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Low Back Pain Triage: Identification of Serious Spinal Pathology

Presented by: Dr Debra Shirley FACP PhD BSc

Specialist Musculoskeletal Physiotherapist

Will commence LIVE from Sydney, Australia at 7:30pm AEST

Andrew Ellis BSc (Ex. Sci), M. Phty

World Health Webinars CEO

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Dr Debra Shirley

• Specialist Musculoskeletal Physiotherapist and Fellow of the

Australian College of Physiotherapy.

• Senior Lecturer in Musculoskeletal Physiotherapy

• Director of Social Inclusion at the Faculty of Health Sciences at the

University of Sydney.

• Extensive experience in teaching musculoskeletal physiotherapy at

entry level and post graduate Masters in Manipulative

Physiotherapy.

• Presented on international manipulative physiotherapy courses at

the University of Birmingham and the DVMT in Germany.

• Debra is a co author of the APA Clinical Guidelines for Assessing

Vertebrobasilar Insufficiency in the Management of Cervical Spine

Disorders (2006).

• Member the NSW Physiotherapy Council and previously served

as Deputy President of The NSW Physiotherapists Registration

Board and as a Director of the Australian Physiotherapy Council.

Specialist Musculoskeletal Physiotherapist

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Low Back Pain Triage:

Identification of serious spinal pathology

[email protected]

Learning Outcomes

1. Describe a selection of specific/serious pathology affecting the lumbar spine that need to be differentiated from non-specific low back pain.

2. Identify the information (red flags) from the history and physical examination that might signal the risk of a specific/serious pathology.

3. Evaluate the diagnostic utility of red flags and discuss how this influences clinical reasoning.

4. Discuss when it is necessary to refer a patient for further medical evaluation.

Where is my pain coming from?

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Diagnostic Triage for LBP

Idiopathic = non-specific Spinal nerve/nerve root compromise

Acute Chronic

Syndrome Idiopathic / NSLBP

~90%

The Back Pain Revolution, G. Waddell (2004)

Diagnostic Triage for LBP

<1%

Benign (e.g. OA) Serious

serious (red flags) eg tumour, cauda equina, fracture, myelopathy, infection

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Serious Pathologies

Fracture

Cancer

Infection

Inflammatory conditions

– eg ankylosing spondylitis

Cauda equina syndromes

Myelopathy

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Red flags for possible serious spinal pathology

Consider prompt referral (less than 4 weeks)

Presentation under age 20 or onset over 55

Non-mechanical pain

Thoracic pain

Past history - carcinoma, steroids, HIV

Unwell, weight loss

Widespread neurological symptoms or signs

Structural deformity

(Waddell 2001 RCGP acute LBP guidelines )

Cauda Equina syndrome

Immediate referral

Sphincter disturbance

Gait disturbance

Saddle anaesthesia

Waddell 2001 RCGP acute LBP guidelines

Red flags for Serious Pathology

<20, >50 yrs

trauma / unwell / RUWL / +’ve investigations

Structural deformity

History of Ca, steroids, drug abuse, HIV

Constant

Non mechanical pain

S&S inflammatory disorders

family history of inflammatory disorders

Need to use clinical reasoning and investigate further if concerned

Waddell (2004): p 12

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Age and Red Flags

Older age: Pre-test probability of a GP patient with back pain having cancer -

<50years - 0.14%

>50years - 0.56%

Back pain in young person < 20, potential red flag conditions (cancer, inflammatory back disease, stress fracture)

Dr J Bleasel 2005

Red Flags

Significant weight loss

Fevers

IV drug use

Constant pain, nocturnal pain

Pre existing Carcinoma

Additional symptoms in other systems

Neurological impairment

Severe, highly localised pain

Red Flags

Appear throughout the history but we actively search

for them in the SPECIAL / SPECIFIC QUESTIONS

Purpose;

To alert the PT to possible serious pathology

Alert PT to precautions or contraindications to treatment

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Special Questions (all conditions)

General health

PH Cancer

Unexplained weight loss

Recent X-rays or investigations

Medications

Oral steroids (osteoporosis)

Other Joints

Special Questions

Lumbar spine

Cord signs

• Bilateral non-dermatomal Sx and ataxia

Cauda Equina syndrome

• Changed bowel or bladder function, saddle anesthesia

Cervical spine

Dizziness (vertibrobasilar insufficiency)

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Debate: “To Screen or Not to Screen?” Ross 2010

Challenge: Identify which red flags are representative of specific pathological conditions Ross 2010

Eg night pain

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Specific pathology/Serious Spinal Pathology

Henschke et al 2008

• Many suggested but none with good sens and spec in isolation and poorly investigated

