What are red flags?
Features from a patient’s subjective and objective assessment
that put the patient at higher risk of serious or sinister pathology and require onward
referral for further investigation and diagnostic testing
Red flags of spinal neoplasm
- history of cancer (breast, bronchus, thyroid, kidney + prostate)
- unexplained weightloss - late sign of neoplasm
- night pain that disturbs sleep + night sweats - early symptom of neoplasm as body’s iflammatory response to the cancer/ hormonal changes
- no improvement in symptoms in a 4-6week period
- pain at rest
- age >50, <20
GP URGENT refferal / bloods / imaging etc
Red flags of Abdominal Aortic Aneurysm
- pulsating abdominal mass
- past history of atherosclerotic vascular disease
- pain at rest
- men aged >66 women >70
- Risk factors Chronic Obstructive Disease, Coronary, Cerevrovascular or peripheral artery disease.
- Smoking
Ambulance/A&E
red flags of pancreatic cancer
- deep epigastric pain –> 60% radiates to the back
- unexplained weight loss
- pain at rest
- nocturnal pain
- Age >75
- Smoking
- Diabetes
**GP refferal **
Red flags of spinal infection
- immunocompramised state
persistent fever/systematically unwell - recent bacterial infection
- hx of lumbar spine surgery (12 month)
- history of IV drug use
- history of turburculosis
urgent GP or A&E depending on S+S
red flags of a vertebral fracture
- prolonged use of systemic steroids - loss of bone densisty ostepenia/osteporosis
- sudden onset of severe central spinal pain which is relieved by lying down
- history of trauma
- localised vertebral tenderness
- structual spinal deformity
A&E
red flags for back pain
UK Royal College of Emergency Medicine
- non-mechanical
- previous hx cancer, steroids, HIV
- generally unwell
- unexplained weight losss
- widespread neurological symptoms
- structual deformity
- thoracic back pain
what is spondyloarthropathy
group of inflammatory rheumatic diseases
what types of spondyloarthropathy presentation are there
peripheral - Arthritis in joints , Enthesitis tendons and ligaments attach to bone, Dactylitis swelling of digits
Axial - inflammationthe sacroiliac joint and acial skeleton
**extra - articular ** - non joint related symptoms, eye disease, ibs, psoriasis
what are some features of back pain caused by inflammation
- before 35 yo
- improvement within 48hrs of NSAIDs
- Improvement with movement
- Buttock pain
- Walking during second half od night due to symptoms
what are the extra articular features of spondyloarthropathies
Skin
Colitis or Chron’s
Relatives
Eyes
Early morning stiffness
Nails
Dactylitis
Enthesitis
Movement and medication
URGENT GP/ eye hospital/ GP lbp
what is Cauda Equina Syndrome
where the lumbrosacral nerve roots become compressed
what are the symptoms of cauda equina
- Urinary Incontinence (loss of sensation when passing urine)
- Painless Urinary Retention with overflow incontinence - loss of sensation bladder fullness
- saddle anasthesia - numbness in genital/ crotch region
- faecal incontinence
- decreased anal sphincter tone
- bilateral lower extremity weakness / numbness
- progressive neurological deficit - major motor weakness - such as major motor weakness with knee extension, ankle eversion, or foot dorsiflexion, major sensory deficit, gair disturbance.
what are some specific causes of lower back pain
- Discogenic
- Spinal stenosis
- Spondylolysis
- Spondylolisthesis
- Fractures
- Radiculopathy
- NSLBP
discogenic
- altered structure to the disc
- radiating pain +/- altered sensatoin/ lower weakness
- pain + symptoms increase in standind flexion + extension
discs usually are reabsorbed
what is the difference between protrusion, extrusion and sequestration
protrusion - nucleus pulposus pushes outward but is still contained by the annulus fibrosus
extrusion - The nucleus pulposus breaks through the outer annulus fibrosus but remains connected to the main disc
sequestration - A piece of the nucleus pulposus breaks off completely and is separated from the main disc
Spinal stenosis
stenosis is a narrowing of space within the vertebra for vascular and neural structures
S+S of Spinal Stenosis
- radiating pain +/- altered sensation
- weakness into buttock/leg
- pain + symptoms standing and walking
- pain + symptoms decrease sitting and flexion
Spondylosis
degenerative changes in the spine
- osteophytes
- stenosis
- stiffness and decreased ROM and generalised pain/stiff
- Radiating pain +/- altered sensation/ weakness into buttock/ leg
Spondylolysis
Unilateral or bilateral pars interarticularis fracture
causes - trauma/stress/birth defect/ spondylotic changes
S+S spondylolysis
- LBP worsened by activity
- relieved by rest
- pain with extension +/- rotational
- referred pain
- tight hamstrings
- Oblique X-ray - scottie dog sign
Spondylolisthesis
the displacement of one vertebral body over another in anterior direction
graded 1-5
1. <25%
2. <50%
3. <75%
4. >75%
5. complete off
S+S spondylolisthesis
- LBP worse with activity
- eased by rest
- pain with extension +/- rotational movement
- pain may be referred
- tight hamstrings
- step in spinous processes
- X-ray / CT / MRI
fractures
- complete or partial interruption of the continuity of the bone
- compression fractures caused by osteoporosis or trauma
- common site is thoracic/ lumbar junction
- Graded: mild: 20-25%, moderate: 25-40%, severe: >40%
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Mobilisation15
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Lumbar pathologies31
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anatomy - cervical and thoracic spine21
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pathology - cervical and thoracic21
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yoga5
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Adverse Neural Dynamics7
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pain19
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persistent / chronic pain31
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cognitive functional therapy5
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Occupational Health and Work12
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Pelvic health5
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outcome measures6
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Objective Ax14
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physical exercise4
