Chronic Back Pain - Spire Healthcare

Chronic Back Pain
Mr Manish Desai
MBBS, MS(Trauma & Ortho), MRCS
Consultant in Spinal Injuries and Rehabilitation Medicine
London SCIC, Stanmore
Spire Bushey Hospital
Royal Bucks Hospital, Aylesbury
MSK GP Masterclass – 10th Feb 2015
Overview
• Background
• Pathophysiology
• Red Flags and Yellow flags
• Case studies
• Specialist Rehabilitation
• Summary
Background
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We will all experience
Leading cause of occupational disability
Most common cause of missed workdays
Lifetime prevalence rate 50-80%
Point prevalence rate 15%- 30%
20% consult a GP
2.6 million pts seek advise per year
62% have persisting pain at 1 year
16% remain off work at 1 year
Litigation
Walker,B.F. 2000
Macfarlane,G.J.,Jones,G.T. and Hannaford P.C., 2003
Aetiology
Pathophysiology
Flags
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RED Flags
Neurological signs
Pain, Pain , Pain
Weight loss/Malignancy
Age (PSA)
Profession/Sports
Fever/inflammatory
disease
Immunosupression
Anatomical change
(Deformity)
Site
• Yellow Flags (predictors
for transition of acute to
chronic Back pain)
• Psycho social barriers to
Recovery
• Belief that pain and activity are
harmful
• Sickness behaviours
• Obesity
• Low/negative mood- social
withdrawal
• Claim/compensation
• Poor job satisfaction-work
problems
• Family dynamics –
overprotective/lack of support
Case 1
• 64 yr old African lady
• Retired Lead surgical nurse
• Low back pain – few months (
No treatment)
• Loss of sensation left leg – 4-5
days
• Bladder dysfunction
• Loss of motor function
• H/o constipation
• No Trauma/Fall
• P/H/O Ca Bowel, resection
2013 and last chemotherapy
July 2014
• Pins and needles in hands and
feet after last chemo
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HF 2/5
KE 4/5
KF 2/5
Ankle DF 0/5
PF 4/5
Soft touch sensation in S
3,4,5
• VAC and DAP present
• Absent pin prick
Case 2
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58 Yr Old Male
Fit, well, active
Plumbing and Heating
Maintenance
contracts
Back pain for 4-5
months
Low intensity
No other symptoms
Seeks GP advice
• Advise and treatment
• Symptoms get better
• Relapse with acute
onset of pain whole
spine, mainly mid
thoracic
• Afebrile
• Seeks advise
• Treatment and rest
24 Hours later
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Later evening
Paraesthesia
Urinary incontinence
Feeling of weakness in
both LL – but could walk
but pain
• Out of hours advise to go
to A&E
• Ambulance crew could
not transport due to
restrictions at
accommodation
• Increasing symptoms
• Own transport
• A&E – early morning
1.00AM
• Waiting for few hours for
X rays
• Paraplegia while turning
on X ray table
• MRI
• NM scan
• Diagnosis?
Similar presentation
MSCC
• 23% presented with MSCC as the first
presentation of malignancy
MSCC - Primary Care Presentation
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Signs and Symptoms
Pain in the middle (thoracic) or upper
(cervical) spine
Progressive lower (lumbar) spinal pain
Severe unremitting lower spinal pain
Spinal pain aggravated by straining (for
example at stool, or when coughing or sneezing)
Localised spinal tenderness
Nocturnal spinal pain preventing sleep
Radicular pain
Any limb weakness or difficulty in walking
Sensory loss, or bladder or bowel dysfunction
Neurological signs of spinal cord or cauda
equina compression.
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Contact MSCC
coordinator of nearest
MSCC treatment
centre.
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Arrange urgent
clinical assessment
by MSCC team.
Case 3
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19 Year old Law student
Slim
Jan 2014 – Acute back pain while
working in the Gym
Medical advise – Treatment for
L5-S1 Disc prolapse
Ongoing chronic back pain –
worsening symptoms of lower
back pain and Left LL pain
No neurological signs
Symptomatic treatment – doing
well
August 2014 – Severe back pain,
Left LL and groin pain and altered
sensations –
Any thoughts?