• >80% prevalence of one red flag

• 11/1172 (serious pathologies, 8 fractures)

• 6/11 identified by clinician

BUT

• Mean age for sample population was 44

Conclusion

• Most patients at least 1 red flag finding

• Individually red flags uninformative

Debate: “Time to Lower the Red Flags?” Underwood 2009

Clinicians should consider a small number of disorders

CE syndrome

Major IA pathology

Focal infections

Fractures

Time as a diagnostic tool for the remainder

Concern screening will lead to increased costs from investigations

Fracture

Traumatic fracture: in normal bone, should be significant history of trauma, eg fall from a height or MVA

Low trauma fracture (fragility fractures): fall from standing height, slip, trip or fall

– Suggests osteoporosis

Fracture after 50 should have bone density test

http://www.orthopaedicsurgeon.uk.com/traumasurgery/spinalfracture/

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Osteoporosis

Decrease density of bone, increase risk of fracture

Risk factors

− Female, post- menopausal

− Increasing age male and female

− Family history

− Medical conditions eg liver, kidney disease, RA, thyroid/parathyroid disease

− Drugs: steroids, alcohol

http://imaging.consult.com/image/chapter/Interventional?title=Vertebral%20Height%20Restoration&image=fig1&locato

r=gr1a&pii=S1933-0332%2808%2973352-4

Vertebral Fractures

Incidence x 3 hip fractures

1 in 3 will come to medical attention

Female : Male 2:1

In Europe, one in eight men and women over the age 50 years have evidence of vertebral deformity (EVOS)

3 fold variation across Europe and up to 2 fold variation within individual countries (EVOS)

White women = Asians > African-American and Hispanic

Woolf Fragility Fractures 2011

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Prevalence of vertebral deformity

In Europe for Age and Gender


Increased Risk of Second Fracture

Prevalent vertebral fracture and new vertebral fracture in next year (Lindsay et al JAMA 2001)

1 prevalent fracture RR 2.6

≥1 RR 5.1

≥2 RR 7.3



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Diagnosis of Osteoporotic Fracture

Xray

Bone scan: will differentiate old vs new fractures

Bone densitometry:

– measure of bone density at hip and lumbar spine

– Does not diagnose fracture

http://www.ajnr.org/cgi/content/full/21/10/1807/F1

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Osteoporosis risk factors

Area of pain

Family history

Weight loss

Family history of op or hip fracture

Early menopause hormone deficiencies etc

Establish amount of height loss since age 25 (+ tsp pain)

Any fractures since age 45-50

Bleicher K, Naganathan V, Cumming RG, Seibel MJ, Sambrook PN, Blyth FM, et al. Prevalence and treatment of osteoporosis in older Australian men: Findings from the CHAMP study. Med J Aust. 2010;In press ; accepted for publication 01/07/2010

Likelihood Ratio

+LR sensitivity/1-specificity

-LR 1-sensitivity/specificity

Eg for Ca previous Hx Ca sens 0.31 sp 0.98

+LR 0.31/1-0.98 = 0.31/0.02 = 15.5

-LR 1-0.31/0.98 = 0.69/0.98 = 0.70

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Screening for spinal fracture

Henschke et al 2008

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Metastatic Cancer

http://images.rheumatology.org/image_dir/album75684/md_99-21-0026.tif.jpg

The skeleton is the most common organ affected by metastatic cancer

tumours arising from breast, prostate, thyroid, lung, and kidney spread to bone

Rarer conditions: leukaemia, lymphoma, 1 bone tumours

Bone pain from structural damage, rate of bone resorption, periosteal irritation and nerve entrapment

Dr J Bleasel 2005

The skeleton is the most common organ affected by metastatic cancer

tumours arising from breast, prostate, thyroid, lung, and kidney spread to bone

Rarer conditions: leukaemia, lymphoma, 1 bone tumours

Bone pain from structural damage, rate of bone resorption, periosteal irritation and nerve entrapment

Key findings / Red flags

Age > 50

Significant recent WL

Previous malignancy

Constant pain not relieved by postural change or rest,

Pain present at night and disturbing sleep

50% clients with back pain from malignancy have an identifiable (or attributable) antecedent injury or trauma

Dr J Bleasel 2005

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Screening for Malignancy

Henschke et al 2007 Eur Spine J (2007) 16:1673–1679

Screening for malignancy

Henschke et al 2007 Eur Spine J (2007) 16:1673–1679

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Case 45 year old male

Quality control manager

Aggs: lying supine, coughing and sneezing, prolonged walking, and sitting >1 hour

Ease: heat, Ibuprofen

PM: pain, difficulty sleeping

CH: 2/12 no incident, p&n 1/52

PH: L LBP no limitation

GH , CE , Nil other SQ

Ross MD. J Orthop Sports Phys Ther. 35(10): 651-58. 2005

Case 45 year old male

PE

Slight antalgic gait

Ext and LLF sl back and thigh

Neuro L2 and L3 strength, Reflexes

L SLR 45 thigh pain



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FIGURE 3. Anterior-posterior radiograph of the lumbar spine demonstrating mottled lucencies overlying the left sacroiliac wing

(oriented to the right in this image).


