1. Retrospective Study to Determine Diagnostic Factors in Patients with Lumbosacral Radiculopathy: Proposal for Future Research Dwan Perry, DO Advisor: Dr. Oscar Ortiz, MD

2. Low Back Pain 5 th most common reason for office visits 5 th most common reason for office visits 25% U.S. adults reported low back pain in past 3 months 25% U.S. adults reported low back pain in past 3 months $26.3 billion dollars in 1998 Substantial costs via loss of work and 2% compensation 3-5% prevalence of lumbar radiculopathy Men develop symptoms in their 40s Women develop symptoms 50-60s Ann Intern Med.Ann Intern Med. 2007 Oct 2;147(7):478-91. Diagnosis and treatment of low back pain: a joint clinical practice guideline from the American College of Physicians and the American Pain Society. Chou RChou R, Qaseem A, Snow V, Casey D, Cross JT Jr, Shekelle P, Owens DK; Clinical Efficacy Assessment Subcommittee of the American College of Physicians; American College of Physicians; American Pain Society Low Back Pain Guidelines Panel.Qaseem ASnow VCasey DCross JT JrShekelle POwens DKClinical Efficacy Assessment Subcommittee of the American College of Physicians American College of PhysiciansAmerican Pain Society Low Back Pain Guidelines Panel

3. Low Back Pain 5 th most common reason for office visits 25% U.S. adults reported low back pain in past 3 months $26.3 billion dollars in 1998 $26.3 billion dollars in 1998 Substantial costs via loss of work and 2% compensation Substantial costs via loss of work and 2% compensation 3-5% prevalence of lumbar radiculopathy Men develop symptoms in their 40s Women develop symptoms 50-60s Ann Intern Med.Ann Intern Med. 2007 Oct 2;147(7):478-91. Diagnosis and treatment of low back pain: a joint clinical practice guideline from the American College of Physicians and the American Pain Society. Chou RChou R, Qaseem A, Snow V, Casey D, Cross JT Jr, Shekelle P, Owens DK; Clinical Efficacy Assessment Subcommittee of the American College of Physicians; American College of Physicians; American Pain Society Low Back Pain Guidelines Panel.Qaseem ASnow VCasey DCross JT JrShekelle POwens DKClinical Efficacy Assessment Subcommittee of the American College of Physicians American College of PhysiciansAmerican Pain Society Low Back Pain Guidelines Panel

4. Low Back Pain 5 th most common reason for office visits 25% U.S. adults reported low back pain in past 3 months $26.3 billion dollars in 1998 Substantial costs via loss of work and 2% compensation 3-5% prevalence of lumbar radiculopathy 3-5% prevalence of lumbar radiculopathy Men develop symptoms in their 40s Men develop symptoms in their 40s Women develop symptoms 50-60s Women develop symptoms 50-60s Ann Intern Med.Ann Intern Med. 2007 Oct 2;147(7):478-91. Diagnosis and treatment of low back pain: a joint clinical practice guideline from the American College of Physicians and the American Pain Society. Chou RChou R, Qaseem A, Snow V, Casey D, Cross JT Jr, Shekelle P, Owens DK; Clinical Efficacy Assessment Subcommittee of the American College of Physicians; American College of Physicians; American Pain Society Low Back Pain Guidelines Panel.Qaseem ASnow VCasey DCross JT JrShekelle POwens DKClinical Efficacy Assessment Subcommittee of the American College of Physicians American College of PhysiciansAmerican Pain Society Low Back Pain Guidelines Panel

5. Low Back Pain Current Guidelines – 1 of 3 broad categories Nonspecific low back pain Pain associated with radiculopathy or spinal stenosis Pain associated with radiculopathy or spinal stenosis Pain associated with another specific spinal cause Ann Intern Med.Ann Intern Med. 2007 Oct 2;147(7):478-91. Diagnosis and treatment of low back pain: a joint clinical practice guideline from the American College of Physicians and the American Pain Society. Chou RChou R, Qaseem A, Snow V, Casey D, Cross JT Jr, Shekelle P, Owens DK; Clinical Efficacy Assessment Subcommittee of the American College of Physicians; American College of Physicians; American Pain Society Low Back Pain Guidelines Panel.Qaseem ASnow VCasey DCross JT JrShekelle POwens DKClinical Efficacy Assessment Subcommittee of the American College of PhysiciansAmerican College of PhysiciansAmerican Pain Society Low Back Pain Guidelines Panel

