Gary Rea MD PhD Gary Rea MD PhD Medical Director Medical Director - - PowerPoint PPT Presentation

Gary Rea MD PhD Gary Rea MD PhD Medical Director Medical Director OSU Comprehensive Spine Center OSU Comprehensive Spine Center

1.

• 1. The less specific the patient is about

The less specific the patient is about symptoms and pain, the less likely a specific symptoms and pain, the less likely a specific diagnosis will be made and the less likely the diagnosis will be made and the less likely the patient will benefit from any procedure patient will benefit from any procedure 2.

• 2. The more diffusely tender the patient the less

The more diffusely tender the patient the less likely spinal pathology is the cause likely spinal pathology is the cause

1.

• 1. Identify

Identify

A.

• A. Patients with RED FLAGS

Patients with RED FLAGS B.

• B. Chronic Pain Patients

Chronic Pain Patients C.

• C. Patients that may have an anatomic explanation

Patients that may have an anatomic explanation for their pain for their pain

2.

• 2. Make a Specific Diagnosis

Make a Specific Diagnosis

1.

• 1. History of Cancer

History of Cancer 2.

• 2. History of Recent Trauma not evaluated

History of Recent Trauma not evaluated 3.

• 3. Possible Spinal Infection

Possible Spinal Infection-

• IV drugs, HIV +,

IV drugs, HIV +, Immunosuppressed Immunosuppressed 4.

• 4. Cauda Equina Syndrome

Cauda Equina Syndrome-

• Bladder retention or

Bladder retention or incontinence, Perineal numbness, Sensory incontinence, Perineal numbness, Sensory Level, Progressive weakness in legs Level, Progressive weakness in legs

• 1. How long have you had this pain?
• 1. How long have you had this pain?
• 2. How long have you been off work?
• 2. How long have you been off work?
• 3. How long have you been on narcotics?
• 3. How long have you been on narcotics?

• 1. How old is the patient?
• 1. How old is the patient?
• 2. Is the pain worse in the back or in the legs?
• 2. Is the pain worse in the back or in the legs?
• a. Back pain
• a. Back pain-
• less likely to find anatomic

less likely to find anatomic cause cause

• b. Leg pain
• b. Leg pain-
• more likely to have anatomic

more likely to have anatomic cause cause

• 3. Numbness and tingling in specific pattern?
• 3. Numbness and tingling in specific pattern?
• 4. Is the pain or numbness positional?
• 4. Is the pain or numbness positional?

Causes and Characteristics of the Pain Causes and Characteristics of the Pain 1.

• 1. “

“What bothers you the most? What bothers you the most?” ” 2.

• 2. When and How did the pain start?

When and How did the pain start? 3.

• 3. Is the pain worsening, improving, staying the

Is the pain worsening, improving, staying the same? same? 4.

• 4. What is the pain level now (0

What is the pain level now (0-

• 10)?

10)? 5.

• 5. How would you describe your pain?

How would you describe your pain?

I I

• 1. WHERE IS THE PAIN?
• 1. WHERE IS THE PAIN?
• Is it more in the back?

Is it more in the back?

• Is it in the buttock?

Is it in the buttock?

• Is it in the thigh, posterior or

Is it in the thigh, posterior or lateral? lateral?

• Is it below the knee?

Is it below the knee?

• Is it in the calf or lateral leg?

Is it in the calf or lateral leg?

Posterior thigh Posterior thigh-

• more likely

more likely S1 S1 Lateral thigh Lateral thigh-

• more likely L5

more likely L5 Top of foot Top of foot-

• more likely L5

more likely L5 Heel Heel-

• more likely S1

more likely S1

2.IS THE PAIN RADICULAR? 2.IS THE PAIN RADICULAR?

IS IT MORE LIKELY DISCOGENIC OR IS IT MORE LIKELY DISCOGENIC OR STENOTIC IN ORIGIN? STENOTIC IN ORIGIN? 1.

• 1. Pain is worse with

Pain is worse with— —sitting(discogenic), sitting(discogenic), standing and walking(stenotic), lying standing and walking(stenotic), lying down(tumor perhaps) down(tumor perhaps) 2.

• 2. Pain is worse with coughing and sneezing

Pain is worse with coughing and sneezing (discogenic) (discogenic)

QUANTITATE WORST SYMPTOMS QUANTITATE WORST SYMPTOMS 1.

