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Between one and five percent of all musculoskeletal presentations in primary care are due to serious pathology and these rates are expected to increase as cancer survival rates improve (REF FINUCANE ET AL 2017).
== Introduction to Spinal Malignancy ==
Between one and five percent of all musculoskeletal presentations in primary care are due to serious pathology and these rates are expected to increase as cancer survival rates improve.<ref name=":0">Finucane L, Greenhalgh S, Selfe J. Which red flags aid the early detection of metastatic bone disease in back pain? Physiotherapy Practice and Research. 2017;38(2): 73-77.</ref>


Metastatic bone disease (MBD) is the second most common serious spinal pathology - vertebral fracture is the most common (REF FINUCANE 2017). Metastases are cancers that have spread from a primary cancer to a new site in the body; bone is a common location for metastases (FINUCANE 2020).  
Metastatic bone disease (MBD) is the second most common serious spinal pathology - vertebral fracture is the most common.<ref name=":0" /> Metastases are cancers that have spread from a primary cancer to a new site in the body; bone is a common location for metastases.<ref name=":1">Finucane LM, Mercer C, Greenhalgh SM, Boissonnault WG, Pool-Goudzwaard AL, Beneciuk JM et al. International framework for red flags for potential serious pathologies. J Orthop Sports Phys Ther. 2020; epub: 1-23.</ref>


The spine is often one of the earliest areas affected, particularly in patients who have a history of breast and prostate cancer (FINUCANE 2017). The five types of cancer that are most likely to spread to the spine are:
The spine is often one of the earliest areas affected, particularly in patients who have a history of breast and prostate cancer.<ref name=":0" /> The five types of cancer that are most likely to spread to the spine are:
Breast  
* Breast
Prostate
* Prostate
Lung
* Lung
Kidney  
* Kidney
Thyroid (REF FINUCANE SPINAL MALIG WEB)
* Thyroid<ref name=":2">Finucane L. Spinal Malignancy Course. Physioplus 2020. </ref>
It is not entirely understood how MBD spreads, but its predilection for the spine is considered to be due to hematogenous spread via the venous or arterial pathways.<ref name=":0" />


It is not entirely understood how MBD spreads, but its predilection for the spine is considered to be due to hematogenous spread via the venous or arterial pathways (FINUCANE 2017).  
The distribution of metastases in the spine varies:
* 70% occur in the thoracic spine
* 20% occur in the lumbar spine
* 10% occur in the cervical spine<ref name=":0" />
NB while 70% of metastases occur in the thoracic spine, the patient may not describe thoracic pain.<ref name=":2" />


The distribution of metastases in the spine varies.  
== Identifying Spinal Malignancy ==
70% occur in the thoracic spine
Despite relatively low presentation rates, serious pathology, including spinal malignancy, should be considered as a differential diagnosis when a patient presents with back pain.<ref name=":3">Finucane L. An Introduction to Red Flags in Serious Pathology. Physioplus 2020.</ref> However, identifying serious pathology as the cause of musculoskeletal pain is highly complex.<ref name=":1" /> Red flags have traditionally been used to help identify these conditions and a “history of cancer” and “strong clinical suspicion” have empirical evidence of high diagnostic accuracy for malignancy.<ref>Verhagen AP, Downie A, Maher CG, Koes BW. Most red flags for malignancy in low back pain guidelines lack empirical support: a systematic review. Pain. 2017;158(10):1860-8.</ref> However, red flags generally have poor diagnostic accuracy<ref>Premkumar A, Godfrey W, Gottschalk MB, Boden SD. Red Flags for Low Back Pain Are Not Always Really Red. J Bone Jt Surg. 2018;100(5):368–74.</ref> and there is a lack of consistency in guidelines over which red flags should be used<ref>Verhagen AP, Downie A, Popal N, Maher C, Koes BW. [https://link.springer.com/article/10.1007%2Fs00586-016-4684-0 Red flags presented in current low back pain guidelines: a review.] European Spine Journal. 2016 Sep 1;25(9):2788-802.</ref> or when health professionals should act.<ref name=":3" /> This has led to inconsistency in management of patients when there is suspicion of serious pathology.<ref name=":1" />
20% occur in the lumbar spine
 
10% occur in the cervical spine (REF FINUCANE 2017)
It is vital to identify patients with spinal malignancy as early as possible as this results in much better outcomes.<ref name=":3" /> This is discussed in more detail [https://physio-pedia.com/An_Introduction_to_Red_Flags_in_Serious_Pathology#cite_note-:2-3 here], but it is known that a patient with a single metastasis or just BMD will do better than a patient with multiple metastases.<ref name=":2" /> However, if a patient presents to you with signs of Metastatic Spinal Cord Compression (eg paralysis, bladder/bowel changes, band like pain), they will likely have a poor prognosis as this condition indicates late stage metastatic cancer.<ref name=":2" />
NB while 70% of metastases occur in the thoracic spine, the patient may not describe thoracic pain (REF WEB).
 
