016</a>
|
|
</p>
|
|
<p>Retrospective cohort study</p>
|
|
<p>Italy</p>
|
|
</td><td headers="hd_h_niceng234er4.tab2_1_1_1_2" rowspan="1" colspan="1" style="text-align:left;vertical-align:top;">
|
|
<p>N=1652</p>
|
|
<p>Patients admitted to an emergency department with non-traumatic musculoskeletal complaints</p>
|
|
<p>Patients with cancer at presentation, n (%): not reported</p>
|
|
<p>Age, mean (SD) years: 51 (17.8)</p>
|
|
<p>Sex: female: n=897; male n=755.</p>
|
|
</td><td headers="hd_h_niceng234er4.tab2_1_1_1_3" rowspan="1" colspan="1" style="text-align:left;vertical-align:top;">
|
|
<ul><li class="half_rhythm"><div>Back pain</div></li><li class="half_rhythm"><div>Low back pain</div></li><li class="half_rhythm"><div>Peripheral joint or periarticular problems</div></li></ul>
|
|
</td><td headers="hd_h_niceng234er4.tab2_1_1_1_4" rowspan="1" colspan="1" style="text-align:left;vertical-align:top;">
|
|
<ul><li class="half_rhythm"><div>Positive predictive value</div></li></ul>
|
|
</td></tr><tr><td headers="hd_h_niceng234er4.tab2_1_1_1_1" rowspan="1" colspan="1" style="text-align:left;vertical-align:top;">
|
|
<p>
|
|
<a class="bibr" href="#niceng234er4.s1.ref2" rid="niceng234er4.s1.ref2">Cook 2012</a>
|
|
</p>
|
|
<p>Retrospective cohort study</p>
|
|
<p>USA</p>
|
|
</td><td headers="hd_h_niceng234er4.tab2_1_1_1_2" rowspan="1" colspan="1" style="text-align:left;vertical-align:top;">
|
|
<p>N=1109</p>
|
|
<p>Patients with low back pain seen at a spine surgery centre</p>
|
|
<p>Patients with cancer at presentation, n (%): not reported</p>
|
|
<p>Age, mean (SD) years: 54.8 (16.3)</p>
|
|
<p>Sex: female n=655; male n=454.</p>
|
|
</td><td headers="hd_h_niceng234er4.tab2_1_1_1_3" rowspan="1" colspan="1" style="text-align:left;vertical-align:top;">
|
|
<ul><li class="half_rhythm"><div>Pain or limitation on movement (during flexion or extension on left and right sides)</div></li><li class="half_rhythm"><div>Scoliosis</div></li><li class="half_rhythm"><div>Kyphosis</div></li><li class="half_rhythm"><div>Midline spinal tenderness</div></li></ul>
|
|
</td><td headers="hd_h_niceng234er4.tab2_1_1_1_4" rowspan="1" colspan="1" style="text-align:left;vertical-align:top;">
|
|
<ul><li class="half_rhythm"><div>Sensitivity, specificity</div></li><li class="half_rhythm"><div>Positive and negative predictive value</div></li><li class="half_rhythm"><div>Likelihood ratios</div></li></ul>
|
|
</td></tr><tr><td headers="hd_h_niceng234er4.tab2_1_1_1_1" rowspan="1" colspan="1" style="text-align:left;vertical-align:top;">
|
|
<p>
|
|
<a class="bibr" href="#niceng234er4.s1.ref3" rid="niceng234er4.s1.ref3">Donner-Banzhoff 2006</a>
|
|
</p>
|
|
<p>Cluster randomised controlled trial</p>
|
|
<p>Germany</p>
|
|
</td><td headers="hd_h_niceng234er4.tab2_1_1_1_2" rowspan="1" colspan="1" style="text-align:left;vertical-align:top;">
|
|
<p>N=1378</p>
|
|
<p>Patients with low back pain presenting to primary care.</p>
|
|
<p>Patients with cancer at presentation, n (%): not reported</p>
|
|
<p>Age, mean (SD) years: 49 (13.3)</p>
|
|
<p>Sex: female n=692; male n=686.</p>
|
|
</td><td headers="hd_h_niceng234er4.tab2_1_1_1_3" rowspan="1" colspan="1" style="text-align:left;vertical-align:top;">
|
|
<ul><li class="half_rhythm"><div>Low back pain</div></li><li class="half_rhythm"><div>Unfamiliar low back pain</div></li></ul>
|
|
</td><td headers="hd_h_niceng234er4.tab2_1_1_1_4" rowspan="1" colspan="1" style="text-align:left;vertical-align:top;">
|
|
<ul><li class="half_rhythm"><div>Sensitivity, specificity</div></li><li class="half_rhythm"><div>Positive and negative predictive value</div></li><li class="half_rhythm"><div>Likelihood ratios</div></li></ul>
|
|
</td></tr><tr><td headers="hd_h_niceng234er4.tab2_1_1_1_1" rowspan="1" colspan="1" style="text-align:left;vertical-align:top;">
|
|
<p>
|
|
<a class="bibr" href="#niceng234er4.s1.ref4" rid="niceng234er4.s1.ref4">He 2020</a>
|
|
</p>
|
|
<p>Retrospective cohort study</p>
|
|
<p>China</p>
|
|
</td><td headers="hd_h_niceng234er4.tab2_1_1_1_2" rowspan="1" colspan="1" style="text-align:left;vertical-align:top;">
|
|
<p>N=14603</p>
|
|
<p>Patients at initial presentation with undiagnosed cancer</p>
|
|
<p>Patients with cancer at presentation, n (%): 14603 (100%)</p>
|
|
<p>Age, mean (SD) years: 58.6 (11.9)</p>
|
|
<p>Sex: female n=5241; male n=9362.</p>
|
|
</td><td headers="hd_h_niceng234er4.tab2_1_1_1_3" rowspan="1" colspan="1" style="text-align:left;vertical-align:top;">
|
|
<ul><li class="half_rhythm"><div>Local pain</div></li><li class="half_rhythm"><div>Radicular pain</div></li><li class="half_rhythm"><div>Night-aggravating pain</div></li><li class="half_rhythm"><div>Limb numbness</div></li><li class="half_rhythm"><div>Limb weakness</div></li><li class="half_rhythm"><div>Unstable gait</div></li><li class="half_rhythm"><div>Claudication</div></li><li class="half_rhythm"><div>Loss of sphincter control</div></li><li class="half_rhythm"><div>Weight loss</div></li><li class="half_rhythm"><div>Symptoms pooled</div></li></ul>
|
|
</td><td headers="hd_h_niceng234er4.tab2_1_1_1_4" rowspan="1" colspan="1" style="text-align:left;vertical-align:top;">
|
|
<ul><li class="half_rhythm"><div>Sensitivity, specificity</div></li><li class="half_rhythm"><div>Positive and negative predictive value</div></li><li class="half_rhythm"><div>Likelihood ratios</div></li></ul>
|
|
</td></tr><tr><td headers="hd_h_niceng234er4.tab2_1_1_1_1" rowspan="1" colspan="1" style="text-align:left;vertical-align:top;">
|
|
<p>
|
|
<a class="bibr" href="#niceng234er4.s1.ref5" rid="niceng234er4.s1.ref5">Henschke 2009</a>
|
|
</p>
|
|
<p>Prospective cohort study</p>
|
|
<p>Australia</p>
|
|
</td><td headers="hd_h_niceng234er4.tab2_1_1_1_2" rowspan="1" colspan="1" style="text-align:left;vertical-align:top;">
|
|
<p>N=1172</p>
|
|
<p>Patients presenting with low back pain to primary care settings</p>
|
|
<p>Patients with cancer at presentation, n (%): 1 (0.1%)</p>
|
|
<p>Age, mean (SD) years: 43.97 (15.1)</p>
|
|
<p>Sex: female n=546; male n=626.</p>
|
|
</td><td headers="hd_h_niceng234er4.tab2_1_1_1_3" rowspan="1" colspan="1" style="text-align:left;vertical-align:top;">
|
|
<ul><li class="half_rhythm"><div>Previous history of cancer</div></li><li class="half_rhythm"><div>Age at onset of back pain</div></li><li class="half_rhythm"><div>Constant, progressive, nonmechanical pain</div></li><li class="half_rhythm"><div>Insidious onset of back pain</div></li><li class="half_rhythm"><div>Tried bed rest, but no relief</div></li><li class="half_rhythm"><div>Systematically unwell</div></li><li class="half_rhythm"><div>Unexplained weight loss (>4.5kg in 6 months)</div></li><li class="half_rhythm"><div>Sensory level (altered sensation from trunk down)</div></li></ul>
|
|
</td><td headers="hd_h_niceng234er4.tab2_1_1_1_4" rowspan="1" colspan="1" style="text-align:left;vertical-align:top;">
|
|
<ul><li class="half_rhythm"><div>Specificity</div></li></ul>
|
|
</td></tr><tr><td headers="hd_h_niceng234er4.tab2_1_1_1_1" rowspan="1" colspan="1" style="text-align:left;vertical-align:top;">
|
|
<p>
|
|
<a class="bibr" href="#niceng234er4.s1.ref6" rid="niceng234er4.s1.ref6">Khoo 2003</a>
|
|
</p>
|
|
<p>Prospective cohort study</p>
|
|
<p>UK</p>
|
|
</td><td headers="hd_h_niceng234er4.tab2_1_1_1_2" rowspan="1" colspan="1" style="text-align:left;vertical-align:top;">
|
|
<p>N=1030</p>
|
|
<p>General practice referrals for lumbar spine radiographs for people with low back pain.</p>
|
|
<p>Patients with cancer at presentation, n (%): not reported</p>
|
|
<p>Age, mean (SD) years: 53. (not reported)</p>
|
|
<p>Sex: not reported.</p>
|
|
</td><td headers="hd_h_niceng234er4.tab2_1_1_1_3" rowspan="1" colspan="1" style="text-align:left;vertical-align:top;">
|
|
<ul><li class="half_rhythm"><div>Low back pain</div></li></ul>
|
|
</td><td headers="hd_h_niceng234er4.tab2_1_1_1_4" rowspan="1" colspan="1" style="text-align:left;vertical-align:top;">
|
|
<ul><li class="half_rhythm"><div>Positive predictive value</div></li></ul>
|
|
</td></tr><tr><td headers="hd_h_niceng234er4.tab2_1_1_1_1" rowspan="1" colspan="1" style="text-align:left;vertical-align:top;">
|
|
<p>
|
|
<a class="bibr" href="#niceng234er4.s1.ref7" rid="niceng234er4.s1.ref7">Lingawi 2004</a>
|
|
</p>
|
|
<p>Retrospective cohort study</p>
|
|
<p>Saudi Arabia</p>
|
|
</td><td headers="hd_h_niceng234er4.tab2_1_1_1_2" rowspan="1" colspan="1" style="text-align:left;vertical-align:top;">
