Spinal

Emergencies

and Red

FlagsJackie Rowles, MBA, CRNA

ANP-BC, FAAPM, FAAN

Meridian Adult Health

Indianapolis, IN

Acknowledgements:

• A special thank you to Mindy Wallace and Paul Darr who have previously given this lecture at the JN workshop and who has shared materials for this lecture. And also to Mindy for the powerpoint design which fits this lecture perfectly!

• Identify and describe common and uncommon medical disorders that may present with back or neck pain.

• Identify pertinent history, physical, and diagnostic findings of serious medical conditions accompanied by pain.

• Identify medical disorders that require immediate or urgent treatment.

Objectives:

Urgencies or Emergencies?

• There are many, many urgencies but true emergencies only occur with spinal cord compression

And …………. Red Flags???

• Signs/Symptoms that are associated with severe or life threatening/altering spinal pathology

So, what exactly are spinal

emergencies?

• Cauda Equina syndrome

• Trauma

• Infection

• Tumor

How do we avoid missing

something so important?

• By acquiring the necessary knowledge,

skills, and competencies needed to assess

and determine an appropriate diagnosis or

list of differential diagnoses!

• By not becoming too comfortable or

complacent with our routine

• By not accepting referrals at face value

• By keeping the focus, and the priority on the

patient and safe provision of care

Required actions

• Obtain a thorough history

• Perform a thorough physical exam

• In depth review medical records

• Ask more questions

• Perform additional assessment

• Order appropriate labs and imaging

• Know Differential Diagnoses!

• Listen to the patient/family

• Listen to your inner voice

Referred Back Pain patterns:

Cardiac ischemia

(atypical)

Cholelithiasis,

peptic ulcer disease,

pancreatitis

Classic low back pain,

Lumbar spondylosis

Activity-related, persistent

Severe, tearing

Colicky

Cramping, spasmodic,

abdominal

Cardiac ischemia(common)

Dissecting abdominal

aortic aneurysm, visceral injury

Pyelonephritis,renal stones

Deep-seated pelvic pain

PID

Ectopic pregnancy

Fibroids

Endometriosis

Prostatitis

Tumors

Masquerade: Medical causes of back pain: REVIEW ERIC KLINEBERG, MD, DANIEL MAZANEC, MD, DOUGLAS ORR, MD, CLEVELAND CLINIC

JOURNAL OF MEDICINE . VOL. 74, 12:2007, pp 905-913.

Visceral pathology pain

patterns (googlesearch.com)

Most Common Causes of Neck &

Back Pain:

• 70% due to: muscle strain, ligament sprain, myospasm, or combination without anatomic abnormality

• Only about 25% involve specific structural lesions that clearly cause the symptoms, primarily:– Disk herniation

– Disc or facet degeneration

– Compression fracture (trauma or osteoporosis)

– Lumbar spinal stenosis

– Osteoarthritis

– Spondylolisthesis

Serious Spinal Disorders:

• Infections

– discitis, epidural abscess, osteomyelitis

• Primary tumors of spinal cord or vertebrae

• Metastatic vertebral tumors

– most often from breasts, lungs, or prostate

• Spinal cord or nerve root compression may result from:

– tumors

– epidural abscess

– hematoma.

– mechanical spine disorders

Serious Extraspinal Disorders:

Emergent Conditions• Dissecting arterial aneurysm• Ectopic pregnancy• Myocardial infarction• Cardiac tamponade• Acute meningitis• Carotid or vertebral artery

dissection

Urgent Conditions• Acute pancreatitis• Duodenal ulcers• Pyelonephritis• Visceral trauma• Acute meningitis

Serious Conditions• Cholecystolithiasis

• Pancreatitis/ appendicitis

• Salpingitis/ pelvic inflammatory disease

• Nephrolithiasis

• Prostatitis

• Ovarian cancer

• Pleuritis/ pneumonia

•Herpes zoster

•Paget's disease

•Torticollis

•Rheumatoid Disorders•Polymyalgia rheumatica•Psoriatic arthritis•Enteropathic arthritis•Reactive arthritis

•TMJ syndrome

•Thoracic outlet syndrome

•Spondyloarthropathies•Ankylosing spondylitis•Bechet’s syndrome•Whipple’s disease•Diffuse idiopathic skeletal hyperostosis•Undifferentiated spondyloarthropathy

Other Less Common Causes:

What to be aware of

• Age, <16 or > 50

• Cancer history (no matter when!)

