September 5th – 8th 2013
Nottingham Conference Centre, United Kingdom
www.nspine.co.uk
Red Flags
Carla Eveleigh
Spinal ESP and Physiotherapist
September 2013
Aims and Objectives
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Recap of red flags
Hierarchical red flag list
Discuss signs, symptoms & management of;
Cancer/metastases/MSCC/myeloma
Fractures
Infection/discitis
Cauda Equina
Definition
• Red flags are a list of prognostic variables for
serious pathology such as:
• Tumour
• Infection
• Fracture
• Cauda Equina Syndrome
(Greenhalgh & Selfe 2010)
Red Flags
• Serious spinal pathology is rare <1% cases
• It is well recognised that the earlier patients
with serious pathology are identified the
better the patient outcome (Wiesel et al 1996)
Hierarchical List of Red Flags
Greenhalgh & Selfe 2010
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Age >50 years
History of cancer
Unexplained weight loss
Failure to improve after 1 month of EB
conservative therapy
Hierarchical List of Red Flags
Greenhalgh & Selfe 2010
•Age <10 & >51
•Medical history of: Cancer, TB, HIV/AIDS, IV drug abuse, OP
•Weight loss (>10% body weight in 3-6 months)
•Severe night pain
•Positive plantar response
•CES symptoms: loss of sphincter tone, altered S4 sensation,
bladder retention, bowel incontinence
Red Flags
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Constant progressive pain
Band-like pain
Thoracic pain
Inability to lie supine
Disturbed gait
Legs feeling heavy, misbehaving
Smoking
Systemically unwell
Bilateral P/Ns in hands +/or feet
Clinician “gut feeling” (Greenhalgh & Selfe 2010)
Cancers, Metastasis
• Cancers most commonly seeding metastases to the spine are:
Breast, Prostate, Lung
• Mechanism of metastatic disease is via tumour emboli
entering the blood stream.
• Venous drainage from the breast is via azygos veins into
thoracic paravertebral venous plexus, therefore commonly
leads to thoracic mets (Frymoyer 1997)
• Up to 85% of women with breast cancer develop skeletal mets
before death (Centre for Chronic Disease Prevention and Control 2007)
Malignant Spinal Cord Compression
(MSCC)
• Spinal mets can cause MSCC
• 5% of all patients with cancer present with MSCC
(Levack et al 2002)
• First symptoms are pain (Levack et al 2002)
• Reduced control of legs, foot drop, dragging legs can
be an early signs but often under reported as it is
vague & as patient not aware of significance (Greenhalgh &
Selfe 2008)
• Can present with radicular symptoms due to
compression
Malignant Spinal Cord Compression
(MSCC)
Management
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MRI scan is the gold standard investigation
Whole spine
Emergency MRI <24 hours
Bloods FBC, ESR, CRP, U&Es, LFTs, bone, PSA (for
men)
• Review with oncologist, spinal consultant
(Levack et al 2002)
• Specialist Oncology Nurse Practitioner
Myeloma
• Primary malignant spinal cancer
• Results in bone reabsorption (secondary to excessive plasma
cells)
• Multiple myeloma is not curable, early diagnosis reduces risk
of spinal cord compression (UK Myeloma Forum 2006)
• Subjective assessment gives clearer indications of serious
pathology than objective (Deyo et al 1992)
• Average age of diagnosis is 65
• Male:Female 2:1 (American Cancer association 2005)
• Can report fatigue due to anaemia (American Cancer Association 2005)
Myeloma
Subjective signs:
• Bone pain – lumbar spine, pelvis, ribs
• Tired
• Thirsty
• Easily bruise
Main objective signs:
• Associated fractures
• LL radiculopathy
• Hypercalcaemia
Myeloma
Investigations
• Whole MRI on urgent basis; can be large
discrepancy between site of pain and level of
compression (Levack et al 2002)
• Referral on to oncologist / consultant
• Bone Scan – full body
• Bone marrow biopsy
• FBC, U&Es
• Urinalysis – Bence Jones protein
Fractures
• Result from trauma or minimal trauma if
osteoporotic
• Individuals are unaware they have
osteoporosis until they sustain a fracture (Bennell et
al 2000)
• In out-patient setting more likely to see
osteoporotic fractures
• DEXA scan is gold standard for diagnosis
Fractures
Osteoporosis risk factors
• Post menopausal women; consider menopausal age,
years since menopause
• Exercise status
• Loss of height
