Hailee Gibson, CCPA Neurosurgery Physician Assistant. Windsor Neurosurgery & Spine Associates. Windsor Regional Hospital Ouellette Campus

Transcription

1 Hailee Gibson, CCPA Neurosurgery Physician Assistant Windsor Neurosurgery & Spine Associates Windsor Regional Hospital Ouellette Campus

2 Disclosures I have no disclosures

3 Learning Objectives Provide information on how to classify acute, subacute, and chronic pain Familiarize PAs with nonsurgical treatment options for low back pain Identify red flags

4 Low Back Pain Facts 4 out of 5 adults will experience LBP at least once Primarily mechanical low back pain Vast majority is self resolving 30% will have recurrence within 6 months

5 Assessment of Low Back Pain Detailed history Physical Exam Identify Red Flags

6 Low Back History Take detailed history Distribution of pain to identify dermatomal pattern Always ask about focal motor weakness (ie. Foot drop) Always ask about neurogenic bowel/bladder Identify with back dominant or leg dominant

7 Types of Back Pain Back Dominant Typically Mechanical Often due to degenerative changes (disc desiccation, facet osteoarthritis) Leg Dominant Disc herniation Spinal stenosis neurogenic claudication

8 Physical Exam Inspection Palpation ROM Gait Strength Reflexes Sensory Tone Straight leg raise

9 Myotomes Lower Limbs Hip Flexion L2 (femoral) Hip Extension L5 (inferior gluteal) Knee Extension L3 & 4 (femoral) Knee Flexion S1 (sciatic) Ankle Dorsiflexion L4 & 5 (deep peroneal) Ankle Plantarflexion S1 (tibial) Great toe flexor L5 (deep peroneal)

10 UMN vs LMN Lesions Upper Motor Neuron Lesion UP, UP, UP Increased tone Hyperreflexia Upgoing plantar responses Lower Motor Neuron Lesion DOWN, DOWN, DOWN Normal to flaccid tone Normal to diminished reflexes Plantar response downgoing

11 Red Flags Cauda equina syndrome/cord compression Severe, worsening pain, especially at night Trauma Constitutional: Wt loss, hx of cancer, fever Use of steroids/iv drug use First episode & over 50 yo

12 When to order imaging Imaging only if red flag for back dominant pain For leg dominant pain imaging if symptoms persisting/failed conservative treatments or red flag present 2/3 of people WITHOUT back pain will have MRI findings

13 Case 1: Acute pain Patient X presents to your office with a 8 week history of LBP. They state there was no significant injury, however they recall doing some gardening around that time. The symptoms radiate into their bilateral buttock without affecting the legs. What would you like to do?

14 Case 1 History Physical exam Rule out RED FLAGS No imaging unless red flags present

15 Management of Acute Low Back Pain Within 12 weeks of onset: Educate patient Self care strategies (heat, cold, continue usual daily activities) Encourage return to work as soon as possible Physical activity & exercise Analgesics 1. Acetaminophen 2. NSAIDs 3. Muscle relaxants (Flexeril or Baclofen)

16 Case 1 Recommend patient to investigate: Physical therapy Chiropractor Osteopath physician Physician specializing in MSK medicine (ie. Physiatry) Multidisciplinary pain program Reassess in 6-8 weeks

17 Case 2 Patient Y presents for the 3 rd visit to your office with LBP for 16 weeks. Symptoms are waxing & waning. Pain is achy & graded as a 4-7/10 on the VAS. States pain is aggravated by sitting and alleviated by laying. States that NSAIDs provide temporary relief. What do you recommend next?

