Red Flags for potential serious spinal pathologies

Red flags

a pragmatic adaptation of the 2020 IFOMPT framework

screening for

Creation: Yannick Tousignant-Laflamme, PT, Ph.D

associated to spinal conditions

Reproduced with permission from the Journal of Orthopaedic and Sports Physical Therapy

Level of concern

STEP 1: Determine your level of concern in regards to the presence of a serious pathology

Based on the prevalence of the different pathologies in your context of practice, on the presence of risk factors/signs/symptoms associated to a high probabiliy of serious pathology and the profile of your patient.

Sous-titre

Reproduced with permission from the Journal of Orthopaedic and Sports Physical Therapy

RED FLAGS: clinical features associated with a high level of suspicion that a fracture is the cause of spinal pain ?

History of osteoporosis*

Neurologicalsigns

spinal deformity

Spine tenderness

History of ostooporotic facture + presence of other osteoporosis risk factors

Especially cancers with a high risk of bone metastasis: breast, prostate, lung, kidney, thyroid

Bilateral (or quadrilateral) neurological symptoms, including gait disturbance and coordination issues, bladder and bowel disturbance

Tenderness or reproduction of symptoms on palpation or percussion/vibration

Menopause that started at a young age

RISK Factor

symptoms

Clinical signs

Sudden changes in anatomical structures associated with trauma or in a patient with known osteoporosis

Creation: Yannick Tousignant-Laflamme

Steroid use (>5mg) for >3 months

corticosteroid*

history of cancer

severe trauma*

Immediate pain during a severe traumatic event

Female sex*

Signs of contusion/abrasion to the spinous processes following trauma

contusion/abrasion

relevant investigations to confirm the hypothesis fracture?

Bilateral (or quadrilateral) symptoms, including gait disturbance and coordination issues, bladder and bowel disturbance

Neurological symptoms

Thoracic pain*

Back pain with a history of cancer, myeloma or osteoporosis

Describes pain that is unfamiliar and possibly worsening pain

Severe and unfamiliar pain

older age*

Women: >65 y.o.; Men > 75 y.o.; for all patients > 80 y.o.

Previous spinal fracture*

History of spinal atraumatic fracture (low impact event)

History of falls

History of falls or comorbidities that increase the risk of falls

*these elements have a high level of Evidence

Reproduced with permission from the Journal of Orthopaedic and Sports Physical Therapy

RED FLAGS: clinical features associated with a high level of suspicion that a cancer is the cause of spinal pain ?

past history of cancer*

Neurologicalsigns

Altered sensation from the trunk down

Spine tenderness

Especially cancers with a high risk of bone metastasis: breast, prostate, lung, kidney, thyroid

Pain described as unfamiliar and possibly worsening

Bilateral (or quadrilateral) neurological symptoms, including gait disturbance and coordination issues, bladder and bowel disturbance

Tenderness or reproduction of symptoms on palpation or percussion/vibration

symptoms

Risk factor

clinical signs

Evidence of loss of sensation in the trunk and/or lower limbs (quadrant)

Bilateral (or quadrilateral) symptoms, including gait disturbance and coordination issues, bladder and bowel disturbance

neurlogical symptoms

Unfamiliar back pain

Severe pain

Severe, constant and progressive pain; described as band-like pain, and inability to lie flat

The patient reports characteristics of hypercalcemia, such as fatigue, nausea, stomach pain and fever. These also tend to be progressive in nature

Back pain, may be painful on percussion over the area of pain. May not be a mechanical pain pattern

Night pain

Systemically unwell

Thoracic pain

People who report having to walk the floors or sit in a chair or lie on the floor, with minimal relief

relevant investigations to confirm the hypothesis of cancer?

> 5% loss of body weight in < 3 months

Unexplained weight loss*

Creation: Yannick Tousignant-Laflamme

*these elements have a high level of Evidence

Reproduced with permission from the Journal of Orthopaedic and Sports Physical Therapy

RED FLAGS: clinical features associated with a high level of suspicion that a cauda equina syndrome is the cause of spinal pain ?

