Red Flags Flashcards
-Initial presentation (LBP) <20 or > 50
- Unusual to have first episode of LBP in these times frames
<10yo could imply infection or tumours of spinal column or cord
> >10yo possible causes: Spondylosis/spondylolisthesis Scheurmann’s disease Herniated nucleus pulposus Overuse syndromes Tumours Incidence of many cancers increase after 50
-Violent trauma e.g. fall from height, RTA
- May imply undiagnosed fracture or head injury
-Minor trauma e.g. lift- osteoporosis
insufficiency fracture
-Constant, progressive, non-mechanical pain
- Consider ‘Aggs and Easers’
- Patients with established serious spinal pathology are unlikely to get any relief even from NSAIDs or analgesics
- Unremitting back pain, not relieved by rest is the most common feature (90% patients) in patient with spinal infection
-Thoracic pain
- Often caused by metastases (breast/lung)
- Could imply tuberculosis (intractable pain)
-PMH - carcinoma
PMH Carcinoma
Personal history & close family history (1st degree relative) should be established
Common warning signs of cancer:
Change in bowel/bladder habits Sores that do not heal Usual bleeding or discharge Thickening or lump in breast or elsewhere Indigestion or difficulty swallowing Obvious change in mole/wart Nagging cough/hoarseness (Pfalzer, 1995)
Cancer causes 12% of all deaths worldwide every year
BUT it is estimated that neoplastic disease accounts for just 0.7% of all LBP (Jarvik & Deyo, 2002)
-Systemic steroids
Closely linked with vertebral compression fracture (#)
Particularly when combined with >50 years old
May also predispose patient to infection
-Drug abuse, HIV
Closely associated with skeletal TB infection
22% of all AIDS patients have TB as opportunistic infection
-Night pain, worse when supine.
Highly significant if night pain is reported as most severe pain episode in any 24 hour period
Patients report needing to get out of bed, pacing or needing to doze in chair should raise concern
Could imply spinal tumour
However patients with mechanical dysfunction can report back pain in bed when turning in bed
Consider the wider clinical presentation
-Systemically unwell.
Differs for adults and children Children – In rare cases could indicate: JIA (Juvenile Idiopathic arthritis) Metastatic neuroblastoma Aplastic anaemia Idiopathic thrombocytopaenia Infections mononucleosis (Glandular fever) Leukaemia (fever, bruising, pallor, mood changes, fatigue)
Adults
Could indicate myeloma
Could indicate infection
-Unexplained weight loss e.g. 1 stone in 6/52
Debate about how much over weight loss over what time period is considered significant (see table)
Rapid weight loss is associated with disseminated tumours
However in some cancers weight loss is rare (myeloma)
Some cancers weight may increase in early stages
> 10% BW loss high index of concern
-Persistent severe restriction Lx flexion.
Could imply serious spinal pathology
Often flexion can be limited by pain therefore restriction must be severe and persistent
-Wide spread neurological S&S.
Rarely the first symptom in serious spinal pathology
May imply a systemic neurological condition
MS, MND, brain tumour
-Structural deformity
Rapid onset of scoliosis could be associated with osteoma or osteoblastoma
-Abdominal pain & change of bowel habit for no apparent reason
Some cancers are associated with hypercalcaemia (breast, lung, myeloma)
Hypercalcaemia is a high calcium (Ca2+) level in the blood serum
Symptoms of hypercalcaemia
Abdominal pain
Constipation
Nausea or vomiting
Poor appetite
However, Opioid drugs are often associated with constipation