|
|
<p>N=634</p>
|
|
<p>Patients with low back pain sent for MRI</p>
|
|
<p>Patients with cancer at presentation, n (%): not reported</p>
|
|
<p>Age, mean (SD) years: 53 (not reported)</p>
|
|
<p>Sex: female n=336; male n=298.</p>
|
|
</td><td headers="hd_h_niceng234er4.tab2_1_1_1_3" rowspan="1" colspan="1" style="text-align:left;vertical-align:top;">
|
|
<ul><li class="half_rhythm"><div>Low back pain</div></li></ul>
|
|
</td><td headers="hd_h_niceng234er4.tab2_1_1_1_4" rowspan="1" colspan="1" style="text-align:left;vertical-align:top;">
|
|
<ul><li class="half_rhythm"><div>Positive predictive value</div></li></ul>
|
|
</td></tr><tr><td headers="hd_h_niceng234er4.tab2_1_1_1_1" rowspan="1" colspan="1" style="text-align:left;vertical-align:top;">
|
|
<p>
|
|
<a class="bibr" href="#niceng234er4.s1.ref8" rid="niceng234er4.s1.ref8">Mijiyawa 2000</a>
|
|
</p>
|
|
<p>Retrospective cohort study</p>
|
|
<p>Togo</p>
|
|
</td><td headers="hd_h_niceng234er4.tab2_1_1_1_2" rowspan="1" colspan="1" style="text-align:left;vertical-align:top;">
|
|
<p>N=3204</p>
|
|
<p>Patients with low back pain visiting the rheumatology unit of the Lomé Teaching Hospital</p>
|
|
<p>Patients with cancer at presentation, n (%): not reported</p>
|
|
<p>Age, mean (SD) years: 44.46 (14.39)</p>
|
|
<p>Sex: female n=1850; male n=1354.</p>
|
|
</td><td headers="hd_h_niceng234er4.tab2_1_1_1_3" rowspan="1" colspan="1" style="text-align:left;vertical-align:top;">
|
|
<ul><li class="half_rhythm"><div>Low back pain</div></li></ul>
|
|
</td><td headers="hd_h_niceng234er4.tab2_1_1_1_4" rowspan="1" colspan="1" style="text-align:left;vertical-align:top;">
|
|
<ul><li class="half_rhythm"><div>Positive predictive value</div></li></ul>
|
|
</td></tr><tr><td headers="hd_h_niceng234er4.tab2_1_1_1_1" rowspan="1" colspan="1" style="text-align:left;vertical-align:top;">
|
|
<p>
|
|
<a class="bibr" href="#niceng234er4.s1.ref9" rid="niceng234er4.s1.ref9">Reito 2018</a>
|
|
</p>
|
|
<p>Retrospective cohort study</p>
|
|
<p>Finland</p>
|
|
</td><td headers="hd_h_niceng234er4.tab2_1_1_1_2" rowspan="1" colspan="1" style="text-align:left;vertical-align:top;">
|
|
<p>N=737</p>
|
|
<p>Patients with low back pain presenting to an emergency department who had a possible specific spinal pathology</p>
|
|
<p>Patients with cancer at presentation, n (%): 59 (6.6%)</p>
|
|
<p>Age, mean (SD) years: 51.3 (17.0)</p>
|
|
<p>Sex: male n=335; female n=402</p>
|
|
</td><td headers="hd_h_niceng234er4.tab2_1_1_1_3" rowspan="1" colspan="1" style="text-align:left;vertical-align:top;">
|
|
<ul><li class="half_rhythm"><div>Low back pain</div></li></ul>
|
|
</td><td headers="hd_h_niceng234er4.tab2_1_1_1_4" rowspan="1" colspan="1" style="text-align:left;vertical-align:top;">
|
|
<ul><li class="half_rhythm"><div>Positive predictive value</div></li></ul>
|
|
</td></tr><tr><td headers="hd_h_niceng234er4.tab2_1_1_1_1" rowspan="1" colspan="1" style="text-align:left;vertical-align:top;">
|
|
<p>
|
|
<a class="bibr" href="#niceng234er4.s1.ref10" rid="niceng234er4.s1.ref10">Street 2020</a>
|
|
</p>
|
|
<p>Retrospective cohort study</p>
|
|
<p>New Zealand</p>
|
|
</td><td headers="hd_h_niceng234er4.tab2_1_1_1_2" rowspan="1" colspan="1" style="text-align:left;vertical-align:top;">
|
|
<p>N=2383</p>
|
|
<p>Patients with back pain referred for lumbar MRI by a specialist in a private secondary care or public tertiary care setting</p>
|
|
<p>Patients with cancer at presentation, n (%): 36 (1.5%)</p>
|
|
<p>Age, mean (SD) years: 52 (not reported)</p>
|
|
<p>Sex: female n=1235; male n=1148.</p>
|
|
</td><td headers="hd_h_niceng234er4.tab2_1_1_1_3" rowspan="1" colspan="1" style="text-align:left;vertical-align:top;">
|
|
<ul><li class="half_rhythm"><div>Low back pain</div></li></ul>
|
|
</td><td headers="hd_h_niceng234er4.tab2_1_1_1_4" rowspan="1" colspan="1" style="text-align:left;vertical-align:top;">
|
|
<ul><li class="half_rhythm"><div>Positive predictive value</div></li></ul>
|
|
</td></tr><tr><td headers="hd_h_niceng234er4.tab2_1_1_1_1" rowspan="1" colspan="1" style="text-align:left;vertical-align:top;">
|
|
<p>
|
|
<a class="bibr" href="#niceng234er4.s1.ref11" rid="niceng234er4.s1.ref11">Thiruganasambandamoorthy 2014</a>
|
|
</p>
|
|
<p>Retrospective cohort study</p>
|
|
<p>Canada</p>
|
|
</td><td headers="hd_h_niceng234er4.tab2_1_1_1_2" rowspan="1" colspan="1" style="text-align:left;vertical-align:top;">
|
|
<p>N=329</p>
|
|
<p>Patients with low back pain who were assessed by an emergency physician.</p>
|
|
<p>Patients with cancer at presentation, n (%): 20 (6.1%)</p>
|
|
<p>Age, mean (SD) years: 49.3 (not reported)</p>
|
|
<p>Sex: female n=167; male n=162.</p>
|
|
</td><td headers="hd_h_niceng234er4.tab2_1_1_1_3" rowspan="1" colspan="1" style="text-align:left;vertical-align:top;">
|
|
<ul><li class="half_rhythm"><div>Low back pain</div></li></ul>
|
|
</td><td headers="hd_h_niceng234er4.tab2_1_1_1_4" rowspan="1" colspan="1" style="text-align:left;vertical-align:top;">
|
|
<ul><li class="half_rhythm"><div>Positive predictive value</div></li></ul>
|
|
</td></tr></tbody></table></div><div class="tblwrap-foot"><div><dl class="temp-labeled-list small"><dl class="bkr_refwrap"><dt></dt><dd><div><p class="no_margin">MRI: magnetic resonance imaging; SD: standard deviation</p></div></dd></dl></dl></div></div></div></article><article data-type="table-wrap" id="figobniceng234er4tab3"><div id="niceng234er4.tab3" class="table"><h3><span class="label">Table 3</span><span class="title">Signs or symptoms of spinal metastasis in people presenting with low back pain</span></h3><p class="large-table-link" style="display:none"><span class="right"><a href="/books/NBK595822/table/niceng234er4.tab3/?report=objectonly" target="object">View in own window</a></span></p><div class="large_tbl" id="__niceng234er4.tab3_lrgtbl__"><table class="no_bottom_margin"><thead><tr><th id="hd_h_niceng234er4.tab3_1_1_1_1" rowspan="2" colspan="1" headers="hd_h_niceng234er4.tab3_1_1_1_1" style="text-align:center;vertical-align:middle;">Study</th><th id="hd_h_niceng234er4.tab3_1_1_1_2" rowspan="2" colspan="1" headers="hd_h_niceng234er4.tab3_1_1_1_2" style="text-align:center;vertical-align:middle;">Sign or symptom (% prevalence)</th><th id="hd_h_niceng234er4.tab3_1_1_1_3" rowspan="2" colspan="1" headers="hd_h_niceng234er4.tab3_1_1_1_3" style="text-align:center;vertical-align:middle;">Prevalence of spinal metastasis in study</th><th id="hd_h_niceng234er4.tab3_1_1_1_4" colspan="2" rowspan="1" style="text-align:center;vertical-align:middle;">Predictive values % [95% CI]</th><th id="hd_h_niceng234er4.tab3_1_1_1_5" rowspan="2" colspan="1" headers="hd_h_niceng234er4.tab3_1_1_1_5" style="text-align:center;vertical-align:middle;">Sensitivity % [95% CI]</th><th id="hd_h_niceng234er4.tab3_1_1_1_6" rowspan="2" colspan="1" headers="hd_h_niceng234er4.tab3_1_1_1_6" style="text-align:center;vertical-align:middle;">Specificity % [95% CI]</th><th id="hd_h_niceng234er4.tab3_1_1_1_7" colspan="2" rowspan="1" style="text-align:center;vertical-align:middle;">Likelihood ratios [95% CI]</th></tr><tr><th headers="hd_h_niceng234er4.tab3_1_1_1_4" id="hd_h_niceng234er4.tab3_1_1_2_1" rowspan="1" colspan="1" style="text-align:center;vertical-align:middle;">PPV</th><th headers="hd_h_niceng234er4.tab3_1_1_1_4" id="hd_h_niceng234er4.tab3_1_1_2_2" rowspan="1" colspan="1" style="text-align:center;vertical-align:middle;">NPV</th><th headers="hd_h_niceng234er4.tab3_1_1_1_7" id="hd_h_niceng234er4.tab3_1_1_2_3" rowspan="1" colspan="1" style="text-align:center;vertical-align:middle;">LR+</th><th headers="hd_h_niceng234er4.tab3_1_1_1_7" id="hd_h_niceng234er4.tab3_1_1_2_4" rowspan="1" colspan="1" style="text-align:center;vertical-align:middle;">LR−</th></tr></thead><tbody><tr><td headers="hd_h_niceng234er4.tab3_1_1_1_1" rowspan="1" colspan="1" style="text-align:left;vertical-align:top;">
|
|
<a class="bibr" href="#niceng234er4.s1.ref2" rid="niceng234er4.s1.ref2">Cook 2012</a>
|
|
