Gary Rea MD PhD Medical Director OSU Comprehensive Spine Center

Gary Rea MD PhD Medical Director OSU Comprehensive Spine Center

1. The less specific the patient is about symptoms and pain, the less likely a specific diagnosis will be made and the less likely the patient will benefit from any procedure 2. The more diffusely tender the patient the less likely spinal pathology is the cause

1. Identify A. Patients with RED FLAGS B. Chronic Pain Patients C. Patients that may have an anatomic explanation for their pain 2. Make a Specific Diagnosis

1. History of Cancer 2. History of Recent Trauma not evaluated 3. Possible Spinal Infection-IV IV drugs, HIV +, Immunosuppressed 4. Cauda Equina Syndrome-Bladder retention or incontinence, Perineal numbness, Sensory Level, Progressive weakness in legs

1. How long have you had this pain? 2. How long have you been off work? 3. How long have you been on narcotics?

1. How old is the patient? 2. Is the pain worse in the back or in the legs? a. Back pain-less likely to find anatomic cause b. Leg pain-more likely to have anatomic cause 3. Numbness and tingling in specific pattern? 4. Is the pain or numbness positional?

Causes and Characteristics of the Pain 1. What bothers you the most? 2. When and How did the pain start? 3. Is the pain worsening, improving, staying the same? 4. What is the pain level now (0-10)? 5. How would you describe your pain?

1. WHERE IS THE PAIN? Is it more in the back? Is it in the buttock? I Is it in the thigh, posterior or lateral? Is it below the knee? Is it in the calf or lateral leg? 2.IS THE PAIN RADICULAR? Posterior thigh-more likely S1 Lateral thigh-more likely L5 Top of foot-more likely L5 Heel-more likely S1

IS IT MORE LIKELY DISCOGENIC OR STENOTIC IN ORIGIN? 1. Pain is worse with sitting(discogenic), standing and walking(stenotic), lying down(tumor perhaps) 2. Pain is worse with coughing and sneezing (discogenic)

QUANTITATE WORST SYMPTOMS 1. How long can you sit before you have to get up? 2. How long can you stand before you have to sit down? 3. How far can you walk?50 feet?100 feet? ¼ block?1/2 block?1block?2blocks?as far as you need?

ARE THERE NEUROLOGIC SYMPTOMS? 1. Is there numbness or tingling and if so, where? Top of foot-l5 Bottom of foot, lateral toes-s1 2. Is there weakness, and if so, in what way?

COULD THIS BE A CAUDA EQUINA SYNDROME? 1. Is there numbness in the perineum? 2. Is there bladder difficulty that could be due to cauda equina syndrome?loss of control?first symptom is often inability to void-overflow overflow incontinence

THIS HAS BEEN TREATED WITH--- 1. Change in activity, physical therapy, narcotics, surgery, injections How long and how many times? 2. Are you working? 3. How long not working and why?

GRBACKPAINTEST Thank you for asking me to see @NAME@ for consultation. As you know @HE@ is a @AGE@ @SEX@ who presents with a @CC@ @CAPHE@ says that of the total pain, {numbers:83020321} % in the back and {numbers:83020321}% in the right leg and {numbers:83020321}% in the left leg. This began {Time; disease onset:18417} ago with {Causes; back pain:32249}. Since then the problem has ({Improved/no change/worse:13112} and the pain level now is {NUMBER 1-10:20435}. The pain is primarily described as {PAIN QUALITY:19443}. The pain is in the {pain location:19643}.

GRBACKPAINTEST (cont.) The pain {does/does not:200015} have the appearance of a radicular pattern {Anatomy Lumbar Site :65019407} The pain is made worse with {Causes; aggravating factors extremity pain:11898}. The patient can stand for *** before they develop pain. They can sit for *** before they have pain. They can lay down for *** before they have pain. Coughing or sneezing {does/does not:200015} not increase the pain. There {IS/IS NOT:9024} numbness or tingling {Anatomy Lumbar Site :65019407} There {IS/IS NOT:9024} weakness in the {pain location:19643}. There {IS/IS NOT:9024} numbness in the perineal region. There {IS/IS NOT:9024} bowel or bladder difficulty that appears to be related to a cauda equina problem.

