Red flags for back pain

Question 1

Which cancers metastasize to bone?

Answer 1

Kinds of Tumours Leaping Promptly To My Bone

Kidney 
Ovarian 
Thyroid 
Lung 
Prostate 
Testicular (only certain types)
Myeloma 
Breast

Question 2

Which cancers are common with back pain?

Answer 2

Metastasis related to a primary tumour.
Myeloma.
Chondrosarcomas.
Sarcomas.

Malignancy is rare but never miss cause and an important group of differential diagnoses.

Question 3

Characteristic of pain that indicates a malignancy?

Answer 3

Night-time pain or pain that is worse when supine.

Thoracic back pain indicates malignancy.

Question 4

How would the investigations for back pain indicate malignancy?

Answer 4

Plain x-rays- may demonstrate lysis of the vertebral body or posterior elements.

MRI- either a lytic or blastic lesion with varying T2 signal intensity. Lesion typically doesn’t cross the end plate, but soft tissue extension may be present.

CT- lytic destruction of the vertebral body with possible soft tissue extension, blastic lesions possible.

Question 5

Which infections can cause back pain?

Answer 5

Infections that could cause back pain includes discitis, osteomyelitis and TB.

Question 6

Which symptoms suggest an infective cause?

Answer 6

Fever
Night-time pain
Wight loss

Question 7

What would the examination show if there is an infective cause?

Answer 7

Specific areas of tender with associated swelling and redness around the affected area.

Question 8

Inflammatory causes of back pain

Answer 8

Inflammatory/autoimmune conditions that can cause back pain includes inflamatory spondyloarthropathy e.g. ankylosing spondylitis, connective tissue diseases and reactive arthritis.

Question 9

What is cauda equina syndrome?

Answer 9

Spinal cord compression at the cauda equina.

If there is compression of the spinal cord, a patient develops myelopathy.

Question 10

Where is the cauda equina?

Answer 10

The cauda equina ‘horses tail’ starts at L1 which is the end of the conus medullaris. This is where all the nerve roots come together.

Question 11

Why is it important to never miss cauda equina syndrome?

Answer 11

If compression occurs at the Cauda equina patients will have a specific set of symptoms that you MUST always ask about. This is a surgical emergency and needs immediate referral. If it is left untreated it can lead to permanent leg paralysis, and loss of bladder and bowel control.

Question 12

What are the symptoms and signs of cauda equina syndrome?

Answer 12

Bilateral sciatica/leg pain.
Severe or progressive bilateral neurological deficit of the legs.
Difficulty initiating micturition or impaired sensation of urinary flow, with later retention and overflow.
Loss of sensation of rectal fullness and later faecal incontinence.
Saddle anaesthesia or paraesthesia.
Laxity of the anal sphincter.
Significant muscle weakness.
Loss of tendon reflexes in the limbs.
Erectile dysfunction.
Urinary retention.
Diagnosis made by X-ray, CT or MRI.

Question 13

Clinical features of cauda equina syndrome

Answer 13

History:
Bowel or bladder or sexual dysfunction, back pain with or without sciatica.
Symptoms may come on gradually; history of lumbar disc herniation, spinal stenosis, spinal injury, spinal neoplasm (primary or metastasis), infection (e.g., tuberculosis), spinal surgery.

Examination:
Sensory changes in saddle or perianal area.
Sensory changes or numbness in the lower limbs.
Lower limb weakness, reduction or loss of reflexes in lower limbs; reduced anal tone.

Question 14

Investigations to diagnose cauda equina syndrome

Answer 14

MRI with or without contrast: compression of the cauda equina.
CT myelography: Compression of the cauda equina.

Question 15

Treatment of cauda equina syndrome

Answer 15

Emergency decompression of the spinal canal within 48 hours after the onset of symptoms.

Question 16

Complications of cauda equina syndrome

Answer 16

Pressure ulcers.
Discectomy-related complications.
Postoperative autonomic dysfunction.
Cardiovascular dysfunction.
Heterotopic ossification.
DVT 
UTIs
PE
MRSA infection.

Question 17

Clinical features of AAA?

Answer 17

Symptoms: 
Sudden onset of intermittent or continuous abdominal pain, radiating to the back. 
Patient may collapse. 
Older age. 
Hx of cardiovascular disease.

Examination:
Pulsatile abdominal mass.
Hypotension or hypertension.
Tachycardia.

Investigations:
Abdominal ultrasound: extent and size of aneurysm.
CT: clearly defines aneurysm and involvement of visceral arteries.

Question 18

Clinical features of MSCC

Answer 18

> 50 years old
Gradual onset
Severe unremitting pain
Night pain disturbing sleep
Pain worse with straining/ coughing/ sneezing
Thoracic pain
Localised spinal tenderness
No symptomatic improvement after four to six weeks of conservative low back pain therapy.
Unexplained weight loss.
Past history of cancer — breast, lung, gastrointestinal, prostate, renal, and thyroid cancers are more likely to metastasize to the spine

Question 19

Clinical features of infective causes of back pain

Answer 19

Fever
Tuberculosis, or recent urinary tract infection
Diabetes
History of intravenous drug useHIV infection, use of immunosuppressants, or the person is otherwise immunocompromised

Question 20

What are x-ray limitations as a diagnostic tool for back pain?

Answer 20

Not very useful as an investigation for back pain.
They can be useful to identify fractures and in established ankylosing spondylitis.
MRI scans are more useful to identify spinal and soft tissue pathology including nerve root compression and Cauda equina.
NICE advices that MRI scans should be done in secondary care if this helps with further management.
Radiation exposure is significantly higher during a spinal X-ray than a CXR.

Question 21

What are the red flag symptoms of back pain?

Answer 21

Fever
Pain at night, progressive or constant pain, pain lying flat
Alcohol or drug use
Trauma
Weight-loss
Reduced appetite
Neurology – weakness, numbness
Bladder or bowel symptoms
History of cancer
Significant trauma (or acute back pain in elderly ? osteoporotic wedge fracture)

Question 22

What are the symptoms of spinal fractures

Answer 22

Sudden onset, severe pain, relieved by lying down.

History of trauma (this may be minor in those with osteoporosis)

Structural spinal deformity

Point tenderness over a vertebral body.