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Red Flags for potential serious spinal pathologies

Yannick Tousignant-L

Created on June 21, 2022

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Transcript

screening for

Red flags

associated to spinal conditions

a pragmatic adaptation of the 2020 IFOMPT framework

Creation: Yannick Tousignant-Laflamme, PT, Ph.D

Reproduced with permission from the Journal of Orthopaedic and Sports Physical Therapy

STEP 1: Determine your level of concern in regards to the presence of a serious pathology

Sous-titre

Level of concern

Reproduced with permission from the Journal of Orthopaedic and Sports Physical Therapy

Based on the prevalence of the different pathologies in your context of practice, on the presence of risk factors/signs/symptoms associated to a high probabiliy of serious pathology and the profile of your patient.

RED FLAGS: clinical features associated with a high level of suspicion that a fracture is the cause of spinal pain ?

Clinical signs

symptoms

RISK Factor

History of osteoporosis*

Neurological signs

Thoracic pain*

History of ostooporotic facture + presence of other osteoporosis risk factors

Back pain with a history of cancer, myeloma or osteoporosis

Bilateral (or quadrilateral) neurological symptoms, including gait disturbance and coordination issues, bladder and bowel disturbance

corticosteroid*

Reproduced with permission from the Journal of Orthopaedic and Sports Physical Therapy

Steroid use (>5mg) for >3 months

Severe and unfamiliar pain

history of cancer

relevant investigations to confirm the hypothesis fracture?

Especially cancers with a high risk of bone metastasis: breast, prostate, lung, kidney, thyroid

Describes pain that is unfamiliar and possibly worsening pain

spinal deformity

Sudden changes in anatomical structures associated with trauma or in a patient with known osteoporosis

severe trauma*

Immediate pain during a severe traumatic event

Neurological symptoms

Female sex*

Spine tenderness

Bilateral (or quadrilateral) symptoms, including gait disturbance and coordination issues, bladder and bowel disturbance

Menopause that started at a young age

Tenderness or reproduction of symptoms on palpation or percussion/vibration

older age*

Women: >65 y.o.; Men > 75 y.o.; for all patients > 80 y.o.

Previous spinal fracture*

contusion/abrasion

*these elements have a high level of Evidence

Signs of contusion/abrasion to the spinous processes following trauma

History of spinal atraumatic fracture (low impact event)

History of falls

History of falls or comorbidities that increase the risk of falls

Creation: Yannick Tousignant-Laflamme

RED FLAGS: clinical features associated with a high level of suspicion that a cancer is the cause of spinal pain ?

symptoms

clinical signs

Risk factor

Neurological signs

past history of cancer*

Severe pain

Severe, constant and progressive pain; described as band-like pain, and inability to lie flat

Bilateral (or quadrilateral) neurological symptoms, including gait disturbance and coordination issues, bladder and bowel disturbance

Especially cancers with a high risk of bone metastasis: breast, prostate, lung, kidney, thyroid

Night pain

Reproduced with permission from the Journal of Orthopaedic and Sports Physical Therapy

People who report having to walk the floors or sit in a chair or lie on the floor, with minimal relief

relevant investigations to confirm the hypothesis of cancer?

Systemically unwell

The patient reports characteristics of hypercalcemia, such as fatigue, nausea, stomach pain and fever. These also tend to be progressive in nature

Altered sensation from the trunk down

Thoracic pain

Evidence of loss of sensation in the trunk and/or lower limbs (quadrant)

Back pain, may be painful on percussion over the area of pain. May not be a mechanical pain pattern

neurlogical symptoms

Bilateral (or quadrilateral) symptoms, including gait disturbance and coordination issues, bladder and bowel disturbance

Spine tenderness

Tenderness or reproduction of symptoms on palpation or percussion/vibration

*these elements have a high level of Evidence

Unexplained weight loss*

> 5% loss of body weight in < 3 months

Unfamiliar back pain

Pain described as unfamiliar and possibly worsening

Creation: Yannick Tousignant-Laflamme

RED FLAGS: clinical features associated with a high level of suspicion that a cauda equina syndrome is the cause of spinal pain ?

