September 5 th – 8 th 2013 Nottingham Conference Centre, United Kingdom nspine.co.uk

1. September 5th – 8th 2013 Nottingham Conference Centre, United Kingdom www.nspine.co.uk

2. Red Flags Carla Eveleigh Spinal ESP and Physiotherapist September 2013

3. Aims and Objectives Recap of red flags Hierarchical red flag list Discuss signs, symptoms & management of; Cancer/metastases/MSCC/myeloma Fractures Infection/discitis Cauda Equina

4. Definition Red flags are a list of prognostic variables for serious pathology such as: Tumour Infection Fracture Cauda Equina Syndrome (Greenhalgh & Selfe 2010)

5. Red Flags Serious spinal pathology is rare <1% cases It is well recognised that the earlier patients with serious pathology are identified the better the patient outcome (Wiesel et al 1996)

6. Hierarchical List of Red Flags Greenhalgh & Selfe 2010 Age >50 years History of cancer Unexplained weight loss Failure to improve after 1 month of EB conservative therapy

7. Hierarchical List of Red Flags Greenhalgh & Selfe 2010 Age <10 & >51 Medical history of: Cancer, TB, HIV/AIDS, IV drug abuse, OP Weight loss (>10% body weight in 3-6 months) Severe night pain Positive plantar response CES symptoms: loss of sphincter tone, altered S4 sensation, bladder retention, bowel incontinence

8. Red Flags Constant progressive pain Band-like pain Thoracic pain Inability to lie supine Disturbed gait Legs feeling heavy, misbehaving Smoking Systemically unwell Bilateral P/Ns in hands +/or feet Clinician “gut feeling” (Greenhalgh & Selfe 2010)

9. Cancers, Metastasis Cancers most commonly seeding metastases to the spine are: Breast, Prostate, Lung Mechanism of metastatic disease is via tumour emboli entering the blood stream. Venous drainage from the breast is via azygos veins into thoracic paravertebral venous plexus, therefore commonly leads to thoracic mets (Frymoyer 1997) Up to 85% of women with breast cancer develop skeletal mets before death (Centre for Chronic Disease Prevention and Control 2007)

10. Malignant Spinal Cord Compression (MSCC) Spinal mets can cause MSCC 5% of all patients with cancer present with MSCC (Levack et al 2002) First symptoms are pain (Levack et al 2002) Reduced control of legs, foot drop, dragging legs can be an early signs but often under reported as it is vague & as patient not aware of significance (Greenhalgh & Selfe 2008) Can present with radicular symptoms due to compression

11. Malignant Spinal Cord Compression (MSCC)

12. Management MRI scan is the gold standard investigation Whole spine Emergency MRI <24 hours Bloods FBC, ESR, CRP, U&Es, LFTs, bone, PSA (for men) Review with oncologist, spinal consultant (Levack et al 2002) Specialist Oncology Nurse Practitioner

13. Myeloma Primary malignant spinal cancer Results in bone reabsorption (secondary to excessive plasma cells) Multiple myeloma is not curable, early diagnosis reduces risk of spinal cord compression (UK Myeloma Forum 2006) Subjective assessment gives clearer indications of serious pathology than objective (Deyo et al 1992) Average age of diagnosis is 65 Male:Female 2:1 (American Cancer association 2005) Can report fatigue due to anaemia (American Cancer Association 2005)

14. Myeloma Subjective signs: Bone pain – lumbar spine, pelvis, ribs Tired Thirsty Easily bruise Main objective signs: Associated fractures LL radiculopathy Hypercalcaemia

15. Myeloma

16. Investigations Whole MRI on urgent basis; can be large discrepancy between site of pain and level of compression (Levack et al 2002) Referral on to oncologist / consultant Bone Scan – full body Bone marrow biopsy FBC, U&Es Urinalysis – Bence Jones protein

17. Fractures Result from trauma or minimal trauma if osteoporotic Individuals are unaware they have osteoporosis until they sustain a fracture (Bennell et al 2000) In out-patient setting more likely to see osteoporotic fractures DEXA scan is gold standard for diagnosis

