Medical Screening: Red Flags for the Lumbar Spine and Lower Extremity

What are broad clinical concerns that warrant a need for a medical referral?

Fever, chills, sweats

Unexplained weight loss

Fatigue/malaise

Unexplained nausea and vomiting

Night pain

Inability to increase or decrease pain/symptoms

Who is most susceptible to pathologic fractures?

older individuals

females (new research showing this to be false)

Risk factors for pathologic fractures

prolonged corticosteroid use

history of osteoporosis

What is the typical MOI/chief complaint for pathologic fratures?

mild trauma or sudden pain without reason

What positions alleviate/aggravate pathologic fracture pain?

WB worse

supine is a position of comfort

What population is most likely to develop a sacral stress fracture?

athletic females

Risk factors for sacral stress fracture

increased level of vigorous/repetitive athletic activity

dietary insufficiency

menstrual irregularities

previous stress fractures

demonstrated no improvement to previous, usually successful SI pain treatments

Where is pain located with a sacral stress fracture? What reproduces this pain?

buttock

reproduced with athletic activities

What is the Sign of the Buttock?

combination of findings that indicates serious pathology of the gluteal or low back region

What are the clinical findings indicating Sign of the Buttock?

limited trunk flex in standing

SLR limited and painful - note: still achieve more than 40 degrees and have no N/T

hip flex w/ knee flexed limited and painful more so than SLR

hip rotation painful and limited but in non-capsular pattern

empty end feel hip flex

Spondylolysthesis/Spondylolysis

fracture of the PARS interarticularis

What age population do Spondys occur most often?

young individuals

Spondy MOI

repetitive hyperextension (gymnasts, wrestlers, football lineman)

What are the clinical findings of a Spondy?

sudden severe b/l sciatica during athletic activity

p! with ext

no urinary bowel incontinence

What aspects of a patient's history would indicate spinal compression fracture?

1. major trauma, like a MVA, fall from height, or direct blow to spine OR

2. minor trauma for osteoporotic or elderly individuals

What age are spinal compression fractures usually seen?

over 75

Risk factors for spinal compression fractures

prolonged corticosteroid use

When to increase the index of suspicion of spinal compression fracture?

increased pain w/ WB

point tenderness over fracture site

When to reduce the index of suspicion of spinal compression fracture?

<50 years old

symptoms not aggravated w/ WB or thoracolumbar flex

clinical findings consistent w/ one or more of ICF-based LBP subgroups

What is a common pain pattern with an abdominal aortic aneurysm (AAA)?

Pain at rest or at night

What type of pain do patients with AAA often describe?

Throbbing pain

What may be found during abdominal inspection or palpation in a patient with AAA?

A pulsating abdominal mass

What family history increases suspicion for AAA?

Family history of cardiovascular disease - especially AAA

Can symptoms of AAA be reproduced during a mechanical examination of the low back?

No. AAA symptoms cannot be provoked with mechanical testing of the lumbar spine

Where is pain for AAA located?

back, abdominal, or groin areas

What in a patient's medical/social history increases the risk of an AAA?

presence of peripheral vascular or coronary artery diseases and associated risk factors (over 50, smoker, HTN, DM)

When to increase the index of suspicion of AAA?

symptoms not related to movement stresses associated with somatic LBP

abdominal girth <100cm

What type of patient is most commonly affected by vascular claudication?

Older individuals

What family history is a risk factor for vascular claudication?

Family history of cardiovascular disease

What is the classic symptom pattern of vascular claudication?

Calf pain with activity that is relieved by rest

What temperature difference may be noted in a patient with vascular claudication?

One foot may be colder than the other

Can symptoms of vascular claudication be reproduced with a mechanical examination of the low back?

No. Symptoms cannot be provoked by mechanical testing of the lumbar spine.

What treadmill test is often positive in patients with vascular claudication?

An inclined treadmill test

Stenosis meaning

narrowing

What is the typical pain pattern of kidney stones?

Sudden, sharp, intermittent pain

Where can pain from kidney stones radiate?

To the testicles (males) or labium/labia (females)

What does kidney stone pain accompanied by fever suggest?

A renal (kidney) infection

Can symptoms of kidney stones be reproduced with a mechanical examination of the low back?

No. Symptoms cannot be provoked by mechanical testing of the lumbar spine

What symptoms are other genitourinary issues/red flags associated with?

lumbosacral pain

night pain

cannot be provoked with mechanical exam of lower back

When does pain from gastrointestinal issues commonly occur?

After eating

Where is pain from gastrointestinal issues commonly felt?

In the upper lumbar region (L1-L2)

What may relieve pain associated with gastrointestinal issues?