symptoms

clinical signs

Sensory change

Abnormal lower-limb neurology

Back pain+ typical signs

History of sensory disturbances in the lower limbs

Neuro examination shows significant deficits in the lower limbs

Back pain WITH: saddle anesthesia, age<50 years, bilateral and/or alternating lower limb symptoms, new motor weakness, obesity

Motor weakness (lower limbs)

Reproduced with permission from the Journal of Orthopaedic and Sports Physical Therapy

History of weaknesses (motor) in the lower limbs

Sensory defecit in saddle to light touch and pinprick

Urinary and/or bowel incontinence

relevant investigations to confirm the hypothesis of cauda equina syndrome?

Saddle sensory disturbance

History of disturbed sensations (tingling) in the perineum

Reports incontinence for no other reason

Changes and sensory loss in the perineum

Unilateral/bilateral leg pain

erection/ejaculation disorders

Reduced anal tone

Unilateral symptoms that have progressed to bilateral symptoms

Recent changes/disorders related to symptom onset

A rectal examination shows a loss of tone

loss of sensation during sexual intercourse

constipation

Associated with other signs and symptoms and the onset of clinical presentation

risk factors

Loss of sensation during sexual relations

Herniated intervertebral disc

Urinary function

Urinary frequency and retention

Clinical evidence of disc herniation

History of falls

lumbar spinal stenosis

History of falls or comorbidities that increase the risk of falls

Clinical evidence of lumbar stenosis

Creation: Yannick Tousignant-Laflamme

Red flags: clinical features associated with a high level of suspicion that an infection is the cause of spinal pain ?

Clinical signs

symptoms

Risk factors

Neurological signs*

spinal pain*

Comorbidities

Unexplained and progressive pain in the spine, limiting ++ mobility

Presence of comorbidities (poorly controlled) that cause immuno-supression + history of infection

Bilateral (or quadrilateral) neurological symptoms, including gait disturbance and coordination issues, bladder and bowel disturbance

Reproduced with permission from the Journal of Orthopaedic and Sports Physical Therapy

neurological symptoms

Surgery: invasive

Bilateral (or quadrilateral) neurological symptoms, including gait disturbance and coordination issues, bladder and bowel disturbance

relevant investigations to confirm the hypothesis of infection?

Recent spinal surgery, especially a revision

Radiculopathy

Intravenous drug use

fatigue

Progressive and significant neurological deficits (weakness <3/5)

ANORMAL fatigue and limiting usual activities

IV drug user with intravenous drug abuse

Fever*

social deprivation

Fever (and chills) consistent with the onset of painful symptoms

Material and social disadvantage, health determinants + unfavorable living conditions, alcoholism

Spine tenderness on palpation

Unexplained weight loss

tuberculosis

Tenderness or reproduction of symptoms on palpation or percussion/vibration

> 5% loss of body weight in < 3 months

Exposure to tuberculosis, without immunization

Recent infection

History of recent infection +progressive symptoms (degenerate)

*classic triad of Evidence of Infection

Creation: Yannick Tousignant-Laflamme

Treat or refer?

STEP 2: Determine your action

Reproduced with permission from the Journal of Orthopaedic and Sports Physical Therapy

Based of your level of concern, should you begin a trial of therapy, treat with a safety net or refer out for medical/urgent investigation?

STEP 3: Establish a trajectory for patients referred out

Trajectory for medical referral

Reproduced with permission from the Journal of Orthopaedic and Sports Physical Therapy

Medical emergency or need a medical consultation? Know your local resources to support patients in need of medical care.

CLINICAL DECISION SUPPORT-TOOL

Patient presenting with S & S consistent with MSK condition

MAJOR evidence of red flags

NO evidence of red flags

Provide care guided by best practice+ monitoring of S & S

SOME evidence of red flags

Medical emergency

Re-evaluation

Appearance of new signs or symptoms that worsen

Normal/expected progress

NO improvement / new signs or symptoms

Refer for further invensitatioins

progress as expected

VIGILENCEbegin trial of treatment WITH safety net

goals attained + discharge

Creation: Yannick Tousignant-Laflamme