</td><td headers="hd_h_niceng234er4.tab3_1_1_1_2" rowspan="1" colspan="1" style="text-align:left;vertical-align:top;">No pain on movement test<sup>1</sup> (42%)</td><td headers="hd_h_niceng234er4.tab3_1_1_1_3" rowspan="1" colspan="1" style="text-align:center;vertical-align:middle;">0.5%<sup>2</sup></td><td headers="hd_h_niceng234er4.tab3_1_1_1_4 hd_h_niceng234er4.tab3_1_1_2_1" rowspan="1" colspan="1" style="text-align:center;vertical-align:top;">1.1 [0.8 to 1.4]</td><td headers="hd_h_niceng234er4.tab3_1_1_1_4 hd_h_niceng234er4.tab3_1_1_2_2" rowspan="1" colspan="1" style="text-align:center;vertical-align:middle;">99.9 [99 to 100]</td><td headers="hd_h_niceng234er4.tab3_1_1_1_5" rowspan="1" colspan="1" style="text-align:center;vertical-align:middle;">91.7 [51.7 to 99.1]</td><td headers="hd_h_niceng234er4.tab3_1_1_1_6" rowspan="1" colspan="1" style="text-align:center;vertical-align:middle;">58 [55 to 60.8]</td><td headers="hd_h_niceng234er4.tab3_1_1_1_7 hd_h_niceng234er4.tab3_1_1_2_3" rowspan="1" colspan="1" style="text-align:center;vertical-align:middle;">2.18 [1.7 to 2.8]</td><td headers="hd_h_niceng234er4.tab3_1_1_1_7 hd_h_niceng234er4.tab3_1_1_2_4" rowspan="1" colspan="1" style="text-align:center;vertical-align:middle;">0.14 [0.01 to 2.04]</td></tr><tr><td headers="hd_h_niceng234er4.tab3_1_1_1_1" rowspan="1" colspan="1" style="text-align:left;vertical-align:top;">
|
|
<a class="bibr" href="#niceng234er4.s1.ref2" rid="niceng234er4.s1.ref2">Cook 2012</a>
|
|
</td><td headers="hd_h_niceng234er4.tab3_1_1_1_2" rowspan="1" colspan="1" style="text-align:left;vertical-align:top;">No pain on movement test (42%)</td><td headers="hd_h_niceng234er4.tab3_1_1_1_3" rowspan="4" colspan="1" style="text-align:center;vertical-align:middle;">6.0%<sup>3</sup></td><td headers="hd_h_niceng234er4.tab3_1_1_1_4 hd_h_niceng234er4.tab3_1_1_2_1" rowspan="1" colspan="1" style="text-align:center;vertical-align:top;">8.4 [6.9 to 10.2]</td><td headers="hd_h_niceng234er4.tab3_1_1_1_4 hd_h_niceng234er4.tab3_1_1_2_2" rowspan="1" colspan="1" style="text-align:center;vertical-align:middle;">95.7 [94.4 to 96.8]</td><td headers="hd_h_niceng234er4.tab3_1_1_1_5" rowspan="1" colspan="1" style="text-align:center;vertical-align:middle;">59 [47 to 69.9]</td><td headers="hd_h_niceng234er4.tab3_1_1_1_6" rowspan="1" colspan="1" style="text-align:center;vertical-align:middle;">59 [56 to 61.9]</td><td headers="hd_h_niceng234er4.tab3_1_1_1_7 hd_h_niceng234er4.tab3_1_1_2_3" rowspan="1" colspan="1" style="text-align:center;vertical-align:middle;">1.44 [1.16 to 1.78]</td><td headers="hd_h_niceng234er4.tab3_1_1_1_7 hd_h_niceng234er4.tab3_1_1_2_4" rowspan="1" colspan="1" style="text-align:center;vertical-align:middle;">0.7 [0.52 to 0.93]</td></tr><tr><td headers="hd_h_niceng234er4.tab3_1_1_1_1" rowspan="1" colspan="1" style="text-align:left;vertical-align:top;">
|
|
<a class="bibr" href="#niceng234er4.s1.ref2" rid="niceng234er4.s1.ref2">Cook 2012</a>
|
|
</td><td headers="hd_h_niceng234er4.tab3_1_1_1_2" rowspan="1" colspan="1" style="text-align:left;vertical-align:top;">Scoliosis (18%)</td><td headers="hd_h_niceng234er4.tab3_1_1_1_4 hd_h_niceng234er4.tab3_1_1_2_1" rowspan="1" colspan="1" style="text-align:center;vertical-align:top;">9.1 [6.2 to 13.1]</td><td headers="hd_h_niceng234er4.tab3_1_1_1_4 hd_h_niceng234er4.tab3_1_1_2_2" rowspan="1" colspan="1" style="text-align:center;vertical-align:middle;">94.7 [93.9 to 95.4]</td><td headers="hd_h_niceng234er4.tab3_1_1_1_5" rowspan="1" colspan="1" style="text-align:center;vertical-align:middle;">27.3 [18 to 39]</td><td headers="hd_h_niceng234er4.tab3_1_1_1_6" rowspan="1" colspan="1" style="text-align:center;vertical-align:middle;">82.5 [80.1 to 84.7]</td><td headers="hd_h_niceng234er4.tab3_1_1_1_7 hd_h_niceng234er4.tab3_1_1_2_3" rowspan="1" colspan="1" style="text-align:center;vertical-align:middle;">1.56 [1.03 to 2.37]</td><td headers="hd_h_niceng234er4.tab3_1_1_1_7 hd_h_niceng234er4.tab3_1_1_2_4" rowspan="1" colspan="1" style="text-align:center;vertical-align:middle;">0.88 [0.76 to 1.02]</td></tr><tr><td headers="hd_h_niceng234er4.tab3_1_1_1_1" rowspan="1" colspan="1" style="text-align:left;vertical-align:top;">
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<a class="bibr" href="#niceng234er4.s1.ref2" rid="niceng234er4.s1.ref2">Cook 2012</a>
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</td><td headers="hd_h_niceng234er4.tab3_1_1_1_2" rowspan="1" colspan="1" style="text-align:left;vertical-align:top;">Kyphosis (11%)</td><td headers="hd_h_niceng234er4.tab3_1_1_1_4 hd_h_niceng234er4.tab3_1_1_2_1" rowspan="1" colspan="1" style="text-align:center;vertical-align:top;">7.3 [4 to 12.9]</td><td headers="hd_h_niceng234er4.tab3_1_1_1_4 hd_h_niceng234er4.tab3_1_1_2_2" rowspan="1" colspan="1" style="text-align:center;vertical-align:middle;">94.2 [93.6 to 94.7]</td><td headers="hd_h_niceng234er4.tab3_1_1_1_5" rowspan="1" colspan="1" style="text-align:center;vertical-align:middle;">13.6 [7.3 to 23.9]</td><td headers="hd_h_niceng234er4.tab3_1_1_1_6" rowspan="1" colspan="1" style="text-align:center;vertical-align:middle;">89 [86.9 to 90.7]</td><td headers="hd_h_niceng234er4.tab3_1_1_1_7 hd_h_niceng234er4.tab3_1_1_2_3" rowspan="1" colspan="1" style="text-align:center;vertical-align:middle;">1.24 [0.66 to 2.33]</td><td headers="hd_h_niceng234er4.tab3_1_1_1_7 hd_h_niceng234er4.tab3_1_1_2_4" rowspan="1" colspan="1" style="text-align:center;vertical-align:middle;">0.97 [0.88 to 1.07]</td></tr><tr><td headers="hd_h_niceng234er4.tab3_1_1_1_1" rowspan="1" colspan="1" style="text-align:left;vertical-align:top;">
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<a class="bibr" href="#niceng234er4.s1.ref2" rid="niceng234er4.s1.ref2">Cook 2012</a>
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</td><td headers="hd_h_niceng234er4.tab3_1_1_1_2" rowspan="1" colspan="1" style="text-align:left;vertical-align:top;">Midline spinal tenderness (53%)</td><td headers="hd_h_niceng234er4.tab3_1_1_1_4 hd_h_niceng234er4.tab3_1_1_2_1" rowspan="1" colspan="1" style="text-align:center;vertical-align:top;">5.1 [3.9 to 6.6]</td><td headers="hd_h_niceng234er4.tab3_1_1_1_4 hd_h_niceng234er4.tab3_1_1_2_2" rowspan="1" colspan="1" style="text-align:center;vertical-align:middle;">93 [91.3 to 94.3]</td><td headers="hd_h_niceng234er4.tab3_1_1_1_5" rowspan="1" colspan="1" style="text-align:center;vertical-align:middle;">45.5 [34 to 57.4]</td><td headers="hd_h_niceng234er4.tab3_1_1_1_6" rowspan="1" colspan="1" style="text-align:center;vertical-align:middle;">46.1 [43.1 to 49.2]</td><td headers="hd_h_niceng234er4.tab3_1_1_1_7 hd_h_niceng234er4.tab3_1_1_2_3" rowspan="1" colspan="1" style="text-align:center;vertical-align:middle;">0.84 [0.64 to 1.11]</td><td headers="hd_h_niceng234er4.tab3_1_1_1_7 hd_h_niceng234er4.tab3_1_1_2_4" rowspan="1" colspan="1" style="text-align:center;vertical-align:middle;">1.18 [0.94 to 1.49]</td></tr><tr><td headers="hd_h_niceng234er4.tab3_1_1_1_1" rowspan="1" colspan="1" style="text-align:left;vertical-align:top;">
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<a class="bibr" href="#niceng234er4.s1.ref3" rid="niceng234er4.s1.ref3">Donner-Banzhoff 2006</a>
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</td><td headers="hd_h_niceng234er4.tab3_1_1_1_2" rowspan="1" colspan="1" style="text-align:left;vertical-align:top;">Unfamiliar low back pain (17%)</td><td headers="hd_h_niceng234er4.tab3_1_1_1_3" rowspan="1" colspan="1" style="text-align:center;vertical-align:middle;">0.2%</td><td headers="hd_h_niceng234er4.tab3_1_1_1_4 hd_h_niceng234er4.tab3_1_1_2_1" rowspan="1" colspan="1" style="text-align:center;vertical-align:middle;">0.5 [0.1 to 1.9]</td><td headers="hd_h_niceng234er4.tab3_1_1_1_4 hd_h_niceng234er4.tab3_1_1_2_2" rowspan="1" colspan="1" style="text-align:center;vertical-align:middle;">99.9 [99.6 to 100]</td><td headers="hd_h_niceng234er4.tab3_1_1_1_5" rowspan="1" colspan="1" style="text-align:center;vertical-align:middle;">50 [1.3 to 98.4]</td><td headers="hd_h_niceng234er4.tab3_1_1_1_6" rowspan="1" colspan="1" style="text-align:center;vertical-align:middle;">82.8 [80.6 to 84.9]</td><td headers="hd_h_niceng234er4.tab3_1_1_1_7 hd_h_niceng234er4.tab3_1_1_2_3" rowspan="1" colspan="1" style="text-align:center;vertical-align:middle;">2.91 [0.72 to 11.71]</td><td headers="hd_h_niceng234er4.tab3_1_1_1_7 hd_h_niceng234er4.tab3_1_1_2_4" rowspan="1" colspan="1" style="text-align:center;vertical-align:middle;">0.6 [0.15 to 2.41]</td></tr><tr><td headers="hd_h_niceng234er4.tab3_1_1_1_1" rowspan="1" colspan="1" style="text-align:left;vertical-align:top;">
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<a class="bibr" href="#niceng234er4.s1.ref5" rid="niceng234er4.s1.ref5">Henschke 2009</a>
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<sup>
