Transcript Lumbar Spine - www.cmsa-ok

A Practical Approach to the
Official Disability Guidelines
ODG
477 Pages of Fun
MICHAEL WRIGHT, M.D.
OSSO SPINE AND HAND CENTER

Direct Med Cost

Lost Work Day
 CAD
 LBP
 MVA
 Mood d/o
 Acute Resp
 MVA
 Joint d/o
 Acute Resp
 HTN
 Joint d/o
 LBP
 Pulmonary

Direct Medical Costs
10-40 Billion

Disability Payments
30-40 Billion
 Absenteeism

Lost Productivity
 Presenteeism
20-25 Billion
Million Days
90
80
70
60
50
Million Days
40
30
20
10
0
55
60
65
Year
70
75
80
85
90
95
2500
2000
1500
Percent increase
1000
500
0
US pop
All
Heart
causes
Schtiz
LBP

Medical costs are 3x higher in WC

30% of WC claims receive TTD

4% of non-WC claims receive TTD
11%
3%
Injury, TD
Non-Injury, TD
WC TD
86%

30% of WC claims responsible for 90% of
total costs

WC TD 4.5x longer than Non-WC injury
200
180
160
140
120
100
PT Consumption
80
60
40
20
0
WC
Non WC

Filing a claim for LBP




Previous History
Smoker
MMPI
Job Satisfaction
p<.001
p<.001
p<.0001
p<.00001
 Weight, Co-morbid (DM), Sedentary





Early Diagnosis
Effective Health Care
Efficient Use of Resources
Eliminate Attorney Litigation (50% incr. cost)
Early Return To Work

It is helpful to distinguish early between
Lumbar Strain (DDD) vs. Radiculopathy
(HNP).

Lumbar Strain
Back Pain Pred.

Radiculopathy
Leg Pain Pred.

History and Exam





X-ray
MRI
EMG
CT Myelography
Discogram




Not all MRI’s are created equal
Open MRI = Inferior resolution(0.3 – 0.7 T)
Older MRI = Inferior resolution(1.5 – 3.0 T)
Poor quality MRI may lead to a missed or
delayed diagnosis, and increased costs.


Boden – 1995
Asymptomatic Volunteers
 30% of 30 yr olds (useful approximation)
 40% of 40 yr olds
 50% of 50 yr olds

Will have a positive MRI despite a lack of clinical symptoms



Injection of Saline and Contrast into Disc
Radiographic Identifiable Pathology
Pain Response to Disc Distension
▪ Pain response most predictive.
Discogram

Controversial
Many studies to support and refute the use of the Discogram
as a diagnostic tool.

NASS

 Pain response is the most important
 Radiographic findings of unknown import
 CT post Discogram of no clinical value






Predominance of Leg Pain
Nerve Tension signs
Motor Weakness
Sensory Deficit
Asymmetrical Reflexes
Radiographic Pathology

2% Incidence of HNP in General Population

80% Recover within 3-6 months.

Equal results at 5 years with op vs. non-op tx.
▪ Large HNP





NSAIDS
Medrol dose pack
Muscle Relaxers/Narcotics (short term)
Physical Therapy (early vs. delayed)
Chiropractic Manipulation (3 visits)

Many studies to suggest effectiveness of ESI

LBP
Leg Pain

20% effective
50% effective
Indications

Large Disc Herniation
 Severe Pain
 Neurologic Deficit
(foot drop, Cauda Eq)
 Failure of Non-operative Treatment

Wide Geographic Variation
120
100
80
Rate of disc
surg/100K
personl comm
60
40
20
0
Calif
Sweeden
Tulsa




Spengler – J Spinal Disorders, 1998
Compare patients with same D/O
Compare patients with different comp
involvement
Evaluate effect of legal involvement on
clinical outcome.




