Downloaded 12 times
More Related Content
Patient cases
- 1. Practical guidelines forthe management of back pain and sciatica Brisbane 24 March 2018
- 2. Dave is a38 year old factory worker on a production line. He comes to see you as a new patient, complaining of back pain. He tells you he has a long history of intermittent back pain which started about 10 years ago. Previous episodes have usually settled with a few days of rest. These episodes have become frequent and severe over the years.
- 3. The most recentepisode started 4 weeks ago and is getting worse. Dave does not recall a particular injury or incident but remembers doing some heavy lifting at about the time the pain started. Dave reports that the current pain is not settling and he has missed time from work using his sick leave. He is unable to return to work now. He wants advice about • what is wrong • what painkillers to take • submitting a WorkCover claim
- 4. Your first stepis to assess him clinically. Dr Angus Forbes is now going to run through a concise history and examination for back pain. 1. What to ask in the history 2. What to look for in the examination Assessment
- 5. HISTORY Past history ofback problems • How long ago • How similar to current pain • How often Current episode • Gradual or sudden • Precipitating event • Evolution Current symptoms • Location and severity • Lower limb pain/weakness/parasthesia • Relationship to activity and position Current treatment • Medication type and frequency • Active and passive therapies SOFT TISSUE SPRAIN AGGRAVATION OF DEGENERATION DISCOGENIC PAIN FACET PAIN REFERRED LOWER LIMB PAIN RADICULAR PAIN FRACTURE TUMOUR INFECTION CAUDA EQUINA SPONDYLOARTHRITIS
- 6. EXAMINATION Look • Alignment • Wasting •Gait (heel/toe/squat) Feel • Tenderness • Percussion • Wasting Move • Flexion (finger-floor) / Extension • Rotation / lateral flexion • SLR / hip / knee / SI joint Neuro • Strength / sensation / reflexes DISCOGENIC FLEXION PAIN FACET EXTENSION PAIN HIP JOINT / SI JOINT RADICULAR / REFERRED PAIN SUPERFICIAL TENDERNESS PAIN ON AXIAL COMPRESSION PAIN ON SIMULATED ROTATION SLR DISCREPANCY GIVING WAY ON MOTOR TESTING REGIONAL SENSORY LOSS NEUROLOGICAL DISORDER SPONDYLOLARTHRITIS INCAPACITATING PAIN FRACTURE TUMOUR INFECTION
- 7. What to watchfor in 5 specific pathological causes of back pain: Vertebral fracture • Minimal trauma vertebral osteoporotic fractures rare in patients <50 years. • Risk factors are: being female; age>70; severe trauma; and long-term glucocorticoids. • If three risk factors are present, probability of a minimum trauma vertebral fracture is 90%. Axial spondyloarthritis • Peak onset between 20-40 years. • Only a slight male predominance. • Morning stiffness that improves with exercise, but not with rest. • Prevalence of radiological disease between 0.3 and 0.8%. • Often a 5-year delay between reporting pain and diagnosis. • Effective treatments exist, so early referral to a rheumatologist advised. Malignancy • 97% of spinal tumours are metastases. • Vertebral metastases occur in 3-5% of people with cancer. • Past history of malignancy, particularly adenocarcinomas, most useful indicator. Infections • Either pyogenic (patients 59-69 years) or granulomatous (immigrant populations). • Rare, but have significant mortality. Cauda equina syndrome • Very rare. Most GPs will not see a case in a working lifetime. • Urinary retention and overflow incontinence are cardinal clinical features. • Consider if new onset perianal sensory change, bladder symptoms or bilateral severe radicular pain with low-back pain of any duration.
- 8. Dave has nothad any previous imaging of his back. He advises he would like a scan to see “what damage work has done”. Dr Greg Cowderoy will now discuss the best imaging to order and how to interpret and explain the findings to Dave. 1. When should imaging be ordered? 2. What imaging should be ordered? 3. How should the results be interpreted? Imaging
- 9. 1. When shouldimaging be ordered? 2. What imaging should be ordered? 3. How should the results be interpreted?