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|
4
|
|
</sup>
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|
</td><td headers="hd_h_niceng234er4.tab3_1_1_1_2" rowspan="1" colspan="1" style="text-align:left;vertical-align:top;">Previous history of cancer (4%)</td><td headers="hd_h_niceng234er4.tab3_1_1_1_3" rowspan="9" colspan="1" style="text-align:center;vertical-align:middle;">0%</td><td headers="hd_h_niceng234er4.tab3_1_1_1_4 hd_h_niceng234er4.tab3_1_1_2_1" rowspan="1" colspan="1" style="text-align:center;vertical-align:middle;">Not estimable</td><td headers="hd_h_niceng234er4.tab3_1_1_1_4 hd_h_niceng234er4.tab3_1_1_2_2" rowspan="1" colspan="1" style="text-align:center;vertical-align:middle;">Not estimable</td><td headers="hd_h_niceng234er4.tab3_1_1_1_5" rowspan="1" colspan="1" style="text-align:center;vertical-align:middle;">Not estimable</td><td headers="hd_h_niceng234er4.tab3_1_1_1_6" rowspan="1" colspan="1" style="text-align:center;vertical-align:middle;">96 [94.8 to 97]</td><td headers="hd_h_niceng234er4.tab3_1_1_1_7 hd_h_niceng234er4.tab3_1_1_2_3" rowspan="1" colspan="1" style="text-align:center;vertical-align:middle;">Not estimable</td><td headers="hd_h_niceng234er4.tab3_1_1_1_7 hd_h_niceng234er4.tab3_1_1_2_4" rowspan="1" colspan="1" style="text-align:center;vertical-align:middle;">Not estimable</td></tr><tr><td headers="hd_h_niceng234er4.tab3_1_1_1_1" rowspan="1" colspan="1" style="text-align:left;vertical-align:top;">
|
|
<a class="bibr" href="#niceng234er4.s1.ref5" rid="niceng234er4.s1.ref5">Henschke 2009</a>
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</td><td headers="hd_h_niceng234er4.tab3_1_1_1_2" rowspan="1" colspan="1" style="text-align:left;vertical-align:top;">Age> 50 (34%)</td><td headers="hd_h_niceng234er4.tab3_1_1_1_4 hd_h_niceng234er4.tab3_1_1_2_1" rowspan="1" colspan="1" style="text-align:center;vertical-align:middle;">Not estimable</td><td headers="hd_h_niceng234er4.tab3_1_1_1_4 hd_h_niceng234er4.tab3_1_1_2_2" rowspan="1" colspan="1" style="text-align:center;vertical-align:middle;">Not estimable</td><td headers="hd_h_niceng234er4.tab3_1_1_1_5" rowspan="1" colspan="1" style="text-align:center;vertical-align:middle;">Not estimable</td><td headers="hd_h_niceng234er4.tab3_1_1_1_6" rowspan="1" colspan="1" style="text-align:center;vertical-align:middle;">65.9 [63.1 to 68.5]</td><td headers="hd_h_niceng234er4.tab3_1_1_1_7 hd_h_niceng234er4.tab3_1_1_2_3" rowspan="1" colspan="1" style="text-align:center;vertical-align:middle;">Not estimable</td><td headers="hd_h_niceng234er4.tab3_1_1_1_7 hd_h_niceng234er4.tab3_1_1_2_4" rowspan="1" colspan="1" style="text-align:center;vertical-align:middle;">Not estimable</td></tr><tr><td headers="hd_h_niceng234er4.tab3_1_1_1_1" rowspan="1" colspan="1" style="text-align:left;vertical-align:top;">
|
|
<a class="bibr" href="#niceng234er4.s1.ref5" rid="niceng234er4.s1.ref5">Henschke 2009</a>
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</td><td headers="hd_h_niceng234er4.tab3_1_1_1_2" rowspan="1" colspan="1" style="text-align:left;vertical-align:top;">Age> 70 (5%)</td><td headers="hd_h_niceng234er4.tab3_1_1_1_4 hd_h_niceng234er4.tab3_1_1_2_1" rowspan="1" colspan="1" style="text-align:center;vertical-align:middle;">Not estimable</td><td headers="hd_h_niceng234er4.tab3_1_1_1_4 hd_h_niceng234er4.tab3_1_1_2_2" rowspan="1" colspan="1" style="text-align:center;vertical-align:middle;">Not estimable</td><td headers="hd_h_niceng234er4.tab3_1_1_1_5" rowspan="1" colspan="1" style="text-align:center;vertical-align:middle;">Not estimable</td><td headers="hd_h_niceng234er4.tab3_1_1_1_6" rowspan="1" colspan="1" style="text-align:center;vertical-align:middle;">95.2 [93.8 to 96.3]</td><td headers="hd_h_niceng234er4.tab3_1_1_1_7 hd_h_niceng234er4.tab3_1_1_2_3" rowspan="1" colspan="1" style="text-align:center;vertical-align:middle;">Not estimable</td><td headers="hd_h_niceng234er4.tab3_1_1_1_7 hd_h_niceng234er4.tab3_1_1_2_4" rowspan="1" colspan="1" style="text-align:center;vertical-align:middle;">Not estimable</td></tr><tr><td headers="hd_h_niceng234er4.tab3_1_1_1_1" rowspan="1" colspan="1" style="text-align:left;vertical-align:top;">
|
|
<a class="bibr" href="#niceng234er4.s1.ref5" rid="niceng234er4.s1.ref5">Henschke 2009</a>
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|
</td><td headers="hd_h_niceng234er4.tab3_1_1_1_2" rowspan="1" colspan="1" style="text-align:left;vertical-align:top;">Constant, progressive, nonmechanical pain (3%)</td><td headers="hd_h_niceng234er4.tab3_1_1_1_4 hd_h_niceng234er4.tab3_1_1_2_1" rowspan="1" colspan="1" style="text-align:center;vertical-align:middle;">Not estimable</td><td headers="hd_h_niceng234er4.tab3_1_1_1_4 hd_h_niceng234er4.tab3_1_1_2_2" rowspan="1" colspan="1" style="text-align:center;vertical-align:middle;">Not estimable</td><td headers="hd_h_niceng234er4.tab3_1_1_1_5" rowspan="1" colspan="1" style="text-align:center;vertical-align:middle;">Not estimable</td><td headers="hd_h_niceng234er4.tab3_1_1_1_6" rowspan="1" colspan="1" style="text-align:center;vertical-align:middle;">97.1 [96 to 98]</td><td headers="hd_h_niceng234er4.tab3_1_1_1_7 hd_h_niceng234er4.tab3_1_1_2_3" rowspan="1" colspan="1" style="text-align:center;vertical-align:middle;">Not estimable</td><td headers="hd_h_niceng234er4.tab3_1_1_1_7 hd_h_niceng234er4.tab3_1_1_2_4" rowspan="1" colspan="1" style="text-align:center;vertical-align:middle;">Not estimable</td></tr><tr><td headers="hd_h_niceng234er4.tab3_1_1_1_1" rowspan="1" colspan="1" style="text-align:left;vertical-align:top;">
|
|
<a class="bibr" href="#niceng234er4.s1.ref5" rid="niceng234er4.s1.ref5">Henschke 2009</a>
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</td><td headers="hd_h_niceng234er4.tab3_1_1_1_2" rowspan="1" colspan="1" style="text-align:left;vertical-align:top;">Insidious onset (17%)</td><td headers="hd_h_niceng234er4.tab3_1_1_1_4 hd_h_niceng234er4.tab3_1_1_2_1" rowspan="1" colspan="1" style="text-align:center;vertical-align:middle;">Not estimable</td><td headers="hd_h_niceng234er4.tab3_1_1_1_4 hd_h_niceng234er4.tab3_1_1_2_2" rowspan="1" colspan="1" style="text-align:center;vertical-align:middle;">Not estimable</td><td headers="hd_h_niceng234er4.tab3_1_1_1_5" rowspan="1" colspan="1" style="text-align:center;vertical-align:middle;">Not estimable</td><td headers="hd_h_niceng234er4.tab3_1_1_1_6" rowspan="1" colspan="1" style="text-align:center;vertical-align:middle;">82.7 [80.5 to 84.8]</td><td headers="hd_h_niceng234er4.tab3_1_1_1_7 hd_h_niceng234er4.tab3_1_1_2_3" rowspan="1" colspan="1" style="text-align:center;vertical-align:middle;">Not estimable</td><td headers="hd_h_niceng234er4.tab3_1_1_1_7 hd_h_niceng234er4.tab3_1_1_2_4" rowspan="1" colspan="1" style="text-align:center;vertical-align:middle;">Not estimable</td></tr><tr><td headers="hd_h_niceng234er4.tab3_1_1_1_1" rowspan="1" colspan="1" style="text-align:left;vertical-align:top;">
|
|
<a class="bibr" href="#niceng234er4.s1.ref5" rid="niceng234er4.s1.ref5">Henschke 2009</a>
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|
</td><td headers="hd_h_niceng234er4.tab3_1_1_1_2" rowspan="1" colspan="1" style="text-align:left;vertical-align:top;">Systematically unwell (2%)</td><td headers="hd_h_niceng234er4.tab3_1_1_1_4 hd_h_niceng234er4.tab3_1_1_2_1" rowspan="1" colspan="1" style="text-align:center;vertical-align:middle;">Not estimable</td><td headers="hd_h_niceng234er4.tab3_1_1_1_4 hd_h_niceng234er4.tab3_1_1_2_2" rowspan="1" colspan="1" style="text-align:center;vertical-align:middle;">Not estimable</td><td headers="hd_h_niceng234er4.tab3_1_1_1_5" rowspan="1" colspan="1" style="text-align:center;vertical-align:middle;">Not estimable</td><td headers="hd_h_niceng234er4.tab3_1_1_1_6" rowspan="1" colspan="1" style="text-align:center;vertical-align:middle;">97.7 [96.6 to 98.4]</td><td headers="hd_h_niceng234er4.tab3_1_1_1_7 hd_h_niceng234er4.tab3_1_1_2_3" rowspan="1" colspan="1" style="text-align:center;vertical-align:middle;">Not estimable</td><td headers="hd_h_niceng234er4.tab3_1_1_1_7 hd_h_niceng234er4.tab3_1_1_2_4" rowspan="1" colspan="1" style="text-align:center;vertical-align:middle;">Not estimable</td></tr><tr><td headers="hd_h_niceng234er4.tab3_1_1_1_1" rowspan="1" colspan="1" style="text-align:left;vertical-align:top;">
|
|
<a class="bibr" href="#niceng234er4.s1.ref5" rid="niceng234er4.s1.ref5">Henschke 2009</a>