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FIGURE 5. Bone scan revealing increased abnormal uptake compatible with metastatic disease throughout the spine, sacrum, and left hemipelvis. An anterior view is on the left and a posterior view is on the right.


Infection

Osteomyelitis of the spine is rare (2-4% osteomyelitis)

Mortality 1 to 20%

Vertebral osteomyelitis children, ages 1-15, adults 50-70

Usually two vertebrae and a disc are involved

The lumbar spine has of osteomyelitis with the thoracic and cervical regions being affected to a lesser extent.

The most common area for spinal osteomyelitis is in the vertebral body

The primary etiology of contamination is from distant infections, often emanating from the respiratory or urinary tract

Boeglin JOSPT Volume 22 (6) 1995 267-271

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Pain is the most frequent symptom associated with osteomyelitis

muscle spasm is the most frequent sign

Decreased active range of motion secondary to pain is also a consistent finding

Infection


Case 32 Year old male

CH Insidious LBP for 2/52 ??due to prolonged sitting

ED Pain meds home GP toradol pain

PH 10 years LB and leg pain


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Case 32 year old male PE

Lateral shift to right

AROM but full passive ROM no pain

Paravertebral muscle tenderness

Neuro NAD

Slump +ve

Segmental mobility forward and backward bending NAD

RX 2/52 but no significant improvement


MRI and Xray- infection

T1-weighted sagittal MRI image, there is decreased signal intensity (black) primarily of L2 and L3

Xray shows loss of L2-3 disc space (white arrow). Infection has spread into epidural space (black arrow)

Disc-space infection and osteomyelitis

http://images.rheumatology.org/viewphoto.php?albumId=75683&imageId=2862066

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Infection as a cause of Back Pain

Suspected primarily on history

Cardinal feature is fever

Other important risk factors

– Previous infection eg UTI

– IVDU

– Skin lesions

– IV catheters and urinary catheters

– Occupational exposure

Dr J Bleasel 2005

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Lumbar Osteomyelitis

Commonest organism (60% of cases) Staphylococcus aureus

Gram negative organisms in elderly and from IVDU

Workers in the meat processing industry - Brucellosis infection

Tuberculous and fungal infections

Elderly

Immunocompromised individuals

May be present for years before diagnosis

http://radiopaedia.org/images/25251

Dr J Bleasel 2005

Sepsis in other sites

Disciitis- localised pain in back

Sacroiliac joint- Pain in low back, buttock

Any septic patient- red flags

– Fever, sweats, night pain

– IVDU, skin lesions

– invasive procedures (IV lines, Urinary catheters

– Recent infection

http://emedicine.medscape.com/article/340211-overview Dr J Bleasel 2005

Septic Sacroiliitis

Right sacroiliac joint-

Increased sclerosis,

joint space widening,

irregular joint margin

left sacroiliac joint is normal.

Joint aspiration:

Staph aureus

Symptoms include acute onset severe right lower back pain associated with high fever.

http://imaging.consult.com/imageSearch?query=joints&qyType=AND&global_search=Search&modality=&thes=true&normalVariantImage=false&groupByNode=none&anatomicRegion=&modalityFilter=Conventional%20Radiography

Dr J Bleasel 2005

Seronegative Spondyloarthropathies

Inflammatory arthropathies

– Axial skeleton

– Sacroiliac joints

– +/- Peripheral joints

Prominent enthesopathy (inflammation at insertion of tendon or ligament)

Extra-articular manifestations eg. skin and gut

http://www.aafp.org/afp/2004/0615/p2853.html Dr J Bleasel 2005

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Disease

Ankylosing spondylitis

Psoriatic arthritis

Reactive arthritis (Reiters Disease)

Ulcerative Colitis, Crohns disease: inflammatory bowel disease may have associatedc Arthritis

Juvenile ankylosing spondylitis

http://homepages.which.net/~ks.burrell/nassdb/Spinal%20xray.htm

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AS Incidence and Prevalence

0.5-2.0% prevalence

– Higher in selected ethnic groups

5:1 male:female ratio

Incidence 6-7 cases per 100,000 per year

Natural history

– Progression towards ankylosis - may be over many decades, some cases asymptomatic - found on x-rays

