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Spinal Disorders - Me > Midterm - General Questions week 1 > Flashcards

Midterm - General Questions week 1 Flashcards

1
Q

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

A

Injury or disease?

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2
Q

Musculoskeletal pain from diseases of the spine include (3)

A
  • Metastatic/ primary tumors
  • spinal infection
  • inflammatory diseases (RA, AS, etc.)
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3
Q

Musculoskeletal pain from diseases not in the spine include (2)

A
  • viscerosomatic referral/ reflexes (e.g. from GI, reproductive, urinary system)
  • other: AAA, endocrine
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4
Q

Where are 3 viscerosomatic referral/ reflexes from

A
  • GI
  • reproductive
  • urinary system
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5
Q

How common are diseases like cancer and spinal infections as a cause of low back pain?

A

About 3% of LBPis due to serious disease

  • 1% = local cancer or spinal infection
  • 2% = referred pain (GI, reproductive, urinary)

*some studies suggest <1%

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6
Q

What is the single strongest red flag from a patient’s history that their LBP may be linked to cancer? (What is the LR)

A

Had cancer before (+LR 16-23, -LR 0.7)

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7
Q

How much unexpected weight loss on average is enough to be considered a red flag for a patient with low back pain? (Sn and Sp?)

A

> 10 lbs over 3 months

Sn = 15%, Sp = 94%

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8
Q

Is no relief from bed rest a more sensitive or more specific sign for cancer as a cause of LBP?

A

Very common in cancer (>90% sensitivity)

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9
Q

What serious condition can result in a patient having to sleep in chair because of their LBP?

A
  • malignant retroperitoneal lymphadenopathy

- Secondary to lymphomas (older patients) and testicular cancer (men) (both cancers are responsive to treatment).

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10
Q

What is the current thinking regarding night pain as a red flag for cancer? Why?

A

Alone, it is not strongly suggestive of serious disease

- A study of 482 patients found that 42% reported some night pain and 20% presented with pain

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11
Q

In what patient population are neurological deficits an increased risk for possible cancer?

A

Older patients

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12
Q

What is the clinical strategy for any patients with persistent back pain or a neurological deficit?

A

Get an x-ray

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13
Q

Spinal percussion that has exquisite pain or lingers indicates (3)

A
  • cancer
  • fracture
  • spinal infection
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14
Q

Severe localized spasm & rigidity of 3 contiguous vertebral segments may be the result of a cord refle

A
  • a vascular lesion in the cervical spine
  • metastasis in the thoracic
  • prostate or uterine cancer in the lumbar.
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15
Q

If you suspect that your patient’s LBP may be due to cancer, what blood tests should you order first?

A
  • Order ESR (erythrocyte sedimentation rate) (and/or CRP (C-reactive protein))
  • Order CBC (complete blood count)
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16
Q

If you suspect that your patient’s LBP may be due to cancer, what steps should you take (3)

A
  1. Plane film radiograph (if suspicion remains
    high– MRI, CT or bone scan)
  2. Order ESR (and/or CRP)
  3. Order CBC
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17
Q

Plane films are ______ for routine evaluation of patients with ACUTE LBP within the first month unless _________

A
  • Not recommended

- A red flag is noted on clinical examination

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18
Q

What fraction of bone cancers are metastatic? Where are they from?

A

2/3

  • usually from breast , lung, prostate or kidney
  • sometimes colon or thyroid
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19
Q

What finding on a bone scan can signal the presence of cancer? What does it look like?

A
  • Most are Osteolytic: a piece of bone is missing (like breast cancer)
  • Osteoblasts (from prostate cancer): extra bone
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20
Q

How does a bone scan work?

A

Radioactive dye accumulates in bone with a higher metabolic rate— in this case, widespread bone cancer.

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21
Q

On average, what are the chances that cancer causing LBP will show up on an x-ray on the first visit?

A

About 68%

22
Q

For NMS cases, ESR and/or CRP are sensitive or specific?

A

Sensitive (good for screening) but not very specific (so a lot of false positive results)

23
Q

What is LeFebvre’s 20-50 rule for interpreting a patient’s ESR?

A

If the ESR is elevated a small amount (1 or 2) you will not be worried if there are no other findings. If it is greater (>50) you will suspect there is something wrong (Do MRI and advanced imaging). If <20 it’s abnormal but probably not clinically meaningful.

24
Q

What kinds of disease categories can an elevated ESR signal? (3)

A
  • Multiple myeloma
  • Temporal arthritis
  • Polymylagia rheumatica
25
Q

A combination of ______ and _______ constitutes a very sensitive screen for serious malignancies or infections

A

Normal ESR and X-rays

26
Q

Anemia is present in about ___% of cases with cancer, compared to 14% in all other cases. You test for anemia with a ____ lab

A

50%, CBC

27
Q

Put in order from greatest +LR to least:

Elevated ESR
Clinical judgment
Reduced HCT (anemia)
Prior history of cancer

A

Prior history of cancer
Reduced HCT (anemia)
Elevated ESR
Clinical judgment

28
Q
  • Increased WBC (>11,500) can signal (3)
  • increased immature WBC can suggest (1)
  • depressed WBC can suggest (1) or other cancers
A
  • infection, cancer, or inflammatory disease
  • leukemia
  • multiple myeloma or other cancers
29
Q

Small increases in serum calcium (>10.2 mg/dL) are (concerning/not)?

