Midterm - General Questions week 1 Flashcards
What is the first step in differential diagnosis of NMS condition?
Injury or disease?
Musculoskeletal pain from diseases of the spine include (3)
- Metastatic/ primary tumors
- spinal infection
- inflammatory diseases (RA, AS, etc.)
Musculoskeletal pain from diseases not in the spine include (2)
- viscerosomatic referral/ reflexes (e.g. from GI, reproductive, urinary system)
- other: AAA, endocrine
Where are 3 viscerosomatic referral/ reflexes from
- GI
- reproductive
- urinary system
How common are diseases like cancer and spinal infections as a cause of low back pain?
About 3% of LBPis due to serious disease
- 1% = local cancer or spinal infection
- 2% = referred pain (GI, reproductive, urinary)
*some studies suggest <1%
What is the single strongest red flag from a patient’s history that their LBP may be linked to cancer? (What is the LR)
Had cancer before (+LR 16-23, -LR 0.7)
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?)
> 10 lbs over 3 months
Sn = 15%, Sp = 94%
Is no relief from bed rest a more sensitive or more specific sign for cancer as a cause of LBP?
Very common in cancer (>90% sensitivity)
What serious condition can result in a patient having to sleep in chair because of their LBP?
- malignant retroperitoneal lymphadenopathy
- Secondary to lymphomas (older patients) and testicular cancer (men) (both cancers are responsive to treatment).
What is the current thinking regarding night pain as a red flag for cancer? Why?
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
In what patient population are neurological deficits an increased risk for possible cancer?
Older patients
What is the clinical strategy for any patients with persistent back pain or a neurological deficit?
Get an x-ray
Spinal percussion that has exquisite pain or lingers indicates (3)
- cancer
- fracture
- spinal infection
Severe localized spasm & rigidity of 3 contiguous vertebral segments may be the result of a cord refle
- a vascular lesion in the cervical spine
- metastasis in the thoracic
- prostate or uterine cancer in the lumbar.
If you suspect that your patient’s LBP may be due to cancer, what blood tests should you order first?
- Order ESR (erythrocyte sedimentation rate) (and/or CRP (C-reactive protein))
- Order CBC (complete blood count)
If you suspect that your patient’s LBP may be due to cancer, what steps should you take (3)
- Plane film radiograph (if suspicion remains
high– MRI, CT or bone scan) - Order ESR (and/or CRP)
- Order CBC
Plane films are ______ for routine evaluation of patients with ACUTE LBP within the first month unless _________
- Not recommended
- A red flag is noted on clinical examination
What fraction of bone cancers are metastatic? Where are they from?
2/3
- usually from breast , lung, prostate or kidney
- sometimes colon or thyroid
What finding on a bone scan can signal the presence of cancer? What does it look like?
- Most are Osteolytic: a piece of bone is missing (like breast cancer)
- Osteoblasts (from prostate cancer): extra bone
How does a bone scan work?
Radioactive dye accumulates in bone with a higher metabolic rate— in this case, widespread bone cancer.
On average, what are the chances that cancer causing LBP will show up on an x-ray on the first visit?
About 68%
For NMS cases, ESR and/or CRP are sensitive or specific?
Sensitive (good for screening) but not very specific (so a lot of false positive results)
What is LeFebvre’s 20-50 rule for interpreting a patient’s ESR?
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.
What kinds of disease categories can an elevated ESR signal? (3)
- Multiple myeloma
- Temporal arthritis
- Polymylagia rheumatica
A combination of ______ and _______ constitutes a very sensitive screen for serious malignancies or infections
Normal ESR and X-rays
Anemia is present in about ___% of cases with cancer, compared to 14% in all other cases. You test for anemia with a ____ lab
50%, CBC
Put in order from greatest +LR to least:
Elevated ESR
Clinical judgment
Reduced HCT (anemia)
Prior history of cancer
Prior history of cancer
Reduced HCT (anemia)
Elevated ESR
Clinical judgment
- Increased WBC (>11,500) can signal (3)
- increased immature WBC can suggest (1)
- depressed WBC can suggest (1) or other cancers
- infection, cancer, or inflammatory disease
- leukemia
- multiple myeloma or other cancers
Small increases in serum calcium (>10.2 mg/dL) are (concerning/not)?
Never ignore even small increases in serum calcium
What are two most common causes of elevated calcium?
- Metastatic cancer
2. Hyperparathyroidism
50-75% of _____ cancer patients will have elevated ALP. Think of 4 things
Osteoblastic
Paget’s disease, healing fracture, growing bones, pregnancy and liver disease
What are clues that a patient’s low back pain may be visceral in origin (4)?
- Menstrual cycle change
- Periodic pain unassociated with movement or activity
- Colicky (pain that comes in waves) or cramping pain (abdomen or pelvis)
- Writhing pain
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)?
Pancreatic cancer
Where are Pain referral patterns for:
- pancreas
- kidney
- urinary bladder
- colon
- gynecological disorders
- sigmoid colon, rectum, pelvic
- 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
When someone has pelvic pain think (3)
- endometriosis
- Fallopian tube pain
- rupture ovarian cyst
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?
- 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
What basic three diagnostic tools do physicians have to figure out what is wrong with their patients?
History
Physical exam
Ancillary studies
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?
Neuropathy Radiculopathy Myelopathy Spread out lesions Deep referred pain
About what vertebral level does the spinal cord end?
L1-L2
What is the most common type of spine related extremity pain seen in practice?
Sclerotogenous referred pain
What is the story of convergence-projection and the role it plays in deep referred pain syndromes?
Neurological pathways from the low back converge with pathways from the leg in the spinal cord
What is the story of central sensitization and the role it plays in the clinical picture?
Pain signals from injured tissue in the facet/disc/ligament activate the spinal cell
When patients have leg or arm symptoms with spinal pain, one of the top priorities is to decide if the symptoms are ________
Neuropathic or not
What are the 5 key clues from the H&P to focus on to see if your patient has neuropathic pain or not?
History
1. Leg pain (territory? quality? more intense
than the LBP?)
2. Paresthesia (territory?)
Physical Exam
- Lumbar tension tests
- Neurological deficits/abnormalities
- Lumbar joint loading procedures that cause immediate leg sx
If there is nervous tissue damage, what is the next step?
Find out where/what part
What are the 5 key findings to look for from the H&P that would support a radicular syndrome?
- 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
- Leg paresthesia: Often present and in a dermatomal distribution
- 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) - Nerve tension tests: Often reproductive leg symptoms
- Spinal loading procedures: Rapid reproduction of leg symptoms possible
- What are 4 characteristics of the pain itself that would be consistent with a radicular syndrome?
- 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
What are three main components of. Neurological exam?
Sensory, motor, reflex
Dermatomal sensory distribution is most often due to _______
Nerve root compression from a herniated disc or spinal stenosis
*sensory disturbance may set in before muscle weakness or atrophy
What is a pure patch? Where are the pure patches for S1, L4 and L5?
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