• 1. How long can you sit before you have to get

How long can you sit before you have to get up? up? 2.

• 2. How long can you stand before you have to sit

How long can you stand before you have to sit down? down? 3.

• 3. How far can you walk?50 feet?100 feet?

How far can you walk?50 feet?100 feet? ¼ ¼ block?1/2 block?1block?2blocks?As far as you block?1/2 block?1block?2blocks?As far as you need? need?

ARE THERE NEUROLOGIC SYMPTOMS? ARE THERE NEUROLOGIC SYMPTOMS? 1.

• 1. Is there numbness or tingling and if so, where?

Is there numbness or tingling and if so, where?

• Top of foot

Top of foot-

• L5

L5

• Bottom of foot, lateral toes

Bottom of foot, lateral toes-

• S1

S1

2.

• 2. Is there weakness, and if so, in what way?

Is there weakness, and if so, in what way?

COULD THIS BE A CAUDA EQUINA COULD THIS BE A CAUDA EQUINA SYNDROME? SYNDROME? 1.

• 1. Is there numbness in the perineum?

Is there numbness in the perineum? 2.

• 2. Is there bladder difficulty that could be due to

Is there bladder difficulty that could be due to cauda equina syndrome?Loss of control?First cauda equina syndrome?Loss of control?First symptom is often inability to void symptom is often inability to void-

• overflow
• verflow

incontinence incontinence

THIS HAS BEEN TREATED WITH THIS HAS BEEN TREATED WITH---

• 1. Change in activity, physical therapy,
• 1. Change in activity, physical therapy,
• narcotics, surgery, injections

narcotics, surgery, injections

• How long and how many times?

How long and how many times?

• 2. Are you working?
• 2. Are you working?
• 3. How long not working and why?
• 3. How long not working and why?

Thank you for asking me to see @NAME@ for consultation. As you know @HE@ is a @AGE@ @SEX@ who presents with a @CC@ @CAPHE@ says that of the total pain, {numbers:83020321} % in the back and {numbers:83020321}% in the right leg and {numbers:83020321}% in the left leg. This began {Time; disease onset:18417} ago with {Causes; back pain:32249}. Since then the problem has ({Improved/no change/worse:13112} and the pain level now is {NUMBER 1-10:20435}. The pain is primarily described as {PAIN QUALITY:19443}. The pain is in the {pain location:19643}.

GRBACKPAINTEST

The pain {does/does not:200015} have the appearance of a radicular pattern {Anatomy Lumbar Site :65019407} The pain is made worse with {Causes; aggravating factors extremity pain:11898}. The patient can stand for *** before they develop pain. They can sit for *** before they have pain. They can lay down for *** before they have pain. Coughing or sneezing {does/does not:200015} not increase the pain. There {IS/IS NOT:9024} numbness or tingling {Anatomy Lumbar Site :65019407} There {IS/IS NOT:9024} weakness in the {pain location:19643}. There {IS/IS NOT:9024} numbness in the perineal region. There {IS/IS NOT:9024} bowel or bladder difficulty that appears to be related to a cauda equina problem.

GRBACKPAINTEST (cont.)

This {has/not:18111} been treated with chiropractic treatments. This {has/not:18111} been treated with activity restrictions for *** weeks. This {has/not:18111} been treated with over the counter meds such as NSAIDS for *** weeks. This {has/not:18111} been treated with narcotics for *** weeks. This {has/not:18111}been treated with physical therapy. This {has/not:18111}been treated with meds such as Gabapentin for *** weeks. This {has/not:18111} been treated with epidural steroids or other injections. This {has/not:18111}been treated with surgery. The effect of these treatments has been {Improving/worsening/no change:60406}.

GRBACKPAINTEST (cont.)

The patient {IS/IS NOT:9024} working. They have been off work for {NUMBER 1-10:20435} months. Their work is {Work Activity Level:20654}. They are currently {Current Work Status:20655}. This {IS/IS NOT:9024} a work related injury. Litigation {IS/IS NOT:9024} involved. Significant other medical issues are {Significant Medical Issues:20656}.

GRBACKPAINTEST (cont.)

