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A Syndrome Approach to Low Back Pain

A Syndrome Approach to Low Back Pain. Hamilton Hall MD FRCSC Professor, Department of Surgery, University of Toronto Executive Director, Canadian Spine Society. Faculty/Presenter Disclosure. Faculty: Hamilton Hall Relationships with commercial interests: Consultant: Stryker Spine USA

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A Syndrome Approach to Low Back Pain

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  1. A Syndrome Approach to Low Back Pain Hamilton Hall MD FRCSC Professor, Department of Surgery, University of Toronto Executive Director, Canadian Spine Society

  2. Faculty/Presenter Disclosure • Faculty: Hamilton Hall • Relationships with commercial interests: • Consultant: Stryker Spine USA • Consultant: Medtronic • Consultant: rti Surgical • Medical Director, Pure Healthy Back • Medical Director, CBI Health Group

  3. Disclosure of Financial Support • This program has received no financial support. • This program has received no in-kind support • Potential for conflict of interest: • Hamilton Hall receives compensation as Medical Director of CBIHG.

  4. Mitigating Potential Bias • This program does not discuss or recommend surgical devices. • CBIHG acknowledges that the Pattern Approach to Low Back Pain was developed by Dr. Hall during his time with CBIHG and that its development included contributions for many CBIHG staff members over many years.

  5. Our current approach isn’t working • The medical paradigm hasn’t solved the problem of low back pain. • Guideline: discordant indicators 23,918 primary care visits for back pain Jan 1999 – Dec 2010 • MRI increase use 7.2% to 11.3% Mafi J et al. JAMA 2013

  6. Our current approach isn’t working

  7. Our current approach isn’t working • Guideline: discordant indicators 23,918 primary care visits for back pain Jan 1999 – Dec 2010 • MRI increase use 7.2% to 11.3% • NSAID/acetaminophen decrease use 36.9% to 24.5% • Narcotic increase use 19.3% to 29.1% • Specialist referrals increase 6.8% to 14.0% Mafi J et al. JAMA 2013

  8. Our current approach isn’t working Specialist referrals increase 6.8% to 14.0% • Less than 30% of referrals to a spine surgeon are appropriate for spine surgery. Wai E et al. Can J Surg 2009

  9. Our current approach isn’t working • Back pain remains an enormous social burden. • More than 13 types of health care provider with over 30 treatment approaches. • Still the commonest cause of recurrent lost time from work.

  10. Our current approach isn’t working • There is no correlation between degenerative changes on plain x-ray and back pain. • CT has a 30% false positive rate. • MRI has a 60-90% false positive rate. Early MRI without indication has a strong iatrogenic effect in acute LBP… it provides no benefits, and worse outcomes are likely. Webster BS et al. Spine 2013

  11. Our current approach isn’t working • With all our technology we can identify the specific patho-anatomic source of pain in only 20% of back pain patients. • Everything else is labeled “non-specific” back pain.

  12. Our current approach isn’t working • With all our technology we can identify the specific patho-anatomic source of pain in only 20% of back pain patients. • Everything else is labeled “non-specific” back pain. It is treated “non-specifically”,

  13. Our current approach isn’t working • With all our technology we can identify the specific patho-anatomic source of pain in only 20% of back pain patients. • Everything else is labeled “non-specific” back pain. It is treated “non-specifically”, which doesn’t work.

  14. Our current approach isn’t working • In most cases it doesn’t give the patient what the patient needs: • immediate pain relief • reassurance • a clear prognosis • a method of control

  15. And our current approach is wrong • Most back pain is not the result of • tumour • infection • major trauma • or any medical problem • Most back pain begins spontaneously. • In a study of over 11,000 patients, 2/3rds of the subjects could not recall any cause for the pain. Hall et al. Clin J Pain 1998

  16. But we still memorize the Red Flags • Sphincter disturbance: bowel or bladder • History of cancer • Unexplained weight loss • Immunosuppression • Intravenous drug use • Recent onset of structural deformity • Recent or on-going infection • Fever • Night sweats • Non-mechanical pattern of pain • Constant pain • Wide spread neurological signs or symptoms • Disproportionate night pain • Lack of treatment response • Thoracic dominant pain • Under 20 and over 55 Noseworthy J.N. Neurological Therapeutics

  17. There is another way • Over 90% of back pain is caused by minor altered mechanics. • Most back pain is mechanical. So why don’t we look there first?

  18. There is another way • Over 90% of back pain is caused by minor altered mechanics. • Mechanical back pain is pain • related to movement • related to position • related to a physical structure It means there is a sore thing in the back.

  19. There is another way We can all recognize there is a sore thing. We just can’t agree on which sore thing. And for all the non-invasive treatments locating the sore thing isn’t even necessary.

  20. There is another way “Distinct patterns of reliable clinical findings are the only logical basis for back pain categorization and subsequent treatment.” Quebec Task Force 1987

  21. Patterns of back pain “Distinct patterns of reliable clinical findings are the only logical basis for back pain categorization and subsequent treatment.”

