Low Back Pain Red Flags Flashcards
Multiple Myeloma General
Most common bone cancer. But still less than 1% of all cancers
Consider in: >50 with chronic LBP and anemia of chronic disease
Order: serum protein electrophoresis for >50 with LBP that don’t respond to care.
MRI is positive. Bone scans are normal
A patient with back pain and recurrent infections in patients over 50. Consider…
Multiple Myeloma OR Spinal Infection
Recognition of red flags and symptoms
Prevention of complications of chiropractic treatment
First step in differential diagnosis of NMS condition
Figure out if it is an injury or disease
Muscloskeletal pain from disease (spine)
Metastatic/primary tumors Spinal Infection Inflammatory diseases (RA, AS, etc.)
Muscloskeletal pain from disease (non-spinal)
Viscerosomatic referral/reflexes (eg, From GI, reproductive, urinary systems)
AAA, endocrine
First step in DDX
Rule out disease
3% of LBP is from serious disease
1% = local cancer or spinal infection
2% = referred pain (usually GI, reproductive system or urinary)
Test characteristics of cancer
Previous cancer: 16-23x
Failure to improve with a month of therapy: 3x
Weight Loss as a Red Flag
Weight Loss (>10 lbs over 3 months)
Sensitivity 15%
Specificity 94%
Better at ruling in
Failure of bed rest to relieve as a Red Flag
Very common in cancer (>90% sensitivity)
Reported in over 1/2 of non-cancer patients - low sensitivity for cancer
Lying down aggravation
Excruciating pain when lying supine, relieved by sitting up or hunched over a table
Possibly from malignant retroperitoneal lymphadenopathy
Secondary to lymphomas and testicular cancer - both are responsive to treatment
Age with LBP as a Red Flag
77-10% of patients were 50 years old or older
Deyo’s study
No patient was found to have cancer and LBP under 50 unless they had:
Prior history of cancer
Unexplained weight loss
Failure of conservative therapy
Night Pain
No longer considered a large concern unless pain is severe, progressive, or unabated by position
42% of pts had night pain and 20% with pain every night
Best questions
Have you ever had cancer?
Yes, think possible recurrence
Have you lost weight recently?
Yes, think cancer
Does bed rest give you any pain relief?
Yes is evidence against cancer.
If pain gets worse then think cancer
When leg symptoms are present
Be more careful especially if:
Female, pediatric, or geriatrics
Bone tumors
Cancer associated with older age and hogher incidence of neurological deficit
Neurological deficits
Primary neoplasm - 55% had objective neurological deficits at the initial visit
20% of patients with spinal malignancy present with neurological deficits
8% with metastatic malignancy have cord compression as the first symptom
Almost 1/3 of prostrate cancer patients have neurological deficits
Clinical strategy for X-Ray
X-Ray any patient with persistent back pain or a neurological deficit
Spinal Percussion for cancer, fracture, spinal infection
Cancer - poor sens and spec
Fracture - poor sens and spec
Spinal infection - 86% sens and 60% spec
Clinical Pearl
Severe localized spasm and rigidity of 3 continuous vertebral segments
May be the result of:
Vascular lesion of cervical spine
Metastasis in thoracic
Prostate or uterine cancer in lumbar
Ancillary Studies: BW and urinalysis
ESR and CRP CBC Blood chemistry panel UA Special blood/urine tests
Ancillary Studies: Imaging
Radiographs
CT/MR
Bone scan/SPECT
Ultrasound
Clinical Strategy for suspicion of disease
Plane film radiograph (if suspicion remians high -MRI, CT or bone scan)
Order ESR
Order CBC
Should you X-Ray a patient for a routine evaluation?
NO
Not recommended for accute LBP w/in first month unless there is a red flag
Metastatic cancer: factoids
2/3 of cancers are metastatic
Usually from breast, lung, prostate, or kidney
Maybe from colon or thyroid
Most metastatic bone cancers are osteolytic
Metastatic bone cancer appearance on x-ray at first visit?
If present it is 68% likely to appear
MRI - Cancer and Infection
Cancer: Sense (83-93%), Spec (90-97%)
Infection: Sense 96%, Spec 92%
Bone Scan: Cancer
Sens - 74-98%
X-ray: cancer
Spec - 95-99%
Initial Blood Work
For NMS cases, start with erythrocyte sedimentation rate (ESR) and/or C-reactive protein (CRP)
These are sensitive but not specific.
Good for screening but with false positives
ESR range
Erythrocyte Sedimentation Rate
Normal: 0-18mm
20-50 rule
20-50 rule
20mm/hr - 50mm/hr
Below 20 is abnormal but not clinically meaningful
Above 50 is probably a significant disease requireing further testing and advanced imaging
ESR > 100
Multiple myeloma
Temporal arteritis
Polymyalgia rheumatica
Combination of normal ESR and x-rays constitutes…
A very sensitive screem for serious malignancies or infections
Complete Blood Count
Anemia plus back pain is a red flag
Anemia is present in about 50% of caseswith cancer
14% in all other patients
Red Flags for Cancer in LBP
Prior history of cancer: (LR-23.7) large post-test change Reduced Hct (anemia): (LR-18.2) large post-test change Elevated ESR: (LR-18)large post-test change Clinical judgement: (LR-12.1) large post-test change
Combination of age _____, prior _____, unexplained _______, failure to improve in ______ had 100% sensitivity
Age > 50, history of cancer, weight loss, 1 month
CBC red flags
Altered white count
Increased white count can signal infection, cancer, or inflammatory disease
Increased immature can suggest leukemia
Depressed white cells can suggest multiple myeloma or other cancers
Two most common causes of elevated calcium
Metastatic cancer: 40-50% of patients with metastatic cancer to bone will have elevated calcium
Hyperparathyroidism
Not usually caused by osteoporosis
Alkaline Phosphatase (from bone)
50-75% of cancer patients will have elevated ALP
Normal value is 0-50
Values increase above 150
Paget’s disease, healing fracture, growing bones, pregnancy and liver disease
Prostate cancer
Viscerosomatic referral and LBP may be due to
Reproductive
Urinary
GI
Causes of back pain from viscera
Menstrual cycle
Periodic pain unassociated with movement or activity
Colicky or cramping pain
Writhing pain
Red Flag in the spine
LBP plus:
Little muscle spasm
Little tenderness
Little impaired segmental mobility
Pancreatic cancer
Associated with nausea or vomiting
May be made worse by recumbency
Relieved by knees drawn up and forward flexion (100% specificity)
Urinary bladder referred pain patterns
Upper gluteal crease
Inner thighs and cross gluteal folds
Pain may be present on the opposite side
because visceral nerves crisscross midline
Kidney referred pain patterns
Low back, lateral back, lateral thighs
Pain may be present on the opposite side
Low back pain referrals
Colon (not sigmoid) referral is often to mid lumbar spine
Gynecological disorders rarely refer above L4
Sigmoid colon, rectum, pelvic referral is usually sacral
