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Spinal Disorders- LeFebvre > 1 - LBP Red Flags > Flashcards

1 - LBP Red Flags Flashcards

1
Q

In multiple myeloma, what advanced imaging is usually normal?

A

Bone Scans

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2
Q

In multiple myeloma, what advanced imaging is usually positive?

A

MRI

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3
Q

In what patient profile should you suspect multiple myeloma?

A

50+ years olds with chronic low back pain and anemia of chronic disease (possible history of recurrent infections)

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4
Q

What blood test has very high sensitivity for multiple myeloma (if negative, unlikely to be multiple myeloma)?

A

Serum protein electrophoresis

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5
Q

What test is done to confirm multiple myeloma after serum protein electrophoresis and MRI have been done?

A

Bone marrow aspiration

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6
Q

What is the first step in differential diagnosis of NMS conditions?

A

Determine if due to injury or disease, must rule out disease first

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7
Q

About what percentage of LBP is due to serious disease?

A

3%

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8
Q

About what percentage of low back pain is due to cancer or spinal infection?

A

1%

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9
Q

About what percentage of low back pain is due to referred pain from viscera?

A

2%

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10
Q

Referred pain from viscera that causes low back pain is usually from what 3 systems?

A

GI
Reproductive
Urinary

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11
Q

What percentage of a diagnosis is made by patient history?

A

90%

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12
Q

How do you calculate a positive likelihood ratio from sensitivity and specificity numbers?

A

Sensitivity / (1- specificity)

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13
Q

How do you calculate a negative likelihood ratio from sensitivity and specificity numbers?

A

(1 - sensitivity)/ specificity

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14
Q

In 2000 consecutive patients with back pain, no patient < 50 was found to have cancer unless they had at least one of these findings:

A

Prior history of cancer
Unexplained weight loss
Failure of 1 month of conservative treatment

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15
Q

What are the biggest red flags from the history that would indicate multiple myeloma?

A

Weight loss (rule in)
Failure of bed rest to relieve pain (rule out)
Age is 50+

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16
Q

Is night pain correlated with serious disease?

A

Sometimes but not often enough to be included in guidelines

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17
Q

Excruciating back pain when lying supine, relieved by sitting up, hunched over a table is common with what serious disease

A

Malignant retroperitoneal lymphadenopathy

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18
Q

Malignant retroperitoneal lymphadenopathy is usually secondary to what two types of primary cancers?

A

lymphomas (more common in elderly) and testicular cancer (more common in young men)

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19
Q

When leg symptoms are present (with or without
accompanying LBP), the index of suspicion for an organic
pathology increases, especially patients who are

A
  • female
  • pediatric
  • geriatric
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20
Q

What are 3 important physical exam findings that would point towards bone cancer?

A
  • neurological deficits in older patient
  • exquisite pain with spinal percussion
  • significant restriction at multiple segments in multiple directions
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21
Q

What is the clinical strategy when you have a patient with persistent back pain and/or neurological deficit?

A

X-ray first

Do spinal percussion

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22
Q

What are the first three ancillary studies in your clinical strategy if you suspect disease?

A
  1. Plain films
  2. ESR and/or CRP
  3. CBC
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23
Q

In addition to your first three ancillary studies that you perform when disease is suspected, what additional tests could be ordered if cancer or infection is suspected?

A

Blood chemistry panel (Calcium, ALP, proteins)

24
Q

In addition to your first three ancillary studies that you perform when disease is suspected, what additional tests could be ordered if arthritic condition is suspected?

A
  • anti CCP, RF, ANA, HLA-B27
25
Q

In addition to your first three ancillary studies that you perform when disease is suspected, what additional tests could be ordered if GU problem is suspected?

A

Urinalysis

26
Q

If you suspect disease and plain films are normal but you still have high suspicion, what ancillary tests would you order next?

A

MRI, CT, bone scan or SPECT

27
Q

What percentage of bone cancers are metastatic? Primary?

A

2/3 are metastatic

1/3 are primary

28
Q

Metastatic bone cancer usually comes from what 4 primary cancers?