• Unexplained weight loss

• Long term use of steroids

• Recent report of serious illness

• Recent report serious infection

Cancer signs: MUST know!

• Bowel or bladder habits changed

• Sores that won’t heal

• Unusual bleeding/discharge

• Breast lump or thickening

• Steady nausea, indigestion, dysphagia

• Change in wart/mole

• Nagging cough/hoarseness

Weight loss

• Without explanation

• More than 5% in one month

• Always considered to be cancer until proven wrong

Response to previous therapy

• Good initial response followed by relapse is always a cause for concern

Misc. things to note

• Long term or high dose steroids

• Appearance of systemic illness

• Presence of bilateral pins and needles

sensation

• History of trauma, TB or osteoporosis

• Smoking

• Severe headache

• S/S of cauda equina

Increased risk for infection

– IV drug use– Immunosuppres

sion– Recent surgery– Penetrating

trauma

– Severe constipation

– Recent UTI– Diabetes– HIV/AIDS

Red Flags by History (S):

Back/Neck Pain with:

• Reported Progressive neurologic deficit

– Loss of sensation

– Saddle anesthesia

– Loss of power

– Urinary or bowel incontinence

– Urinary retention

• Excruciating pain

• Abdominal pain

• Nocturnal Pain Dominant

• Thoracic pain

• Pain with sneeze, cough or valsalva

• Severe pain > 4-6 weeks• Acute, tearing mid-back pain

• Constant & Increasing Pain

• Constant, non-mechanical pain

Red Flags by Assessment (O)

• Spinal deformity

• Severely limited ROM (tumor, osteoma)

• Myospasm with scoliosis or deformity

• Neurological deficit: myotome or dermatomal abnormality; + Babinski (plantar reflex) + Hoffmans and clonus may equal upper motor neuron lesion

Red Flags by Physical Exam

(O)

Observation– Diaphoresis – Cachexia– Skin erythema– Fever– Structural deformity– Pain behavior

Testing– Persisting severe restriction

of forward trunk flexion– Spine tenderness to

percussion– Meningismus– Lhermitte’s sign

Palpation– Lymphadenopathy– Costovertebral angle

tenderness– Abdominal aorta that

is > 5 cm (particularly if tender)

– Localized abdominal tenderness

– Lower-extremity pulse deficits

Red Flags by Physical Exam

(O):

Strength– Severe weakness in extremities

or in myotomal pattern

– Muscle atrophy

– Widespread or progressive loss of strength in the legs

– Gait disturbance

Reflexes– Hyperreflexia with clonus

– Hoffman’s reflex/ Babinski

– Asymmetric reflexes

Progressive Neurologic Deficits as compared to earlier PE:

Sensory– Loss of pain and temperature

sensation in extremities

– Loss of position, vibration sense

(long tract signs)

– Sensory deficits in dermatomal

pattern

– Pain or deficits in “stocking

glove” pattern

– Saddle anesthesia

– Loss of perianal/perineal sensation

– Loss of bulbocavernous or anal wink reflexes

Establishment of a Diagnosis

(A)

• Differential Diagnosis:

systematically processing results of clinical information/test results to identify the appropriate diagnosis from a list of possible diagnoses.

Establishment of Treatment

(P)

• Definitive diagnosis or R/O

• Appropriate treatment plan

• Periodic evaluation

• Plan modification as needed

What does the evidence say?

• An 2009 article in Physiotherapy reported the results of obtained from a focus group results of 7 palliative care providers concerning the most common objective based red flags.

• 3 responses were in strongest agreement

What does the evidence say

about Red Flags?

• 1. Trunk pain in a band-like distribution

– Often proceeded by vague symptoms

– Commonly bilateral in distribution

– Related to bone or nerve root pathology

What does the evidence say

about Red Flags?

• 2. Vague and nonspecific LE symptoms

– Late in disease process

– Often predating overt spinal cord

compression

– Leg sensation “odd or strange” before

progressing to heaviness

– Reports that legs “misbehave”

What does the evidence say

about Red Flags?

• 3. Reduced Mobility

– May present with mild foot drop

– May drag one leg

– Lack of recognition of these symptoms as

significant or important

– Greenbaugh,S and Selfe, J. Physiotherapy, 2009.

What

might I

see?

