diagnosis of red flags & differential low back · pdf filered flags & differential...
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Red Flags
nRed flags are a list of prognosticvariables for serious pathology
n CSP Guidelines 2007:n AGE <20, >45 with no precipitating eventn Night painn Pain that causes the patient to be constantlymoving or curled up in the sitting position
n Back pain with constitutional symptoms – fatigue,nausea, diarrhoea, fever etc
Red Flags continuedn Back pain with unexplained weight lossn Back pain with bladder/ bowel dysfunction or legweakness
n Insidious onset/ progressionn Sacral pain – in absence of trauman Back pain not eased by lying/bedrest = (0.9sensitivity)
n Back pain that doesn't vary with activityn Back pain that is eased by sitting up and leaningforward (pancreas)
Red Flags continued
n Back pain with multiple joint involvementor sustained morning stiffness
n Severe persistent back pain with fullpainfree ROM
n Sudden localised back pain, not easing, inpost-menopausal women – osteoporotic/fracture
Differential Diagnosis of Low Back Pain
Mechanical Low Back Painor Leg Pain (97%)Lumbar strain (70%)
Degenerative process of discs /facets, usually age related(10%)Herniated disc (4%)
Spinal stenosis (3%)
Osteoporotic compression # (4.5%)
Spondylolisthesis (2%)
Traumatic # (1%)
Congenital disease (<1%)Severe kyphosis
Severe scoliosis
Transitional vertebrae
Spondylolysis
Internal disc disruption ordiscogenic low back pain
Presumed instability
Non-Mechanical SpinalConditions approx (1%)Neoplasia (0.7%)
Multiple myeloma
Metastatic carcinoma
Lymphoma & leukemia
Spinal chord tumour
Retroperitonal tumours
Primary vertebral tumours
Infection (0.01%)
Osteomyelitis
Septic discitis
Paraspinous abscess
Shingles
Inflammatory Arthritis (oftenassoc with HLAB27 (0.3%)
Ankylosing Spondylitis
Psoratic spondylitis
Reiters syndrome
Inflammatory bowel disease
Scheuermann’s disease
Paget’s disease
Visceral Disease (2%)
Disease of Pelvic organs
Prostatitis
Endometriosis
Chronic pelvicinflammatory disease
Renal disease
Nephrolithiasis
Pyelonephritis
Perinephric abscess
Aortic aneurysm
Gastrointestinal disease
Pancreatitis
Cholecystitis
Penetrating ulcer
Differential Diagnosis of Low BackPain
n Mechanical low back or leg pain (97%)
n Lumbar strain, sprain (70%)n Degenerative processes of disks and facets, usually age-related
(10%)n Herniated disk (4%)n Spinal stenosis (3%)n Osteoporotic compression fracture (4%)n Spondylolisthesis (2%)n Traumatic fracture (<1%)n Congenital disease (<1%)n Severe kyphosis, Severe scoliosis, Transitional vertebrae
Spondylolysis, Internal disk disruption or diskogenic low backpain
Evaluation in older adults
n Probabilities changen Cancer, compression fractures, spinal stenosis,aortic aneurysms more common
n Osteoporotic fractures without trauman Spinal Stenosis secondary to degenerativeprocesses and spondylolisthesis more common
n Increased AAA associated with CADn Early radiography recommended
Imaging
n Plain Radiography limited to patients with: -findings suggestive of systemic disease -trauman Failure to improve after 4 to 6 weeksn CT and MRI more sensitive for cancer andinfections – also reveal herniation andstenosis
n Reserve for suspectedmalignancy,infection or persistentneurologic defecit
CT Scan
n Shows bone (e.g., fractures) very welln Good in acute situations (trauma)n Sagittal reconstruction is mandatoryn Soft tissues (discs, spinal cord) are poorlyvisualized
n CT-myelogram adds contrast in the CSFand shows the spinal cord and nervescontour better
Spinal stenosisn Epidural steroid injections may be effective forreducing symptoms four months at a time
n In most cases, physical therapy is not helpful,but occassionally…
n Tolerance for standing and walking will decreaseslowly with time in most cases
n Surgical decompression results are excellentand this should be considered earlier in thecourse of the disease than it often is.
