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Lumbar Spine

A Practical Approach to the Official Disability Guidelines ODG 477 Pages of Fun MICHAEL WRIGHT, M.D. OSSO SPINE AND HAND CENTER. Lumbar Spine. Cost of Health Care. Direct Med Cost CAD MVA Acute Resp Joint d/o HTN LBP. Lost Work Day LBP Mood d/o MVA Acute Resp Joint d/o

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Lumbar Spine

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  1. A Practical Approach to the Official Disability Guidelines ODG 477 Pages of Fun MICHAEL WRIGHT, M.D. OSSO SPINE AND HAND CENTER Lumbar Spine

  2. Cost of Health Care • Direct Med Cost • CAD • MVA • Acute Resp • Joint d/o • HTN • LBP • Lost Work Day • LBP • Mood d/o • MVA • Acute Resp • Joint d/o • Pulmonary

  3. Low Back Pain • Direct Medical Costs 10-40 Billion • Disability Payments 30-40 Billion • Absenteeism • Lost Productivity 20-25 Billion • Presenteeism

  4. Lost Work Days Due to LBPGreat Britain Million Days Year

  5. US SS Disability : 1957 - 76

  6. Low Back Pain • Medical costs are 3x higher in WC • 30% of WC claims receive TTD • 4% of non-WC claims receive TTD

  7. Temporary Disability Payments 11% 3% 86%

  8. Low Back Pain • 30% of WC claims responsible for 90% of total costs • WC TD 4.5x longer than Non-WC injury

  9. Physical Therapy

  10. Risk For LBPBoeing • Filing a claim for LBP • Previous History p<.001 • Smoker p<.001 • MMPI p<.0001 • Job Satisfaction p<.00001 • Weight, Co-morbid (DM), Sedentary

  11. Goals • Early Diagnosis • Effective Health Care • Efficient Use of Resources • Eliminate Attorney Litigation (50% incr. cost) • Early Return To Work

  12. Diagnosis • It is helpful to distinguish early between Lumbar Strain (DDD) vs. Radiculopathy (HNP). • Lumbar Strain Back Pain Pred. • Radiculopathy Leg Pain Pred.

  13. Diagnosis • History and Exam • X-ray • MRI • EMG • CT Myelography • Discogram

  14. MRI • 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.

  15. MRI • 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

  16. Discogram • Injection of Saline and Contrast into Disc • Radiographic Identifiable Pathology • Pain Response to Disc Distension • Pain response most predictive.

  17. Discogram

  18. 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

  19. Herniated Disc • Predominance of Leg Pain • Nerve Tension signs • Motor Weakness • Sensory Deficit • Asymmetrical Reflexes • Radiographic Pathology

  20. Herniated Disc • 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

  21. Herniated DiscInitial Treatment • NSAIDS • Medrol dose pack • Muscle Relaxers/Narcotics (short term) • Physical Therapy (early vs. delayed) • Chiropractic Manipulation (3 visits)

  22. Epidural Steroids • Many studies to suggest effectiveness of ESI • LBP 20% effective • Leg Pain 50% effective

  23. Surgery for HNP Indications • Large Disc Herniation • Severe Pain • Neurologic Deficit (foot drop, Cauda Eq) • Failure of Non-operative Treatment • Wide Geographic Variation

  24. Rate of Surgery for HNP

  25. Outcome of Lumbar Discectomy • 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.

  26. Groups of Patients • Private, non-workers’ compensation • Workers’ compensation • Workers’ compensation plus attorney • Third party liability

  27. Parameters Evaluated • Age • Sex • Occupation • Length of symptoms • OPES (objective patient eval score) • Outcome

  28. Demographics • 32 Males • 38 Labor • 27 Non comp • 37 Non legal • 22 Females • 16 Management • 27 Compensation • 17 Legal

  29. Objective Patient Evaluation Score OPES • Neurological signs 25 pts • Sciatic Tension Signs 25 pts • Personality factors (drawing) 25 pts • Imaging studies 25 pts • 100 pts

  30. OPES • 50 Points desired to recommend a lumbar Discectomy procedure • No negative explorations were observed • (All patients had pathology)

  31. Outcomes of Total

  32. Outcomes Results Legal vs. No Legal %

  33. Summary • All patients had proven Disc herniation • Claimants had poorer outcomes than non claimants • Outcomes progressively worsened as legal involvement increased

  34. Medico-Legal Claim and Outcome After Lumbar Disk Surgery • Moskovitz – 1998 • Mehta Analysis • 9 Papers • 1160 pts • Claimant 2.8x more likely to have fair/poor outcome as a non-claimant

  35. Atlas Article, JBJS 2000 • 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.

  36. Workers Comp System • 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.

  37. Orthopedic Pearls • Marketing frequently exceeds Science • Smaller is not always better • Percutaneous Discectomy • IDET • Laser

  38. Lumbar Spine - ODG • 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)

  39. Lumbar Spine - ODG • Makes my job easier • Acupuncture (NR) • Vax D traction table. (NR) • PT guidelines • Spine Injections (ESI)

  40. Lumbar Spine - ODG • 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

  41. Lumbar Spine - ODG • 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.

  42. Lumbar Spine - ODG • LBP WITH Radiculopathy • LBP WITHOUT Radiculopathy

  43. Low Back Pain / ODG Identify Radicular Signs Medical History Dermatologic sensory Loss Pain below the knee Reflexes Tension Signs Motor Weakness

  44. Dermatomes Reflexes

  45. Myotomes / Motor Exam

  46. Nerve Tension Test

  47. LBP without Radiculopathy Visit 1, Day 1 Rx Activity modifications NSAIDS, MR if muscle spasms Stretching RTW in 72 hours Except severe (Pain Meds ?)

  48. LBP without Radiculopathy • 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 (?)

  49. LBP without Radiculopathy • 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.

  50. LBP W/O Radiculopathy • 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

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