A

Never ignore even small increases in serum calcium

30
Q

What are two most common causes of elevated calcium?

A
  1. Metastatic cancer

2. Hyperparathyroidism

31
Q

50-75% of _____ cancer patients will have elevated ALP. Think of 4 things

A

Osteoblastic

Paget’s disease, healing fracture, growing bones, pregnancy and liver disease

32
Q

What are clues that a patient’s low back pain may be visceral in origin (4)?

A
  1. Menstrual cycle change
  2. Periodic pain unassociated with movement or activity
  3. Colicky (pain that comes in waves) or cramping pain (abdomen or pelvis)
  4. Writhing pain
33
Q

Which type of cancer is

  • usually associated with nausea and vomiting
  • may be made worse by recumbency
  • relieved by knees drawn up and forward flexion (pathognomic)?
A

Pancreatic cancer

34
Q

Where are Pain referral patterns for:

  • pancreas
  • kidney
  • urinary bladder
  • colon
  • gynecological disorders
  • sigmoid colon, rectum, pelvic
A
  • pancreas: similar to a low back support brace
  • kidney: above belt on one side
  • urinary bladder: inside legs on both sides
  • colon: mid lumbar
  • gynecological disorders: rarely refer above L4
  • sigmoid colon, rectum, pelvic: usually sacral
35
Q

When someone has pelvic pain think (3)

A
  • endometriosis
  • Fallopian tube pain
  • rupture ovarian cyst
36
Q

Your patient his low back pain secondary to spinal cancer. What would be the likely results in the following tests? CRP? CBC? Blood chemistry panel?

A
  • CRP: elevated
  • CBC: anemia, increased white cells signal infection cancer or inflammatory disease, increased immature white cells signal leukemia, depressed white cells suggest multiple myeloma or other cancers
  • Blood chemistry panel: increased serum calcium, alkaline phosphatase
37
Q

What basic three diagnostic tools do physicians have to figure out what is wrong with their patients?

A

History
Physical exam
Ancillary studies

38
Q

Your patient has both LBP and symptoms in their leg. What are the 5 possible diagnostic possibilities you need to explore to solve the patient’s back and foot complaints?

A 
Neuropathy
Radiculopathy 
Myelopathy 
Spread out lesions 
Deep referred pain
39
Q

About what vertebral level does the spinal cord end?

A

L1-L2

40
Q

What is the most common type of spine related extremity pain seen in practice?

A

Sclerotogenous referred pain

41
Q

What is the story of convergence-projection and the role it plays in deep referred pain syndromes?

A

Neurological pathways from the low back converge with pathways from the leg in the spinal cord

42
Q

What is the story of central sensitization and the role it plays in the clinical picture?

A

Pain signals from injured tissue in the facet/disc/ligament activate the spinal cell

43
Q

When patients have leg or arm symptoms with spinal pain, one of the top priorities is to decide if the symptoms are ________

A

Neuropathic or not

44
Q

What are the 5 key clues from the H&P to focus on to see if your patient has neuropathic pain or not?

A

History
1. Leg pain (territory? quality? more intense
than the LBP?)
2. Paresthesia (territory?)

Physical Exam

  1. Lumbar tension tests
  2. Neurological deficits/abnormalities
  3. Lumbar joint loading procedures that cause immediate leg sx
45
Q

If there is nervous tissue damage, what is the next step?

A

Find out where/what part

46
Q

What are the 5 key findings to look for from the H&P that would support a radicular syndrome?

A
  1. Leg pain: May be past the knee & dermatomal, feel superficial. Often: Stabbing, electrical, sharp. Severity: Often worse than back pain. May be affected by spine position
  2. Leg paresthesia: Often present and in a dermatomal distribution
  3. Sensory, motor, reflex testing: May be one or more deficits usually corresponding to the same tests)
    nerve root (instead of sensory deficit, there may be hypersensitivity)
  4. Nerve tension tests: Often reproductive leg symptoms
  5. Spinal loading procedures: Rapid reproduction of leg symptoms possible
47
Q
  1. What are 4 characteristics of the pain itself that would be consistent with a radicular syndrome?
A
  • Location: Past the knee, dermatomal, feels superficial
  • Quality: Often sharp, stabbing, electrical, painful cold, lancinating
  • Severity: Leg pain often worse than back pain
  • Affected by spinal position: Sometimes affected by spine position
48
Q

What are three main components of. Neurological exam?

A

Sensory, motor, reflex

49
Q

Dermatomal sensory distribution is most often due to _______

A

Nerve root compression from a herniated disc or spinal stenosis

*sensory disturbance may set in before muscle weakness or atrophy

50
Q

What is a pure patch? Where are the pure patches for S1, L4 and L5?

A

An area of the skin where only one nerve root supplies

  • S1 = just below lateral malleolus
  • L4 = medial shin
  • L5 = top or medial side of big toe

Spinal Disorders - Me (8 decks)

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