1. Considering the Neurological
Angela Sarro RN(EC)
Nurse Practitioner Adult
Spine Surgery
Toronto Western Hospital

2. Overview
Clinical findings that present as common musculoskeletal conditions can increase the level of suspicion of more serious pathologies
Known as ‘red flags’, they often have non- mechanical elements that place individuals at higher risk of a more serious condition
Red flags can be subjective or objective findings
These red flags often warrant further assessment in the form of imaging and/or referrals to specialists

3. Common Red Flags Subjective Objective Physical appearance
Age
History of cancer
Unexplained weight loss
Pain
Constant – no variation in 24 hr
Night pain – non weight bearing
Thoracic pain – common area of metastases
Systemically unwell
Smoking – effects on disc degeneration
PMHx osteoporosis
Physical appearance
Deformity of the spine
Rapid onset scoliosis
Swelling, tenderness
Muscle spasm
Neurological assessment
Dermatomes, myotomes, reflexes

4. Red flags must be considered in context with a full exam
Four main categories of serious pathology include1:
Malignancy
Fracture
Infection
Cauda equina

5. Case Study
53 year old female presents with low back pain, left lower extremity weakness progressive since July 2017
No leg pain, but numbness to entire leg (present for 10 years)
Numbness worsened in July 2017
Now unable to ambulate without use of aid (rollator walker)
Has had to stop working
Increased episodes of falls secondary to left leg giving out

6. Clinical Findings Unable to perform tandem gait Left lower extremity:
Hip flexion 3/5
Knee extension 4/5
Dorsiflexion/EHL 3/5
Plantarflexion/FHL 3/5
Left ankle inversion and eversion 3/5
Babinski down going\bilateral Hoffman's
No clonus
Patellar reflexes brisk bilaterally
Sensation to light touch intact

8. Upper motor neurons2
Originate in cerebral cortex and descend through the spinal cord
Common Findings:
Hyperreflexia
Spasticity
Weakness
Positive Babinski and Hoffman’s signs
Sustained clonus

9. Common Clinical findings
Positive upper motor neuron reflexes
Gait imbalance
Loss fine motor control
Dropping objects
Progressive decline functional abilities
Motor and sensory deficits upper and lower limbs

10. Case Study - Red Flags Positive upper motor neuron reflexes
Gait imbalance
Loss fine motor control
Dropping objects
Progressive decline functional abilities
Motor and sensory deficits upper and lower limbs

11. MRI Lumbar Spine

12. Next steps Findings warrant further imaging of spine
MRI cervical, thoracic spine
EMG/NVC studies
Referral to spine specialist

13. MRI Cervical / Thoracic Spine

14. MRI Thoracic Spine

15. Case Study #2 68 year old gentleman
1 year history of claudicant symptoms with subjective right foot drop
Two falls in past 4 months
Progressive decline in functional ability secondary to symptoms

16. Clinical Findings Normal power lower extremities (5/5)
Decreased sensation right L5 distribution
Mild muscle atrophy in right calf
Reflexes within normal limits
Normal bowel function
Urinary frequency
Upon further questioning:
After 10 minutes of walking, both legs feel weak, right>left
Right foot becomes weaker with activity
Pain and numbness increase in right leg with standing/walking
Sitting relieves all symptoms
Intermittent saddle paresthesia

17. Lower motor neurons2 Located in central and peripheral nervous systems
Responsible for innervating skeletal muscle
Common Findings:
Loss of muscle tone
Muscle atrophy
Weak or absent reflexes

18. Common Clinical findings
Radicular pain and paresthesias
Dynamic weakness
Loss muscle mass
Changes in bowel and bladder function
Saddle paresthesia

19. Case Study – Red Flags Radicular pain and paresthesias
Dynamic weakness
Loss muscle mass
Changes in bowel and bladder function
Saddle paresthesia

20. Next Steps EMG/NVC studies MRI Lumbar Spine
Referral to spine specialist

21. MRI Lumbar Spine

22. Stand Alone Red Flags Cauda Equina Syndrome3,4 Back pain1
Perianal/perineal sensory loss
Bladder dysfunction
Fecal incontinence
Neurological deficit lower extremity
Decreased anal sphincter tone
Back pain1
Constant or occurring at night (non weight bearing) in background of Cancer, osteoporosis history

23. Conclusion Red flags need to be taken into context
Red flags considered to be medical emergencies requiring immediate medical attention from a spine perspective tie back to:
Malignancy
Fracture
Infection
Cauda equina

24. References
1. Verhagen, A.P., Downie, A., Popal, N. et al. (2016). Red flags presented in current low back pain guidelines: a review. Eur Spine J 25: Tymianski, Sarro, Green. (2012). Neuroanatomy and physiology, in Navigating Neuroscience Nursing: A Canadian Perspective. Pappin Communications, Pembroke ON. 3. Hatgis J., Hall A.J. (2017) Cauda Equina Syndrome. In: Kahn S., Xu R. (eds) Musculoskeletal Sports and Spine Disorders. Springer, Cham 4. Chau, AM; Xu, LL; Pelzer, NR; Gragnaniello, C (2014). "Timing of surgical intervention in cauda equina syndrome: a systematic critical review". World neurosurgery. 81 (3-4): 640– 50. doi: /j.wneu PMID