  22. Syndromes of back pain “Distinct syndromes of reliable clinical findings are the only logical basis for back pain categorization and subsequent treatment.” What is a syndrome?

  23. A syndrome is a constellation of signs and symptoms that appear together in a consistent manner

  24. A syndrome is a constellation of signs and symptoms that appear together in a consistent mannerand respond to treatment in a predictable fashion.

  25. A syndrome is a constellation of signs and symptoms that appear together in a consistent mannerand respond to treatment in a predictable fashion.What is the difference between a disease and a syndrome?

  26. The only difference is that we know the etiology of a disease. • A disease has an etiology. • Does a syndrome have an etiology? • Do you think that constellation of signs and symptoms just appears in exactly the same way every time merely by chance? • Of course, a syndrome has an etiology. • We just don’t know what it is yet.

  27. Syndrome recognition • The key to syndrome recognition is the history. and that begins with three questions. Where is your pain the worst?

  28. Where is your pain the worst? • Is it back or leg dominant? • Back dominant pain is referred pain from a physical structure. • Back dominant: • back • buttocks • coccyx • greater trochanters • groin

  29. Where is your pain the worst? • Is it back or leg dominant? • Back dominant pain is referred pain from a physical structure. • Sites of referred pain can become locally tender. • Trochanteric bursitis • Piriformis syndrome

  30. Where is your pain the worst? • Is it back or leg dominant? • Leg dominant pain is radicular pain from nerve root involvement. • Leg dominant: • Around or below the gluteal fold, to the: • thigh • calf • ankle • foot

  31. Where is your pain the worst? • Is it back or leg dominant? • The patient will often report both. • But it must be one or the other. • “ If I could stop only one pain, which one do I stop? • “I have a back pill and a leg pill, which one do you want?”

  32. Syndrome recognition • The key to syndrome recognition is the history. and that begins with three questions. Where is your pain the worst? Is your pain constant or intermittent?

  33. Part A Is there ever a time when you are in your best position, in your best time of your day and everything is going well when your pain stops even for a moment? I know it comes right back but is there ever a time, even a short time when the pain is gone?

  34. Part B When your pain stops does it stop completely? Is it all gone? Are you completely without your pain?

  35. When the pain is constant consider: • Malignancy • Systemic conditions • Pain disorder • Constant mechanical pain

  36. Syndrome recognition • The key to syndrome recognition is the history. and that begins with three questions. Where is your pain the worst? Is your pain constant or intermittent? Does bending forward make your typical pain worse?

  37. Where is your pain the worst? • Is your pain constant or intermittent? • Does bending forward make your typical pain worse? • What are the aggravating movements/positions?

  38. Where is your pain the worst? • Is your pain constant or intermittent? • Does bending forward make your typical pain worse? • Has there been a change in your bowel or bladder function • since the start of your pain?

  39. Where is your pain the worst? • Is your pain constant or intermittent? • Does bending forward make your typical pain worse? • Has there been a change in your bowel or bladder function • What can’t you do now that you could do before you were in pain and why?

  40. Where is your pain the worst? • Is your pain constant or intermittent? • Does bending forward make your typical pain worse? • Has there been a change in your bowel or bladder function • What can’t you do now that you could do before you were in pain and why? • What are the relieving movements/ positions?

  41. Where is your pain the worst? • Is your pain constant or intermittent? • Does bending forward make your typical pain worse? • Has there been a change in your bowel or bladder function • What can’t you do now that you could do before you were in pain and why? • What are the relieving movements/ positions? • Have you had this same pain before?

  42. Where is your pain the worst? • Is your pain constant or intermittent? • Does bending forward make your typical pain worse? • Has there been a change in your bowel or bladder function • What can’t you do now that you could do before you were in pain and why? • What are the relieving movements/ positions? • Have you had this same pain before? • What treatment have you had? Did it work?

  43. History takes precedence over physical examination. But the physical examination must support the history.

  44. Physical Examination • Observation • general activity and behaviour • back specific: • contour • colour • scars • palpation (if you must)

  45. Physical Examination • Observation • Movement • flexion • extension

  46. Physical Examination • Observation • Movement • Nerve root irritation tests • straight leg raising

  47. A positive straight leg raise: • Passive test - the examiner lifts the leg • Reproduction/exacerbation of typical leg dominant pain • Back pain is not relevant • Produced at any degree of leg elevation To reduce confusion with hamstring tightness, flex the opposite hip and knee.

  48. Physical Examination • Observation • Movement • Nerve root irritation tests • straight leg raising • femoral stretch test-when history indicates

  49. Physical Examination • Observation • Movement • Nerve root irritation tests • Nerve root conduction tests • L4 • L5 • S1 knee reflex great toe extension hip abduction ankle dorsiflexion (+ L4) great toe flexion hip extension-gluteus maximus power ankle reflex ankle plantar flexion

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