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Lumbar Spine

Lumbar Spine

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Lumbar Spine

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  1. A Practical Approach to the Official Disability Guidelines ODG 477 Pages of Fun MICHAEL WRIGHT, M.D. OSSO SPINE AND HAND CENTER Lumbar Spine

  2. Cost of Health Care • Direct Med Cost • CAD • MVA • Acute Resp • Joint d/o • HTN • LBP • Lost Work Day • LBP • Mood d/o • MVA • Acute Resp • Joint d/o • Pulmonary

  3. Low Back Pain • Direct Medical Costs 10-40 Billion • Disability Payments 30-40 Billion • Absenteeism • Lost Productivity 20-25 Billion • Presenteeism

  4. Lost Work Days Due to LBPGreat Britain Million Days Year

  5. US SS Disability : 1957 - 76

  6. Low Back Pain • Medical costs are 3x higher in WC • 30% of WC claims receive TTD • 4% of non-WC claims receive TTD

  7. Temporary Disability Payments 11% 3% 86%

  8. Low Back Pain • 30% of WC claims responsible for 90% of total costs • WC TD 4.5x longer than Non-WC injury

  9. Physical Therapy

  10. Risk For LBPBoeing • Filing a claim for LBP • Previous History p<.001 • Smoker p<.001 • MMPI p<.0001 • Job Satisfaction p<.00001 • Weight, Co-morbid (DM), Sedentary

  11. Goals • Early Diagnosis • Effective Health Care • Efficient Use of Resources • Eliminate Attorney Litigation (50% incr. cost) • Early Return To Work

  12. Diagnosis • It is helpful to distinguish early between Lumbar Strain (DDD) vs. Radiculopathy (HNP). • Lumbar Strain Back Pain Pred. • Radiculopathy Leg Pain Pred.

  13. Diagnosis • History and Exam • X-ray • MRI • EMG • CT Myelography • Discogram

  14. MRI • Not all MRI’s are created equal • Open MRI = Inferior resolution(0.3 – 0.7 T) • Older MRI = Inferior resolution(1.5 – 3.0 T) • Poor quality MRI may lead to a missed or delayed diagnosis, and increased costs.

  15. MRI • Boden – 1995 • Asymptomatic Volunteers • 30% of 30 yr olds (useful approximation) • 40% of 40 yr olds • 50% of 50 yr olds • Will have a positive MRI despite a lack of clinical symptoms

  16. Discogram • Injection of Saline and Contrast into Disc • Radiographic Identifiable Pathology • Pain Response to Disc Distension • Pain response most predictive.

  17. Discogram

  18. Discogram • Controversial • Many studies to support and refute the use of the Discogram as a diagnostic tool. • NASS • Pain response is the most important • Radiographic findings of unknown import • CT post Discogram of no clinical value

  19. Herniated Disc • Predominance of Leg Pain • Nerve Tension signs • Motor Weakness • Sensory Deficit • Asymmetrical Reflexes • Radiographic Pathology

  20. Herniated Disc • 2% Incidence of HNP in General Population • 80% Recover within 3-6 months. • Equal results at 5 years with op vs. non-op tx. • Large HNP

  21. Herniated DiscInitial Treatment • NSAIDS • Medrol dose pack • Muscle Relaxers/Narcotics (short term) • Physical Therapy (early vs. delayed) • Chiropractic Manipulation (3 visits)

  22. Epidural Steroids • Many studies to suggest effectiveness of ESI • LBP 20% effective • Leg Pain 50% effective

  23. Surgery for HNP Indications • Large Disc Herniation • Severe Pain • Neurologic Deficit (foot drop, Cauda Eq) • Failure of Non-operative Treatment • Wide Geographic Variation

  24. Rate of Surgery for HNP

  25. Outcome of Lumbar Discectomy • Spengler – J Spinal Disorders, 1998 • Compare patients with same D/O • Compare patients with different comp involvement • Evaluate effect of legal involvement on clinical outcome.