A
  • breast
  • lung
  • prostate
  • kidney

Sometimes from colon or thyroid

29
Q

Are most metastatic bone cancers osteolytic or osteoblastic?

A

Osteolytic

30
Q

What primary cancer, when it metastasizes to the bone is osteoblastic?

A

Prostate

31
Q

What are the first blood tests to run in a neuromuscular case when trying to rule out disease?

A

ESR and/or CRP

Then CBC

32
Q

What is LeFebvre’s rule regarding ESR values?

A

20-50
Anything less than 20 is not clinically significant
Anything over 50 is probably a disease process (get more testing)
Between 20-50 would have to be a judgement call based on other clinical indicators

33
Q

What are the three diseases that commonly present with an ESR over 100

A

Multiple myeloma
Temporal arteritis
Polymyalgia rheumatic a

34
Q

What combination of ancillary test results are a very sensitive screen for serious malignancies or infections in NMS conditions?

A

Normal ESR and X-ray is very sensitive (good at ruling out serious disease)

35
Q

What combination of 4 signs and symptoms from the history had 100% sensitivity for cancer in LBP patients?

A
  • prior history of cancer
  • unexplained weight loss
  • failure to improve in 1 month
  • over 50 years old
36
Q

Increased WBC count (as seen with increased ESR) in a patient with chronic low back pain can indicated what diseases?

A
  • infection
  • cancer
  • inflammatory disease
37
Q

Increased immature WBC in a patient with chronic LBP can indicate what disease?

A

Leukemia

38
Q

Decreased WBC in a patient with chronic LBP can indicated what disease?

A

Multiple myeloma

39
Q

What is being checked with a blood chemistry panel?

A

Proteins and other metabolic indicators

40
Q

What are the two most common causes of elevated serum calcium?

A
  • metastatic cancer (osteolytic)
  • hyperparathyroid (unlikely to cause back pain)
  • these two account for about 90% of hypercalcemia
  • osteoporosis does not cause increased serum calcium
41
Q

When would you see elevated ALP (alkaline phosphatase)?

A
  • metabolically active bone (growing and healing fracture, Paget’s disease, pregnancy, liver disease)
  • osteoblastic bone cancer
42
Q

What percentage of patient with metastatic bone cancer will have elevated calcium?

A

40-50%

43
Q

What percentage of patients with metastatic bone cancer will have elevated alkaline phosphatase?

A

50-75%

44
Q

What organ systems most commonly have viscerosomatic referral pain to the low back?

A
  • reproductive
  • urinary
  • gastrointestinal
45
Q

Back pain from viscera will often have one or more of these characteristics?

A
  • coincide with menstrual cycle
  • be periodic and unassociated with movement or activity
  • colicky or cramping
  • writhing pain
46
Q

Low Back pain plus what three things would cause suspicion (red flag) that pain is not musculoskeletal?

A
  • little or no muscle spasm
  • little or no tenderness on palpation
  • little or no impairment of segmental mobility
47
Q

Bilateral thoracolumbar referred pain, usually associated with nausea or vomiting, made worse with recumbency is commonly associated with what organ?

A

Pancreas

48
Q

Relief of low back pain by what pathognomic position is a strong indicator for pancreas as cause of low back pain?

A

Knees drawn up and forward flexed

49
Q

What is the pain referral pattern for the urinary bladder?

A

Central spot on superior gluteal cleft and posteromedial upper thigh

50
Q

What is the pain referral pattern for kidney

A

Flanks and lateral hip/thigh
Usually unilateral
Pain may be present on opposite side because visceral nerves cross midline

51
Q

Where does the colon (except sigmoid) refer pain to?

A

Mid lumbar spine

52
Q

Where do gynecological disorders refer pain to?

A

Low back, rarely above L4

53
Q

Where does the sigmoid colon and rectum refer pain to?

A

Sacral area

54
Q

What are some examples of gynecological conditions that could cause referred back pain?

A
  • endometriosis
  • Fallopian tube
  • ruptured ovarian cyst
  • ectopic pregnancy
55
Q

When will spinal percussion be positive?

A

Fracture, spinal infection, cancer

Spinal Disorders- LeFebvre (25 decks)

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