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</td><td headers="hd_h_niceng234er4.tab3_1_1_1_2" rowspan="1" colspan="1" style="text-align:left;vertical-align:top;">Tried bed rest, but no relief (17%)</td><td headers="hd_h_niceng234er4.tab3_1_1_1_4 hd_h_niceng234er4.tab3_1_1_2_1" rowspan="1" colspan="1" style="text-align:center;vertical-align:middle;">Not estimable</td><td headers="hd_h_niceng234er4.tab3_1_1_1_4 hd_h_niceng234er4.tab3_1_1_2_2" rowspan="1" colspan="1" style="text-align:center;vertical-align:middle;">Not estimable</td><td headers="hd_h_niceng234er4.tab3_1_1_1_5" rowspan="1" colspan="1" style="text-align:center;vertical-align:middle;">Not estimable</td><td headers="hd_h_niceng234er4.tab3_1_1_1_6" rowspan="1" colspan="1" style="text-align:center;vertical-align:middle;">83.3 [81 to 85.3]</td><td headers="hd_h_niceng234er4.tab3_1_1_1_7 hd_h_niceng234er4.tab3_1_1_2_3" rowspan="1" colspan="1" style="text-align:center;vertical-align:middle;">Not estimable</td><td headers="hd_h_niceng234er4.tab3_1_1_1_7 hd_h_niceng234er4.tab3_1_1_2_4" rowspan="1" colspan="1" style="text-align:center;vertical-align:middle;">Not estimable</td></tr><tr><td headers="hd_h_niceng234er4.tab3_1_1_1_1" rowspan="1" colspan="1" style="text-align:left;vertical-align:top;">
|
|
<a class="bibr" href="#niceng234er4.s1.ref5" rid="niceng234er4.s1.ref5">Henschke 2009</a>
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</td><td headers="hd_h_niceng234er4.tab3_1_1_1_2" rowspan="1" colspan="1" style="text-align:left;vertical-align:top;">Weight loss (<1%)</td><td headers="hd_h_niceng234er4.tab3_1_1_1_4 hd_h_niceng234er4.tab3_1_1_2_1" rowspan="1" colspan="1" style="text-align:center;vertical-align:middle;">Not estimable</td><td headers="hd_h_niceng234er4.tab3_1_1_1_4 hd_h_niceng234er4.tab3_1_1_2_2" rowspan="1" colspan="1" style="text-align:center;vertical-align:middle;">Not estimable</td><td headers="hd_h_niceng234er4.tab3_1_1_1_5" rowspan="1" colspan="1" style="text-align:center;vertical-align:middle;">Not estimable</td><td headers="hd_h_niceng234er4.tab3_1_1_1_6" rowspan="1" colspan="1" style="text-align:center;vertical-align:middle;">99.7 [99.2 to 99.9]</td><td headers="hd_h_niceng234er4.tab3_1_1_1_7 hd_h_niceng234er4.tab3_1_1_2_3" rowspan="1" colspan="1" style="text-align:center;vertical-align:middle;">Not estimable</td><td headers="hd_h_niceng234er4.tab3_1_1_1_7 hd_h_niceng234er4.tab3_1_1_2_4" rowspan="1" colspan="1" style="text-align:center;vertical-align:middle;">Not estimable</td></tr><tr><td headers="hd_h_niceng234er4.tab3_1_1_1_1" rowspan="1" colspan="1" style="text-align:left;vertical-align:top;">
|
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<a class="bibr" href="#niceng234er4.s1.ref5" rid="niceng234er4.s1.ref5">Henschke 2009</a>
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</td><td headers="hd_h_niceng234er4.tab3_1_1_1_2" rowspan="1" colspan="1" style="text-align:left;vertical-align:top;">Sensory level (altered sensation from trunk down; 2%)</td><td headers="hd_h_niceng234er4.tab3_1_1_1_4 hd_h_niceng234er4.tab3_1_1_2_1" rowspan="1" colspan="1" style="text-align:center;vertical-align:middle;">Not estimable</td><td headers="hd_h_niceng234er4.tab3_1_1_1_4 hd_h_niceng234er4.tab3_1_1_2_2" rowspan="1" colspan="1" style="text-align:center;vertical-align:middle;">Not estimable</td><td headers="hd_h_niceng234er4.tab3_1_1_1_5" rowspan="1" colspan="1" style="text-align:center;vertical-align:middle;">Not estimable</td><td headers="hd_h_niceng234er4.tab3_1_1_1_6" rowspan="1" colspan="1" style="text-align:center;vertical-align:middle;">98.3 [97.4 to 98.9]</td><td headers="hd_h_niceng234er4.tab3_1_1_1_7 hd_h_niceng234er4.tab3_1_1_2_3" rowspan="1" colspan="1" style="text-align:center;vertical-align:middle;">Not estimable</td><td headers="hd_h_niceng234er4.tab3_1_1_1_7 hd_h_niceng234er4.tab3_1_1_2_4" rowspan="1" colspan="1" style="text-align:center;vertical-align:middle;">Not estimable</td></tr></tbody></table></div><div class="tblwrap-foot"><div><dl class="temp-labeled-list small"><dl class="bkr_refwrap"><dt></dt><dd><div><p class="no_margin">LR+: positive likelihood ratio; LR−: negative likelihood ratio; NPV: negative predictive value; PPV: positive predictive value</p></div></dd></dl><dl class="bkr_refwrap"><dt>1</dt><dd><div id="niceng234er4.tab3_1"><p class="no_margin">Absence of pain during flexion, extension and lateral flexion movements</p></div></dd></dl><dl class="bkr_refwrap"><dt>2</dt><dd><div id="niceng234er4.tab3_2"><p class="no_margin">For spinal metastasis without concomitant diagnosis – (the back pain was due to the spinal metastasis and not another [non-malignant] cause)</p></div></dd></dl><dl class="bkr_refwrap"><dt>3</dt><dd><div id="niceng234er4.tab3_3"><p class="no_margin">For any spinal metastasis</p></div></dd></dl><dl class="bkr_refwrap"><dt>4</dt><dd><div id="niceng234er4.tab3_4"><p class="no_margin">No cases of spinal metastasis were found in this study – included for specificity only.</p></div></dd></dl></dl></div></div></div></article><article data-type="table-wrap" id="figobniceng234er4tab4"><div id="niceng234er4.tab4" class="table"><h3><span class="label">Table 4</span><span class="title">Signs or symptoms of spinal metastasis in people presenting with cancer</span></h3><p class="large-table-link" style="display:none"><span class="right"><a href="/books/NBK595822/table/niceng234er4.tab4/?report=objectonly" target="object">View in own window</a></span></p><div class="large_tbl" id="__niceng234er4.tab4_lrgtbl__"><table class="no_bottom_margin"><thead><tr><th id="hd_h_niceng234er4.tab4_1_1_1_1" rowspan="2" colspan="1" headers="hd_h_niceng234er4.tab4_1_1_1_1" style="text-align:center;vertical-align:middle;">Study</th><th id="hd_h_niceng234er4.tab4_1_1_1_2" rowspan="2" colspan="1" headers="hd_h_niceng234er4.tab4_1_1_1_2" style="text-align:center;vertical-align:middle;">Sign or symptom (% prevalence)</th><th id="hd_h_niceng234er4.tab4_1_1_1_3" rowspan="2" colspan="1" headers="hd_h_niceng234er4.tab4_1_1_1_3" style="text-align:center;vertical-align:middle;">Prevalence of spinal metastasis in study</th><th id="hd_h_niceng234er4.tab4_1_1_1_4" colspan="2" rowspan="1" style="text-align:center;vertical-align:middle;">Predictive values % [95% CI]</th><th id="hd_h_niceng234er4.tab4_1_1_1_5" rowspan="2" colspan="1" headers="hd_h_niceng234er4.tab4_1_1_1_5" style="text-align:center;vertical-align:middle;">Sensitivity % [95% CI]</th><th id="hd_h_niceng234er4.tab4_1_1_1_6" rowspan="2" colspan="1" headers="hd_h_niceng234er4.tab4_1_1_1_6" style="text-align:center;vertical-align:middle;">Specificity % [95% CI]</th><th id="hd_h_niceng234er4.tab4_1_1_1_7" colspan="2" rowspan="1" style="text-align:center;vertical-align:middle;">Likelihood ratios [95% CI]</th></tr><tr><th headers="hd_h_niceng234er4.tab4_1_1_1_4" id="hd_h_niceng234er4.tab4_1_1_2_1" rowspan="1" colspan="1" style="text-align:center;vertical-align:middle;">PPV</th><th headers="hd_h_niceng234er4.tab4_1_1_1_4" id="hd_h_niceng234er4.tab4_1_1_2_2" rowspan="1" colspan="1" style="text-align:center;vertical-align:middle;">NPV</th><th headers="hd_h_niceng234er4.tab4_1_1_1_7" id="hd_h_niceng234er4.tab4_1_1_2_3" rowspan="1" colspan="1" style="text-align:center;vertical-align:middle;">LR+</th><th headers="hd_h_niceng234er4.tab4_1_1_1_7" id="hd_h_niceng234er4.tab4_1_1_2_4" rowspan="1" colspan="1" style="text-align:center;vertical-align:middle;">LR−</th></tr></thead><tbody><tr><td headers="hd_h_niceng234er4.tab4_1_1_1_1" rowspan="1" colspan="1" style="text-align:left;vertical-align:top;">
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<a class="bibr" href="#niceng234er4.s1.ref4" rid="niceng234er4.s1.ref4">He 2020</a>
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</td><td headers="hd_h_niceng234er4.tab4_1_1_1_2" rowspan="1" colspan="1" style="text-align:left;vertical-align:top;">Local pain (16%)</td><td headers="hd_h_niceng234er4.tab4_1_1_1_3" rowspan="10" colspan="1" style="text-align:center;vertical-align:middle;">11.4%</td><td headers="hd_h_niceng234er4.tab4_1_1_1_4 hd_h_niceng234er4.tab4_1_1_2_1" rowspan="1" colspan="1" style="text-align:center;vertical-align:top;">56 [54.4 to 57.6]</td><td headers="hd_h_niceng234er4.tab4_1_1_1_4 hd_h_niceng234er4.tab4_1_1_2_2" rowspan="1" colspan="1" style="text-align:center;vertical-align:top;">96.8 [96.5 to 97]</td><td headers="hd_h_niceng234er4.tab4_1_1_1_5" rowspan="1" colspan="1" style="text-align:center;vertical-align:middle;">76.2 [74.1 to 78.2]</td><td headers="hd_h_niceng234er4.tab4_1_1_1_6" rowspan="1" colspan="1" style="text-align:center;vertical-align:middle;">92.3 [91.8 to 92.8]</td><td headers="hd_h_niceng234er4.tab4_1_1_1_7 hd_h_niceng234er4.tab4_1_1_2_3" rowspan="1" colspan="1" style="text-align:center;vertical-align:middle;">9.9 [9.28 to 10.57]</td><td headers="hd_h_niceng234er4.tab4_1_1_1_7 hd_h_niceng234er4.tab4_1_1_2_4" rowspan="1" colspan="1" style="text-align:center;vertical-align:middle;">0.26 [0.24 to 0.28]</td></tr><tr><td headers="hd_h_niceng234er4.tab4_1_1_1_1" rowspan="1" colspan="1" style="text-align:left;vertical-align:top;">