18 Case 2: History Physical exercise Reassess for red flags Analgesics: Acataminophen NSAIDs (consider PPI) Anti-epileptics (Pregabalin, Gabapentin) Short term cyclobenzaprine (Flexeril) PRN

19 Case 2: Further options for moderate to severe pain: Opioids (short duration 4-6 weeks) Referral to: Multidisciplinary chronic pain clinic Cortisone injections Prolotherapy (ozone & cortisone) Possible surgery in selective patients

20 Types of Injections Cortisone injections Epidurals Facets Medial branch block & medial branch ablation Selective nerve blocks

21 Case 2: Consider referrals Rehab program Self management/cognitive behaviour program Other options Acupuncture Massage therapy (adjunctive therapy) TENs (adjunctive therapy) Aquatherapy Yoga

22 Case 3 Patient A is a 65 yo with a 1 year history of constant LBP with radiculopathy down the bilateral legs. Symptoms described as burning in the legs and aching in the LB. The pain is graded as a 3-8/10 on VAS. Aggravated by standing and walking. Alleviated by sitting or bending forward. Conservative treatments provide short term temporary relief.

23 Case 3: If all conservative options have been investigated without controlling symptoms consider referral to Neurosurgery for surgical opinion with MRI

24 When to refer to Neurosurgery Red flag urgent referral

25 When to refer to Neurosurgery Neurogenic claudication not responding to conservative treatments Shopping cart sign

26 When to refer to Neurosurgery Dominant radiculopathy Typically pain worse when bending forward Straight leg raising important

27 So what does the research actually recommend for chronic pain

28 Recommended: Patient Education: Provide information/educational material on preventative back pain recommendations & emphasize patients role Ensure patient acute LBP primarily benign and generally resolves in 1-6 weeks Physical Activity/Remaining active: Insufficient data on specific type or frequency Good evidence for CORE STRENGTHENING

29 Recommended: Early return to work Provide patient information/assurance Heat/Cold packs Analgesics Multidisciplinary treatment programs Yoga Aquatic therapy

30 Recommended: Massage therapy (as adjunctive therapy) Acupuncture Muscle Relaxants Behavioural therapy/relaxation Injections

31 Recommended: SMOKING CESSATION: Everyone s spine will age Smoking approximately doubts the aging process Smoking and manual labour significantly increased odds of degeneration of spine Has been shown early signs of CAD is early degeneration of L5/S1 disc

32 We Don t Know Type of mattress/chair Prolotherapy (injections of dextrose solution or other irritating substances into the joint, tendon, or painful tissue in order to provoke a regenerative tissue response) Therapeutic ultrasound Laser therapy Spinal Manipulation

33 What is not recommended: Shoe insoles/orthotics Lumbar supports Bed Rest Motorized Traction TENs (acceptable if in adjunct therapy)

34 LOW BACK PAIN PATTERN 1 Pain worse in the back, buttocks, upper thighs, or groin but may radiate to legs Pain may be constant or intermittent Pain is worse when sitting or bending forward Pain may be eased by bending backwards. Walking and standing are better than sitting

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37 LOW BACK PAIN PATTERN 2 Pain is worst in the lower back and may spread to the buttocks or legs Pain is always intermittent Pain is worse when bending backward and when standing or walking for extended periods Pain may be eased by bending forward or sitting

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40 LOW BACK PAIN PATTERN 3 Pain is mainly in the legs but back pain may be present Pain is constant Pain is often worse when sitting or bending, but in the acute stage can be made worse by any movement Pain may be lessened in some rest positions The best position is the one that most reduces the leg pain There is no place for exercise or repeated movement

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43 LOW BACK PAIN PATTERN 4 Pain is worst in the legs and can be described as heaviness or aching Pain is intermittent and is made worse by activity (often walking) Pain is relieved by a change in position, usually by bending forward

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46 Take Home Points Patient education, patient education, patient education Conservative treatments Cortisone injections Referral to Neurosurgery in select patients

47 Patient Resources Low back pain patient resource video: Exercises for primarily LBP improved with extension Exercises for primarily LBP improved with flexion

48 More Patient Resources Exercises for primarily leg symptoms however back pain present. Worse when sitting or bending. Exercises for primarily leg symptoms. Worse when walking or standing. Info on acute LBP: LowBackPain+Patient+Handout+Acute.pdf Info on chronic LBP: LowBackPain+Patient+Handout+Chronic.pdf