  26. Groups of Patients • Private, non-workers’ compensation • Workers’ compensation • Workers’ compensation plus attorney • Third party liability

  27. Parameters Evaluated • Age • Sex • Occupation • Length of symptoms • OPES (objective patient eval score) • Outcome

  28. Demographics • 32 Males • 38 Labor • 27 Non comp • 37 Non legal • 22 Females • 16 Management • 27 Compensation • 17 Legal

  29. Objective Patient Evaluation Score OPES • Neurological signs 25 pts • Sciatic Tension Signs 25 pts • Personality factors (drawing) 25 pts • Imaging studies 25 pts • 100 pts

  30. OPES • 50 Points desired to recommend a lumbar Discectomy procedure • No negative explorations were observed • (All patients had pathology)

  31. Outcomes of Total

  32. Outcomes Results Legal vs. No Legal %

  33. Summary • All patients had proven Disc herniation • Claimants had poorer outcomes than non claimants • Outcomes progressively worsened as legal involvement increased

  34. Medico-Legal Claim and Outcome After Lumbar Disk Surgery • Moskovitz – 1998 • Mehta Analysis • 9 Papers • 1160 pts • Claimant 2.8x more likely to have fair/poor outcome as a non-claimant

  35. Atlas Article, JBJS 2000 • Prospective, observational study 507 patients • Diagnosis of sciatica due to HNP • At 4 years 66% were working and not receiving Disability payments. • Surgery associated with better relief of symptoms, improved functional status, and higher patient satisfaction • Surgery had no effect on disability, or work outcomes at four year follow-up.

  36. Workers Comp System • We have a challenging task to care for these patients • We all want to help the injured worker. • There appears to be a discrepancy between patient reported clinical outcomes and physical capabilities. • Satisfaction, clinical result, and video surveillance can demonstrate wide disparity.

  37. Orthopedic Pearls • Marketing frequently exceeds Science • Smaller is not always better • Percutaneous Discectomy • IDET • Laser

  38. Lumbar Spine - ODG • Guidelines not Laws • A great framework to aid in the treatment decisions of Injured Workers. • Scientific Approach, Evidence Based Medicine • Not all science is good science. • Not every patient situation has a scientific study that is applicable. (Revision Spine)

  39. Lumbar Spine - ODG • Makes my job easier • Acupuncture (NR) • Vax D traction table. (NR) • PT guidelines • Spine Injections (ESI)

  40. Lumbar Spine - ODG • Challenges • MRI- Aside from treatment issues • Causation, Apportionment, Restrictions, impairment • Fear Avoidance Beliefs Questionnaire • Physical Therapy, (directed or self directed) • Psychological Screening • Overall impact ? • Herbal Medicines • Devils Claw, Willows Bark

  41. Lumbar Spine - ODG • Great Start • Should be embraced as a means to apply science to the treatment of our patients. • No substitute for common sense, Biological Science is never perfect.

  42. Lumbar Spine - ODG • LBP WITH Radiculopathy • LBP WITHOUT Radiculopathy

  43. Low Back Pain / ODG Identify Radicular Signs Medical History Dermatologic sensory Loss Pain below the knee Reflexes Tension Signs Motor Weakness

  44. Dermatomes Reflexes

  45. Myotomes / Motor Exam

  46. Nerve Tension Test

  47. LBP without Radiculopathy Visit 1, Day 1 Rx Activity modifications NSAIDS, MR if muscle spasms Stretching RTW in 72 hours Except severe (Pain Meds ?)

  48. LBP without Radiculopathy • Visit 2, Day 3-10 • Document progress • If still 50% disabled the Rx Physical Therapy • (PT, DC, Massage Therapy, Occupational Therapy) • 3 visits of manual therapy first week • Discontinue Muscle Relaxers (?)

  49. LBP without Radiculopathy • Visit 3, Day 10-17 • Document progress • Muscle conditioning exercises • Consider imaging (x-ray) • Manual therapy 2 visits ( total of 5 visits) • 2/3 to 3/4 should be back to regular work. • End of manual therapy at 4 weeks. • 1 visit in last week • Total PT of 8 visits in 4 weeks.

  50. LBP W/O Radiculopathy • Visit 4 • No Specific recommendations provided. • Physical therapy • Sprain / Strain • 10 visits over 8 weeks • Radiculopathy • Post ESI 1-2 visits • Post LLD 16 visits over 8 weeks • Fusion candidate • Post Fusion 34 visits over 16 weeks