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<a class="bibr" href="#niceng234er4.s1.ref4" rid="niceng234er4.s1.ref4">He 2020</a>
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</td><td headers="hd_h_niceng234er4.tab4_1_1_1_2" rowspan="1" colspan="1" style="text-align:left;vertical-align:top;">Radicular pain (6%)</td><td headers="hd_h_niceng234er4.tab4_1_1_1_4 hd_h_niceng234er4.tab4_1_1_2_1" rowspan="1" colspan="1" style="text-align:center;vertical-align:top;">53.6 [50.6 to 56.5]</td><td headers="hd_h_niceng234er4.tab4_1_1_1_4 hd_h_niceng234er4.tab4_1_1_2_2" rowspan="1" colspan="1" style="text-align:center;vertical-align:top;">91.4 [91.2 to 91.7]</td><td headers="hd_h_niceng234er4.tab4_1_1_1_5" rowspan="1" colspan="1" style="text-align:center;vertical-align:middle;">29.7 [27.6 to 32]</td><td headers="hd_h_niceng234er4.tab4_1_1_1_6" rowspan="1" colspan="1" style="text-align:center;vertical-align:middle;">96.7 [96.4 to 97]</td><td headers="hd_h_niceng234er4.tab4_1_1_1_7 hd_h_niceng234er4.tab4_1_1_2_3" rowspan="1" colspan="1" style="text-align:center;vertical-align:middle;">8.98 [7.98 to 10.11]</td><td headers="hd_h_niceng234er4.tab4_1_1_1_7 hd_h_niceng234er4.tab4_1_1_2_4" rowspan="1" colspan="1" style="text-align:center;vertical-align:middle;">0.73 [0.7 to 0.75]</td></tr><tr><td headers="hd_h_niceng234er4.tab4_1_1_1_1" rowspan="1" colspan="1" style="text-align:left;vertical-align:top;">
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<a class="bibr" href="#niceng234er4.s1.ref4" rid="niceng234er4.s1.ref4">He 2020</a>
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</td><td headers="hd_h_niceng234er4.tab4_1_1_1_2" rowspan="1" colspan="1" style="text-align:left;vertical-align:top;">Night-aggravating pain (7%)</td><td headers="hd_h_niceng234er4.tab4_1_1_1_4 hd_h_niceng234er4.tab4_1_1_2_1" rowspan="1" colspan="1" style="text-align:center;vertical-align:top;">92.4 [90.6 to 93.8]</td><td headers="hd_h_niceng234er4.tab4_1_1_1_4 hd_h_niceng234er4.tab4_1_1_2_2" rowspan="1" colspan="1" style="text-align:center;vertical-align:top;">94.6 [94.3 to 94.8]</td><td headers="hd_h_niceng234er4.tab4_1_1_1_5" rowspan="1" colspan="1" style="text-align:center;vertical-align:middle;">55.7 [53.3 to 58]</td><td headers="hd_h_niceng234er4.tab4_1_1_1_6" rowspan="1" colspan="1" style="text-align:center;vertical-align:middle;">99.4 [99.3 to 99.5]</td><td headers="hd_h_niceng234er4.tab4_1_1_1_7 hd_h_niceng234er4.tab4_1_1_2_3" rowspan="1" colspan="1" style="text-align:center;vertical-align:middle;">94.16 [75 to 118.22]</td><td headers="hd_h_niceng234er4.tab4_1_1_1_7 hd_h_niceng234er4.tab4_1_1_2_4" rowspan="1" colspan="1" style="text-align:center;vertical-align:middle;">0.45 [0.42 to 0.47]</td></tr><tr><td headers="hd_h_niceng234er4.tab4_1_1_1_1" rowspan="1" colspan="1" style="text-align:left;vertical-align:top;">
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<a class="bibr" href="#niceng234er4.s1.ref4" rid="niceng234er4.s1.ref4">He 2020</a>
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</td><td headers="hd_h_niceng234er4.tab4_1_1_1_2" rowspan="1" colspan="1" style="text-align:left;vertical-align:top;">Limb numbness (5%)</td><td headers="hd_h_niceng234er4.tab4_1_1_1_4 hd_h_niceng234er4.tab4_1_1_2_1" rowspan="1" colspan="1" style="text-align:center;vertical-align:top;">52.1 [48.8 to 55.4]</td><td headers="hd_h_niceng234er4.tab4_1_1_1_4 hd_h_niceng234er4.tab4_1_1_2_2" rowspan="1" colspan="1" style="text-align:center;vertical-align:top;">90.9 [90.6 to 91.1]</td><td headers="hd_h_niceng234er4.tab4_1_1_1_5" rowspan="1" colspan="1" style="text-align:center;vertical-align:middle;">24 [22 to 26.1]</td><td headers="hd_h_niceng234er4.tab4_1_1_1_6" rowspan="1" colspan="1" style="text-align:center;vertical-align:middle;">97.2 [96.9 to 97.4]</td><td headers="hd_h_niceng234er4.tab4_1_1_1_7 hd_h_niceng234er4.tab4_1_1_2_3" rowspan="1" colspan="1" style="text-align:center;vertical-align:middle;">8.44 [7.4 to 9.64]</td><td headers="hd_h_niceng234er4.tab4_1_1_1_7 hd_h_niceng234er4.tab4_1_1_2_4" rowspan="1" colspan="1" style="text-align:center;vertical-align:middle;">0.78 [0.76 to 0.8]</td></tr><tr><td headers="hd_h_niceng234er4.tab4_1_1_1_1" rowspan="1" colspan="1" style="text-align:left;vertical-align:top;">
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<a class="bibr" href="#niceng234er4.s1.ref4" rid="niceng234er4.s1.ref4">He 2020</a>
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</td><td headers="hd_h_niceng234er4.tab4_1_1_1_2" rowspan="1" colspan="1" style="text-align:left;vertical-align:top;">Limb weakness (13%)</td><td headers="hd_h_niceng234er4.tab4_1_1_1_4 hd_h_niceng234er4.tab4_1_1_2_1" rowspan="1" colspan="1" style="text-align:center;vertical-align:top;">29.9 [28.2 to 31.7]</td><td headers="hd_h_niceng234er4.tab4_1_1_1_4 hd_h_niceng234er4.tab4_1_1_2_2" rowspan="1" colspan="1" style="text-align:center;vertical-align:top;">91.4 [91.1 to 91.7]</td><td headers="hd_h_niceng234er4.tab4_1_1_1_5" rowspan="1" colspan="1" style="text-align:center;vertical-align:middle;">34.3 [32.1 to 36.6]</td><td headers="hd_h_niceng234er4.tab4_1_1_1_6" rowspan="1" colspan="1" style="text-align:center;vertical-align:middle;">89.7 [89.1 to 90.2]</td><td headers="hd_h_niceng234er4.tab4_1_1_1_7 hd_h_niceng234er4.tab4_1_1_2_3" rowspan="1" colspan="1" style="text-align:center;vertical-align:middle;">3.32 [3.05 to 3.61]</td><td headers="hd_h_niceng234er4.tab4_1_1_1_7 hd_h_niceng234er4.tab4_1_1_2_4" rowspan="1" colspan="1" style="text-align:center;vertical-align:middle;">0.73 [0.71 to 0.76]</td></tr><tr><td headers="hd_h_niceng234er4.tab4_1_1_1_1" rowspan="1" colspan="1" style="text-align:left;vertical-align:top;">
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<a class="bibr" href="#niceng234er4.s1.ref4" rid="niceng234er4.s1.ref4">He 2020</a>
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</td><td headers="hd_h_niceng234er4.tab4_1_1_1_2" rowspan="1" colspan="1" style="text-align:left;vertical-align:top;">Unstable gait (3%)</td><td headers="hd_h_niceng234er4.tab4_1_1_1_4 hd_h_niceng234er4.tab4_1_1_2_1" rowspan="1" colspan="1" style="text-align:center;vertical-align:top;">39 [35 to 43.2]</td><td headers="hd_h_niceng234er4.tab4_1_1_1_4 hd_h_niceng234er4.tab4_1_1_2_2" rowspan="1" colspan="1" style="text-align:center;vertical-align:top;">89.6 [89.4 to 89.7]</td><td headers="hd_h_niceng234er4.tab4_1_1_1_5" rowspan="1" colspan="1" style="text-align:center;vertical-align:middle;">11.7 [10.3 to 13.4]</td><td headers="hd_h_niceng234er4.tab4_1_1_1_6" rowspan="1" colspan="1" style="text-align:center;vertical-align:middle;">97.6 [97.4 to 97.9]</td><td headers="hd_h_niceng234er4.tab4_1_1_1_7 hd_h_niceng234er4.tab4_1_1_2_3" rowspan="1" colspan="1" style="text-align:center;vertical-align:middle;">4.97 [4.19 to 5.91]</td><td headers="hd_h_niceng234er4.tab4_1_1_1_7 hd_h_niceng234er4.tab4_1_1_2_4" rowspan="1" colspan="1" style="text-align:center;vertical-align:middle;">0.9 [0.89 to 0.92]</td></tr><tr><td headers="hd_h_niceng234er4.tab4_1_1_1_1" rowspan="1" colspan="1" style="text-align:left;vertical-align:top;">
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<a class="bibr" href="#niceng234er4.s1.ref4" rid="niceng234er4.s1.ref4">He 2020</a>