- 10. Ineffectiveness of imagingfor nonspecific LBP • Favourable natural Hx – Most improve by 4 weeks; unaffected by imaging • Nonspecificity: loose association between findings and symptoms – ‘Abnormalities’ or normal aging? • Potential harms: – Radiation – ‘Labelling’ – Incidental findings Ann Intern Med 2011;154:181-190
- 11. LOW BACK PAINGUIDELINES Diagnostic triage 1. Non-specific LBP 2. Radiculopathy 3. Specific LBP • ‘Red flags’ ‘Red Flags’ • Cauda equina syndrome • Known 10 tumour • Weight loss • Severe symptoms, not settling • Fever • Recent infection or Sx • Osteoporosis • Steroid use • Non-mechanical pain • Child*
- 12. 1. When shouldimaging be ordered? 2. What imaging should be ordered? – Radiographs (X-rays) – Scintigraphy (bone scan) – CT – MRI 3. How should the results be interpreted?
- 13. Imaging modalities • Radiographs(X-rays) • Scintigraphy (bone scan) • CT • MRI
- 14. MRI What you see •Bony anatomy and alignment • Bone pathology • Multiplanar view of spinal canal and foramina • Disc: hydration and structure • Neural structures: cord, nerve roots
- 15. 1. When shouldimaging be ordered? 2. What imaging should be ordered? 3. How should the results be interpreted? – Carefully! – Clinical correlation
- 16. Degenerative changes onimaging • Ubiquitous and nonspecific Brinjikji AJNR 2015;36:811 ystematic literature review of imaging features of spinal degeneration in asymptomatic populations Imaging Finding Age (yr) 20 30 40 50 60 70 80 Disk degeneration 37% 52% 68% 80% 88% 93% 96% Disk signal loss 17% 33% 54% 73% 86% 94% 97% Disk height loss 24% 34% 45% 56% 67% 76% 84% Disk bulge 30% 40% 50% 60% 69% 77% 84% Disk protrusion 29% 31% 33% 36% 38% 40% 43% Annular fissure 19% 20% 22% 23% 25% 27% 29% Facet degeneration 4% 9% 18% 32% 50% 69% 83% Spondylolisthesis 3% 5% 8% 14% 23% 35% 50% Brinjikji AJNR 2015;36:811
- 23.
- 24.
- 26. Dave has takenonly over the counter medication for his previous episodes of back pain. However, his wife had Endone in the cupboard which she was prescribed after some recent surgery. Dave has taken that for the last few days but advises that it is not helping and he needs something stronger. Dr Brendan Moore will now discuss Dave’s medication plan. 1. Comprehensive medication plan 2. What to do with a flare of pain 3. Other pain management options
- 27. Dave recalls seeinga physiotherapist in the past. He didn’t think anything really helped. You note that he is avoiding all physical activity for fear of making things worse. He has become quite anxious and frustrated about his situation. He is happy to see someone again at your suggestion. Stephen Boyd will discuss the place for physical therapy. 1. Role of physiotherapist and what to ask for i. Role of active therapy eg exercise physiology ii. Role of passive therapy eg massage
- 28. Dave tells youthat he wants to open a WorkCover claim and would like a certificate backdated to when the pain started. He tells you that he now thinks that work caused the problem in the first place. Dr Angus Forbes will discuss the implications of WorkCover in the process. 1. Your ethical obligations to the patient and the insurer 2. What to put on the certificate 3. Meaning of significant contributing factor and aggravation WorkCover
- 29. WORKCOVER • your ethicalobligations • to the patient • to the insurer • what to put on the certificate • relationship to employment • capacity vs total incapacity • meaning of • significant contributing factor • aggravation vs exacerbation