Sensory change

Abnormal lower-limb neurology

Sensory defecit in saddle to light touch and pinprick

Reduced anal tone

History of sensory disturbances in the lower limbs

History of disturbed sensations (tingling) in the perineum

Neuro examination shows significant deficits in the lower limbs

A rectal examination shows a loss of tone

Clinical evidence of lumbar stenosis

symptoms

risk factors

clinical signs

Changes and sensory loss in the perineum

Creation: Yannick Tousignant-Laflamme

History of weaknesses (motor) in the lower limbs

Motor weakness (lower limbs)

Saddle sensory disturbance

erection/ejaculation disorders

Recent changes/disorders related to symptom onset

Herniated intervertebral disc

Associated with other signs and symptoms and the onset of clinical presentation

constipation

relevant investigations to confirm the hypothesis of cauda equina syndrome?

Unilateral symptoms that have progressed to bilateral symptoms

Unilateral/bilateral leg pain

Back pain+typical signs

Back pain WITH: saddle anesthesia, age<50 years, bilateral and/or alternating lower limb symptoms, new motor weakness, obesity

Reports incontinence for no other reason

Urinary and/or bowel incontinence

loss of sensation during sexual intercourse

Loss of sensation during sexual relations

Urinary function

Urinary frequency and retention

History of falls

History of falls or comorbidities that increase the risk of falls

Clinical evidence of disc herniation

lumbar spinal stenosis

Reproduced with permission from the Journal of Orthopaedic and Sports Physical Therapy

Red flags: clinical features associated with a high level of suspicion that an infection is the cause of spinal pain ?

Comorbidities

Neurologicalsigns*

Radiculopathy

Spine tenderness on palpation

Presence of comorbidities (poorly controlled) that cause immuno-supression + history of infection

IV drug user with intravenous drug abuse

Bilateral (or quadrilateral) neurological symptoms, including gait disturbance and coordination issues, bladder and bowel disturbance

Tenderness or reproduction of symptoms on palpation or percussion/vibration

Exposure to tuberculosis, without immunization

symptoms

Risk factors

Clinical signs

Progressive and significant neurological deficits (weakness <3/5)

Creation: Yannick Tousignant-Laflamme

Recent spinal surgery, especially a revision

Surgery: invasive

Intravenous drug use

social deprivation

Material and social disadvantage, health determinants + unfavorable living conditions, alcoholism

tuberculosis

History of recent infection +progressive symptoms (degenerate)

Recent infection

spinal pain*

Unexplained and progressive pain in the spine, limiting ++ mobility

ANORMAL fatigue and limiting usual activities

> 5% loss of body weight in < 3 months

neurological symptoms

fatigue

Fever*

Fever (and chills) consistent with the onset of painful symptoms

Unexplained weight loss

Bilateral (or quadrilateral) neurological symptoms, including gait disturbance and coordination issues, bladder and bowel disturbance

relevant investigations to confirm the hypothesis of infection?

*classic triad of Evidence of Infection

Reproduced with permission from the Journal of Orthopaedic and Sports Physical Therapy

STEP 2: Determine your action

Based of your level of concern, should you begin a trial of therapy, treat with a safety net or refer out for medical/urgent investigation?

Treat or refer?

Reproduced with permission from the Journal of Orthopaedic and Sports Physical Therapy

Trajectory for medical referral

STEP 3: Establish a trajectory for patients referred out

Medical emergency or need a medical consultation? Know your local resources to support patients in need of medical care.

Reproduced with permission from the Journal of Orthopaedic and Sports Physical Therapy

Provide care guided by best practice+monitoring ofS & S

Refer for further invensitatioins

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CLINICAL DECISION SUPPORT-TOOL

goals attained + discharge

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VIGILENCEbegin trial of treatment WITHsafety net

Patient presenting with S & S consistent with MSK condition

NO evidence of red flags

MAJOR evidence of red flags

Normal/expected progress

SOME evidence of red flags

progress as expected

Medical emergency

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Creation: Yannick Tousignant-Laflamme

NO improvement / new signs or symptoms

Appearance of new signs or symptoms that worsen

Re-evaluation

This is a case for me - I process and monitor progress adjusting if the condition changes unexpectedly

I have good reason to believe that this is not a case for me… I refer without treating

This is a case for me, but I monitor closely because I noticed the presence of some elements (risk factors, signs or symptoms)

Safety netting is a management strategy used for people who may present with possible serious pathology. These strategies should include advice on which signs and symptoms to look out for, which action to take if symptoms deteriorate, and the time frame within which action should be taken.

I have evidence that this is an URGENT case - I send my patient to the emergency or without an appointmen