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</td><td headers="hd_h_niceng234er4.tab4_1_1_1_2" rowspan="1" colspan="1" style="text-align:left;vertical-align:top;">Claudication (3%)</td><td headers="hd_h_niceng234er4.tab4_1_1_1_4 hd_h_niceng234er4.tab4_1_1_2_1" rowspan="1" colspan="1" style="text-align:center;vertical-align:top;">32.3 [28.2 to 36.5]</td><td headers="hd_h_niceng234er4.tab4_1_1_1_4 hd_h_niceng234er4.tab4_1_1_2_2" rowspan="1" colspan="1" style="text-align:center;vertical-align:top;">89.3 [89.1 to 89.4]</td><td headers="hd_h_niceng234er4.tab4_1_1_1_5" rowspan="1" colspan="1" style="text-align:center;vertical-align:middle;">8.8 [7.5 to 10.2]</td><td headers="hd_h_niceng234er4.tab4_1_1_1_6" rowspan="1" colspan="1" style="text-align:center;vertical-align:middle;">97.6 [97.3 to 97.9]</td><td headers="hd_h_niceng234er4.tab4_1_1_1_7 hd_h_niceng234er4.tab4_1_1_2_3" rowspan="1" colspan="1" style="text-align:center;vertical-align:middle;">3.7 [3.06 to 4.48]</td><td headers="hd_h_niceng234er4.tab4_1_1_1_7 hd_h_niceng234er4.tab4_1_1_2_4" rowspan="1" colspan="1" style="text-align:center;vertical-align:middle;">0.93 [0.92 to 0.95]</td></tr><tr><td headers="hd_h_niceng234er4.tab4_1_1_1_1" rowspan="1" colspan="1" style="text-align:left;vertical-align:top;">
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<a class="bibr" href="#niceng234er4.s1.ref4" rid="niceng234er4.s1.ref4">He 2020</a>
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</td><td headers="hd_h_niceng234er4.tab4_1_1_1_2" rowspan="1" colspan="1" style="text-align:left;vertical-align:top;">Loss of sphincter control (15%)</td><td headers="hd_h_niceng234er4.tab4_1_1_1_4 hd_h_niceng234er4.tab4_1_1_2_1" rowspan="1" colspan="1" style="text-align:center;vertical-align:top;">24.5 [23 to 26.1]</td><td headers="hd_h_niceng234er4.tab4_1_1_1_4 hd_h_niceng234er4.tab4_1_1_2_2" rowspan="1" colspan="1" style="text-align:center;vertical-align:top;">90.9 [90.6 to 91.2]</td><td headers="hd_h_niceng234er4.tab4_1_1_1_5" rowspan="1" colspan="1" style="text-align:center;vertical-align:middle;">32.1 [29.9 to 34.4]</td><td headers="hd_h_niceng234er4.tab4_1_1_1_6" rowspan="1" colspan="1" style="text-align:center;vertical-align:middle;">87.2 [86.7 to 87.8]</td><td headers="hd_h_niceng234er4.tab4_1_1_1_7 hd_h_niceng234er4.tab4_1_1_2_3" rowspan="1" colspan="1" style="text-align:center;vertical-align:middle;">2.52 [2.32 to 2.74]</td><td headers="hd_h_niceng234er4.tab4_1_1_1_7 hd_h_niceng234er4.tab4_1_1_2_4" rowspan="1" colspan="1" style="text-align:center;vertical-align:middle;">0.78 [0.75 to 0.8]</td></tr><tr><td headers="hd_h_niceng234er4.tab4_1_1_1_1" rowspan="1" colspan="1" style="text-align:left;vertical-align:top;">
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<a class="bibr" href="#niceng234er4.s1.ref4" rid="niceng234er4.s1.ref4">He 2020</a>
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</td><td headers="hd_h_niceng234er4.tab4_1_1_1_2" rowspan="1" colspan="1" style="text-align:left;vertical-align:top;">Weight loss (14%)</td><td headers="hd_h_niceng234er4.tab4_1_1_1_4 hd_h_niceng234er4.tab4_1_1_2_1" rowspan="1" colspan="1" style="text-align:center;vertical-align:top;">23.7 [22.1 to 25.3]</td><td headers="hd_h_niceng234er4.tab4_1_1_1_4 hd_h_niceng234er4.tab4_1_1_2_2" rowspan="1" colspan="1" style="text-align:center;vertical-align:top;">90.6 [90.4 to 90.9]</td><td headers="hd_h_niceng234er4.tab4_1_1_1_5" rowspan="1" colspan="1" style="text-align:center;vertical-align:middle;">29.4 [27.3 to 31.7]</td><td headers="hd_h_niceng234er4.tab4_1_1_1_6" rowspan="1" colspan="1" style="text-align:center;vertical-align:middle;">87.8 [87.2 to 88.4]</td><td headers="hd_h_niceng234er4.tab4_1_1_1_7 hd_h_niceng234er4.tab4_1_1_2_3" rowspan="1" colspan="1" style="text-align:center;vertical-align:middle;">2.41 [2.21 to 2.63]</td><td headers="hd_h_niceng234er4.tab4_1_1_1_7 hd_h_niceng234er4.tab4_1_1_2_4" rowspan="1" colspan="1" style="text-align:center;vertical-align:middle;">0.8 [0.78 to 0.83]</td></tr><tr><td headers="hd_h_niceng234er4.tab4_1_1_1_1" rowspan="1" colspan="1" style="text-align:left;vertical-align:top;">
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<a class="bibr" href="#niceng234er4.s1.ref4" rid="niceng234er4.s1.ref4">He 2020</a>
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</td><td headers="hd_h_niceng234er4.tab4_1_1_1_2" rowspan="1" colspan="1" style="text-align:left;vertical-align:top;">Symptoms pooled (41%)</td><td headers="hd_h_niceng234er4.tab4_1_1_1_4 hd_h_niceng234er4.tab4_1_1_2_1" rowspan="1" colspan="1" style="text-align:center;vertical-align:top;">25 [24.5 to 25.5]</td><td headers="hd_h_niceng234er4.tab4_1_1_1_4 hd_h_niceng234er4.tab4_1_1_2_2" rowspan="1" colspan="1" style="text-align:center;vertical-align:top;">98.2 [97.9 to 98.5]</td><td headers="hd_h_niceng234er4.tab4_1_1_1_5" rowspan="1" colspan="1" style="text-align:center;vertical-align:middle;">90.8 [89.4 to 92.1]</td><td headers="hd_h_niceng234er4.tab4_1_1_1_6" rowspan="1" colspan="1" style="text-align:center;vertical-align:middle;">64.9 [64.1 to 65.7]</td><td headers="hd_h_niceng234er4.tab4_1_1_1_7 hd_h_niceng234er4.tab4_1_1_2_3" rowspan="1" colspan="1" style="text-align:center;vertical-align:middle;">2.59 [2.52 to 2.66]</td><td headers="hd_h_niceng234er4.tab4_1_1_1_7 hd_h_niceng234er4.tab4_1_1_2_4" rowspan="1" colspan="1" style="text-align:center;vertical-align:middle;">0.14 [0.12 to 0.16]</td></tr></tbody></table></div><div class="tblwrap-foot"><div><dl class="temp-labeled-list small"><dl class="bkr_refwrap"><dt></dt><dd><div><p class="no_margin">LR+: positive likelihood ratio; LR−: negative likelihood ratio; NPV: negative predictive value; PPV: positive predictive value</p></div></dd></dl></dl></div></div></div></article><article data-type="table-wrap" id="figobniceng234er4appjtab1"><div id="niceng234er4.appj.tab1" class="table"><h3><span class="label">Table 10</span><span class="title">Excluded studies and reasons for their exclusion</span></h3><p class="large-table-link" style="display:none"><span class="right"><a href="/books/NBK595822/table/niceng234er4.appj.tab1/?report=objectonly" target="object">View in own window</a></span></p><div class="large_tbl" id="__niceng234er4.appj.tab1_lrgtbl__"><table><thead><tr><th id="hd_h_niceng234er4.appj.tab1_1_1_1_1" rowspan="1" colspan="1" style="text-align:left;vertical-align:top;">Study</th><th id="hd_h_niceng234er4.appj.tab1_1_1_1_2" rowspan="1" colspan="1" style="text-align:left;vertical-align:top;">Code [Reason]</th></tr></thead><tbody><tr><td headers="hd_h_niceng234er4.appj.tab1_1_1_1_1" rowspan="1" colspan="1" style="text-align:left;vertical-align:top;">
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De la Garza Ramos, Rafael, Benton, Joshua A, Gelfand, Yaroslav
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et al. (2020) Racial disparities in clinical presentation, type of intervention, and in-hospital outcomes of patients with metastatic spine disease: An analysis of 145,809 admissions in the United States. Cancer epidemiology
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68: 101792 [<a href="https://pubmed.ncbi.nlm.nih.gov/32781406" ref="pagearea=body&targetsite=entrez&targetcat=link&targettype=pubmed">PubMed<span class="bk_prnt">: 32781406</span></a>]
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</td><td headers="hd_h_niceng234er4.appj.tab1_1_1_1_2" rowspan="1" colspan="1" style="text-align:left;vertical-align:top;">Outcomes do not match review protocol</td></tr><tr><td headers="hd_h_niceng234er4.appj.tab1_1_1_1_1" rowspan="1" colspan="1" style="text-align:left;vertical-align:top;">
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Downie, Aron, Williams, Christopher M, Henschke, Nicholas
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et al. (2013) Red flags to screen for malignancy and fracture in patients with low back pain: systematic review. BMJ (Clinical research ed.)
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347: f7095 [<a href="/pmc/articles/PMC3898572/" ref="pagearea=body&targetsite=entrez&targetcat=link&targettype=pmc">PMC free article<span class="bk_prnt">: PMC3898572</span></a>] [<a href="https://pubmed.ncbi.nlm.nih.gov/24335669" ref="pagearea=body&targetsite=entrez&targetcat=link&targettype=pubmed">PubMed<span class="bk_prnt">: 24335669</span></a>]
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</td><td headers="hd_h_niceng234er4.appj.tab1_1_1_1_2" rowspan="1" colspan="1" style="text-align:left;vertical-align:top;">Study design - systematic review without pooled results/ quantitative data, checked for relevant studies</td></tr><tr><td headers="hd_h_niceng234er4.appj.tab1_1_1_1_1" rowspan="1" colspan="1" style="text-align:left;vertical-align:top;">
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Dubosh, N.M., Edlow, J.A., Goto, T.