GRBACKPAINTEST (cont.) This {has/not:18111} been treated with chiropractic treatments. This {has/not:18111} been treated with activity restrictions for *** weeks. This {has/not:18111} been treated with over the counter meds such as NSAIDS for *** weeks. This {has/not:18111} been treated with narcotics for *** weeks. This {has/not:18111}been treated with physical therapy. This {has/not:18111}been treated with meds such as Gabapentin for *** weeks. This {has/not:18111} been treated with epidural steroids or other injections. This {has/not:18111}been treated with surgery. The effect of these treatments has been {Improving/worsening/no change:60406}.

GRBACKPAINTEST (cont.) The patient {IS/IS NOT:9024} working. They have been off work for {NUMBER 1-10:20435} months. Their work is {Work Activity Level:20654}. They are currently {Current Work Status:20655}. This {IS/IS NOT:9024} a work related injury. Litigation {IS/IS NOT:9024} involved. Significant other medical issues are {Significant Medical Issues:20656}.

1.Sensory exam is least important; get sensory on history Top of foot, big toe- L5 Bottom of foot little toe-s1 2. Most important reflex-aj, if absent on one side, think S1 radiculopathy(l5s1 hnp) 3. Most important strength test-ehl If weak on one side think L5 radiculopathy(l45 hnp) If bilateral in >65 think stenosis L45

4. Hip or Spine? SLR-pain down back of leg, past knee Faber test-usually more hip 5. Spine flexion/extension More pain with flexion - think disc More pain with extension - think stenosis 6. More tenderness Less likely to have anatomic cause for their pain

Physical exam tests to identify and quantitate findings that indicate a low likelihood of identifying an anatomic cause for the pain Use with a grain of salt Tenderness Over-reaction reaction to pain Regionalization Distraction Simulation-Compression Rotation

HOW I DO IT

GLRPHYSICALEXAM Physical Examination: Awake: yes Alert: yes Oriented: yes Head and Neck: Tenderness: Negative Range of Motion: Normal Carotids: Right: Full, no thrills Left: Full, no thrills Spurlings-Negative Distribution of Numbness or tingling or pain- Cervical Adenopathy: Anterior Cervical-negative, Posterior Cervical-negative, Supra-Clavicularnegative, Infra-Clavicular-negative

Head and Neck (cont) Range of Motion: Right: Shoulder-normal, Elbow-normal, Wrist-normal Left: Shoulder-normal, Elbow-normal, Wrist-normal Tenderness: Right: Shoulder-negative, Upper Arm-negative, Forearm-negative Left: Shoulder-negative, Upper Arm-negative, Forearm-negative Strength: Right: Deltoids-5, Biceps-5, Triceps-5, Wrist Extensors-5, Intrinsics-5 Left: Deltoids-5, Biceps-5, Triceps-5, Wrist Extensors-5, Intrinsics-5 Reflexes: Right: Biceps-2+, Triceps-2+, Brachio-radialis-2+, Hoffmans-minimal Left: Biceps-2+, Triceps-2+, Brachio-radialis-2+, Hoffmans-minimal Sensory: Right: Normal Left: Normal Pulses in Wrist: Right:Normal Left: Normal

GLRPHYSICALEXAM Thoracic Spine and Lumbar Spine Tenderness: Negative Location: Range of Motion: Flexion of Lumbar Spine: Degrees of ROM-Full, without pain Extension of Lumbar Spine: Degrees of ROM-Full, without pain Straight Leg Raising: Right: Negative Left: Negative Tenderness: Right: Buttocks-0, Thighs-0 Left: Buttocks-0, Thighs-0

ROM of Hip: Right: normal Left: normal ROM of Knee: Right: normal Left: normal ROM of Ankle: Right: normal Left: normal Reflexes: Right: Knee-2+, Ankle-2+ Left: Knee-2+, Ankle-2+ Babinski- negative Strength: Right: Hip Flexors-5, Quads-5, Hamstrings-5, Dorsiflexors-5, Plantar flexors-5, EHL-5 Left: Hip Flexors-5, Quads-5, Hamstrings-5, Dorsiflexors-5,Plantar flexors-5, EHL-5

Sensory: Right: Normal Left: Normal Pulses in Feet: Normal Gait: Normal Waddells Signs- Tenderness- Negative Regionalization-Negative Simulation-Rotation-Negative Compression-Negative