1. www.pspbc.ca Mechanical Low Back Pain (Sciatica) Case 3: Karen

2. 2 Faculty/Presenter Disclosure with Faculty’s Name:Faculty’s Name:

3. 3 Disclosure of Commercial Support. Mitigating potential bias N/A.

4. 4 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

5. 5 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.

6. 6 What are your Key Questions?  How do you determine if this is mechanical back pain ?

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8. 8 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

9. 9 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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11. 11 Pain History What would you ask to determine optimal pain management strategy ?

12. 12 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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15. 15 Management Tools  How would you determine if investigations were appropriate ? We used:  Is there poor or no response to appropriate treatment?  Are pain levels unmanaged with best medications?  Are there prolonged neurological deficits greater than 6 week ?

16. 16 Understanding symptoms of neurological origin

17. 17 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

18. 18 Facilitating recovery through home based exercise and recovery postures  What would you suggest ?

19. 19 Facilitating your patient to set Goals

20. 20 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 ?

21. 21 Referral to a Specialist

22. 22 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

23. 23 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.

24. 24 Summary When working with Mechanical Leg Dominant Pain, it is important to: 1. Take a targeted history 2. Do a full neurological examination 3. Refer for goal oriented rehab treatment and evaluate 4. response. 5. 4. Consider MRI if no response to appropriate therapy and escalating leg dominant pain. 6. 5. Consider short term opioid management.

25. 25 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/