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et al. (2019) Missed Serious Neurologic Conditions in Emergency Department Patients Discharged With Nonspecific Diagnoses of Headache or Back Pain. Annals of Emergency Medicine
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74(4): 549–561 [<a href="https://pubmed.ncbi.nlm.nih.gov/30797572" ref="pagearea=body&targetsite=entrez&targetcat=link&targettype=pubmed">PubMed<span class="bk_prnt">: 30797572</span></a>]
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</td><td headers="hd_h_niceng234er4.appj.tab1_1_1_1_2" rowspan="1" colspan="1" style="text-align:left;vertical-align:top;">Outcomes do not match review protocol</td></tr><tr><td headers="hd_h_niceng234er4.appj.tab1_1_1_1_1" rowspan="1" colspan="1" style="text-align:left;vertical-align:top;">
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Galliker, Gabriela, Scherer, Dominique Eva, Trippolini, Maurizio Alen
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et al. (2020) Low Back Pain in the Emergency Department: Prevalence of Serious Spinal Pathologies and Diagnostic Accuracy of Red Flags. The American journal of medicine
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133(1): 60–72e14 [<a href="https://pubmed.ncbi.nlm.nih.gov/31278933" ref="pagearea=body&targetsite=entrez&targetcat=link&targettype=pubmed">PubMed<span class="bk_prnt">: 31278933</span></a>]
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</td><td headers="hd_h_niceng234er4.appj.tab1_1_1_1_2" rowspan="1" colspan="1" style="text-align:left;vertical-align:top;">Study design - systematic review without pooled results/ quantitative data, checked for relevant studies</td></tr><tr><td headers="hd_h_niceng234er4.appj.tab1_1_1_1_1" rowspan="1" colspan="1" style="text-align:left;vertical-align:top;">
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Helweg-Larsen, S and Sorensen, P S (1994) Symptoms and signs in metastatic spinal cord compression: a study of progression from first symptom until diagnosis in 153 patients. European journal of cancer (Oxford, England : 1990)
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30a(3): 396–8 [<a href="https://pubmed.ncbi.nlm.nih.gov/8204366" ref="pagearea=body&targetsite=entrez&targetcat=link&targettype=pubmed">PubMed<span class="bk_prnt">: 8204366</span></a>]
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</td><td headers="hd_h_niceng234er4.appj.tab1_1_1_1_2" rowspan="1" colspan="1" style="text-align:left;vertical-align:top;">Outcomes do not match protocol - does not report on the diagnostic value of validated clinical tools, or specific signs and symptoms in relation to the presence of spinal metastatic disease or direct malignant infiltration of the spine. The study focuses on the diagnosis of spinal cord compression.</td></tr><tr><td headers="hd_h_niceng234er4.appj.tab1_1_1_1_1" rowspan="1" colspan="1" style="text-align:left;vertical-align:top;">
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Henschke, Nicholas, Maher, Christopher G, Ostelo, Raymond W J G
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et al. (2013) Red flags to screen for malignancy in patients with low-back pain. The Cochrane database of systematic reviews: cd008686 [<a href="/pmc/articles/PMC10631455/" ref="pagearea=body&targetsite=entrez&targetcat=link&targettype=pmc">PMC free article<span class="bk_prnt">: PMC10631455</span></a>] [<a href="https://pubmed.ncbi.nlm.nih.gov/23450586" ref="pagearea=body&targetsite=entrez&targetcat=link&targettype=pubmed">PubMed<span class="bk_prnt">: 23450586</span></a>]
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</td><td headers="hd_h_niceng234er4.appj.tab1_1_1_1_2" rowspan="1" colspan="1" style="text-align:left;vertical-align:top;">Study design - systematic review without pooled results/ quantitative data, checked for relevant studies</td></tr><tr><td headers="hd_h_niceng234er4.appj.tab1_1_1_1_1" rowspan="1" colspan="1" style="text-align:left;vertical-align:top;">
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Kanna, Rishi Mugesh, Kamal, Younis, Mahesh, Anupama
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et al. (2017) The impact of routine whole spine MRI screening in the evaluation of spinal degenerative diseases. European spine journal : official publication of the European Spine Society, the European Spinal Deformity Society, and the European Section of the Cervical Spine Research Society
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26(8): 1993–1998 [<a href="https://pubmed.ncbi.nlm.nih.gov/28110361" ref="pagearea=body&targetsite=entrez&targetcat=link&targettype=pubmed">PubMed<span class="bk_prnt">: 28110361</span></a>]
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</td><td headers="hd_h_niceng234er4.appj.tab1_1_1_1_2" rowspan="1" colspan="1" style="text-align:left;vertical-align:top;">Population do not match review protocol</td></tr><tr><td headers="hd_h_niceng234er4.appj.tab1_1_1_1_1" rowspan="1" colspan="1" style="text-align:left;vertical-align:top;">
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Kitagawa, Yasuyuki, Ito, Toshihiko, Mizuno, Yoshihiro
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et al. (2019) Symptoms Related to Moderate Skeletal-Related Events as Clues for the Diagnosis of Bone Metastasis. Journal of Nippon Medical School = Nippon Ika Daigaku zasshi
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86(3): 159–164 [<a href="https://pubmed.ncbi.nlm.nih.gov/31292327" ref="pagearea=body&targetsite=entrez&targetcat=link&targettype=pubmed">PubMed<span class="bk_prnt">: 31292327</span></a>]
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</td><td headers="hd_h_niceng234er4.appj.tab1_1_1_1_2" rowspan="1" colspan="1" style="text-align:left;vertical-align:top;">Population do not match review protocol</td></tr><tr><td headers="hd_h_niceng234er4.appj.tab1_1_1_1_1" rowspan="1" colspan="1" style="text-align:left;vertical-align:top;">
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Leichtle, UG, Wünschel, M, Socci, M
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et al. (2015) Spine radiography in the evaluation of back and neck pain in an orthopaedic emergency clinic. Journal of back and musculoskeletal rehabilitation
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28(1): 43–8 [<a href="https://pubmed.ncbi.nlm.nih.gov/24968795" ref="pagearea=body&targetsite=entrez&targetcat=link&targettype=pubmed">PubMed<span class="bk_prnt">: 24968795</span></a>]
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</td><td headers="hd_h_niceng234er4.appj.tab1_1_1_1_2" rowspan="1" colspan="1" style="text-align:left;vertical-align:top;">Outcomes do not match review protocol – does not report data relevant to diagnostic accuracy</td></tr><tr><td headers="hd_h_niceng234er4.appj.tab1_1_1_1_1" rowspan="1" colspan="1" style="text-align:left;vertical-align:top;">
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Levack, P, Graham, J, Collie, D
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et al. (2002) Don’t wait for a sensory level--listen to the symptoms: a prospective audit of the delays in diagnosis of malignant cord compression. Clinical oncology (Royal College of Radiologists (Great Britain))
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14(6): 472–80 [<a href="https://pubmed.ncbi.nlm.nih.gov/12512970" ref="pagearea=body&targetsite=entrez&targetcat=link&targettype=pubmed">PubMed<span class="bk_prnt">: 12512970</span></a>]
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</td><td headers="hd_h_niceng234er4.appj.tab1_1_1_1_2" rowspan="1" colspan="1" style="text-align:left;vertical-align:top;">Population do not match review protocol</td></tr><tr><td headers="hd_h_niceng234er4.appj.tab1_1_1_1_1" rowspan="1" colspan="1" style="text-align:left;vertical-align:top;">
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Lu, Charles, Gonzalez, Ramon G, Jolesz, Ferenc A
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et al. (2005) Suspected spinal cord compression in cancer patients: a multidisciplinary risk assessment. The journal of supportive oncology
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3(4): 305–12 [<a href="https://pubmed.ncbi.nlm.nih.gov/16092602" ref="pagearea=body&targetsite=entrez&targetcat=link&targettype=pubmed">PubMed<span class="bk_prnt">: 16092602</span></a>]
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</td><td headers="hd_h_niceng234er4.appj.tab1_1_1_1_2" rowspan="1" colspan="1" style="text-align:left;vertical-align:top;">Population do not match review protocol</td></tr><tr><td headers="hd_h_niceng234er4.appj.tab1_1_1_1_1" rowspan="1" colspan="1" style="text-align:left;vertical-align:top;">
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Raison, NT, Alwan, W, Abbot, A
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et al. (2014) The reliability of red flags in spinal cord compression. Archives of trauma research
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3(1): e17850 [<a href="/pmc/articles/PMC4080478/" ref="pagearea=body&targetsite=entrez&targetcat=link&targettype=pmc">PMC free article<span class="bk_prnt">: PMC4080478</span></a>] [<a href="https://pubmed.ncbi.nlm.nih.gov/25032171" ref="pagearea=body&targetsite=entrez&targetcat=link&targettype=pubmed">PubMed<span class="bk_prnt">: 25032171</span></a>]
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</td><td headers="hd_h_niceng234er4.appj.tab1_1_1_1_2" rowspan="1" colspan="1" style="text-align:left;vertical-align:top;">Population does not match review protocol – does not report proportion of included patients who went on to be diagnosed with spinal metastases/cord compression resulting from malignancy</td></tr><tr><td headers="hd_h_niceng234er4.appj.tab1_1_1_1_1" rowspan="1" colspan="1" style="text-align:left;vertical-align:top;">
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ROBERTS, JAMES R. (2017) Detecting the Red Flags of Acute Spinal Cord Compression. Emergency Medicine News
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39(11): 12–14
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</td><td headers="hd_h_niceng234er4.appj.tab1_1_1_1_2" rowspan="1" colspan="1" style="text-align:left;vertical-align:top;">Study design - expert review/narrative</td></tr><tr><td headers="hd_h_niceng234er4.appj.tab1_1_1_1_1" rowspan="1" colspan="1" style="text-align:left;vertical-align:top;">
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Spencer, R.J.; Amer, S.; St
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George, E.J. (2021) A retrospective analysis of emergency referrals and admissions to a regional neurosurgical centre 2016-2018. British Journal of Neurosurgery
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35(4): 438–443 [<a href="https://pubmed.ncbi.nlm.nih.gov/33292027" ref="pagearea=body&targetsite=entrez&targetcat=link&targettype=pubmed">PubMed<span class="bk_prnt">: 33292027</span></a>]
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</td><td headers="hd_h_niceng234er4.appj.tab1_1_1_1_2" rowspan="1" colspan="1" style="text-align:left;vertical-align:top;">Population do not match review protocol – study does not report signs/ symptoms</td></tr><tr><td headers="hd_h_niceng234er4.appj.tab1_1_1_1_1" rowspan="1" colspan="1" style="text-align:left;vertical-align:top;">
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Verhagen, Arianne P, Downie, Aron, Popal, Nahid
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et al. (2016) Red flags presented in current low back pain guidelines: a review. European spine journal, 25, 2788–802 [<a href="https://pubmed.ncbi.nlm.nih.gov/27376890" ref="pagearea=body&targetsite=entrez&targetcat=link&targettype=pubmed">PubMed<span class="bk_prnt">: 27376890</span></a>]
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</td><td headers="hd_h_niceng234er4.appj.tab1_1_1_1_2" rowspan="1" colspan="1" style="text-align:left;vertical-align:top;">Study design - systematic review without pooled results/ quantitative data, checked for relevant studies</td></tr></tbody></table></div></div></article></div><div id="jr-scripts"><script src="/corehtml/pmc/jatsreader/ptpmc_3.22/js/libs.min.js"> </script><script src="/corehtml/pmc/jatsreader/ptpmc_3.22/js/jr.min.js"> </script></div></div>
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