• Medical advise, Self referred
to A&E twice – Gynae
examination for groin pain and
numbness - discharged
• Within two weeks, h/o
paraesthesia, perianal sensory
disturbances, Difficulty in
voiding, could walk
• Self referred to A&E third time
• Any thoughts?
CES-Classifying Symptoms
Back pain +/- unilateral radiculopathy
• CES risk - bilateral
radiculopathies
• CESI - incomplete CES
(retains control of
bladder)
• CESR - neurogenic
retention of urine
(paralysed, insensate
bladder, incontinence)
• CESC - total loss of all
CE function
• Must prevent CESI >
CESR
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SEVERE back pain
Severe sciatica
Bilateral sciatica
Severely restricted
bilateral SLR
Medicolegal aspect
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NHSLA information
1997-2006
107 CES cases
Excludes GP cases
CES - Litigation
• A major source of litigation against GP’s,
emergency care doctors and orthopaedic
surgeons.
• The average compensation following missed or
delayed diagnosis of CES is £336,000 per case
in the United Kingdom and $549,427 per case
in the United States.
Volume 02 / Issue 03 / August 2014 l boa.ac.uk
Case 4 - Post op revision L4-5 Disc Nov 2012
Now – Acute Left LL radiculopathy pain, numbness in groin
and left leg, some bladder dysfunction
L4-5 Disc now( 8 months post MRI- May 2014)
Case 5
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48 yr old gentleman
Short stature
Fit and well
3 days h/o right anterior
abdominal wall pain
No back pain
Did not seek medical advise.?
Renal Pain
Urinary incontinence- wearing
pads
Gradual onset Paraesthesia
and Motor function loss
Paraplegia
• p/m/h of laminectomy and
decompression at
Lumbar levels in 2007
and 2009
• No postop neurological
deficit
• Type 2 DM
• Hypertension
• Any thoughts?
Case 6 - Osteoporosis
Abnormal MRI scans of lumbar spine in asymptomatic
individuals. Boden et al JBJS 1990
Persistent Lumbo-sacral Pain
• Disc pathology – 40%
• Facet Joint 15-30%
• SI Joint 15%
• ? Muscle/Soft Tissue?
Rehabilitation - MDT Approach
• Integrated Back Clinic/Bio-psycho-social Model
• Inpatient/ outpatient rehab, Pain Management, PT,
Surgery, Radiology
• Active Back Programme
• Sports activities
Active Back Programme
• Education – anatomy, pain, posture, seating, fitness,
healing processes, lifting & handling, ergonomics,
dealing with a flare-up, relaxation, employment
• Physical – stretch, swimming, sports, postural muscle
retraining, fitness gym
• Psychological – addressing the emotional effects of
long-term pain, including how to deal with stress, anger,
anxiety and frustration
• Goal Setting – goals are set throughout the programme
to help maintain motivation and facilitate change
Active Back Programme
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Decrease the effects of pain on lifestyle
Increase physical fitness
Restore confidence in performing activities
Improve quality of life
Manage back problem more effectively
Improved understanding ( education) of how to manage
back pain – self management
3 R’s in the treatment of Chronic Back Pain
• Reasurance (psychotherapy)
• Relief (intervention/pharmacotherapy)
• Rehabilitation (Medical + physiotherapy)
Update
• Anaerobic bacteria linked to disc herniation with
modic changes and associated back pain
• 100 days of antibiotics improves pain markedly
• Interest by Media ..”Daily Mail”, “Independent”
Summary
• Most people will at some time experience an episode of
serious low back pain, but most cases resolve with
minimal intervention
• The main value of a history ( red flags) and physical
examination is to determine which patients should be
referred for imaging and interventions
• Medicolegal impact
• The risk factors for progression to chronic back pain are
predominantly psychosocial and occupational.
• European & UK guidelines recommend intensive MDT
rehabilitation for chronic LBP
Further Reading
• Europeon Guidelines
For The Management Of
Chronic Nonspecific Low back
Pain
• NICE clinical guidelines on
management of persistent nonspecific LBP
• www.mapofmedicine.com
• Oxford Pain Management
Library – Back Pain
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Macnab’s Backache
Thank you
Acknowledgements
• Dr Jan Gawronski ( Consultant in Rehabilitation
medicine )
• Pain Master class (Pfizer)