2 Red Flags Flashcards
Spinal diseases that can cause back pain
Metastatic/primary tumors
Spinal infection
Inflammatory diseases
Non-spinal diseases that can cause back pain
Viscerosomatic referral/reflexes
Other: AAA, endocrine
Of acute LBP patients, what percent are spinal fractures, cancer, spinal infection, CES or inflammatory disease?
<1%
What is the BIGGEST red flags for cancer
Previous cancer
What are the red flags of cancer in order of relevance
- Previous cancer
- Unexplained weight loss
- Failure of bed rest to relieve//laying down aggravates sx
Other:
4. >50yo
Excruciating pain when supine that is relieved by sitting up, hunched over a table may be what?
Malignant retroperitoneal lymphadenopathy
2˚ to lymphomas and testicular cancer
What 3 physical exam findings do you expect with cancer patient? (Not an exhaustive list)
- Neuro deficits in older pts
- Exquisite pain with spinal percussion
- Significant restriction at multiple segments in multiple directions
Patient presents with persistent back pain or neurological deficit. What ancillary study will you always do?
“X-ray any pt with persistent back pain or neuro deficit”
Spinal percussion is exquisitely painful and lingers. What is your DDX
- Cancer
- Fracture
- Spinal infection
Patient presents with severe localized spasm and rigidity of 3 contiguous vertebral segments which may be the result of cord reflex from… (3)
- vascular lesion in cervical spine
- metastasis in thoracic
- prostate or uterine cancer in lumbar
What ancillary studies will be your go-to when you suspect disease?
What if you suspect cancer or infection?
What if you suspect arthritis?
What if you suspect urinary problem?
- Plain film
- Order ESR and/or CRP
- Order CBC
Consider blood chemistry panel (Ca2+, ALP, protein)
Anti-CCP, RF, ANA, HLA-B27
UA
Metastatic vs primary tumors and which one is more common?
Metastatic = starts elsewhere Primary = starts in this tissue
2/3 cancers are metastatic
Where do metastatic cancers start from?
Breast, lung, prostate, kidney
Sometimes colon, thyroid
What is osteolytic bone cancer? Example?
Missing bone
E.g. breast cancer
What is osteoblastic metastatic cancer? Example?
White, bone build up.
E.g. prostate cancer
For NMS case, what is your general blood work up?
erythrocytes sedimentation rate (ESR)
C-reactive protein (CRP)
What is ESR normal range?
Normal 0-18 mm/hr
What is LeFebvre’s 20-50 rule about ESR range?
<20mm/hr is abnormal but not clinically meaningful
> 50mm/hr is probably a significant disease the requires further testing and advanced imaging
If ESR > 100 what are your top 3 DDX?
Multiple myeloma
Temporal arteritis
Polymylagia rheumatica
Your patient has anemia plus back pain, what might it be?
Anemia is present in 50% of cancer cases (compared to 14% of all other patients)
You ordered a CBC for your patient who has LBP.
- HgB is low
- White count is increased
- Increased immature white cells
Anemia (more common with cancer patients)
Increased WBC suggests infection, cancer, or inflammation
Increased immature white cells suggests leukemia
If your CBC shows depressed white cells, what might that suggest?
Multiple myeloma or other cancers
What is normal serum calcium?
10.2 mg/dL
Anything over this number is a big problem!
2 most common causes elevated calcium
- Metastatic cancer
2. Hyperparathyroidism
Increased ALP suggests what disease state?
What is normal values?
50-75% of osteoblastic cancer pts have elevated ALP
Normal values: 0-50. So anything >150 is a big deal
What 3 parts of the viscera refer pain to the low back?
Reproductive
Urinary
Gastrointestinal
4 types of back pain from viscera
- Menstrual cycle
- Periodic pain unassociated with movement or activity
- Colicky or cramping pain
- Writhing pain
Your patient has LBP plus, in the history and physical exam, you notice three things that are red flags:
- no muscle spasm
- no tenderness
- no impaired segmental mobility
What is a pathognomic position for thoracolumbar pain?
Knees drawn up and in forward flexion (cross legged and hunched over)
Colon referral is where?
Mid lumbar spine (not sigmoid)
Gynecological disorders rarely refer above what spinal segment?
L4
Sigmoid colon, rectum, and pelvic referral is where?
Sacral
What might pelvic pain be for a woman?
Endometriosis
Fallopian tube pain
Ruptured ovarian cyst
If you suspect arthritic conditions, what blood work will you order?
Anti-CCP: RA
RF:
ANA: lupus, sjogren’s, scleroderma, RA, polymyositis
HLA-B27: ankylosing spondylitis
