1 - LBP Red Flags

Question 1

In multiple myeloma, what advanced imaging is usually normal?

Answer 1

Bone Scans

Question 2

In multiple myeloma, what advanced imaging is usually positive?

Answer 2

MRI

Question 3

In what patient profile should you suspect multiple myeloma?

Answer 3

50+ years olds with chronic low back pain and anemia of chronic disease (possible history of recurrent infections)

Question 4

What blood test has very high sensitivity for multiple myeloma (if negative, unlikely to be multiple myeloma)?

Answer 4

Serum protein electrophoresis

Question 5

What test is done to confirm multiple myeloma after serum protein electrophoresis and MRI have been done?

Answer 5

Bone marrow aspiration

Question 6

What is the first step in differential diagnosis of NMS conditions?

Answer 6

Determine if due to injury or disease, must rule out disease first

Question 7

About what percentage of LBP is due to serious disease?

Answer 7

3%

Question 8

About what percentage of low back pain is due to cancer or spinal infection?

Answer 8

1%

Question 9

About what percentage of low back pain is due to referred pain from viscera?

Answer 9

2%

Question 10

Referred pain from viscera that causes low back pain is usually from what 3 systems?

Answer 10

GI
Reproductive
Urinary

Question 11

What percentage of a diagnosis is made by patient history?

Answer 11

90%

Question 12

How do you calculate a positive likelihood ratio from sensitivity and specificity numbers?

Answer 12

Sensitivity / (1- specificity)

Question 13

How do you calculate a negative likelihood ratio from sensitivity and specificity numbers?

Answer 13

(1 - sensitivity)/ specificity

Question 14

In 2000 consecutive patients with back pain, no patient < 50 was found to have cancer unless they had at least one of these findings:

Answer 14

Prior history of cancer
Unexplained weight loss
Failure of 1 month of conservative treatment

Question 15

What are the biggest red flags from the history that would indicate multiple myeloma?

Answer 15

Weight loss (rule in)
Failure of bed rest to relieve pain (rule out)
Age is 50+

Question 16

Is night pain correlated with serious disease?

Answer 16

Sometimes but not often enough to be included in guidelines

Question 17

Excruciating back pain when lying supine, relieved by sitting up, hunched over a table is common with what serious disease

Answer 17

Malignant retroperitoneal lymphadenopathy

Question 18

Malignant retroperitoneal lymphadenopathy is usually secondary to what two types of primary cancers?

Answer 18

lymphomas (more common in elderly) and testicular cancer (more common in young men)

Question 19

When leg symptoms are present (with or without
accompanying LBP), the index of suspicion for an organic
pathology increases, especially patients who are

Answer 19

• female
• pediatric
• geriatric

Question 20

What are 3 important physical exam findings that would point towards bone cancer?

Answer 20

• neurological deficits in older patient
• exquisite pain with spinal percussion
• significant restriction at multiple segments in multiple directions

Question 21

What is the clinical strategy when you have a patient with persistent back pain and/or neurological deficit?

Answer 21

X-ray first

Do spinal percussion

Question 22

What are the first three ancillary studies in your clinical strategy if you suspect disease?

Answer 22

1. Plain films
2. ESR and/or CRP
3. CBC

Question 23

In addition to your first three ancillary studies that you perform when disease is suspected, what additional tests could be ordered if cancer or infection is suspected?

Answer 23

Blood chemistry panel (Calcium, ALP, proteins)

Question 24

In addition to your first three ancillary studies that you perform when disease is suspected, what additional tests could be ordered if arthritic condition is suspected?

Answer 24

• anti CCP, RF, ANA, HLA-B27

Question 25

In addition to your first three ancillary studies that you perform when disease is suspected, what additional tests could be ordered if GU problem is suspected?

Answer 25

Urinalysis

Question 26

If you suspect disease and plain films are normal but you still have high suspicion, what ancillary tests would you order next?

Answer 26

MRI, CT, bone scan or SPECT

Question 27

What percentage of bone cancers are metastatic? Primary?

Answer 27

2/3 are metastatic | 1/3 are primary

Question 28

Metastatic bone cancer usually comes from what 4 primary cancers?

