Spinal Disorders Week 1 - Ts versino Terms in this set (146) How much unexpected weight loss on average is enough to be considered a red flag for a patient with LBP? 10lbs or more over 3 months Is no relief from bed rest a more sensitive or more specific

Spinal Disorders Week 1 - Ts versino Terms in this set (146) How much unexpected weight loss on average is enough to be considered a red flag for a patient with LBP? 10lbs or more over 3 months Is no relief from bed rest a more sensitive or more specific sign for cancer as a cause of LBP? Highly sensitive (>90%) -meaning is a good cancer screening tool for patients with LBP What is the first step in the DDX of a NMS condition? Decide if the LBP is due to disease or injury Then determine if there is nerve damage or not About what % of LBP patients have a serious condition like cancer or spinal infection? Older estimates are about 3% -1% due to local disease, 2% referred pain from GI, reproductive, or urinary systems Later study suggests it may be <1% Which red flag would have the strongest influence on when the suspect possible spinal cancer causing LBP? Having a prior history of cancer (+LR 16-23) Other red flags: -failure to respond to conservative care for 1 month (+LR 3.1) -weight loss >10lbs in 3 months (+LR 2.5) You percuss the SPs of a patient with LBP and the patient experiences a lingering sharp pain. What are the three conditions that might do that? Spinal infection Cancer Fracture You think your patient may have multiple myeloma. What specific blood test could you order that would help you confirm that diagnosis? Serum protein electrophoresis What three systems can cause visceral referred pain to the low back? Give examples Reproductive (endometriosis) GI (pancreatitis) Urinary (bladder cancer) What are the first 3 ancillary tests to order if there are sufficient red flags from the history Radiograph ESR or CRP Spinal Disorders Week 1 - Ts versino What are the key elements of LeFebvre's 20- 50 rule for ESRs? ESR elevated but <20mm/hr = generally not a concern ESR >20mm/hr = more concerning that there may be a disease lurking, often you can treat and monitor carefully if not too high ESR >50mm/hr = likely a disease process present, after radiograph consider advanced imaging -the closer you get to 50, the more you want to do more tests What 3 tests on a blood chemistry panel relate to spinal cancer? Serum calcium ALP Serum proteins What are the two most common causes of elevated calcium? Metastatic cancer -40-50% of pts with metastatic cancer to bone will have elevated calcium Hyperparathyroidism Cancer/hyperparathyroidism account for 90% of people with hypercalcemia What are 3 blood test values that when elevated suggest an inflammatory disease (including infections and cancers)? ESR CRP CBC (WBCs) What are 5 diagnostic possibilities for a patient presenting with leg and back pain? Nerve involvement 1. Cord lesions (only upper lumbar lesions) 2. Nerve root lesions (include cauda equina) 3. Peripheral nerve lesions (sciatica/femoral neuropathy) No nerve involvement 4. Deep referred pain (from SI/lumbar structures) 5. Separate lesions (along the kinetic chain) What are the 5 key clues/tools from the history and physical exam in a patient with LBP and leg pain? History 1. Leg pain (territory? quality? more intense than LBP?) 2. Paresthesia (territory?) Physical exam 3. Nerve tension tests 4. Neurological deficits/abnormalities (SMRs) 5. Lumbar joint loading procedures that cause immediate leg symptoms What parts of the nervous system are you tensioning with the SLR? Sciatic nerve L4, L5, S1 Your patient has weak dorsiflexors. Where in the nervous system could the lesion be? Deep peroneal nerve, L4, or L5 What are the signs and symptoms of cauda equina syndrome (CES)? Urinary retention Urinary incontinence Saddle paresthesia Sexual dysfunction Rectal sphincter weakness What are the 2 most common causes of cauda equina syndrome (CES)? Large midline disc herniation Lumbar spinal stenosis What ancillary tests would you order to confirm if there was nervous tissue damage and to locate where that lesion might be for a patient with anterior thigh pain? Needle EMG Nerve conduction study (NCV) Spinal Disorders Week 1 - Ts versino What are 3 UMNL findings? DTRs hyperreflexia (+3, +4) Pathological reflexes (eg Babinski) Clonus Remember: sensory changes are not examples of UMNL findings and muscle fasciculations indicate a LMNL What is the blood test of choice to screen for diabetes? Hgb A1C (>6.5% or 7%) What is central sensitization? Cells in the pain pathway of the spinal cord become easily excitable (the WDR spinal cell's excitatory threshold lowers) and discharge in circumstances that they normally would not One result is spinal cord cells in the "leg" pathway can now discharge even when stimulated by injured tissue that is only embryo logically related (low back tissue). Made possible because of convergence projection "cross-wiring" linking the low back pathway with leg pathway What is multiple myeloma? Most common primary malignant bone cancer -MRI + -bone scans appear normal -forms in WBC (plasma cells - which help fight infections by making antibodies that recognize/attack germs) -multiple myeloma causes cancer cells to accumulate in the bone marrow, where they crowd out healthy blood cells Who is at higher risk for developing multiple myeloma? Patients >50 with chronic LBP and anemia (of chronic disease) Consider multiple myeloma or spinal infection in patients with above symptoms and recurrent infections What is the blood test of choice to help diagnose multiple myeloma? Serum protein electrophoresis What does the radiograph look like in someone with multiple myeloma? Less dense Affected spinal segments appear with increased translucency Which advanced imaging would be best to diagnose multiple myeloma, a bone scan or an MRI? MRI is preferred (bone scan would be normal so it would be useless) Multiple myeloma is the exception, most bone cancers will have a positive bone scan What serious condition can result in a patient having to sleep in a chair because of their LBP? Malignant retroperitoneal lymphadenopathy -causes excruciating pain when lying supine, relieved by sitting up/hunched over a table What is the current thinking regarding night pain as a red flag for cancer? Why? A study of 482 patients found that 43% reported some night pain and 20% presented with pain "every night." There was NO correlation with serious disease (Harding 2004) A number of guidelines no longer include night pain, although there may still be concern when the (exception) pain is severe, progressive, or unabated by position Is unexplained weight loss better at ruling in possible cancer or ruling it out? Ruling in (94% specificity) +LR 2.5 In what patient population are neurological deficits an increased risk for possible cancer? Elderly Any patient over 50+ back and leg pain + neurological deficits = consider possibility of cancer, order at least an x-ray If you suspect that your patient's LBP may be due to cancer, what blood tests should you order first? 1st: ESR and/or CRP (tests for general diseases, primarily inflammatory infections and sometimes cancer) 2nd: CBC 3rd: Blood chemistry panel (serum Ca, ALP, protein) Spinal Disorders Week 1 - Ts versino What finding on a bone scan can signal the presence of cancer? What does it look like? With radioactive dye > malignancy typically show as "hotspots" due to increased metabolic activity On average, what are the chances that cancer causing LBP will show up on an x-ray on the first visit? 68% Note: plain films are not recommended for routine evaluation of acute LBP unless a red flag is present If we suspect pathology + LBP, start by ordering plain films. If suspicion still high, order MRI, CT, or bone scan What kinds of disease categories can an elevated ESR signal? Inflammation Cancer Infection Kidney Thyroid disease (>100mm = multiple myeloma, temporal arthritis, polymyalgia rheumatica) Your patient has LBP, loss of calcium as seen on an x-ray, and elevated ESR of 90mm/hr. What condition do you think of first? Primary or metastatic bone cancer 40-50% of patients with metastatic cancer have elevated calcium What types of bone conditions does ALP go up in? Blastic lesions, Paget's disease, growing bones, pregnancy, liver disease, and prostate cancer 50-75% of cancer patients have elevated ALP What are clues that a patient's low back pain may be visceral in origin? Periodic and non-associated with movement (not aggravated by bending/lifting) Colicky (cramping) Writhing pain (can't sit still) Menstrual cycle abnormalities Little low back muscle spasm, tenderness, or segmental restriction compared to MSK issue Where are pain referral patterns in the back for kidney disease, colon disease, urinary pain, and pancreatitis? Pancreatitis: relieved by knees drawn up and forward flexion -refers pain in a band on the lumbars/low back Pelvic organs: pain may be on opposite side as pathology Kidney refers on one side in low back, urinary bladder refers into coccyx and groin area Colon: refers to mid lumbar spine Gynaecological disorders: refers usually L4 and below Sigmoid colon, rectum, pelvic organs: refers usually sacral Your patient has LBP secondary to spinal cancer. What would be the likely results in the following tests? (CRP, CBC, blood chemistry panel) Elevated CRP Increased EST Low Hgb and anemia Increased serum calcium or ALP What are the 3 options you have to choose from when you see red flags and LBP? First need to find out from history and physical exam how many red flags there are, and decide how serious they are -treat anyways but monitor patient carefully to see if they worsen or don't respond to care Worried enough that you order more tests (plain film, blood work, etc) Red flags are very worrying, might order tests yourself or refer out immediately Your patient has LBP and you decide to perform spinal percussion. What constitutes a positive test? What does it mean if percussion is positive? Patient reports pain that is exquisite and lingers Spinal infection (most sensitive and specific), cancer, or fracture Spinal Disorders Week 1 - Ts versino You do motion palpation of your patient's spine and find severe local muscle spasm with severe lack of ROM of 3 continuous spinal segments. What might be the cause? Cord reflex from: -cervical spine: vascular lesion -thoracic spine: spinal metastasis -lumbar spine: prostate or uterine cancer You suspect possible cancer in your patient whose ESR came back elevated. Next you order a CBC. What results might come back that confirm your suspicion of cancer? Low Hgb/anemia -50% of cancer patients have anemia (14% in all other patients) -anemia and LBP is a red flag Increased WBC -signals spinal infection, cancer, or inflammatory disease ( just like elevated ESR) Increased immature WBC -suggests leukaemia Decreased WBC -suggests multiple myeloma or other cancers Altered WBC and LBP is a red flag In patients with sensory loss and back or leg pain, what three types of neurological lesions are in your differential diagnosis? Myelopathy: cord lesions (most common in upper lumbar/TL junction) Radiculopathy: nerve root lesions (cauda equina, disc herniation, stenosis) Neuropathy: peripheral nerve lesions (sciatica, femoral, etc) What are the different sensory modalities that are tested? What spinal cord tracts does each one travel in? Posterior (dorsal) column: proprioception, vibration, fine touch, 2pt discrimination Lateral spinothalamic tract: pain, temperature Anterior spinothalamic tract: crude touch, pressure What is paresthesia? How does it differ from pain? Paresthesia is not painful Paresthesia is pins/needles, itchy, crawly What is the proper term for diminished pain sensation? Hypoalgesia What is the proper term for diminished ability to feel a cotton ball? Hypesthesia (or hypoesthesia) What is the proper term for absence of the ability to discriminate light touch? Anesthesia What is the proper term for increased sensitivity to a noxious stimulus? Hyperalgesia What is the proper term for a pain response to a Semmes-Weinstein assessment? Allodynia What is the proper term for exaggerated pain response to a pinwheel? Hyperalgesia What is the proper term for increased sensitivity (but no pain) to light brushing over the skin? Hyperesthesia What is the proper term for unpleasant but not painful reaction to a cotton ball? Dysesthesia What does the term dermatome refer to? The area of the skin that is supplied by a specific nerve root What nerve root, family of nerves, or peripheral nerve may be implicated in loss of feeling along the side of the little toe? S1 (pure patch) Superficial peroneal nerve What nerve root, family of nerves, or peripheral nerve may be implicated in loss of feeling on the medial side of the great toe? L5 (L5 pure patch is medial head of 1st