Acute low back pain

• “A focused history taking is the most critical tool for identifying risk factors for serious disease in a patient who presents with low back pain. Directing the history taking toward the red flags allows for an efficient, cost-effective assessment”

Della-Giustina, D. 2013

Cauda Equina Syndrome

History (S)• Saddle anesthesia• Bladder dysfunction (distended bladder; loss of sensation when

passing urine)• Fecal incontinence (loss of sensation of rectal fullness)• Erectile dysfunction

Physical Examination (O)• Perianal / perineal sensory loss• Unexpected laxity of the anal sphincter• Severe or progressive neurological deficit in the lower extremities

– Major motor weakness with knee extension, ankle eversion, or foot dorsiflexion.

– Bilateral lower extremity weakness or numbness

Cauda Equina Syndrome

Causes (A)

• Usually disc, spondylolisthesis, rarely tumor,

abscess, advanced AS

Diagnosis/Treatment (P)

• Urgent MRI and surgical decompression

Cervical Myelopathy

History (S)

• Insidious progression of symptoms usually

Physical Exam (O)

• Gait disturbance; clumsy or weak hands; loss of sexual/bladder/bowel function

• Lhermitte's sign (flexing the neck causes electric shock-like sensations that extend down the spine and shoot into the limbs)

• Upper motor neuron signs UEs: Hoffman’s reflex

• Upper motor neuron signs LEs: Upgoing toes/ babinski, hyperreflexia, clonus, spasticity)

• Lower motor neuron signs in the upper limbs (atrophy, hyporeflexia)

Cervical Myleopathy

• (A) amyotrophic lateral sclerosis, multiple sclerosis, syringomyelia, and spinal tumors.

• (P) immobilization of the neck, steroids, NSAIDS, PT, surgery

Vascular Insufficiency

History• Dizziness and blackouts (restriction of vertebral

artery) on movement, especially upward gaze

• Fainting or drop attacks

• Headaches

Physical Exam• May be normal

• Claudication

• Pulse deficits

• Trophic changes (changes resulting from interruption of nerve supply: wasting away of the skin, tissues, or muscle, thinning of the bones, thickening or thinning of hair or brittle nails)

Abdominal Aortic Aneurysm

History

• Age greater than 60 years

• Atherosclerotic vascular disease

• Pain at rest or nocturnal pain

Physical Exam

• Abdominal pulsating mass

Visceral Problems

• Renal

• GU

• GI

• Hepatic

• GYN

• Cardiopulmonary

• Refer quickly!!

Spinal FracturesHistory

• Sudden onset of severe central pain, relieved by lying down

• Recent significant trauma at any age – Ejection from motor vehicle – Fall from substantial height

• Minor trauma, or even strenuous lifting, in people with osteoporosis

• Prolonged use of Corticosteroids

• Mild trauma over age 50 years

• Age greater than 70 years

Physical Exam

• Structural deformity of the spine

Compression Fractures

CancerHistory• History of cancer• Onset in a person over 50 years, or under 20 years, of age• Constitutional symptoms, such as fever, chills, or unexplained

weight loss• Recent bacterial infection (e.g. urinary tract infection)• Intravenous drug abuse• Immune suppression• Pain that remains when supine• Aching night-time pain disturbing sleep • Thoracic pain (which also suggests aortic aneurysm) • Failure to improve with therapy • Pain persists for more than 4 to 6 weeksPhysical Exam• Structural deformity of the spine• Vague low back pain • Nonmechanical back pain• Systemic symptoms

Cancer

• Metastatic / primary tumors such as multiple myeloma more common than spinal infections / inflammatory conditions

• 80% of patients with an underlying malignancy are over age 50

• Predilection for vertebral body and pedicles

• Cancer associated with lumbar pain include:

– pancreas, duodenum, colon, uterus, cervix, and ovary

Cancer

Cancer

Infection

History

• History of intravenous Drug Abuse

• Recent bacterial infection – Urinary Tract Infection or Pyelonephritis – Cellulitis – Pneumonia

• Immunocompromised states – Systemic Corticosteroids – Organ transplant – Diabetes Mellitus – Human Immunodeficiency Virus (HIV) – Rest Pain

Physical Exam

• Persistent fever (temperature over 100.4 F)

Infection Facts

• Discitis, osteomyelitis, and epidural abscess

• Hematogenic spread

• Post-op symptoms 2 to 4 weeks after surgery

• One third have fever

• 3% to 15% present with neurologic deficit

• Infections typically involve intervertebral disc/ vertebral

body endplate

• Occur in about 1% of patients

• More frequently in diabetics/ immunocompromised

Infection: Imaging Studies

• Radiographic changes at 2 to 4 weeks

• Bone scan positive as early as 2 days,

75% specific.

