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STYDO4 Essay

Red Flags of the Spinal Assessment

Red Flags are important in the diagnosis of spinal assessment pathologies as some important pathologies can have different diagnosis due to the variety of symptoms presented within an spinal assessment. Red Flags are important as the more red flags they show the more likely they are to show a cause for their back pain (Michael, Newman & Rao, 2010). Some red flags such as low back pain could be split into 4 etiologies which are fractures, malignancy, infection and cauda equina syndrome (Premkumar, Godfrey, Gottschalk & Boden, 2018). Several red flags are commonly associated with these pathologies such as trauma for a fracture and previous history of cancers for malignancy (Verhagen, Downie, Popal, Maher & Koes, 2016).

Fractures

One potential pathology within spine assessment is a fracture and this pathology can show a few red flags which can determine if they have a spinal fracture. A spinal fracture is the most common serious pathology affecting the spine with 1%-4% of patients will have a spinal fracture when complaining of lower back pain (Downie et al, 2013). One common red flag associated with a spinal fracture could be trauma due to age as this could be a fall from height for a young patient or a minor fall or heavy lifting with an older patient with osteoporosis (Casazza, 2012). Another red flag to consider is gender and age as compression fractures are common among older people with a minor trauma (Reito, Kyrölä, Pekkanen & Paloneva, 2018). One study from Deyo, Jarvik & Chou, 2014 shows that if the patients is an older age and  is  female render them as a higher risk patient for an osteoporotic vertebral compression fracture. Furthermore, vertebral fractures such as osteoporotic fractures are most common within older women (Parizel et al, 2010).

Malignancy

Cancer is seen as a serious pathology within spinal assessment which could show serious red flags such as spinal tumours (Duong et al, 2012). Some serious pathologies associated with cancer and the spinal cord could be malignant spinal cord compression which can affect different cancers mainly breast renal, prostate and lung cancer (Savage et al, 2014).  Some of the red flags which the therapist could find with malignancy could be a history of metastatic cancer as this could show the therapist that the patient has previously had a metastatic cancer and could be developing cancer again (Will, Bury & Miller, 2018). Another red  flag could be unexplained weight loss as cancer can affect the way our immune system or the way our body gets energy from food causing a sudden weight loss (Cooney, Graham, Jeffery & Hellawell, 2017).

Infection

Another serious pathology the therapist will have to consider when doing a spinal assessment is infection and it can show some red flags such as Fever and Spinal Pain (Yusuf, Finucane & Selfe, 2019). One potential red flag with infection could be fever however, due to the usual different diagnosis of patients complaining of having a fever the physio should consider other red flags as well but diagnosing if a client has a spinal infection (Uckay et al, 2010). Another potential red flag that patient might show in the assessment is a history of corticosteroids, as the use of corticosteroids could increase the risk of immunodeficiency which could lead to an increase risk of infection (Rolston, 2017). These red flags are important to find early as a spinal infection can cause complications such as paralysis and instability of the spine (Amadoru, Lim, Tacey & Aboltins, 2017).

Cauda Equina

Cauda Equina Syndrome is a serious medical pathology which consists of the patients spinal roots being compressed meaning the patient might require emergency surgery to treat (Herndon, Zoberi & Gardner, 2015). One red flag which the patient might show is severe low back pain and sciatica, even though these two are common, sciatica which is severe and bi-lateral should ring alarm bells for a therapist with an emergency team to be contacted immediately (Gardner, Gardner & Morley, 2011). Another red flag the patient may show with cauda equina could be an altered bladder function leading to painless urinary retention and this can be in a wide range of differences such as increased urinary frequency and urinary incontinence for the patient (Greenhalgh, Finucane, Mercer & Selfe, 2018). This contributes to the reason that finding these signs early is vital as mismanagement to do so can result in life changing consequences for the patient and the physio assessing (Comer, Finucane, Mercer & Greenhalgh, 2020).