Answer 28

- breast - lung - prostate - kidney Sometimes from colon or thyroid

Question 29

Are most metastatic bone cancers osteolytic or osteoblastic?

Answer 29

Osteolytic

Question 30

What primary cancer, when it metastasizes to the bone is osteoblastic?

Answer 30

Prostate

Question 31

What are the first blood tests to run in a neuromuscular case when trying to rule out disease?

Answer 31

ESR and/or CRP Then CBC

Question 32

What is LeFebvre’s rule regarding ESR values?

Answer 32

20-50 Anything less than 20 is not clinically significant Anything over 50 is probably a disease process (get more testing) Between 20-50 would have to be a judgement call based on other clinical indicators

Question 33

What are the three diseases that commonly present with an ESR over 100

Answer 33

Multiple myeloma Temporal arteritis Polymyalgia rheumatic a

Question 34

What combination of ancillary test results are a very sensitive screen for serious malignancies or infections in NMS conditions?

Answer 34

Normal ESR and X-ray is very sensitive (good at ruling out serious disease)

Question 35

What combination of 4 signs and symptoms from the history had 100% sensitivity for cancer in LBP patients?

Answer 35

- prior history of cancer - unexplained weight loss - failure to improve in 1 month - over 50 years old

Question 36

Increased WBC count (as seen with increased ESR) in a patient with chronic low back pain can indicated what diseases?

Answer 36

- infection - cancer - inflammatory disease

Question 37

Increased immature WBC in a patient with chronic LBP can indicate what disease?

Answer 37

Leukemia

Question 38

Decreased WBC in a patient with chronic LBP can indicated what disease?

Answer 38

Multiple myeloma

Question 39

What is being checked with a blood chemistry panel?

Answer 39

Proteins and other metabolic indicators

Question 40

What are the two most common causes of elevated serum calcium?

Answer 40

- metastatic cancer (osteolytic) - hyperparathyroid (unlikely to cause back pain) * these two account for about 90% of hypercalcemia * osteoporosis does not cause increased serum calcium

Question 41

When would you see elevated ALP (alkaline phosphatase)?

Answer 41

- metabolically active bone (growing and healing fracture, Paget’s disease, pregnancy, liver disease) - osteoblastic bone cancer

Question 42

What percentage of patient with metastatic bone cancer will have elevated calcium?

Answer 42

40-50%

Question 43

What percentage of patients with metastatic bone cancer will have elevated alkaline phosphatase?

Answer 43

50-75%

Question 44

What organ systems most commonly have viscerosomatic referral pain to the low back?

Answer 44

- reproductive - urinary - gastrointestinal

Question 45

Back pain from viscera will often have one or more of these characteristics?

Answer 45

- coincide with menstrual cycle - be periodic and unassociated with movement or activity - colicky or cramping - writhing pain

Question 46

Low Back pain plus what three things would cause suspicion (red flag) that pain is not musculoskeletal?

Answer 46

- little or no muscle spasm - little or no tenderness on palpation - little or no impairment of segmental mobility

Question 47

Bilateral thoracolumbar referred pain, usually associated with nausea or vomiting, made worse with recumbency is commonly associated with what organ?

Answer 47

Pancreas

Question 48

Relief of low back pain by what pathognomic position is a strong indicator for pancreas as cause of low back pain?

Answer 48

Knees drawn up and forward flexed

Question 49

What is the pain referral pattern for the urinary bladder?

Answer 49

Central spot on superior gluteal cleft and posteromedial upper thigh

Question 50

What is the pain referral pattern for kidney

Answer 50

Flanks and lateral hip/thigh Usually unilateral Pain may be present on opposite side because visceral nerves cross midline

Question 51

Where does the colon (except sigmoid) refer pain to?

Answer 51

Mid lumbar spine

Question 52

Where do gynecological disorders refer pain to?

Answer 52

Low back, rarely above L4

Question 53

Where does the sigmoid colon and rectum refer pain to?

Answer 53

Sacral area

Question 54

What are some examples of gynecological conditions that could cause referred back pain?

Answer 54

- endometriosis - Fallopian tube - ruptured ovarian cyst - ectopic pregnancy

Question 55

When will spinal percussion be positive?

Answer 55

Fracture, spinal infection, cancer