The pneumonic RED FLAGS can be used to detect early warning signs of metastatic spinal cord compression.<ref name=":4">The Christie NHS Foundation Trust. The use of red flags to identify serious spinal pathology. Greater Manchester and Cheshire. 2013. Available from https://www.christie.nhs.uk/media/1121/legacymedia-4941-briefing-paper-use-of-red-flags-to-identify-serious-spinal-pathology-updated-jan-2016.pdf (accessed 18 June 2020).</ref>
* R: Referred back pain that is multi-segmental or band like
* E: Escalating pain that responds poorly to treatment including medication
* D: Different character or site to previous symptoms
* F: Funny feelings, odd sensations or heavy legs
* L: Lying flat increases back pain
* A: Agonising pain causing anguish or despair
* G: Gait disturbance, unsteadiness especially on stairs (not just a limp)
* S: Sleep grossly disturbed due to pain being worse at night<ref name=":4" />

Revision as of 03:42, 19 June 2020

‘’'Original Editor ‘’'- Jess Bell ‘’'Top Contributors’’' - Jess Bell, Lucinda hampton, Kim Jackson, Tarina van der Stockt, Admin, Tony Lowe and Vidya Acharya

Introduction to Spinal Malignancy[edit | edit source]

Between one and five percent of all musculoskeletal presentations in primary care are due to serious pathology and these rates are expected to increase as cancer survival rates improve.[1]

Metastatic bone disease (MBD) is the second most common serious spinal pathology - vertebral fracture is the most common.[1] Metastases are cancers that have spread from a primary cancer to a new site in the body; bone is a common location for metastases.[2]

The spine is often one of the earliest areas affected, particularly in patients who have a history of breast and prostate cancer.[1] The five types of cancer that are most likely to spread to the spine are:

  • Breast
  • Prostate
  • Lung
  • Kidney
  • Thyroid[3]

It is not entirely understood how MBD spreads, but its predilection for the spine is considered to be due to hematogenous spread via the venous or arterial pathways.[1]

The distribution of metastases in the spine varies:

  • 70% occur in the thoracic spine
  • 20% occur in the lumbar spine
  • 10% occur in the cervical spine[1]

NB while 70% of metastases occur in the thoracic spine, the patient may not describe thoracic pain.[3]

Identifying Spinal Malignancy[edit | edit source]

Despite relatively low presentation rates, serious pathology, including spinal malignancy, should be considered as a differential diagnosis when a patient presents with back pain.[4] However, identifying serious pathology as the cause of musculoskeletal pain is highly complex.[2] Red flags have traditionally been used to help identify these conditions and a “history of cancer” and “strong clinical suspicion” have empirical evidence of high diagnostic accuracy for malignancy.[5] However, red flags generally have poor diagnostic accuracy[6] and there is a lack of consistency in guidelines over which red flags should be used[7] or when health professionals should act.[4] This has led to inconsistency in management of patients when there is suspicion of serious pathology.[2]

It is vital to identify patients with spinal malignancy as early as possible as this results in much better outcomes.[4] This is discussed in more detail here, but it is known that a patient with a single metastasis or just BMD will do better than a patient with multiple metastases.[3] However, if a patient presents to you with signs of Metastatic Spinal Cord Compression (eg paralysis, bladder/bowel changes, band like pain), they will likely have a poor prognosis as this condition indicates late stage metastatic cancer.[3]

The pneumonic RED FLAGS can be used to detect early warning signs of metastatic spinal cord compression.[8]

  • R: Referred back pain that is multi-segmental or band like
  • E: Escalating pain that responds poorly to treatment including medication
  • D: Different character or site to previous symptoms
  • F: Funny feelings, odd sensations or heavy legs
  • L: Lying flat increases back pain
  • A: Agonising pain causing anguish or despair
  • G: Gait disturbance, unsteadiness especially on stairs (not just a limp)
  • S: Sleep grossly disturbed due to pain being worse at night[8]
  1. ↑ 1.0 1.1 1.2 1.3 1.4 Finucane L, Greenhalgh S, Selfe J. Which red flags aid the early detection of metastatic bone disease in back pain? Physiotherapy Practice and Research. 2017;38(2): 73-77.
  2. ↑ 2.0 2.1 2.2 Finucane LM, Mercer C, Greenhalgh SM, Boissonnault WG, Pool-Goudzwaard AL, Beneciuk JM et al. International framework for red flags for potential serious pathologies. J Orthop Sports Phys Ther. 2020; epub: 1-23.
  3. ↑ 3.0 3.1 3.2 3.3 Finucane L. Spinal Malignancy Course. Physioplus 2020.
  4. ↑ 4.0 4.1 4.2 Finucane L. An Introduction to Red Flags in Serious Pathology. Physioplus 2020.
  5. ↑ Verhagen AP, Downie A, Maher CG, Koes BW. Most red flags for malignancy in low back pain guidelines lack empirical support: a systematic review. Pain. 2017;158(10):1860-8.
  6. ↑ Premkumar A, Godfrey W, Gottschalk MB, Boden SD. Red Flags for Low Back Pain Are Not Always Really Red. J Bone Jt Surg. 2018;100(5):368–74.
  7. ↑ Verhagen AP, Downie A, Popal N, Maher C, Koes BW. Red flags presented in current low back pain guidelines: a review. European Spine Journal. 2016 Sep 1;25(9):2788-802.
  8. ↑ 8.0 8.1 The Christie NHS Foundation Trust. The use of red flags to identify serious spinal pathology. Greater Manchester and Cheshire. 2013. Available from https://www.christie.nhs.uk/media/1121/legacymedia-4941-briefing-paper-use-of-red-flags-to-identify-serious-spinal-pathology-updated-jan-2016.pdf (accessed 18 June 2020).
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