Common Spine Pathologies

Most spinal pathologies are related to causing lower back pain and this is evident in our society as 36%-70% of older adults in the world suffer from lower back pain due to many different factors (Wong, Karppinen & Samartzis, 2017). One of these factors could be age and this can be seen in a report where in the United Sates of America approximately 20.4% (50 million) of U.S adults had chronic pain which could either keep them off work most or everyday of work in the past 6 months (Dahlhamer, Lucas & Helmick, 2018). Another one of these factors could be due to could be gender as even though studies on this risk factors are not yet clear, a systemic review showed that older women on average are more likely to suffer with low back pain than older men (Hoy, Brooks, Blyth & Buchbinder, 2010). All these factors which cause lower back pain can help contribute to the cause of many different pathologies within the spine such as spondylosis (Ferrara,2012). Also, other pathologies which could occur could be scoliosis (Konieczny, Senyurt &Krauspe, 2013)

One common spinal pathology is spondylosis and this is the degeneration of the vertebral process and the formation of osteophytes in the cervical cord causing this is to be the most common cause of spinal cord impairment worldwide (Kardimas, Gatzounis & Fehlings, 2015). Some of the possible factors which could cause spondylosis could be age and this is seen in an article as 95% of patients by the age of 65 years old (Mullin, Shedid & Benzel, 2011). The symptoms which can be shown due to spondylosis could be stiffness in the neck with or without radiation, numbness and tingling in the later stage of spondylotic myelopathy of upper limb and formation of marginal osteophytes (Singh, Kumar & Kumar, 2014).

Another common spinal pathology is scoliosis and this is three dimensional deformity of the spine where the curvature of the spine within the coronal plane is more than 10 degrees (Atlaf, Gibson, Dannawi & Noordeen, 2013). One type of scoliosis is congenital scoliosis and this is a form of curvature due to the presence of an underlying congenital vertebral malformation (Giampierto, 2012). Another type of scoliosis is idiopathic scoliosis which can be classidied by age with infantile, juvenile and adolescent idiopathic scoliosis and these are all determined at what age they show signs and symptoms of scoliosis (Trobisch, Suess & Schwab, 2010). The most common type of scoliosis is idiopathic as this counts for approximately 85% of scoliosis cases (Horne, Flannery & Usman, 2014). Even though it is not clear the main reasons for the main cause of idiopathic scoliosis, it has suggested that idiopathic scoliosis could be multi-factorial due to the association between the development of the scoliosis and growth and hormonal secretion of the patient (Chiru, 2011).

Reflection

The first test that I had performed was for a client who showed client who showed signs of a potential scoliosis in the lumbar section of their spine (Appendix 1). From their assessment form I could see that the client didn’t have any pain symptoms just some stiffness around the lumbar section of their spine (Appendix 1). After this the client performed side flexion to see if their was any pain symptoms as on observation the right hip was higher than the level of the left hip (Appendix 2). After seeing no pain around this movement for passive, active and resisted movement we then did some functional movements such as squatting down and bending forward and again there was no pain within these movements (Appendix 2). I therefore decided to prescribe a few exercises such as cat camel and glute bridges to help strengthen the core muscles and help realign the spine (Appendix 2). I believe I could of improved this test by performing further tests to help with more measurable goals such as different angles of degrees within the movements with the use of a goniometer (Appendix 2).

The next test was the one that I had observed and this client showed symptoms of pain when performing squatting movements as they have VAS scale of a 3/10 with moderate pain and irritability (Appendix 3). The physio then observed the client which showed a slight curvature of lumbar section of the spine with a the right side of hip lower than the left side. On palpation the client showed a 2/10 of pain on the VAS Scale when palpating the right PSIS (Appendix 4). On the movements the client showed a 4/10 pain on left side of side flexion (Appendix 4). From this the physio moved onto special tests which was the Adam’s Bend Forward Test which was positive when showing for pain for the client (Appendix 4). From this data from the tests the physio was confident that the client may have a form of lumbar scoliosis (Appendix 4). The physio then prescribed the client with a period of rest from squatting movements that cause the pain and some exercises such as cat camel to help realign the spine (Appendix 4). However, if the client doesn’t show any improvements the physio may refer the client to a doctor for further testing or a corticosteroid injection to help with the pain of the lumbar scoliosis (Appendix 4).

Conclusion

These red flags are important for therapists for a variety of reasons. For example, finding red flags will help give a more consistent result in the pathology given which will help with differential diagnosis for the patient. Also, these red flags are important for the patient as finding the signs early can help prevent any life changing consequences such as instability of the spine for infection and life changing effects on the sexual function and bladder system with cauda equina syndrome for the patient.

There are many different types of spinal pathologies such as spondylosis and scoliosis which show a vast number of signs and symptoms which show if a patient is going through this pathology or not. For example, there is support to show the link between the development of scoliosis and age for the development of idiopathic scoliosis However, due to the research within these studies of spondylosis and scoliosis further research is needed to 100% confirm the main signs and symptoms which can cause these pathologies.

Reference List

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Appendices

             Appendix 1

                Appendix 2

             Appendix 3

           Appendix 4