• Difficultly lying in bed (Bennell et al 2000)
• Altered bone absorption; coelaic disease, IBS, eating
disorder, hyperthyroidism
• Corticosteroids use; RA patient, weight lifter (International
Osteoporosis Foundation 2008)
Infection / Discitis
• Inflammation of vertebral disc, often associated with infection
and can co-exist with vertebral osteomyelitis
• Most commonly in lumbar spine, cervical then thoracic spine
• usually haematogenous spread of infection. Urinary tract,
lungs and soft tissues are common primary sites
• Staphylococcus aureus is the most common pathogen
• Most common in males >50
• Risk factors; immunosuppressed, lifestyle, substance misuse
Infection / Discitis
Infection / Discitis
• Presentation; insideous onset, pain on movement,
fever, weight loss, can affect mobility, can have
neurological deficit
• Investigations; blood tests (ESR, CPR, WBC), MRI is
most sensitive, blood, sputum, urine cultures to
identify source of infection
• Treatment; antibiotics oral / IV, analgesia, surgical
intervention
Cauda Equina Syndrome
• Cauda Equina is a bundle of nerve roots which
descend within the spinal canal, distal to the conus
medullaris, approx L1-L2 (Williams et al 2003)
• Compression can cause variety of motor and sensory
problems of LLs, pelvic viscera and pelvic floor
dysfunction (Wiesel et al 1996)
• Most significant is compromise of S4 which leads to
bladder/bowel disturbance (Brier 1999)
Cauda Equina Compression
Symptoms
Symptom
Sensitivity
Urinary retention
0.90
Unilateral or bilateral sciatica
>0.80
Sensory / motor defcit and reduced
SLR
>0.80
Saddle anaesthesia
0.75
Other symptoms: Faecal incontinence, sexual dysfunction
Objective assessment:
• Reduced anal tone and power (60-80%)
• Sacral sensory loss (85% cases) (Jalloh & Minhas 2007)
• Bladder scan (post void) >150ml
Management
• Emergency MRI scan
• Follow local CES pathway, spinal fellow oncall
• Post operative follow up in specialist CE clinic
Masqueraders
Carla Eveleigh
Spinal ESP and Physiotherapist
September 2013
Aims and Objectives
• Awareness of visceral pain
• Visceral pain referral patterns
• Signs and Symptoms of non-MSK pain
Groups
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Body Chart – visceral referral
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List signs and symptoms of:
1. Cardiovascular system
2. Genitourinary system
3. Respiratory
4. Nervous system / MSK
5. Endocrine
Anatomy Reminder
Cardiovascular system
Potential signs and symptoms:
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Chest pain on exertion, can be minimal
Angina can be throat, jaw, left arm
Breathlessness
Waking at night (paroxysmal nocturnal dysnoea)
Palpitations
Limb pain on activity
Claudication pain in LLs
Ankle swelling
BP high or low
Persistent cough
Ausculation findings
Genitourinary system
• Dysuria (pain on micturation)
• Frequency during the day and/or night
• Urine offensive / discoloured
• Haematuria (blood in urine)
• Sexual partners – unprotected
intercourse
Genitourinary system
Men:
• Prostatic problems – hesitancy, poor flow, terminal dribbling
• Incontinence
• Urethral discharge
• Erectile difficulties
Women:
• Pregnant
• Timing and regularity of periods
• Abnormal bleeding
• Vaginal discharge
• Pain during intercourse
• Incontinence – stress and urge
Respiratory system
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Shortness of breath – at rest or on exertion
Cough
Hoarseness
Wheeze
Night sweats
Sputum production
Chest pain
Nervous system
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Headaches
Dizziness
Faints, fits, LOC
Altered sensation, non dermatomal
Weakness
Co-ordination difficulties
Reduced proprioception / balance problems
Dysphasia
Difficultly reading / writing
Hearing problems
Memory and concentration changes
Musculoskeletal
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Joint pain
Stiffness
Swelling
Redness
Mobility
Falls
Endocrine
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Heat or cold intolerance
Change in sweating
Weight change, appetite change
Fruity breath odour
Heart palpitations, tachycardia
Excessive thirst
Mood change
Hair and nail changes
Joint or muscle pain
Visceral Pain Referral
Types of Pain
