Mr Dean Mistry Katy Street - GP CME North/Sat_room8_0830 GP CME Red flags … · Mr Dean Mistry Orthopaedic ... • Review serious pathologies in the cervical and lumbar ... acute

Mr Dean MistryOrthopaedic Spine Surgeon

Auckland

8:30 - 9:25 WS #94: Red Flags in the Spine

9:35 - 10:30 WS #106: Red Flags in the Spine (Repeated)

Katy StreetPhysiotherapist

Auckland Physiotherapy

Middlemore Hospital

Auckland

Screening for Significant Pathology in the cervical

and lumbar spine

Introductions

Mr Dean Mistry

BHB, MBChB (Auckland) 2000

FRACS (Ortho) 2009

Spine Fellowships in Sydney 2010, Vancouver 2012

www.spinesurgeon.co.nz

Katy Street

BPhty, Cert. MDT, PGDip (Musculoskeletal)

Physiotherapist for Middlemore Hospital Spine Team

Presenting Masters thesis data; Street, K., White, S., & Vandal, A. (2016)

Workshop aims

Review serious pathologies in the cervical and lumbar spine

When to refer patients?

Case presentations

Goals

Categoriseo Neurogenico LBP

Urgently refer or arrange Ix for RFs

Reassure appropriately

Make them comfortable

Keep them active

Watch them get better.

OR, if not getting better, Refer them on

+/- RED FLAGS

Low back pain

8th most common presentation to GPs ~2% case load, affects 80% of people during adulthood

For many, acute low back pain is the first reason to seek medical care as an adult.

Most will be non-specific = no defined pathoanatomical cause, benign course (a study by Deyofound that only 15% of patients receive a specific diagnosis)

Some will not be benign.

Non-specific LBP vs ????

Red Flag Conditions

Red Flags

Cauda Equina Syndrome

Tumour

Fracture

Infection

Cervical Myelopathy

Red Flag Conditions 8th most common presentation to GPs ~2% case load

Inflammatory Disease 5% 1 in 20 patients

Spinal Fracture 4% 1 in 25 patients

Spinal Tumour 2% 1 in 50 patients

Cauda Equina 1% 1 in 100 patients

Spinal Infection 1% 1 in 100 patients

Red Flag Conditions

Rare

Suspected on the basis of HISTORY and EXAMINATION findings

Some will be missed, or have delayed dx (up to 75%)

Many red flags have been proposed and tested very few raise the post-test probability to greater than 1%. The exceptions are previous history of cancer and unexplained weight

loss.

Combinations of positive results are more predictive but are rarely reported on in the literature

Cauda Equina Syndrome (CES)

Sudden loss of function of the lumbar and lumbosacral plexus below the conus

Causes disc herniation tumour infection Stenosis

Early recognition and early decompression can stop progress of neurological deficits


Screening (sensitive tests) useful NOT diagnostic in isolation

Absence of Trauma - most useful

Worse with walking

Unsteady gait

In combination with the following risk factors (specific tests)

Bladder incontinence - PARTICULARLY BLADDER OVERFLOW

Bowel Incontinence

Change in sexual function

Perineal Anaesthesia


Take home message

CES symptoms are varied in presentation

Patients may present with bladder and / or bowel symptoms.

Normal anal tone does not rule out CES.

All risk factors have poor sensitivity

HIGH INDEX OF SUSPICION REQUIRED

Infection

Discitis / osteomyelitis

Epidural abscess

Psoas abscess

Wide presentation , typical vs atypical bacteria

Infection

Fever and back pain are cardinal symptoms

Screening Age > 55y Pain insidious onset, night

pain, worsening pain especially with walking

Fatigue

Risk Factors Immunosuppression Sx of toxicity Exposure recent infection

Infection

Fever and back pain are cardinal symptoms

Investigations

WCC/Neutrophils

ESR

CRP

If all negative then less likely to have infection

Tumour

Most Spinal tumours in adults are metastases

The spine is the most common site for mets and may effect 30-70% of patients (Hatrick et al, 2000)

Mori people had the highest risk of malignancy 12.5 per 100,000 person years, versus 1.2 for Asian people.

Tumour

Screening sensitive BUT NOT specific

Age greater than 42 years and the question has your pain been worsening over time both had diagnostic utility for screening (sensitivity 100%).

Risk factors

A history of cancer, unexplained weight loss (specificity 89-95%).

Night pain had a high false positive rate of 62%

Fracture

2 Groups

1. Traumatic

2. Pathological

(Abnormal Bone) Osteoporosis

Rheumatoid

Ank Spondylitis

Fracture

1. Traumatic High Energy

Neurological involvement

Contusion

Distracting injuries

All

Be suspicious!

Nexus C Spine Rules

For patients with Cervical Spine Trauma

1. Midline Tenderness

2. Neurological change

3. Abnormal Alertness/Intoxication/Distracting injuries

If any of above exist 3 shot C Spine series

If XR normal + Neuro normal Collar and re-XR in 10days Flex/Ext views

If XR normal + Neuro Abnormal Need referral for Hi-tech imaging

Fracture

Pathological Fracture Group

Screening >60yr think

pathological frature

Risk Factors HIV +ve IV Drug Use Osteoporosis

Fracture

Abnormal Bone Rheumatoid Arthritis

AnkylosingSpondylitis/DISH

Fractures are easily missed, particularly in the C-Spine

RA/AS + Trauma + Pain

= Imaging Required

Cervical Myelopathy

Cervical Myelopathy

Narrowing of the cervical spinal canal, causing compression of the spinal cord

Usually degenerative in nature

Common in NZ

Maori and PI populations have a tendency to congenital stenosis

Cervical Myelopathy

Once symptomatic patients have a ~60% chance of neurological deterioration in the next 5-10 years

Cervical Myelopathy

Please be aware of symptomatic patients

Older age group

Neck +/- radicular pain

Clumsiness in hands

Writing

Doing up buttons

Gait disturbance/Imbalance

GROUP 1:

REFER IMMEDIATELY

GROUP 2:EXPIDITIOUS

SPECIALIST REFERRAL

GROUP 3: TRIAL OF TREATMENT

+ INVESTIGATIONS

GROUP 4:

TRIAL OF TREATMENT

GROUP 4:

TRIAL OF TREATMENT

GROUP 2:EXPIDITIOUS

SPECIALIST REFERRAL


+ INVESTIGATIONS

GROUP 1: REFER IMMEDIATELY

Risk FactorsSevere, worsening painSepticemia febrile, back painCatastrophic neurological changes

Sphincter lossSaddle/perianal anaesthesiaBilateral radicular symptomsProgressive neurologyHigh energy trauma or trauma with neurological sx

Pathologies Cauda equinaInfection with systemic toxemiaHigh likelihood of spinal tumourUnstable Fractures/Spinal Cord Injury