metatarsal) Deep peroneal nerve What nerve root, family of nerves, or peripheral nerve may be implicated in loss of feeling along the medial side of the lower leg? L4 Saphenous nerve What nerve root, family of nerves, or peripheral nerve may be implicated in loss of feeling along the lateral side of the lower leg? L5 Superficial peroneal nerve What nerve root, family of nerves, or peripheral nerve may be implicated in loss of feeling in the thumb and first finger? C6 Radial nerve (dorsal surface) Median nerve (palmar surface) What nerve root, family of nerves, or peripheral nerve may be implicated in loss of feeling in the middle finger? C7 Radial nerve (dorsal surface) Median nerve (palmar surface) What nerve root, family of nerves, or peripheral nerve may be implicated in loss of feeling in the lateral aspect of the upper arm? C5 Axillary nerve (upper) Radial nerve (lower) What nerve root, family of nerves, or peripheral nerve may be implicated in loss of feeling down the midline of the anterior upper thigh? L2 Anterior femoral cutaneous nerve What nerve root, family of nerves, or peripheral nerve may be implicated in loss of feeling just above the knee? L3 Anterior femoral cutaneous nerve What nerve root, family of nerves, or peripheral nerve may be implicated in loss of feeling in the 5th finger? C8 Ulnar nerve What nerve root, family of nerves, or peripheral nerve may be implicated in loss of feeling in the medial forearm and upper arm? T1 Medial brachial cutaneous nerve (upper arm) Medial antebrachial cutaneous nerve (forearm) Where is the pure patch for C8/ulnar nerve? Medial tip of the 5th digit Where is the pure patch for C7? There is none Where is the pure patch for C6/radial nerve? Thumb web (dorsal aspect) Where is the pure patch for C6/median nerve? Lateral tip of index finger Where is the pure patch of C5/axillary nerve? Over deltoid tubercle Where is the pure patch of L4? Midway medial lower leg Where is the pure patch for L5? Medial head of 1st metatarsal Where is the pure patch for S1? Lateral little toe You discover that your patient has diminished sense of pain at the tip of her thumb. What's the very next thing to do before you move on to other procedures? Map out the boundaries of the abnormal pain sensation -work from distal to proximal to find an area of normal sensation Next will have to figure out of it is a nerve root, peripheral nerve, its it's bilateral/unilateral etc Your patient has loss of vibration. What are some diseases that affect the spinal cord that would be in your DDX? What are diseases of peripheral nerves that you should consider? Spinal stenosis, upper lumbar disc herniation, TL junction compression fracture, tabes dorsalis, or a tumor Diabetic neuropathy, multiple sclerosis, alcoholic neuropathy, vitamin B12 deficiency What is the advantage and disadvantage of hot and cold testing over testing for pain? Advantages: temperature loss may precede loss of pain perception and this has been found to be more discriminatory than loss of pain perception Disadvantages: pain is easier to assess How is position sense usually tested? Patients eyes closed, move finger and/or toe up and down and ask which way it was moved Where do temperature signals cross the body in the CNS? Where does vibratory sense cross the CNC? Where does pain cross? Where does proprioception cross? Pain, temperature, and crude touch (lateral/anterior spinothalamic tracts) crosses immediately at the same spinal cord level -this means that a spinal cord lesion on one side would result in deficits in the opposite extremity Vibration, proprioception, and fine touch (dorsal columns) crosses in the medulla (brainstem) -lesion is on the same side as the deficits Your patient has an area where he cannot feel touch, vibration, pain, or position sense. Is the lesion more likely in the spinal cord, a nerve root, or peripheral nerve? Either the spinal cord was completely severed (which is not possible as there would be more obvious issues with the patient than just sensory less), or the injury happened before the sensory impulse had a chance to split into the different tracts in the spinal cord Therefore, a nerve root or peripheral nerve issue is most likely, but we would need more specific information regarding the sensory loss to distinguish