• Visceral - pain that results from the activation of
nocieptors in the thoracic, abdominal or pelvic
viscera
• Somatic – pain caused by activation of nociceptors in
either body surface or musculoskeletal tissues ie
skin, muscle
• Neuropathic – pain caused by injury or malfunction
to the spinal cord or peripheral nerves
Visceral Pain
• Visceral structures are highly sensitive to distention,
ischemia and inflammation
• Afferent supply to internal organs is in close
proximity to blood vessels along a path similar to the
sympathetic nervous system (Rex 2004, Christianson 2009)
• 3 main theories:
1. Embryonic development
2. Multisegmental innervation
3. Direct pressure and shared pathways
Visceral Pain
Clinical presentation:
•Generally vague and diffuse
•Autonomic nervous system involvement, pallor,
sweating, nausea, change in vital signs, anxiety
•Intensity of the pain has little correlation to
extent of internal injury
Sources of Visceral Pain
• Inflammation – appendicitis, diverticulitis,
colitis, gastric ulcer
• Distention of a organ – bowel obstruction,
blockage of bile duct by gallstones
• Swelling of liver capsule – hepatitis, tumours
• Ischemia / loss of blood supply – tumour
invasion of blood supply, ischemic colitis
To sum it up
• Recognising pain patterns that are characteristic
of systemic disease is a necessary step in the
screening process
• Visceral pain referral can vary massively
between individuals
• Subjective assessment provides majority of the
information needed to clarify cause of symptom
(Goodman and Snyder 2007)
References
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American Cancer Association 2005 Multiple Myeloma. Online. www.cancer.org
Bennell K, Khan K, McKay H 2000 The role of physiotherapy in the prevention and
treatment of osteoporosis. Manual Therapy 5: 198-213
Boissonnault, WG. 1995. Examination in physical therapy practice: screening for
medical disease, 2nd edition. Churchill Livingstone. New York
Brier S R 1999Primary care orthopaedics. Mosby, St Louis
Centre for Chronic Disease Prevention and Control 2007 Breast Cancer. Online.
http://www.phac-aspc.gc.ca
Christianson JA: Development, plasticity and modulation of visceral afferents. Brain
Research Reviews 60(1):171-178
Deyo RA, Rainville J, Kent DL. 1992. What can the history and physical examination
tell us about low back pain? JAMA 268 (6): 760-765
References
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Douglas, Nicol & Robertson (Editors): Macloud’s Clinical Examination, 11th edition,
Elsevier, Churchill Livingstone, Edinburgh
Frymoyer J W 1997 The adult spine:priniciples and practice, 2nd edition. LippincottRaven, Philadelphia
Goodman CC and Snyder T E K (2013): Differential Diangnosis for Physical
Therapists; screening for referral, 5th edition, Saunders Elsevier, USA
Greenhalgh S and Selfe J. Red Flags: A guide to identifying serious pathology of the
spine, 2006 and 2010; Churchill Livingstone, Elsevier
Greenhalgh S and Selfe J. A qualititative investigation of Red flags for serious spinal
pathology, Physiotherapy 2009; 95: 223-226
International Osteoporosis Foundation 2008 Osteoporosis. Online.
www.iofbonehealth.org/home
Levack P, Graham J, Collie D 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 14:472-480
References
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Rex L (2004): Evaluation and treatment of somatovisceral dysfunction of the
gastrointestinal system, Edmonds WA, URSA Foundation
Rex L (2004): Evaluation and treatment of somatovisceral dysfunction of the
gastrointestinal system, Edmonds WA, URSA Foundation
Siemionow K et al (2008). Identifying serious causes of back pain: cancer, infection,
fracture. Cleveland Clinic Journal of Medicine, 75 (8), 557-566.
Sizer PS, Brismee J-M, Cook C. Medical Screening for Red Flags in the Diagnosis and
Management of Musculoskeletal Spine Pain, World Institute of Pain 2007; 7(1); 5371
UK Myeloma Forum 2006 Myeloma. Online. www.ukmf.org.uk
Wiesel SW, Weinstein JN, Herkowitz H et al. 1996. The lumbar spine. International
soceity for the study of the lumbar spine. 2nd edition. Saunders. Philadelphia
Williams P L, Bannister LH, Berry MM et al 2003 Gray’s anatomy, 38th edition.
Churchill Livingstone, New York