Spondylolysis
n Pain at first with activity, later may be constant
n Fracture may heal, may not
n In those that do not heal, instability can developover time and become symptomatic
n Spondylolisthesis may develop and needs to befollowed at intervals to assess for progression
Lumbar instability
n L4-L5 is the most common level in degenerativeinstability, followed by L3-L4, and less commonL5-S1
n L5-S1 is the most common level affected inyounger patients with spondylolysis
Waddell Signs For Non-organicPain
n Superficial non-anatomic tendernessn Pain from maneuvers that should not ellicit painn Distraction maneuvers that should elicit painBUT don’t
n Disturbances not consistent with known patternsof pain
n Over-reacting during the examn Not definitive to rule out organic disease
Clues To Systemic Disease
n Agen History of Cancern Fevern Unexplained Weight Lossn Injection Drug Usen Chronic Infection Elsewheren Duration and Quality of Pain
-Infection and Cancer not relieved supinen Response to previous therapyn Hx inflammatory arthritis elsewhere
General clues to systemic LBP
n Previous history of Ca, Chron's disease orbowel obstruction
n Long-term use of NSAIDs (GI bleeding),steroids or immunosupressants (infection)
n Recent/ previous history of surgeryn History of osteoporosis/ vertebralcompression fractures
General clues continued
n History of heart murmur or prosthetic valvein an older patient (bacterial endocarditis)
n History of intermittent claudication andheart disease, with deep mid lumbar pain(AAA)
n History of diseases associated withhypercalcaemia such ashyperparathyroidism, multiple myeloma,senile osteoporosis, hyperthyroidism,cushings disease or renal disease
Tumours
Three groups:
§ extradural (outside of the dura) 60%
§ intradural-extramedullary (between thespinal cord and the dura) 30%
§ intramedullary (within the substance of thespinal cord itself) 10%
Mets
C.Spine
Multiple myeloma
n Primary malignant bone tumour.n Excessive plasma cell growth in the bonemarrow resulting in bone re-absorption,leading to osteoporosis.
n Normal blood forming functions of thebone marrow affected – leads to anaemia,fatigue, and problems with clotting, andreduced resistance to infection.
Multiple myeloma - subjective
n Increasing age is most significant riskfactor for multiple myeloma
n 95% cases diagnosed after 50 yearsn Average age of onset 65n Males twice as likely to develop myelomacompared to females
n More common in some families, especiallyif sibling or parent has had it, as increasesrisk by 4x
Multiple myeloma - subjective
n HPCn myeloma can remain dormant for as longas 3 years
n prodormal phase can last 5-20 yearsn most common presentation = bone pain inthe back, commonly associated with lowerlimb radiculopathy; these may beassociated with fractures
Paget’s Disease
§ Affects an estimated 3 percent of people over the age of 40.§ More common in men than in women and is more prevalent inEurope and Australia.
Cauda equina syndrome
n 2 MAIN CAUSESnprolpased discnmalignant spinal cord compression
n Nerve roots in CE covered in a sparse layer ofconnective tissue as opposed to the thickepineurium found in peripheral nerves, offeringlittle protection against tensile forces.
n Lack of regionalised segmental blood supplyalso compounds the vulnerability of theanatomical region .
Cauda equina
n Most common cause is central discprolapse which occupies all or most of thespinal canal compressing lumbar andsacral nerves at that level and lower levelsof the spinal column. Compression of thenerves leads to a potential loss ofsphincter tone, incomplete emptying of thebladder and compromise of the stretchreceptors and/ or difficulty initiatingmicturition or defecation.
Cauda equina symptomsn Back pain with nerve root distribution of pain (one ormore nerve roots involved)
n Sciatican Saddle parathaesia and/ or anesthesia around the anus,perineum or genitals
n Faecal incontinencen Bladder dysfunction= e.g. urinary retention with orwithout overflow incontinence, difficult voiding
n sexual dysfunction e.g erectile dysfunction, dyspareunia(pain during intercourse)
n Weak/ heavy legsn Gait disturbance
Sensitivity of Symptoms ofCauda Equina Syndrome
n Urine retention 0.90sensitivity
n Unilateral or bilateral sciatica>0.80
n Sensory/ motor deficit and reduced SLR>0.80
n Saddle anaesthesia0.75
n OBJECTIVE EXAMINATIONn decreased anal sphincter tone (60-80%cases)
n sacral sensory loss (85% cases)(Lurie 2005)
Malignant spinal cordcompression
n Pain almost always first presenting symptomn Can start of as mild but escalates out ofcontrol despite analgesia
n Constant progressive severe pain 8-10/10n New pain or described as different to existinglong standing pain
n Pain can be referred around the abdomen orchest in band like manner often bilateral.Described as being squeezed
Malignant spinal cordcompression
n Pain usually located in the back but radicularpain can be caused by valsalvas manoeuvreeg straining, coughing
n Pain described as shooting, sharp, deepn Pain may be aggravated by lying down, bonepain sometimes less if lying prone
n Night painn Pain may be eased by sittingn Nerve pain in upper thighs
Subjective
n Highest prevalence 40-65 yearsn (89% patients over 50n Men less likely to consult for medical adviceand therefore often present late
n Patients with cancer who describe severeback or spinal root pain require urgentassessment
n Altered sensations in legsn Heaviness in the legs often associated withmuscle weakness or legs may feel odd orstrange
Objective
n Neurological deficit often occurs late indisease process
n Muscle weakness can begin in lower limbsregardless of level of cord compression
n Difficulty in mobility such as climbingstairs, reported falls, difficulty walking.