• MRI appearance is abnormal in infected

disc

• Enhancement after gadolinium

Infection

Infection

Ankylosing Spondylitis

History

•Morning stiffness and pain >30 mins -1

hr

•Better with activity

•Peripheral joint involvement

•Inflammatory bowel disease

•Recent GI or GU infection

•Family history of similar problems

•Gradual onset before the age of 40

years

Ankylosing Spondylitis

Physical Exam

• Peripheral joint involvement

• Eye inflammation

• Psoriasis

• Colitis

• Decreased spinal range of motion in all

planes

Ankylosing Spondylitis

Psychosocial Disorders

History

• Negative attitude that back pain is harmful or potentially severely disabling

• Fear avoidance behavior and reduced activity levels

• An expectation that passive, rather than active, treatment will be beneficial

• A tendency to depression, low morale, and social withdrawal

• Social or financial problems

• Intolerance of treatments

• Constant pain

Psychosocial Disorders

Physical Findings• Superficial tenderness• Non-dermatomal numbness / sensory

loss• Increased pain with axial loading /rotation

distraction• Emotional and overt pain behaviors• SLR improves with distraction• Non-anatomical pain complaint

When do I send for Advanced

Imaging?

• Objective neurologic deficits

• Potential surgical treatment

• Signs of spinal stenosis

• Pathological reflexes

• Cervical myelopathy

• Chest/Abdominal pain

And, what imaging type is

indicated?

• Plain films – fracture (AP, Lateral)

• MRI – is the best visualization of lesions in the vertebral bodies, soft tissue, spinal canal, spinal cord, of disc disease

• Emergent MRI for suspected spinal infection (vertebral osteomyelitis or epidural abscess) and epidural compression syndrome.

Type of imaging indicated:

• MRI (routine or urgent) for evaluation of neoplastic spinal processes, disc disease or when the patient’s symptoms continue after 6 to 8 weeks

• CT -- superior to MRI for evaluation of bony spine details. Best for evaluating vertebral fractures, facet joints, and the posterior spinal elements. of the spine..

Type of imaging indicated

• CT myelogram -- best for spinal canal lesions, or if the patient cannot have an MRI.

• If epidural compression or spinal infection is suspected, go directly to MRI as CT without myelography will not identify lesions inside the spinal canal

Labs

• CBC, erythrocyte sedimentation rate (ESR), and UA for suspected infection or tumor.

• WBC may be normal or elevated in patients with infection; ESR is almost always elevated in patients with osteomyelitis and epidural abscess.

Labs

• C-reactive protein levels may be elevated in patients with acute infection, but they may not be elevated in those are severely immunocompromised.

• ESR may be elevated in patients with neoplastic disease

• UA to r/o UTI as infection source causing referred back pain. If WNL, order MRI to r/o infection or tumor

Take away thoughts

Although serious extraspinal disorders (e.g., cancers, aortic aneurysms, epidural abscesses, osteomyelitis) are uncommon causes of back pain, they are not rare,

particularly in high-risk groups.

Remember

• Serious underlying pathology not common (around 3%)

• Red flags should be explicitly sought

• Cannot rely on referring practitioners to rule out these conditions

Pearls

• Most neck and back pain is caused by mechanical spinal disorders,

usually nonspecific, self-limited musculoskeletal derangements.

• Back pain is often multifactorial, making diagnosis difficult.

• Red flag findings often indicate a serious disorder and the need for

testing.

• Patients with segmental neurologic deficits suggesting spinal cord

compression require MRI or CT myelography as soon as possible.

• Normal spinal cord function during physical examination is best confirmed

by tests of sacral nerve function (eg, rectal tone, anal wink reflex,

bulbocavernosus reflex).

• Pain not worsened by movement is often extraspinal, particularly if no

vertebral or paravertebral tenderness is detected.

• Abdominal aortic aneurysm should be considered in any elderly patient

with low back pain, even if no physical findings suggest this diagnosis.

June 2008 by Sally Pullman-Mooar, MD, online Merck Manual

Evidence Based Practice

• http://www.cochrane.org

• http://www.ahrq.gov

• http://www.cebm.net• http://www.evidencebasedradiology.net

• http://www.merck.com/mmpe/sec04/ch041/ch041a.html

References

• Della-Giustina, D. Acute Low Back Pain: Recognizing the “Red Flags” in the Workup. Consultant. 2013;53(6):436-440.

• Greenbaugh, S., Selfe, J. Red Flags: A qualitative investigation of Red Flags for serious spinal pathology. Physiotherapy. 95, pp: 223-226. 2009

Thank

You!

Any Questions?