Private, non-workers’ compensation
Workers’ compensation
Workers’ compensation plus attorney
Third party liability






Age
Sex
Occupation
Length of symptoms
OPES (objective patient eval score)
Outcome
32 Males
38 Labor
 27 Non comp
 37 Non legal


22 Females
16 Management
 27 Compensation
 17 Legal






Neurological signs
Sciatic Tension Signs
Personality factors (drawing)
Imaging studies

25 pts
25 pts
25 pts
25 pts
100 pts

50 Points desired to recommend a lumbar
Discectomy procedure

No negative explorations were observed
 (All patients had pathology)
30
25
20
15
# of patients
10
5
0
Good
Fair
Poor
%
80
70
60
50
no legal
legal
40
30
20
10
0
Good
Fair
Poor

All patients had proven Disc herniation

Claimants had poorer outcomes than non
claimants

Outcomes progressively worsened as legal
involvement increased



Moskovitz – 1998
Mehta Analysis
9 Papers
 1160 pts
 Claimant 2.8x more likely to have fair/poor
outcome as a non-claimant

Prospective, observational study 507 patients
 Diagnosis of sciatica due to HNP
 At 4 years 66% were working and not receiving Disability payments.
 Surgery associated with better relief of symptoms, improved
functional status, and higher patient satisfaction
 Surgery had no effect on disability, or work outcomes at four year
follow-up.

We have a challenging task to care for these
patients
 We all want to help the injured worker.
 There appears to be a discrepancy between patient
reported clinical outcomes and physical capabilities.
 Satisfaction, clinical result, and video surveillance can
demonstrate wide disparity.

Marketing frequently exceeds Science

Smaller is not always better
 Percutaneous Discectomy
 IDET
 Laser

Guidelines not Laws
 A great framework to aid in the treatment
decisions of Injured Workers.
 Scientific Approach, Evidence Based Medicine
 Not all science is good science.
 Not every patient situation has a scientific study
that is applicable. (Revision Spine)

Makes my job easier

Acupuncture (NR)
Vax D traction table. (NR)
PT guidelines
Spine Injections (ESI)




Challenges
 MRI- Aside from treatment issues
▪ Causation, Apportionment, Restrictions, impairment
 Fear Avoidance Beliefs Questionnaire
▪ Physical Therapy, (directed or self directed)
 Psychological Screening
▪ Overall impact ?
 Herbal Medicines
▪ Devils Claw, Willows Bark

Great Start

Should be embraced as a means to apply
science to the treatment of our patients.

No substitute for common sense, Biological
Science is never perfect.

LBP WITH Radiculopathy

LBP WITHOUT Radiculopathy
Identify Radicular Signs
Medical History
Dermatologic sensory Loss
Pain below the knee
Reflexes
Tension Signs
Motor Weakness
Visit 1, Day 1
Rx
Activity modifications
NSAIDS, MR if muscle spasms
Stretching
RTW in 72 hours Except severe
(Pain Meds ?)

Visit 2, Day 3-10
▪
▪
▪
▪
▪
Document progress
If still 50% disabled the Rx Physical Therapy
(PT, DC, Massage Therapy, Occupational Therapy)
3 visits of manual therapy first week
Discontinue Muscle Relaxers
(?)

Visit 3, Day 10-17
▪
▪
▪
▪
▪
▪
▪
▪
Document progress
Muscle conditioning exercises
Consider imaging (x-ray)
Manual therapy 2 visits ( total of 5 visits)
2/3 to 3/4 should be back to regular work.
End of manual therapy at 4 weeks.
1 visit in last week
Total PT of 8 visits in 4 weeks.

Visit 4
▪ No Specific recommendations provided.
▪ Physical therapy
 Sprain / Strain
 10 visits over 8 weeks
 Radiculopathy
 Post ESI 1-2 visits
 Post LLD 16 visits over 8 weeks
 Fusion candidate
 Post Fusion 34 visits over 16 weeks
MRI
Prior surgery
Myelopathy ( cord compression)
Spine Trauma (Fall from height, MVA)
Red Flags - Cancer, infection,
Cauda Equina Syndrome
Uncomplicated LBP with Radiculopathy after 1 month of TX
Progressive Neuro Deficit.
? What if LBP w/o radiculopathy
? Discussion







Cauda Equina Syndrome
Lumbar Spine Trauma, w Neuro deficit
Lumbar Spine Trauma, fracture
LBP, Red flags (cancer, Infection)
LBP radiculopathy, 1 month TX
LBP prior surgery
LBP Myelopathy, (cord compression)

LBP without the above not addressed

MRI - no rec for uncomplicated LBP
 Valuable aside from treatment issues.
▪
▪
▪
▪
▪
Causation
Apportionment
Impairment
RTW restriction
Objective ? ( value of a NL MRI)
▪ Discussion ?
▪ Can you close a litigated WC case without an MRI?

