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Spinal Stenosis


Title: Spinal Stenosis Author: eleanor.dunstan Last modified by: Damien Created Date: 8/7/2013 10:19:20 AM Document presentation format: On-screen Show (4:3) – PowerPoint PPT presentation

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Title: Spinal Stenosis

September 5th 8th 2013 Nottingham Conference
Centre, United Kingdom www.nspine.co.uk
Red Flags
  • Carla Eveleigh
  • Spinal ESP and Physiotherapist
  • September 2013

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

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

Red Flags
  • Serious spinal pathology is rare lt1 cases
  • It is well recognised that the earlier patients
    with serious pathology are identified the better
    the patient outcome (Wiesel et al 1996)

Hierarchical List of Red Flags
  • Greenhalgh Selfe 2010
  • Age gt50 years
  • History of cancer
  • Unexplained weight loss
  • Failure to improve after 1 month of EB
    conservative therapy

Hierarchical List of Red Flags
  • Greenhalgh Selfe 2010
  • Age lt10 gt51
  • Medical history of Cancer, TB, HIV/AIDS, IV drug
    abuse, OP
  • Weight loss (gt10 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

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)

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)

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

Malignant Spinal Cord Compression (MSCC)
  • MRI scan is the gold standard investigation
  • Whole spine
  • Emergency MRI lt24 hours
  • Bloods FBC, ESR, CRP, UEs, LFTs, bone, PSA (for
  • Review with oncologist, spinal consultant
  • (Levack et al 2002)
  • Specialist Oncology Nurse Practitioner

  • 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
  • Average age of diagnosis is 65
  • MaleFemale 21 (American Cancer association
  • Can report fatigue due to anaemia (American
    Cancer Association 2005)

  • Subjective signs
  • Bone pain lumbar spine, pelvis, ribs
  • Tired
  • Thirsty
  • Easily bruise
  • Main objective signs
  • Associated fractures
  • LL radiculopathy
  • Hypercalcaemia

  • 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, UEs
  • Urinalysis Bence Jones protein

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

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)

Infection / Discitis
  • Inflammation of vertebral disc, often associated
    with infection and can co-exist with vertebral
  • 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 gt50
  • Risk factors immunosuppressed, lifestyle,
    substance misuse

Infection / Discitis
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

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
  • 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)

Cauda Equina Compression
Symptom Sensitivity
Urinary retention 0.90
Unilateral or bilateral sciatica gt0.80
Sensory / motor defcit and reduced SLR gt0.80
Saddle anaesthesia 0.75
  • Other symptoms Faecal incontinence, sexual
  • Objective assessment
  • Reduced anal tone and power (60-80)
  • Sacral sensory loss (85 cases) (Jalloh Minhas
  • Bladder scan (post void) gt150ml

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

  • Carla Eveleigh
  • Spinal ESP and Physiotherapist
  • September 2013

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

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

Anatomy Reminder
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

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

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

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

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

  • Joint pain
  • Stiffness
  • Swelling
  • Redness
  • Mobility
  • Falls

  • 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

Visceral Pain Referral
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

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

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

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

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
  • Subjective assessment provides majority of the
    information needed to clarify cause of symptom

  • 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.g
  • 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

  • Douglas, Nicol Robertson (Editors) Maclouds
    Clinical Examination, 11th edition, Elsevier,
    Churchill Livingstone, Edinburgh
  • Frymoyer J W 1997 The adult spinepriniciples and
    practice, 2nd edition. Lippincott-Raven,
  • 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 Dont
    wait for a sensory level listen to the
    symptoms a prospective audit of the delays in
    diagnosis of malignant cord compression. Clinical
    Oncology 14472-480

  • Rex L (2004) Evaluation and treatment of
    somatovisceral dysfunction of the
    gastrointestinal system, Edmonds WA, URSA
  • Rex L (2004) Evaluation and treatment of
    somatovisceral dysfunction of the
    gastrointestinal system, Edmonds WA, URSA
  • Siemionow K et al (2008). Identifying serious
    causes of back pain cancer, infection, fracture.
    Cleveland Clinic Journal of Medicine, 75 (8),
  • 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.
  • Wiesel SW, Weinstein JN, Herkowitz H et al. 1996.
    The lumbar spine. International soceity for the
    study of the lumbar spine. 2nd edition. Saunders.
  • Williams P L, Bannister LH, Berry MM et al 2003
    Grays anatomy, 38th edition. Churchill
    Livingstone, New York
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