between the two What basic 3 diagnostic tools do physicians have to figure out what is wrong with their patients? History Physical exam findings Ancillary studies About what vertebral level does the spinal cord end? L1-L2 What are three causes of spinal cord compression in the TLJ region of the spine? TLJ compression fracture Upper lumbar disc lesion Spinal canal stenosis Tumor Besides leg symptoms, what other symptoms do you need to ask a patient to screen for cord involvement and LBP? Check for SMR deficits Check for + babinski Check for + Romberg Check for - nerve tension tests and spinal loading tests Ask about bowel/bladder function How do you perform Romberg's test? Ask the patient to stand with their feet touching one another, and ask them to close their eyes. With their eyes remained closed, see how long the subject may stand with minimal to no swaying Patient should be able to stand for 20 or 30 seconds What conditions can a positive Romberg test suggest? #1 cause is myelopathy Less common but possible causes are peripheral nerve lesions, multiple nerve root lesions, cerebella's disease, or vestibular disorders What sensory modalities are conducted in the posterior column of the spinal cord? PVT-2nd class (proprioception, vibration, touch, 2pt discrimination) What spinal tract does pain and temperature travel in? Lateral spinothalamic tract Spinal Disorders Week 1 - Ts versino If you had a spinal cord compression on the right, which leg would likely to lose pain sensation, position sense, 2pt discrimination, vibration? The left leg would lose pain and temperature: these tracts decussate at the level of the spinal cord The right leg would lose proprioception, vibration, and 2pt discrimination: these decusate in the brainstem What are the key lower extremity reflex changes to check for in the lower extremity if the patient has myelopathy? Clonus Babinski sign Loss of cremasteric reflex What are the 5 key exam findings suggesting a cauda equina syndrome? Which one is the most common? 1. Saddle anesthesia: 80% sensitivity -bilateral, but can be unilateral -should test light touch and sharp -altered perineal sensation may be most important predictor of impending bowel or bladder dysfunction 2. Bladder -painless urinary retention and overflow incontinence (retention is the most common CES symptom) -incomplete CES: urinary difficulty, altered urinary sensation, loss of desire to void, poor urinary stream, need to strain to urinate -complete CES: urinary retention, overflow incontinence, complete saddle anesthesia 3. Bowel -inability to control defecation -sense rectal fullness -decreased anal sphincter tone 4. Anal "wink" -normal response (-): contraction of the external anal sphincter when perianal skin is scratched -abnormal response (+): no contraction 5. Sexual dysfunction: -decrease in penile/labial sensation -inability to get or maintain an erection -reduced sensation during sexual stimulation **when both urinary dysfunction and saddle hypesthesia are present, CES is strongly suspected What are the 3 most common causes of cauda equina syndrome? Midline disc herniation Severe spinal stenosis Tumor Other causes: Infection Hematoma Keep in mind that CES is extremely rare, but requires urgent referral What nerve roots are affected in CES? S2, S3, S4 **not a spinal cord injury An exam finding has +LR of 18. Is that considered a small increase, moderate increase, or large increase in the probability of a particular diagnosis? A large increase A test has a -LR of 0.1. Does that tend to decrease the probability of a specific disease a small amount, a moderate amount, or a large amount? A large amount What is the relationship of bilateral sciatica Bilateral sciatica isn't unique to CES, but is often present Spinal Disorders Week 1 - Ts versino What peripheral nerve injury can mimic some of the neurological symptoms of CES? What can cause this condition? Pudendal nerve compression (Alcock's syndrome) -caused by a fall on the buttocks, childbirth, chronic defecation straining, vigorous bicycling -may be present as unilateral or bilateral perineal pain (burning/foreign body in rectum/vagina) What are 4 characteristics of the pain itself that would be consistent with a neuropathic syndrome? Sharp, electrical, stabbing, lancinating