Diagnosis. Lumpers vs splitters. Non specific Low back pain Biopsychosocial model good GPs already incorporate this into daily practice

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Todd Melton
5 years ago
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1 Spinal Pain COL Tony Delaney RFD MB BS FACSP Sports Physician Narrabeen Sports Medicine Centre Sydney Academy of Sport Chair ADF Musculoskeletal, Sports, Rehabilitation Consultative Group

2 Background The following review of clinical conditions is drawn from my experience with Sports Medicine Clinics at -- Narrabeen Sports Medicine Centre, Sydney Academy of Sport, Fleet Base East Health Centre (RAN) ( KHC) 1 st Health Services Battalion (Australian Army). The clinics provided a tertiary referral resource for difficult neuromusculoskeletal problems from all 3 services of the ADF. RAN, Army and RAAF.

3 Background ADF members, male and female, different shapes, sizes, ages and genetics frequently perform arduous duties in extremes of climate, altitude and underwater. They may be in the upper percentiles of fitness, but still hurting, due to overuse injuries Conventional general, specialist and hospital training does not prepare us well to diagnose and manage these people. Eyes, hands, brains and communication with our patients remain the most sophisticated clinical resources.

4 Spinal/Back Pain 80 to 95% of the population experience back pain at some time in their lives A systematic approach to history and examination help achieve a reasonable diagnosis in 80 and to 90% of patients The demands that society places on General Practitioners, expecting both broader and deeper knowledge is not entirely reasonable

5 Diagnosis Lumpers vs splitters. Non specific Low back pain Biopsychosocial model good GPs already incorporate this into daily practice Accurate anatomical diagnosis

6 History Mechanical back pain is usually associated with one episode or repeated twisting flexing activity Posture Duration of days to weeks Family History-60 to 70% of patients with significant disc disease Tobacco use leads to the decreased disc nutrition and connective tissue degeneration

7 History The pain associated with medical conditions is usually more insidious in onset Red flags Fever Weight loss Malaise Night pain, increased pain at rest Morning stiffness lasting hours Acute localised Lumbosacral bone pain Systemic, lung, genitourinary,gastrointestinal

11 Red Flags- Diagnosis Infection-vertebral osteomyelitis, discitis Benign neoplasms-osteoid osteoma, osteochondroma, giant cell tumour, ABC Skeletal metastases, multiple myeloma, lymphoma Rheumatology-ankylosing spondylitis, Reiter s syndrome, Psoriatic arthritis, enteropathic arthritis

12 Red flags, diagnosis 2 Endocrine/metabolic-osteoporosis, osteomalacia,- hyperparathyroidism Haematologic-haemoglobinopathy, myelofibrosis, mastocytosis Miscellaneous-Paget s disease, subacute endocarditis, sarcoidosis, retroperitoneal fibrosis General practitioners usually triage these patients. We may establish these diagnoses when reviewing back pain patients from other health practitioners

13 Osteochondromas

14 Spinal pain Pain sensitive structures- Annulus fibrosis Facet joints Meninges Bone Thoracic spine-costovertebral and costotransverse joints- source of difficult pain Costochondritis?Muscle, tendon,,ligament involvement in low back pain

15 Spinal pain-history I am not dealing with acute major spinal trauma today Presentation - acute versus chronic age- adolescent-pars defects, disc tears disc tears 50+, disc, facet joint, spinal stenosis, red flags

16 Common levels of disc/facet injury/degeneration Cervical spine C4/5/6/7 Low back 90% L4/5/S1 Thoracic T6/7 paratroopers T 11/12/L1 junction Upper to mid thoracic - Scheuermanns

17 Spinal pain-presentation Spinal pain, Central or lateralised Spinal pain, with referred buttock or limb pain, Radicular limb symptoms, Pain-aching, electric, shooting, burning, pins and needles, numbness, Motor Weakness Reflexes,Biceps triceps? supinater knee, ankle, plantar NB Cauda Equina Syndrome

18 Examination A clear understanding of the anatomy is essential Gait, walking, heel(l4,5), toe( L5, S1) Pelvic stability, Trendelenberg and Spine flexion, extension, quadrant, rotation, Axial load, quadrant Schober s test, A Sit patient on the couch, -sensation, power, reflexes, peripheral pulses, slump=neural tension Supine-leg length, SLR,neural tension, pelvic stability Prone- PA glide, extension, femoral nerve

19 Galeazzi sign Leg length discrepancy

20 Dermatomes

22 Motor and reflex

23 Management Exercise as comfortable, rest as necessary Leg length, gait correction. Paracetamol, Analgesics, NSAIDS, Opioids= Constipation Benzodiazepines do not help underlying pain, risks= falls, coordination, driving Lumbosacral stabilising exercises-home based Physiotherapists as spinal exercise coaches Chiropractic and adjustments, manipulation and mobilisation Imaging guided nerve root, facet, epidural CS Surgery-Mini/microdiscectomy, fusion, laminectomy, disc replacement synthetic, allograft

24 Imaging PXR CT MRI Bone scan Imaging guided intervention. HSDI- High Speed Digital Imaging Progress is judged clinically

25 Annular Disc Tear

27 Pars Interarticularis Defects

28 Costovertebral joint, vertebral oedema

31 CT PRT /Facet Block

32 Facet Arthralgia

33 Summary History, history, history Examination Spinal ROM Neurology ( C5/6/7/8, L4/5/S1) Gait, toe walk, heel walk, Erect movement- active, passive- thoracolumbar, pelvis, hip, Schobers Seated-Hip, knee, ankle, L2-S2, dermatomes, reflexes, slump, peripheral pulses Supine, leg length, SLR, cross leg symptoms Prone, Pa glide/pain,? Step/spondylolisthesis?stability Extension facet vs post disc tear vs interspinous impingement

36 True sciatica- piriformis syndrome

37 ? Questions

Paul Allan Regional Clinical Lead - South. Lumbar Spine. Assessment & Differential Diagnosis

Paul Allan Regional Clinical Lead - South Lumbar Spine Assessment & Differential Diagnosis Aims Refresh lumbar spine anatomy Red flags Discuss common pathologies seen in general practice Subjective and