Oh-My Aching BackA panel discussion of spinal pain-diagnosis & treatment

Michael Kassels, D.O.

Diablo Valley Specialist in Internal & Sports Medicine

Introduction

• Musculoskeletal Conditions: OA, LBP, Fibromyalgia a diverse group disorders linked in their common symptoms; pain, decreased well-being, physical

and psych impact.

• Pain : Based on Duration. 1) ACUTE- less than 3 months duration 2) CHRONIC- beyond the healing period and disruption of sleep and normal activity. Lack of

pathology to explain the presence or extent of pain.

Impact of Chronic Pain

• 25% of all adults in the past 3 months had LBP

• One of the most common reasons for PCP visits- 26 million age 20-64 yrs and 6 million age 65 and older.

• Most common reason for work related disability in patients less then age 45 - 2% US work force annually at direct cost of $90 billion and indirect(lost wages, absences) cost of $100 billion/ year.

Pain Control Studies

• American Pain Society only 55% non cancer pain patients felt adequate pain control.

• Michigan Chronic Pain Study: 70% adults receiving txmt reported inadequate control.

Pathopysiology of Neck & LBP

• Mechanical or chemical irritants to sensory neurons innervating ligaments, neural or muscular tissues. Compressive vs Auto immune theory of lumbar disc ds.

• Natural aging of the spine. ie. Spondylosis, spondylolisthesis

• Majority all cases is mechanical.

• Differential of Non mechanical etio. <2% of all cases i.e.. CA, infection, inflammatory disease, and visceral ds. (PID, endometriosis, nephrolithiasis)

• Strain/Sprain 57% of LBP cases. DJD 12.5% , Disc Hern. 11%, Stenosis 4%, Instability 2%, Failed Back <1%

Osteopathic Physicians’ Approach to Diagnosis

• Osteopathic Medicine- adjunctive diagnosis and txmt approaches to common muscular skeletal injuries that involve traditional allopathic (MD) and Osteopathic (DO) structural examination skills employing a holistic approach via the use of (OMT) Osteopathic Manipulative Treatment.

• Anatomical Dysfunction- is evaluated via palpatory and muscular skeletal testing maneuvers that illicit “lesions” in the spine that can be corrected via various forms of structural medicine

techniques.

Diagnosis of Neck & LBP

• Diagnostic testing- initially not required.

• Simplistic and time consuming exam - 1) patient interview. 2) physical and neuro exam. 3) Diagnostic test and pain measures. 4) clinical knowledge and recognition of “RED FLAGS”

Patient Interview

• Pain Description- how long in pain, quality, intensity, location, impact on quality of life.

• Current and Past txmts-how long have you been on medications.

• Psychological Status- support, family and caregiver relationships.

• Prior Diagnostic Studies- often multiple and need not be repeated.

Physical Examination

• Determine Overall Musculoskeletal Health Status- vitals, (signs of withdrawal), physical function, site of the pain.

• General Inspection: Spinal asymmetry, Posture

• ROM (flexibility) and Gait.-Anterior flexion (Loading the Discs), Extension, Lateral Rotation and Side Bending.

• Palpation: for swelling, tenderness, and laxity

Neurological Examination• Measure Pain

Intensity- • Strength & Symmetry-

Test for Sciatica-SLR Testing, active vs. passive testing w reproducible radicular pain at 70% flexion, significance of contra-lateral testing & Sciatic notch compression. False + if Hamstring tightness- seated and standing

flexion testing or bow string exam. • Sensory /Motor Exam

Diagnostic Testing

• Labs-r/o RED FLAGS infection, cancer, etc. CBC, calcium, esr, LFT, Alk Phos.

• Electro diagnostics- EGD and NC for myopathies/neuropathies.

• Diagnostic Blocks Epidural Nerve blocks- diagnostic and therapeutic. Local anesthetics- Facet Syndrome and Sacroiliitis.

• Radiographics-MRI, Plain

Films, CT and Myelograms

RED FLAGS

• ID ETIO: anxiety, depression, substance abuse, work stress, PTSD.

• Non Mechanical: <2%

• age -exclude spinal stenosis pt >50 yrs.

• Wt loss/fever- CA or infection.

• Trauma- Recent or remote MVA, Sports ?spondylolisthesis/lysis- Fx neck of the Scotty dog.

• Recent skin infection or UTI- bacteremia or osteomyelitis.

• Other: hs of malign, immunosuppression, corticosteroid use, substance abuse, pain or weakness in BOTH legs, increase pain when supine. Ankylosis

• When to refer to surgeon- cauda equina symptoms, foot drop, unremitting pain, spinal infection or neurologic compromise, Arachnoiditis, spinal abscess or tumor. When ever it is Out of your scope of practice. Before the lawyer does.

Osteopathic Treatment

• Stand Alone: established utility in ACUTE pain syndromes with statistically significant pain reduction of 50% or greater. Annals of Internal Medicine-UCLA RAND STUDY 1993

• The same study failed to show the value of long term treatment in CHRONIC pain conditions. These findings have been refuted in both the DO and DC literature.

• Adjunct to Medication and Other Treatment: length of injury time decreased in acute and chronic injury with the addition of manipulative medicine treatments improving overall deconditioning, pain scores and recovery times in acute LBP.

Other Non Drug Treatments

• MULTI DISCIPLINE APPROACH

• PATIENT EDUCATION

• PSYCHOSOCIAL- biofeedback, relaxation, cognitive behavioral therapy.

• EXERCISE - increases quality of life.

• MASSAGE, PHYSICAL, and ACCUPRESSURE Therapies

• WORK HARDENING

• Heat and Ice Packs -only heat stimulates release of endogenous opioids. Ice rebounds pain.

• Assistance Devices - cane or walker.

• Homeopathy• Acupuncture

Pharmacologic Therapy

Acetaminophen

Topical Analgesics

Muscle Relaxants

NSAIDs

COX -2 Inhibitors

Tramadol

Opioids

Interventional Options

• Intra-articular Steroids-Epidural and Selective Nerve Root Blocks.

• Botulinum and Sclerotherpy Injections• Spinal Cord Stimulator and Pumps-steroid delivery to CSF • IDET • Joint and Disc Replacement• Disectomy, Laminectomy w or w/o Instrumentation

(rods, cages) etc.• Future: Endoscopic Disectomy

Osteopathic Treatment

• Stand Alone: established utility in ACUTE pain syndromes with statistically significant pain reduction of 50% or greater. Annals of Internal Medicine-UCLA RAND STUDY 1993

• The same study failed to show the value of long term treatment in CHRONIC pain conditions. These findings have been refuted in both the DO and DC literature.

• Adjunct to Medication and Other Treatment: length of injury time decreased in acute and chronic injury with the addition of manipulative medicine treatments improving overall deconditioning, pain scores and recovery times in acute LBP.