- 31. WORKCOVER • the treatingdoctor is a key and critical stakeholder in the RTW process • WorkCover highly values communication with the treating doctor • direct contact with case manager very useful • the more information available in the medical certificate, the easier it is for WorkCover to support the injured worker • provide as much information as possible • esp. for subsequent certificates (rather than just extending dates) • focus on capacity and what the injured worker can do, not incapacity • assists with goal of supporting return to appropriate employment • the more time the injured worker is off work, the harder it is to return to work
- 32. Dave returns, sayingthat nothing is helping his pain. He has stopped doing the exercises prescribed and didn’t return to the psychologist as he feels that he isn’t crazy. He went to see an after hours doctor and has been prescribed Targin and Endone, as the medications that the pain physician prescribed weren’t working. His WorkCover claim has been rejected and he has seen a solicitor. He wants an operation to fix the problem. You organise a referral. Dr Paul Licina will talk about the role of surgery in back pain. 1. Who is a good candidate for surgery? 2. What type of surgery? 3. Does surgery work and does it lead to further problems? Surgery
- 34. Are they eligiblefor surgery? IMAGING • Isolated disc degeneration • Marked narrowing • End-plate reactive changes • Specific conditions • Isthmic spondylolisthesis • Revision or lateral disc herniation
- 36. Are they suitablefor surgery? PATIENT
- 37. SUITABLE CANDIDATE • Self-employed •Successful business • No specific injury • No compensation or litigation • Works with some difficulty • Has given up some of more active sports • Uses intermittent over-the-counter analgesics • Non-smoker • Normal body weight • Goal is to be able to return to active lifestyle • No abnormal illness behaviour
- 38. UNSUITABLE CANDIDATE • Employeeundertaking manual work • Dissatisfied with employment • Unremitting pain after lifting at work • Unresolved WorkCover claim with civil action pending • Failed attempts at return to work • Has given up all social activities • Uses regular narcotic analgesia • Smoker • Unfit and overweight • Goal is for someone to get rid of their pain • Abnormal illness behaviour on examination
- 39. What type ofsurgery? SURGEON • Fusion • Posterior or anterior • Disc replacement
- 44. Peta is a32 year old accountant. She has a 3 week history of left sciatica. Peta recalls no accident or injury; she just woke up with the pain. She managed to continue working through the busy tax time but three days ago woke with excruciating pain, together with numbness and weakness, involving her whole leg. She was taken by ambulance to the Emergency Department, where a lumbar CT scan was performed, and she was given analgesics and sent home with advice to see her GP for followup.
- 45. You see Petaand review her results. Dr Greg Cowderoy will discuss the imaging. 1. MRI characteristics of disc herniations 2. Other causes of radiculopathy Imaging
- 46. 1. MRI characteristicsof disc herniations 2. Other causes of radiculopathy
- 47. 1. MRI characteristicsof disc herniations 2. Other causes of radiculopathy
- 48. • Disc bulge •Herniation • Extrusion • Sequestration
- 49. • Disc bulge •Herniation • Extrusion • Sequestration
- 50. • Disc bulge •Herniation • Extrusion • Sequestration
- 51. • Disc bulge •Herniation • Extrusion • Sequestration
- 52. 1. MRI characteristicsof disc herniations 2. Other causes of radiculopathy – Spinal stenosis: osteophyte +/- disc – Synovial cyst – Tumour
- 54.