Further intake of food

Can gastrointestinal symptoms be reproduced with a mechanical examination of the low back?

No. Symptoms cannot be provoked by mechanical testing of the lumbar spine.

How do gastrointestinal symptoms typically progress over time?

They are usually chronic and progressive

What other symptom commonly accompanies gastrointestinal-related back pain?

Abdominal pain

Who is typically affected by ankylosing spondylitis?

Middle-aged individuals

What is the pain pattern in ankylosing spondylitis?

Pain is on and off and not related to exertion

How does ankylosing spondylitis affect range of motion over time?

Progressive loss of range of motion

What is a characteristic movement-related symptom in ankylosing spondylitis?

Alternating pain in the sacroiliac joints with walking

What is a later physical sign of ankylosing spondylitis?

Gross bilateral limitation of side bending

What direction does pain travel in ankylosing spondylitis?

Vertically, not laterally or into the lower extremities

How does morning stiffness present in ankylosing spondylitis?

Morning stiffness that improves with movement

Are paresthesias present in ankylosing spondylitis?

no

What eye condition is associated with ankylosing spondylitis?

Inflammation of the eye (uveitis), worsened by bright light, occurs in about 25% of cases

What type of condition is cauda equina syndrome (CES)?

A devastating neurologic emergency

Why is early treatment important in cauda equina syndrome?

Treatment within the first 48 hours is associated with better outcomes

What is a common cause of cauda equina syndrome?

Atraumatic midline posterior disc herniation at L3-S1

What are common motor symptoms of cauda equina syndrome?

Bilateral severe pain or weakness in the lower extremities

What sensory symptom is characteristic of cauda equina syndrome?

Saddle pain or saddle paresthesia

What bladder symptom is most characteristic and early in cauda equina syndrome?

Urinary retention (key symptom of reference)!!!!

Why can bowel and bladder dysfunction occur in cauda equina syndrome?

Involvement of nerve roots below S4

When is the index of suspicion for cauda equina increased?

saddle anesthesia

sensory or motor deficits in feet (L4, L5, S1)

When is the index of suspicion for cauda equina reduced?

LE sensation normal or improving

LE muscle performance is normal or improving

What is a major risk factor for spinal cancer presenting as low back pain?

Previous history of cancer

In which age group should new onset low back pain raise concern for spinal cancer?

Patients over 50 years old

What systemic symptom is a red flag for spinal tumor?

Unexplained weight loss

What pain pattern is concerning for spinal cancer?

Night pain and worsening pain over time

Consistent pain not affected by position or activity

How does spinal cancer typically respond to conservative treatment?

No improvement with conservative management

What mnemonic helps remember cancers that commonly cause low back pain?

"PB KTLL" or "lead kettle."

What cancers are included in the "PB KTLL" mnemonic?

Prostate, Breast, Kidney, Thyroid, Lung, Lymphoma

When is the index of suspicion for back related tumor increased?

constant pain not affected by movement, but worse with WB

pain not responsive to therapy (within 30 days)

When is the index of suspicion for back related tumor reduced?

clinical findings consistent with one or more of ICF-based LBP subgroups

symptoms resolving with subgroup matched interventions

What systemic sign is commonly associated with spinal infection?

fever

What recent medical history increases suspicion for spinal infection?

Recent bacterial infection

What surgical history is a risk factor for spinal infection?

Recent lumbar spine surgery

What patient population is at higher risk for spinal infection?

Immunocompromised individuals

What pain pattern is concerning for spinal infection?

Night pain and worsening pain

How does spinal infection typically respond to conservative treatment?

no response

When is the index of suspicion for back related infection increased?

fever, malaise, and swelling

spine rigidity; accessory mobility may be limited

elevated body temperature

When is the index of suspicion for back related infection reduced?

body temp normal

clinical findings consistent with ICF-based LBP subgroup(s)

What type of condition is central sensitization in the context of red flags?

Not a traditional red flag, but still requires medical management

What is the typical clinical history of patients with central sensitization?

Chronic condition with past episodes of back pain and poor recovery/inability to heal

What is a key pain distribution pattern in central sensitization?

Widespread pain that does not follow a clear anatomical pattern

How does pain behave with testing in central sensitization?

Pain is disproportionate to provocation and easing tests

What psychological feature is commonly associated with central sensitization?

High psychological distress

What sensory finding may be present in central sensitization?

Hypersensitivity to light touch (allodynia)

What is a yellow flag?

proceed with caution - there is a co-morbidity typically

MSK disorder that can be treated with PT but also an underlying medical or psychological issue that may need co-management or referral