Transcript Chronic Pelvic Pain - A Partnership between Doctors of BC

Mechanical Low Back Pain (Sciatica)
Case 3: Karen
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Objectives
When working with CPP, you will be able to:
 Identify abnormal neurological signs and
symptoms
 List 3 assessment tools that may be useful
 Address patient expectations for diagnostic
imaging and surgical referral
 Indications for Opioid Use
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Mechanical Low Back Pain
 “Karen”, 35 year old female, Nurse, presenting
with 6 week history of right leg dominant pain
 She first noticed it after having difficulty with a
patient transfer and experience immediate low
back and right posterior leg pain.
 She tried to maintain work but found it
increasingly difficult and was advised by her
therapist to stop work since she was not
responding to treatment.
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What are your Key Questions?
 How do you determine if
this is mechanical back
pain ?
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On History, we found…
 She rates her pain as 9/10 and
finds that sitting and walking
are difficult and aggravate her
symptoms
 She experiences increased
pain with coughing and
sneezing
 Morning stiffness is 30
minutes
 There are no changes in his
bowel and bladder habits
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Physical Exam
 What physical examination techniques would you use?
We found:
Flexion and Extension aggravated low back pain
Difficult to find any comfortable position
 Positive SLR causing reproduction of leg pain
Decreased right Achilles reflex
 Decreased myotomal strength of right toe extension
 Hypersensitivity over lateral calf & intermittent tingling.
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Pain History
What would you ask to determine optimal pain
management strategy ?
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We found
 Lives with husband and 7 year old daughter in Richmond
 Tried over-the-counter meds initially but found that she was
taking 12-14 tablets per day of acetaminophen and
ibuprofen.
 Has been put on Codeine based analgesia for 3 weeks and
is experiencing constipation with little relief
 Has asked about using Lyrica or Percocet which her
colleagues have suggested
 Mood is “anxious and stressed”
 Concerned that she will not be able to go back to work due
to pain

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Management Tools
 How would you determine if investigations were
appropriate ?
We used:
a) Is there poor or no response to appropriate treatment?
b) Are pain levels unmanaged with best medications?
c) Are there prolonged neurological deficits greater than 6
week ?
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Understanding symptoms of neurological origin
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Imaging Options ?
 XRAY
 suspected trauma or fragility fracture
 Bone Scan
 infection, metastases, systemic inflammatory process
 MRI
 Progressive neurological deficits, unresponsive radicular
syndrome, neurogenic claudication, cauda equina
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Facilitating recovery through home based
exercise and recovery postures
 What would you suggest ?
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Facilitating your patient to set Goals
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No Improvement noted
 Despite best efforts for therapy and medication,
Karen is not improving and she has had
increasingly more pain and withdrawal from
activities.
 The MRI demonstrated a right large paracentral
disc herniation with nerve compression.
 Would you refer to a surgeon or not ?
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Referral to a Specialist
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Clinical Impression
 Pattern 3 –Leg Dominant Pain
 Leg dominant and flexion continually increases pain
 Positive Neurological exam
 She is anxious and apprehensive of pain
 Her pain management has not been successful
although she is compliant, may need opioids
 Should have a trial of conservative therapy but
may need referral for surgical opinion
 Appropriate for MRI investigation
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Key Clinical Information
 What are the key criteria for MRI investigation?
 Lack of treatment response
 Evolving Neurological tests
 Leg Dominant Pain Syndrome
 What Medication may be best for her ?

Short acting opioids for best treatment.
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Summary
When working with Mechanical Leg Dominant Pain, it is
important to:
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Take a targeted history
Do a full neurological examination
Refer for goal oriented rehab treatment and evaluate
response.
4. Consider MRI if no response to appropriate
therapy and escalating leg dominant pain.
6. 5. Consider short term opioid management.
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References
 Alberta TOP (Towards Optimizing Practice) Low
Back Pain Guideline
http://www.topalbertadoctors.org/cpgs/885801
 The Opioid Manager
http://nationalpaincentre.mcmaster.ca/opioidma
nager/
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