n May no correlation between severity ofpain and extent of neurological deficit
Objective continuedn Compression at thoracic or cervical levels canresult in upper limb weakness
n L'Hermittes signs may be present with a tingling/shock like sensation passing down the arms ortrunk when the neck is flexed
n autonomic dysfunction such as constipationand/or retention along with ataxic gait anduncoordinated movements are usually latepresenting symptoms
n thoracic spine most commsite (68%) followed bylumbar (21%), cervical (7%) sacral 4%
§ 23 million American adults over age 20 suffersfrom chronic kidney disease > 10%.§ More than a half-million patients are undertreatment for end-stage renal disease.
Kidney Disease
Renal/Urologic
n Renal and urethral pain -T9 -L1dermatomes
n Back pain at the level of the kidneys – canbe caused by ovarian or testicular cancer
n Back and shoulder pain, alternate/together
n Associated signs and symptoms – blood inurine, frequency, hesitancy, testicular pain
Cardiovascular
n Throbbing back painn Back pain with leg pain that is eased bystanding still or rest
n Back pain in all spinal positions andincreased with exertion
n Back pain with a pulsing sensation orpalpable abdominal pulse
Cardiovascular continued
n Low back pain / or leg pain withtemperature changes from one leg to theother (involved side warmer – venousocclusion or tumour, involved side colder –arterial occlusion)
n AAA – may present with severe LBP,addition of testicular pain ominous andoften precedes fatal rupture
Gastrointestinaln Back and abdominal pain at the same level(together/ alternate) ?associated GI symptoms
n Back and abdominal pain at lower level thanback pain
n Back pain associated with mealsn Back pain with heartburn (reduced with antacids)n Associated with GI symptoms- early satiety withweight loss, tender over McBurneys point, bloodin stools, dysphagia
n Sacral pain during bowel movements
Pulmonary
n Associated signs and symptoms(dyspnoea, cough etc)
n Back pain eased by respiration- deepbreathing, coughing etc
n Back pain eased by lying on affected side,or fixing ribs
n Weak and rapid pulse with fall in BP -pneumothorax
Finding Balance
Underactive Overactive ShortenedStabiliser Synergist Antagonist
Glut Medius TFL, QL, Pirif ormis Thigh adductors
Glut Maximus Iliocast, Hamstring Iliopsoas, Rec Fem
Lower Trapezius Levator Scapulae Pectoralis MajorUpper trapezius
Geraci, M. Rehabilitation of the hip and pelvis. In: Kibler WB. Functional Rehab SportsMusculoskeletal Med; Aspen Publishers,1998. With permission.
Reeves, L.J., M.D. & Montero, A., M.D., M.P.H (2012): Low Back Pain
References:
Carragee EJ & Hannibal M. (2004). Evaluation of Low Back Pain. TheOrthopedic clinics of North America 2004; 35: 7–16.
Deyo RA & Weinstein JN. (2001) back pain. The New England Journal of Medicine2001; 344(5): 363–370.
Waddell G. Biopsychosocial analysis of low back pain. (1993) Acta OrthopaedicaScandinavica. Supplementum 1993;251: 21–24.
Atlas SJ & Deyo RA. (2001) Evaluating and managing acute low back pain in theprimary care setting. Journal ofGeneral Internal Medicine 2001; 16(2): 120–131.
Jarvik JG, Deyo RA, (2002). Diagnostic evaluation of low back painwith emphasis on imaging. Ann Intern Med 2002;137:586–97.
Lurie, JD. 2005. What diagnostic tests are useful for low back pain? BestPractice & Research Clinical Rheumatology, 19, 4, 557-575
Greenhalgh , S and Selfe J 2010 Red flags II: a guide to solving serious pathologyof the spine. Churchill Livingstone, Edinburgh