18. Fractures

19. Osteoporosis risk factors • Post menopausal women; consider menopausal age, years since menopause • Exercise status • Loss of height • Difficultly lying in bed (Bennell et al 2000) • Altered bone absorption; coelaic disease, IBS, eating disorder, hyperthyroidism • Corticosteroids use; RA patient, weight lifter (International Osteoporosis Foundation 2008)

20. Infection / Discitis Inflammation of vertebral disc, often associated with infection and can co-exist with vertebral osteomyelitis Most commonly in lumbar spine, cervical then thoracic spine usually haematogenous spread of infection. Urinary tract, lungs and soft tissues are common primary sites Staphylococcus aureus is the most common pathogen Most common in males >50 Risk factors; immunosuppressed, lifestyle, substance misuse

21. Infection / Discitis

22. Infection / Discitis • Presentation; insideous onset, pain on movement, fever, weight loss, can affect mobility, can have neurological deficit • Investigations; blood tests (ESR, CPR, WBC), MRI is most sensitive, blood, sputum, urine cultures to identify source of infection • Treatment; antibiotics oral / IV, analgesia, surgical intervention

23. Cauda Equina Syndrome Cauda Equina is a bundle of nerve roots which descend within the spinal canal, distal to the conus medullaris, approx L1-L2 (Williams et al 2003) Compression can cause variety of motor and sensory problems of LLs, pelvic viscera and pelvic floor dysfunction (Wiesel et al 1996) Most significant is compromise of S4 which leads to bladder/bowel disturbance (Brier 1999)

24. Cauda Equina Compression

25. Symptoms Other symptoms: Faecal incontinence, sexual dysfunction Objective assessment: • Reduced anal tone and power (60-80%) • Sacral sensory loss (85% cases) (Jalloh & Minhas 2007) • Bladder scan (post void) >150ml

26. Management Emergency MRI scan Follow local CES pathway, spinal fellow oncall Post operative follow up in specialist CE clinic

27. Masqueraders Carla Eveleigh Spinal ESP and Physiotherapist September 2013

28. Aims and Objectives • Awareness of visceral pain • Visceral pain referral patterns • Signs and Symptoms of non-MSK pain

29. Groups • Body Chart – visceral referral • List signs and symptoms of: • Cardiovascular system 2. Genitourinary system 3. Respiratory 4. Nervous system / MSK 5. Endocrine

30. Anatomy Reminder

31. Cardiovascular system Potential signs and symptoms: • Chest pain on exertion, can be minimal • Angina can be throat, jaw, left arm • Breathlessness • Waking at night (paroxysmal nocturnal dysnoea) • Palpitations • Limb pain on activity • Claudication pain in LLs • Ankle swelling • BP high or low • Persistent cough • Ausculation findings

32. Genitourinary system • Dysuria (pain on micturation) • Frequency during the day and/or night • Urine offensive / discoloured • Haematuria (blood in urine) • Sexual partners – unprotected intercourse

33. Genitourinary system Men: • Prostatic problems – hesitancy, poor flow, terminal dribbling • Incontinence • Urethral discharge • Erectile difficulties Women: • Pregnant • Timing and regularity of periods • Abnormal bleeding • Vaginal discharge • Pain during intercourse • Incontinence – stress and urge

34. Respiratory system • Shortness of breath – at rest or on exertion • Cough • Hoarseness • Wheeze • Night sweats • Sputum production • Chest pain

35. Nervous system • Headaches • Dizziness • Faints, fits, LOC • Altered sensation, non dermatomal • Weakness • Co-ordination difficulties • Reduced proprioception / balance problems • Dysphasia • Difficultly reading / writing • Hearing problems • Memory and concentration changes

36. Musculoskeletal • Joint pain • Stiffness • Swelling • Redness • Mobility • Falls

37. Endocrine • Heat or cold intolerance • Change in sweating • Weight change, appetite change • Fruity breath odour • Heart palpitations, tachycardia • Excessive thirst • Mood change • Hair and nail changes • Joint or muscle pain

38. Visceral Pain Referral

39. Types of Pain • Visceral - pain that results from the activation of nocieptors in the thoracic, abdominal or pelvic viscera • Somatic – pain caused by activation of nociceptors in either body surface or musculoskeletal tissues ie skin, muscle • Neuropathic – pain caused by injury or malfunction to the spinal cord or peripheral nerves