- 56. You then clinicallyassess Peta. Dr Simone Headrick will focus on the neurological assessment. 1. Clinical assessment of radiculopathy 2. Differential diagnosis of foot drop 3. Specialised nerve studies Neurology
- 57. Radiculopa thy • Radicular pain •Sensory loss- dermatomal • Myotomal weakness • +/- Reflex loss KJ = L3 & 4 AJ = S1
- 58. Common Clinical Presentationsin Patients with Lumbosacral Radiculopathies Pain Radiation Sensory Impairment Provocative Tests Weakness Hypo/Areflexia L1 To groin Inguinal region None None None L2 To groin and anterior thigh Anterolateral thigh Reversed straight leg test Hip Flexion None L3 To anterior thigh and knee Groin and medial thigh Reversed straight leg test Hip flexion and adduction, and knee extension Knee Jerk L4 anterior thigh, knee, and medial foreleg Anterior thigh and medial leg Reversed straight leg test Knee extension, hip adduction, and ankle dorsiflexion Knee Jerk L5 buttock, lateral thigh and leg, and dorsal foot Lateral leg, dorsal foot, and big toe Straight leg test Toe and ankle dorsiflexion, inversion and eversion None S1 buttock, posterior thigh and leg, and lateral foot Posterior thigh, lateral foot, and little toe Straight leg test Plantar flexion, toe flexion GMaximus HExt Ankle Jerk Katirji, B. (2007). Electromyography in Clinical Practice. United States of America: Mosby Elsevier.
- 59. Common Peroneal Nerve Sciaticnerve Lumbosacral plexus L4 nerve root L5 nerve root FOOT DROP S1-3
- 60. Common Peroneal Nerve -Motor weak ankle DF & eversion - Reflexes normal - Sensation anterolateral leg & dorsum foot - Pain is rare Sciatic nerve Lumbosacral plexus L4 nerve root L5 nerve root FOOT DROP S1- 3
- 61. Weakness isolated toperoneal nerve Recognisable compression episode observe 2/12 +/- AFO if progressive then investigate MRI EMG Most common cause of foot drop – peroneal at fibular head Recent surgery TKR? ICU? “Strawberry picker palsy” “Slimmer’s palsy”
- 62. Common Peroneal Nerve -Motor weak ankle DF & eversion, inversion spared - Reflexes normal - Sensation anterolateral leg & dorsum foot - Pain is rare Sciatic nerve Lumbosacral plexus L4 nerve root L5 nerve root FOOT DROP – weak Ankle inversion beyond territory of Peroneal nerveS1- 3 Ankle inversion = Tibialis Posterior = L5
- 63. Sciatic nerve L4 nerveroot L5 nerve root Upper motor neuron signs? CENTRAL causes Foot drop Peripheral causes Parasagittal meningioma, stroke MND + Mixed UMN + LMN signs …. progressive weakness with time (painless & no sensory symptoms) Common Peroneal Nerve Lumbosacral plexus
- 64. NCS & EMG •Stimulate over skin & record • record electrical potentials generated in muscle belly
- 65. NCS Peroneal motor study– EDB Stimulate @ankle Stimulate at Fibular head Above fibular head
- 66. •NCS & EMG Diagnostic sensitivity overlaps MRI Physiologic information AnatomicAims of NCS & EMG in radiculopathy: • 1. Exclude distal Mononeuropathy or generalised PN • 2. Confirm nerve root compression - Localise to single or multiple roots - Time course (distant past vs active ongoing) - Severity Challenging cases… • Inconsistent clinical & MRI findings yet persistent disabling symptoms of radiculopathy • Motor deficit absent or uncertain EMG objective evidence of denervation • Persistent weakness evaluation – most useful > 3wks • MRI Normal identify non-structural radiculopathy mimics (DM, infective, malignant) • MRI multiple abnormalities precisely localise if neuroimaging findings are causing the specific neurologic deficits • Non-specific spinal pain: distinguish pain-related reduced muscular effort vs true neurogenic weakness • Pain only or sensory loss only – NCS EMG = low yield
- 67. You refer Petato see a spine surgeon. He recommends surgery. She undergoes a left L5-S1 microdiscectomy as a day patient. She is working from home two days after surgery, having stopped her analgesia. Two weeks after surgery Peta contacts the practice nurse to advise she has been experiencing the pain in her leg again.
- 68. She is referredto see a pain specialist. Dr Brendan Moore will now discuss his plan for Peta’s postoperative flare of pain.
- 69. At the threeweek clinic review, Peta’s leg pain has settled. She has minimal back discomfort and no residual weakness.