1.Sensory exam is least important; get sensory on 1.Sensory exam is least important; get sensory on history history

• Top of foot, big toe

Top of foot, big toe-

• L5

L5

• Bottom of foot little toe

Bottom of foot little toe-

• S1

S1

• 2. Most important reflex
• 2. Most important reflex-
• AJ, if absent on one side,

AJ, if absent on one side, think S1 radiculopathy(L5S1 hnp) think S1 radiculopathy(L5S1 hnp)

• 3. Most important strength test
• 3. Most important strength test-
• EHL

EHL

• If weak on one side think L5 radiculopathy(L45

If weak on one side think L5 radiculopathy(L45 hnp) hnp)

• If bilateral in >65 think stenosis L45

If bilateral in >65 think stenosis L45

• 4. Hip or Spine?
• 4. Hip or Spine?
• SLR

SLR-

• pain down back of leg, past knee

pain down back of leg, past knee

• Faber test

Faber test-

• usually more hip

usually more hip

• 5. Spine flexion/extension
• 5. Spine flexion/extension
• More pain with flexion

More pain with flexion -

• think disc

think disc

• More pain with extension

More pain with extension -

• think stenosis

think stenosis

• 6. More tenderness
• 6. More tenderness
• Less likely to have anatomic cause for their pain

Less likely to have anatomic cause for their pain

• Physical exam tests to identify and quantitate

Physical exam tests to identify and quantitate findings that indicate a low likelihood of findings that indicate a low likelihood of identifying an anatomic cause for the pain identifying an anatomic cause for the pain

• Use with a grain of salt

Use with a grain of salt

• Tenderness

Tenderness

• Over

Over-

• reaction to pain

reaction to pain

• Regionalization

Regionalization

• Distraction

Distraction

• Simulation

Simulation-

• Compression Rotation

Compression Rotation

HOW I DO IT HOW I DO IT

GLRPHYSICALEXAM

Physical Examination:

• Awake: yes
• Alert: yes
• Oriented: yes

Head and Neck: Tenderness: Negative Range of Motion: Normal Carotids:

• Right: Full, no thrills
• Left: Full, no thrills

Spurlings-Negative

• Distribution of Numbness or tingling or pain-

Cervical Adenopathy:

• Anterior Cervical-negative, Posterior Cervical-negative, Supra-Clavicular-

negative, Infra-Clavicular-negative

Head and Neck (cont) Range of Motion:

• Right: Shoulder-normal, Elbow-normal, Wrist-normal
• Left: Shoulder-normal, Elbow-normal, Wrist-normal

Tenderness:

• Right: Shoulder-negative, Upper Arm-negative, Forearm-negative
• Left: Shoulder-negative, Upper Arm-negative, Forearm-negative

Strength:

• Right: Deltoids-5, Biceps-5, Triceps-5, Wrist Extensors-5, Intrinsics-5
• Left: Deltoids-5, Biceps-5, Triceps-5, Wrist Extensors-5, Intrinsics-5

Reflexes: Right: Biceps-2+, Triceps-2+, Brachio-radialis-2+, Hoffmans-minimal

• Left: Biceps-2+, Triceps-2+, Brachio-radialis-2+, Hoffmans-minimal

Sensory:

• Right: Normal
• Left: Normal

Pulses in Wrist:

• Right:Normal
• Left: Normal

Thoracic Spine and Lumbar Spine Tenderness: Negative Location: Range of Motion: Flexion of Lumbar Spine:

• Degrees of ROM-Full, without pain

Extension of Lumbar Spine:

• Degrees of ROM-Full, without pain

Straight Leg Raising:

• Right: Negative
• Left: Negative

Tenderness:

• Right: Buttocks-0, Thighs-0
• Left: Buttocks-0, Thighs-0

GLRPHYSICALEXAM

ROM of Hip:

• Right: normal
• Left: normal

ROM of Knee:

• Right: normal
• Left: normal

ROM of Ankle:

• Right: normal
• Left: normal

Reflexes:

• Right: Knee-2+, Ankle-2+
• Left: Knee-2+, Ankle-2+
• Babinski- negative

Strength:

• Right: Hip Flexors-5, Quads-5, Hamstrings-5, Dorsiflexors-5, Plantar flexors-5,

EHL-5

• Left: Hip Flexors-5, Quads-5, Hamstrings-5, Dorsiflexors-5,Plantar flexors-5, EHL-5

Sensory:

• Right: Normal
• Left: Normal

Pulses in Feet: Normal Gait: Normal Waddells Signs-

• Tenderness- Negative
• Regionalization-Negative
• Simulation-Rotation-Negative
• Compression-Negative