Serious lumbar spine conditions

Red flags include:

• Bilateral sciatica - sudden onset bilateral radicular pain, or unilateral radicular pain, that has progressed to bilateral
• Severe or progressive bilateral neurological deficits of the legs such as major motor weakness with knee extension, ankle everson or foot dorsiflexion
• Difficulty initiating micturition or impaired sensation of urinary flow, if untreated this may lead to irreversible
  • urinary retention with overflow urinary incontinence
• Loss of sensation of rectal fullness, if untreated this may lead to
  • irreversible faecal incontinence
• Perianal, perineal or genital sensory loss (saddle anaesthesia or paraesthesia)
• Laxity of the anal sphincter
• Sexual dysfunction – inability to achieve erection or to ejaculate, or loss of genital sensation.

Foot drop is a symptom of a variety of disorders and can be classified as either a central or peripheral problem. Peripheral problems can be differentiated into peripheral neuropathy or radiculopathy.

Foot drop from a spinal source causes weakness due to compression of L4 and/or L5 nerve roots causing weakness predominantly in the tibialis anterior muscle and characteristic slapping gait (high stepping gait).

• Foot drop is classified as weakness of Dorsiflexion grade 3 or less (Oxford scale).
• There is no current agreed timescale that would define an acute episode.
• For acute cases early opinion is considered essential to see if surgery is indicated.

Consideration for Surgery is based on a number of factors including duration since onset, grade of power, age, medical fitness and patient’s preference.

Red flags include:

• Sudden onset of severe central spinal pain which is relieved by lying down
• There may be a history of trauma (such as road traffic collision or fall from height), minor trauma, or even just strenuous lifting in people with osteoporosis or those who use corticosteroids
• Structural deformity of the spine (such as a step from one vertebra to an adjacent vertebra) may be present
• There may be point tenderness over a vertebral body.

Key risk factors

• Older age (>50 years for women and >65 years for men)
• Previous fragility fracture
• Long term glucocorticoids
• History of falls
• Family history of hip fracture
• Other causes of secondary OP, e.g., RA & problems with malabsorption
• Low body mass (<18.5kg/m2)
• Smoking
• Alcohol intake >3.5 units /day
• Full overview - SIGN142 Osteoporosis.

History

• Sudden pain in thoracic or lumbar spine
• Minimal trauma
• Pain that gets worse when sitting (esp. a straight-backed chair) & leaning backwards or standing leaning forwards.

Physical Examination

• No clinical signs specific for VFF
• In acute phase may have: Local tenderness / pain on percussion over spine level
• Potential for: Height loss of person > 2.5cm
• Thoracic Kyphosis.

Why is it important to identify a VFF

• A vertebral fracture is a powerful predictor of another vertebral fracture (5x more likely) & of future hip fracture (3x more likely) without treatment (ROS, 2021).
• There are high rates of mortality within the first year after fragility fractures such as the hip (The Vertebral Fractures Study, 2022).
• All patients with a VFF should be considered for fracture risk assessment to reduce fracture risk and prevent further fractures (ROS, 2022).

Immediately follow MSCC pathway if patient has cancer (or strongly suspected) or is under follow up from a previous cancer and one of the following:

• Severe, intractable progressive pain, especially thoracic
• New spinal nerve root pain (burning numb, shooting)
• Any new difficulty walking
• Reduced power/ altered sensation in limbs
• Bowel/ bladder disturbance.

Lothian Metastatic Spinal Cord Compression Pathway

Available at: NHS Lothian Malignant Spinal Cord Compression Intranet Site

• A pathway of care for patients with suspected metastatic spinal cord compression with the aim of ensuring optimal co-ordination and early investigation.
• In addition, the protocol strives to reduce the time spent in hospital and to enhance the healthcare experience for patients.
• Inform patients at high risk of developing bone metastases, patients with diagnosed bone metastases, or patients with cancer who present with spinal pain about the symptoms of MSCC.
• Please Note: Separate documents available for NHS Lothian & NHS West Lothian - Please select appropriate depending on work area.

Relevant resources and guidelines

• RefHelp Malignant Spinal Cord Compression Page
• NICE Guideline (NG234) Spinal metastases and metastatic spinal cord compression

Such as discitis, vertebral osteomyelitis, or spinal epidural abscess.

Red flags include:

• Fever
• Tuberculosis, or recent urinary tract infection
• Diabetes
• History of IV drug use
• HIV infection, use of immunosuppressants, or the person is otherwise immunocompromised.

Red flags include:

• Person being 50 years of age or more
• Gradual onset of symptoms
• Severe unremitting pain that remains when the person is supine, aching night pain that prevents or disturbs sleep, pain aggravated by straining (eg at stool, coughing, sneezing) and thoracic pain
• Localised spinal tenderness
• No symptomatic improvement after 4-6 weeks of conservative low back pain therapy
• Unexplained weight loss
• Past history of cancer- breast, lung, gastrointestinal, prostate, renal, thyroid cancers are more likely to metastasize to the spine.