Lumbar Spine

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