40. Visceral Pain • Visceral structures are highly sensitive to distention, ischemia and inflammation • Afferent supply to internal organs is in close proximity to blood vessels along a path similar to the sympathetic nervous system (Rex 2004, Christianson 2009) • 3 main theories: • Embryonic development 2. Multisegmental innervation 3. Direct pressure and shared pathways

41. Visceral Pain Clinical presentation: • Generally vague and diffuse • Autonomic nervous system involvement, pallor, sweating, nausea, change in vital signs, anxiety • Intensity of the pain has little correlation to extent of internal injury

42. Sources of Visceral Pain • Inflammation – appendicitis, diverticulitis, colitis, gastric ulcer • Distention of a organ – bowel obstruction, blockage of bile duct by gallstones • Swelling of liver capsule – hepatitis, tumours • Ischemia / loss of blood supply – tumour invasion of blood supply, ischemic colitis

43. To sum it up • Recognising pain patterns that are characteristic of systemic disease is a necessary step in the screening process (Goodman and Snyder 2007) • Visceral pain referral can vary massively between individuals • Subjective assessment provides majority of the information needed to clarify cause of symptom

44. References • American Cancer Association 2005 Multiple Myeloma. Online. www.cancer.org • Bennell K, Khan K, McKay H 2000 The role of physiotherapy in the prevention and treatment of osteoporosis. Manual Therapy 5: 198-213 • Boissonnault, WG. 1995. Examination in physical therapy practice: screening for medical disease, 2nd edition. Churchill Livingstone. New York • Brier S R 1999Primary care orthopaedics. Mosby, St Louis • Centre for Chronic Disease Prevention and Control 2007 Breast Cancer. Online. http://www.phac-aspc.gc.ca • Christianson JA: Development, plasticity and modulation of visceral afferents. Brain Research Reviews 60(1):171-178 • Deyo RA, Rainville J, Kent DL. 1992. What can the history and physical examination tell us about low back pain? JAMA 268 (6): 760-765

45. References Douglas, Nicol & Robertson (Editors): Macloud’s Clinical Examination, 11th edition, Elsevier, Churchill Livingstone, Edinburgh Frymoyer J W 1997 The adult spine:priniciples and practice, 2nd edition. Lippincott-Raven, Philadelphia Goodman CC and Snyder T E K (2013): Differential Diangnosis for Physical Therapists; screening for referral, 5th edition, Saunders Elsevier, USA Greenhalgh S and Selfe J. Red Flags: A guide to identifying serious pathology of the spine, 2006 and 2010; Churchill Livingstone, Elsevier Greenhalgh S and Selfe J. A qualititative investigation of Red flags for serious spinal pathology, Physiotherapy 2009; 95: 223-226 International Osteoporosis Foundation 2008 Osteoporosis. Online. www.iofbonehealth.org/home Levack P, Graham J, Collie D et al 2002 Don’t wait for a sensory level – listen to the symptoms: a prospective audit of the delays in diagnosis of malignant cord compression. Clinical Oncology 14:472-480

46. References Rex L (2004): Evaluation and treatment of somatovisceral dysfunction of the gastrointestinal system, Edmonds WA, URSA Foundation Rex L (2004): Evaluation and treatment of somatovisceral dysfunction of the gastrointestinal system, Edmonds WA, URSA Foundation Siemionow K et al (2008). Identifying serious causes of back pain: cancer, infection, fracture. Cleveland Clinic Journal of Medicine, 75 (8), 557-566. Sizer PS, Brismee J-M, Cook C. Medical Screening for Red Flags in the Diagnosis and Management of Musculoskeletal Spine Pain, World Institute of Pain 2007; 7(1); 53-71 UK Myeloma Forum 2006 Myeloma. Online. www.ukmf.org.uk Wiesel SW, Weinstein JN, Herkowitz H et al. 1996. The lumbar spine. International soceity for the study of the lumbar spine. 2nd edition. Saunders. Philadelphia Williams P L, Bannister LH, Berry MM et al 2003 Gray’s anatomy, 38th edition. Churchill Livingstone, New York