Injections
 ESI
▪
▪
▪
▪
▪
Radiculopathy must be documented
Failure of conservative treatment, NSAIDS, MR, PT
No more than 2 Root levels injected, or 1 Intra Lam
No more than 2 ESI
Additional injections if initial injection/s produce pain red by 50%
for 6-8 weeks
▪ Max of 4 ESI / year.

Injections
 Facet injections / Medial Branch Block
▪ Diagnostic tool
 Facet Radiofrequency Rhizotomy
▪ Under Study
▪ Conflicting evidence

Facet syndrome dx , from ODG
 Tenderness to palpation
 Normal Sensory Exam
 Absence of radicular findings
 Normal Straight leg raising exam
 Large dose of Common Sense.

Under Study, conflicting evidence

My opinion
 Weak science to support
 Over utilized in our community
 MBB relief based upon Narcotics vs MBB?
 Person evaluating success of MBB is same person to determine if the
next procedure in indicated (RFA). Biased ?
 Literature suggest 25% conversion of MBB to RFA. My observation is
closer to 90%
 Some role in recalcitrant LBP with diffuse degenerative changes in the
discs and facets.
 Results decay w time
 1x / year maximum







One MBB, NOT 2
No evidence of radicular pain
No more than 2 joint levels may be blocked an any
one time
Formal plan with additional evidenced based
approach. (PT, NSAIDS)
Pain relief from MBB not narcotic related.
Should not be repeated unless initial procedure
produces >50% for > 12wks
Max 3/year. (Costly, unending?)

OSSO Spine experience







6700 patient office visits 2011
47 patients referred for a MBB
09 patients treated w RFA
00 patients referred for a repeat RFA
Minimal sedation if any given during MBB
MHW evaluated all patients post MBB
Decision to proceed to RFA not made by the same
physician that ultimately performed the RFA
 Attempt to reduce internal bias.


Meds (NSAIDS, pain, MR, Neurontin, Cymbalta)
PT
ESI
Facet disease
Home therapy, stretching, weight loss,
Activity modification
Devils Claw. (herbal medicines - ODG rec)pg 86/477

Continued severe pain?






Fusion should not be considered for LBP
within the first 6 months, except
▪
▪
▪
▪
▪
Fracture
Dislocation
Progressive neurologic loss
Science vs Practical approach
Discussion

Indications
 Neural Arch Defect (Spondylolisthesis)
 Segmental Instability
 Primary Mechanical Back Pain
▪ 2 levels
 Revision Surgery
 Infection
 2 failed LLD







Indications
All pain generators identified and TX
All Phys med and PT completed
X-ray, MRI, discogram correlate w SXs
Spine pathology limited to 2 levels
Psychological Screening
6 wks nonsmoker

After screening for psychosocial variables,
outcomes are improved and fusion may be
recommended for degenerative disc disease
with spinal segment collapse with or without
neurologic compromise after 6 months of
compliance with recommended conservative
therapy.









4 wks (NSAIDS, PT, Stretching, MR) MRI?
8 wks PT - Total of 10/ 8 wks, ESI ?
12 wks Facet Injections ? Home ex program?
16 wks ?
20 wks ?
24 wks ?
30 wks ?
Off work, Light duty, TTD cost ?
Different for BC than WC ?
Few patients with LBP are surgical candidates
Evidence based medicine does support the use of
spinal fusion in a minority of patients with 1 and 2
level disc pathology
 Ideal timing of a surgical decision 6 months ?






Pain level back vs leg pain.
Neurologic exam and complaints
Level of confidence in outcome
Overall patient presentation
MICHAEL WRIGHT, M.D.
OSSO SPINE AND HAND CENTER