D. Special Studies Consideration in the presence of Red Flags.
Since ~90% of all those with back pain recover within 4 weeks from each episode, immediate special studies are only considered in the few patients with "Red Flags
." The following red flags issues warrant the suggested testing:
For Metabolic, Tumor, Infection concerns, consider your laboratory studies (CBC, Chem. panel, UA, TSH, RA, ESR).
New Bowel & Bladder symptoms or obvious multilevel neurologic dysfunction warrant immediate consultation for specialist's choice of imaging techniques (MRI
or Myelo-CT scan) to avoid duplication.
For a question of Fracture due to significant trauma, X-ray or later bone scan (more sensitive at 7-10 days) may detect abnormalities that may need to be defined further by CT
Other findings may trigger specific approaches based upon specific leads from History & Physical Examination.
Studies in the absence of "Red Flags
" or before four weeks of limited activity are worthless for 90% of patients and commonly confusing in for the slowest 10% to recover. Patient should be made aware that any use of special studies are for seeking serious problems and to expect age related and sometimes termed “degenerative” changes are to be expected even at a young age. In the presence of lingering symptoms, lasting longer than four weeks, you might consider seeking special studies according to the patient's ability to make a living. Keep in mind changes on X-rays and other imaging changes are common even at an early age and are thusly poor screening tools. If studies are available from another practitioner, review the latest imaging and physiologic study (See Diagnostic Considerations for Delayed Recovery
). It is important to consider the following when evaluating studies: 1. prior surgery and aging makes imaging studies more difficult to evaluate and, 2. changes on some physiologic tests do not be occur immediately (3-4 weeks EMG
) or (7-10 for Bone Scan
). The type of Symptoms (neurologically documented or not) determine the type of diagnostic tests after 4 wks depending upon work activity limitation. Since 90% reasonably recover within 4 weeks from each episode, early special studies are considered in few patients without "Red Flags
". After 4 weeks the timing is relative to the patient's needs. Special studies for the slowest to recover are usually performed closer to the 4 week point for a patient whose job is in jeopardy than those less impacted by work issues.
Table Initial Assessment Summary
In the working age adult Sciatic Tension Signs greatly help determine if a symptoms will have a neurological or non-neurological course of expected course of recovery and special study considerations if recovery is slow.
Table Decisions and Timing Summary- Since 90% recover within 4 weeks from each episode, special studies are needed in few patients with "Red Flags". Duration (4 wks?) guide timing & kind of work-up.(neuro +/?)
-Neuro = Neurologically Negative, Neuro+ = Neurologically Postive radiculopathy, Ca = Cancer, Inf.=Infection, Cauda Equinae = syndrome of threatening paraplegia or paraparesis indicating multiple nerve roots are in jeopardy, especially those related to bowel or bladder function or severe multi-level leg paralysis.
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