Dr J Bleasel 2005

Red flags Inflammatory disease

Onset before age 40

Insidious onset

Morning stiffness lasting >30 mins

Persisting beyond 3 months

Not responsive to conservative treatment

Peripheral joint involvement

In combination are suggestive of sero negative arthridities

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Ankylosing Spondylitis

Medical History Sensitivity Specificity LR+ LR-

Ankylosing Spondylitis

4 out of 5 0.23 0.82 1.28 0.94

Onset <40 1 0.07 1.08 0

Pain not relieved supine 0.8 0.49 1.57 0.41

Morning stiffness 0.64 0.59 1.56 0.61

Pain duration >3/12 0.71 0.54 1.54 0.54

Case 32 year old female

Commercial Pilot

10/12 LBP L buttock and thigh

GP after 2/12 LB strain

Sev month later worse MRI L4/5 degen disc

Agg “twisting”, lying down to sitting and sit to standing, walking for exercise, and coughing or sneezing,

Ease changing positions and gentle exercise, but not with prolonged rest.

AM pain few mins moving eases

Day with increasing levels of activity, not as active as usual.

GH NAD meds

Seif and Elliott Physiotherapy Theory and Practice, 28(1):2012, 63–70

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Case 32 year old female PE

Two of the four SIJ provocation tests (sacroiliac distraction and compression) were +ve

Special tests (FABER), painful and limited hip flexion

The positive slump test

Full, pain-free LROM

RX muscle energy motor control some improvement

Worse after 3-4 visits, by 5th visit markedly worse, am stiffness, difficulty getting dressed refer


http://imaging.birjournals.org/cgi/content-nw/full/17/3/171/F33

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Radiology

Sacroiliitis

– Erosions

– Subchondral sclerosis

– Ankylosis

Spine

– Anterior erosions

– Squaring

– Syndesmophytes- anterior border to anterior border

– Fusion- Bamboo spine

http://homepages.which.net/~ks.burrell/nassdb/Spinal%20xray.htm

Dr J Bleasel 2005

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Syndesmophytes

http://www.nature.com/nrrheum/journal/v8/n1/full/nrrheum.2011.183.html

http://wiki.cns.org/wiki/index.php/Ankylosing_spondylitis

http://www.radrounds.com/photo/1791588:Photo:9383?context=top

KATARIA et al Am Fam Physician. 2004 Jun 15;69(12):2853-2860

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Spinal canal stenosis

Occurs in older individuals, >65

Hypertrophic degenerative processes in spine

⇒ critical narrowing of spinal canal

Due to combination of features

– Osteoarthritic changes at facet joints

– Degenerative disc bulges

– Ligamentum flavum hypertrophy

– Degenerative spondylolisthesis

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Clinical Presentation

?? Burning pain (neurogenic)

No change to pulse

No trophic changes

symptoms with spinal Ext

symptoms with spinal Fl

symptoms standing

Symptoms may respond to rest

Vascular claudication

Throbbing pain

Diminished or absent pulses

Trophic changes

Pain not related to spinal positions

No pain on standing

symptoms with activity, promptly relieved by rest or cessation of activity

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Red Flags in a child with back pain

Progressive pain not responding to analgesia Pain that awakes the child at night Fever Weight loss Severe constipation Adoption of abnormal postures Development of scoliosis Reduction in mobility & abnormalities of gait Sphincter dysfunction

Dr J Bleasel 2005

Spine injury in young athletes

Lumbar spine # less common than c spine

Compression fractures most common

Disc herniation (associated with fracture of the ring apophyses)

Spondylolysis (47% of adolescents with back pain), 85-95% L5

Maxfield. Radiol Clin N Am 48 (2010) 1237–1248

Spondylolysis in children with LBP

Presents as LBP

Agg by activity

Minimal physical findings

Misdiagnosis common

Up to 45% of LBP in athletic adolescents

Early diagnosis important to prevent progression

Plain xrays not always helpful

Treatment with activity restriction

Ralston and Weir 1998

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Summary

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Red Flags requiring evaluation

Back pain or symptoms not improving

Steady pain irrespective of activity

Symptoms increasing

Development of new or progressive neurological deficits

Identifying Serious pathology

Sound Clinical reasoning

Knowledge of red flags

May not be apparent on first visit

Monitor progress

Develop expectation from treatment ie expected outcome and timeframe

Reassessment really important

Clinical Judgment shouldn’t be underestimateed

http://gal3.piclab.us/key/lower%20back%20pain%20cartoons

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Live Q & A With Debra Shirley

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Live Q & A With Debra Shirley

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From Debra Shirley

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