To determine the accuracy of clinical features in diagnosing vertebral fracture in low back pain patients and assess the psychometric properties of the Quality Assessment of Studies of Diagnostic Accuracy Included in Systematic Reviews (QUADAS) scale.
Study Design and Setting
A diagnostic systematic review was performed on all available records in MEDLINE, CINAHL, and EMBASE. Studies were considered eligible if they investigated clinical features associated with vertebral fracture in a cohort of low back pain patients. All eligible studies were assessed for methodological quality using the QUADAS scale, and two authors extracted true-positive, true-negative, false-positive, and false-negative data for each clinical feature.
Twelve studies were identified by the review, investigating 51 clinical features. Five clinical features were useful to raise or lower the probability of vertebral fracture: age >50 years (likelihood ratio [LR]+=2.2, LR−=0.34), female gender (LR+=2.3, LR−=0.67), major trauma (LR+=12.8, LR−=0.37), pain and tenderness (LR+=6.7, LR−=0.44), and a distracting painful injury (LR+=1.7, LR−=0.78). The QUADAS had low internal consistency, and only three items had high inter-rater reliability. There was inadequate reporting of many methodological quality items.
Five clinical features were identified that can be used to screen for vertebral fracture. The psychometric properties of the QUADAS scale raise concerns about its use to rate the quality of low back pain diagnosis studies.
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- Clinical guidelines for the management of low back pain in primary care: an international comparison.Spine. 2001; 26: 2504-2513
- The back pain revolution.2nd edition. Churchill Livingstone, Edinburgh2004
- Back pain, disability, and radiographic vertebral fracture in European women: a prospective study.Osteoporos Int. 2004; 15: 760-765
- The epidemiology of vertebral fractures. European Vertebral Osteoporosis Study Group.Bone. 1993; 14: S89-S97
- Use of lumbar radiographs for the early diagnosis of low back pain. Proposed guidelines would increase utilization.JAMA. 1997; 277: 1782-1786
- What can the history and physical examination tell us about low back pain?.JAMA. 1992; 268: 760-765
- Diagnosis and management of vertebral fractures in elderly adults.Am J Med. 2002; 113: 220-228
- Recognizing and reporting osteoporotic vertebral fractures.Eur Spine J. 2003; 12: S104-S112
- Complications for manipulation of the low back.Chiropr J Aust. 1992; 22: 129-139
- Epidemiology, etiology, diagnostic evaluation, and treatment of low back pain.Curr Opin Rheumatol. 2001; 13: 128-134
- Acute low back problems in adults. Clinical practice guideline no. 14.Agency for Health Care Policy and Research, Public Health Service, U.S. Department of Health and Human Services, Rockville, MD1994
- Evidence-based management of acute musculoskeletal pain.Australian Academic Press, Bowen Hills, Queensland2003
- Low back pain evidence review.Royal College of General Practitioners, London1996
van Tulder M, Becker A, Bekkering T, Breen A, Gil del Real MT, Hutchinson A, et al. European guidelines for the management of acute nonspecific low back pain in primary care, 2004. Available at www.backpaineurope.org. Accessed May 1, 2005.
- The development of QUADAS: a tool for the quality assessment of studies of diagnostic accuracy included in systematic reviews.BMC Med Res Methodol. 2003; 3: 25
- Systematic reviews of diagnostic research. Considerations about assessment and incorporation of methodological quality.Eur J Epidemiol. 2001; 17: 301-306
- Meta-analytic methods for diagnostic test accuracy.J Clin Epidemiol. 1995; 48 ([discussion 131-2]): 119-130
- Guidelines for meta-analyses evaluating diagnostic tests.Ann Intern Med. 1994; 120: 667-676
- Conducting systematic reviews of diagnostic studies: didactic guidelines.BMC Med Res Methodol. 2002; 2: 9
- The STARD statement for reporting studies of diagnostic accuracy: explanation and elaboration.Ann Intern Med. 2003; 138: W1-W12
- Empirical evidence of design-related bias in studies of diagnostic tests.JAMA. 1999; 282: 1061-1066
- Kappa coefficients in medical research.Stat Med. 2002; 21: 2109-2129
- Interval estimation for the difference between independent proportions: comparison of eleven methods.Stat Med. 1998; 17: 873-890
- Spinal radiographic findings and nonspecific low back pain. A systematic review of observational studies.Spine. 1997; 22: 427-434
- Clinical use of bone densitometry: scientific review.JAMA. 2002; 288: 1889-1897
- Diagnostic evaluation of low back pain with emphasis on imaging.Ann Intern Med. 2002; 137: 586-597
- Shock trauma room management of spinal injuries in the framework of multiple trauma. A systematic review of the literature.Unfallchirurg. 2004; 107: 911-918
- Lumbar spine films in primary care: current use and effects of selective ordering criteria.J Gen Intern Med. 1986; 1: 20-25
- Use of lumbar spine films. Statistical evaluation at a university teaching hospital.JAMA. 1981; 246: 1105-1108
- Evidence against the use of lumbar spine radiography for low back pain.Clin Radiol. 2004; 59: 69-76
- Selective indications for thoracic and lumbar radiography in blunt trauma.Ann Emerg Med. 1995; 26: 126-129
- ‘Routine’ radiologic evaluation of the thoracolumbar spine in blunt trauma patients: a reappraisal.J Trauma. 1993; 34: 85-89
- Use of lumbosacral spine radiographs in a level II emergency department.Am J Roentgenol. 1998; 170: 443-447
- Prospective evaluation of criteria for obtaining thoracolumbar radiographs in trauma patients.J Emerg Med. 2003; 24: 1-7
- Thoracolumbar fracture in blunt trauma patients: Guidelines for diagnosis and imaging.Injury. 2003; 34: 426-433
- Radiography for back pain presenting to accident and emergency departments.Arch Emerg Med. 1992; 9: 28-31
- Evaluation of the lower spine after blunt trauma using abdominal computed tomographic scanning supplemented with lateral scanograms.J Trauma. 2002; 53: 9-14
- Indications for obtaining surveillance thoracic and lumbar spine radiographs.J Trauma. 1994; 37: 673-676
- Evaluation of the thoracic and lumbar spine after blunt trauma.Am J Surg. 1995; 170: 681-684
- A one-way components of variance model for categorical data.Biometrics. 1977; 33: 671-679
- The New Zealand acute low back pain guide.Accident Compensation Corporation, Wellington, New Zealand2003
- Interrater reliability in assessing quality of diagnostic accuracy studies using the QUADAS tool. A preliminary assessment.Acad Radiol. 2006; 13: 803-810
- Evaluation of QUADAS, a tool for the quality assessment of diagnostic accuracy studies.BMC Med Res Methodol. 2006; 6: 9
- Cancer as a cause of back pain: frequency, clinical presentation, and diagnostic strategies.J Gen Intern Med. 1988; 3: 230-238
- An approach to backache.Br J Hosp Med. 1982; 28: 187-194
Published online: August 28, 2007
Accepted: April 20, 2007
© 2008 Elsevier Inc. Published by Elsevier Inc. All rights reserved.