Red flags

Question 1

Common red flags- cancer

Answer 1

Previous history of cancer, unintentional weight loss (5% weight over 6/12)m pt feels generally unwell, smoking, obesity, ethnicity, gender, age

Question 2

cancer- malignant

Answer 2

metastasize through blood, lymph or direct extension
cells display uncontrollable rapid and often aggresive growth, cells invade and destroy structures adjacent to the tumour, cannot be removed with surgery alone, will need to be combined with radiotherapy or chemo

Question 3

cancer- benign

Answer 3

do not metastasize, do not grow in unlimited, out of control, aggressive manner, do not invade surrounding tissues, can be removed with surgery alone

Question 4

spinal tumors

Answer 4

60% extradural (outside CNS) usually in the vertebral body, presenting features of spinal tumours: PMH of cancer, smoking history, localised pain, night pain, weight loss, mass>?

Question 5

Metastatic spinal cord compression- RED FLAGS

Answer 5

Reffered back pain, Escalating pain that responds poorly to Rx, Different location of sx to previous, Funny feeling, heavy legs, Lying flat increases back pain, Agonising back pain causing despair, Gait disturbances, Sleep disturbed

Question 6

Local pathway for MSCC with a hx of cancer

Answer 6

Oncology emergency- should be discussed with MSCC coordinators available through UHL switchboard

Question 7

Local pathway for MSCC without a hx of cancer

Answer 7

Should have full bloood screen by GP and referred through 2 week pathway to acute spine clinic.

Question 8

New onset of hard neurology red flags that are suspected of being an emergency and no known Hx of Ca

Answer 8

can be discussed with on-call spine consultant

Question 9

Signs of spinal malignancy- history of cancer and constant pain

Answer 9

History of cancer- 50% metastasise in first 5 years- ask where was the cancer and how aggressive was it?
Severe, constant or progressive pain- can increase with lying flat- check for band-like pain (MSCC)

Question 10

Signs of spinal malignancy- night pain and systemtically unwell

Answer 10

Night pain- pain unremitting
Systemically well- stages of fatigue, nausea, constipation, stomach pain and fever

Question 11

Signs of spinal malignancy- thoracic pain, neurological S+S, Unexplained weight loss

Answer 11

Thoracic- most common site for metastatic bone cancer, might have a mechanical pattern to start with, might be tender to touch
Neurological S+S- loss of nerve function (Espicially BL or QL) or UMN or CES
Unexplained weight loss- 5-10% over 3-6 months

Question 12

Signs of spinal malignancy- unfamiliar back pain, altered sensation from trunk down, spinal tenderness

Answer 12

unfamiliar back pain- not like normal back pain and progressively worse
Altered sensation from trunk down- non-dermatomal and strange sensation in legs- difficult to describe, decreased mobility
Spinal tenderness- tenderness on palpation, percussion or vibration

Question 13

what is it Cauda equina syndrome?

Answer 13

A person presenting with acute back pain and/or leg pain with suggestions of bladder or bowel function and/or saddle sensory disturbance should be suspected of having CES

Question 14

When does CES occur

Answer 14

As a result of compression of 2 or more of the 20 nerve roots that originate from the conus meduallris

Question 15

Risk factor CES

Answer 15

Large central disc herniation at the L4-5 or L5-S1- higher risk in <50 year olds and obese people
Lumber spinal stenosis- can result in slow onset of CES, typically leg aching or cramping or tingling and heaviness provoked by walking and eased by sitting
Lumber surgery- can cause extradural spinal haematoma

Question 16

CES delve deeper- urinary dysfunction

Answer 16

How often do you pass urine? how much do you drink? what do you drink in a day?

Question 17

CES delve deeper- bowel dysfinction

Answer 17

any abnormal pain or distention, have the constancy or colours of stools changed, have you vomited lately

Question 18

Medical considerations CES

Answer 18

Other medical condition- DM/MA/alcholism/Smoker/CV

Question 19

Medical considerations CES- medication

Answer 19

tramadol/coedine- constipation, reduced bladder sensation
Gabapentin/pregabalin- urinary incontinence
Amitriptyline- retention/ reduced awareness to pass urine, sexual dysfunction
Naproxen/ibuprofen- retention

Question 20

CES delve deeper

Answer 20

hobbies- cycling- pudendal nerve compression
previous surgery/interventions with childbirth
psychological distress
pain- inhibiting B+B or sexual function

Question 21

CES +/- leg pain with CES symptoms under 4 weeks

Answer 21

emergency scan (same day), contact on call T&O or spinal consultant or registrar to discuss case
Send pt with letter- ensure pt understands urgency/seriousness

Question 22

CES +/- leg pain with CES symptoms over 4 weeks

Answer 22

urgent scan- MRI within 2/52

Question 23

Bilateral sciatica- gross motor weakness (<3/5) or deterioating neurology

Answer 23

Urgent MRI, saftey net for CES

Question 24

Bilateral sciatica with normal neurology

Answer 24

treat s per radicular pathway. saftey net for CES

Question 25

Saftey net

Answer 25

saftey net patient with CES card and a clear explanation to seek urgent medical help- 111 or A+E within 24 hours, explain the consequences, document it