6. Lumbar Radiculopathy Traditional Presentation – Hx/PE findings (traditional) Back pain radiating to lower extremity (unilateral or bilateral Numbness in LE Muscle Weakness Precipitous factors (sneezing, coughing, standing, sitting) Location of pain Ann Intern Med.Ann Intern Med. 2007 Oct 2;147(7):478-91. Diagnosis and treatment of low back pain: a joint clinical practice guideline from the American College of Physicians and the American Pain Society. Chou RChou R, Qaseem A, Snow V, Casey D, Cross JT Jr, Shekelle P, Owens DK; Clinical Efficacy Assessment Subcommittee of the American College of Physicians; American College of Physicians; American Pain Society Low Back Pain Guidelines Panel.Qaseem ASnow VCasey DCross JT JrShekelle POwens DKClinical Efficacy Assessment Subcommittee of the American College of PhysiciansAmerican College of PhysiciansAmerican Pain Society Low Back Pain Guidelines Panel

7. Lumbar Radiculopathy Physical Exam (traditional) – Straight Leg Raise – Lasegue’s Test – Tendon Reflexes – Weakness – Muscle Atrophy Cochrane Database Syst Rev.Cochrane Database Syst Rev. 2010 Feb 17;(2):CD007431. Physical examination for lumbar radiculopathy due to disc herniation in patients with low-back pain. van der Windt DAvan der Windt DA, Simons E, Riphagen II, Ammendolia C, Verhagen AP, Laslett M, Devillé W, Deyo RA, Bouter LM, de Vet HC, Aertgeerts B.Simons ERiphagen IIAmmendolia CVerhagen APLaslett MDevillé WDeyo RABouter LMde Vet HC

8. Accuracy of Physical Exam Cochrane Database Syst Rev.Cochrane Database Syst Rev. 2010 Feb 17;(2):CD007431. Physical examination for lumbar radiculopathy due to disc herniation in patients with low-back pain. van der Windt DAvan der Windt DA, Simons E, Riphagen II, Ammendolia C, Verhagen AP, Laslett M, Devillé W, Deyo RA, Bouter LM, de Vet HC, Aertgeerts B.Simons ERiphagen IIAmmendolia CVerhagen APLaslett MDevillé WDeyo RABouter LMde Vet HC

9. Accuracy of Physical Exam Cochrane Database Syst Rev.Cochrane Database Syst Rev. 2010 Feb 17;(2):CD007431. Physical examination for lumbar radiculopathy due to disc herniation in patients with low-back pain. van der Windt DAvan der Windt DA, Simons E, Riphagen II, Ammendolia C, Verhagen AP, Laslett M, Devillé W, Deyo RA, Bouter LM, de Vet HC, Aertgeerts B.Simons ERiphagen IIAmmendolia CVerhagen APLaslett MDevillé WDeyo RABouter LMde Vet HC

10. Accuracy of Physical Exam Cochrane Database Syst Rev.Cochrane Database Syst Rev. 2010 Feb 17;(2):CD007431. Physical examination for lumbar radiculopathy due to disc herniation in patients with low-back pain. van der Windt DAvan der Windt DA, Simons E, Riphagen II, Ammendolia C, Verhagen AP, Laslett M, Devillé W, Deyo RA, Bouter LM, de Vet HC, Aertgeerts B.Simons ERiphagen IIAmmendolia CVerhagen APLaslett MDevillé WDeyo RABouter LMde Vet HC

11. Accuracy of Physical Exam Cochrane Database Syst Rev.Cochrane Database Syst Rev. 2010 Feb 17;(2):CD007431. Physical examination for lumbar radiculopathy due to disc herniation in patients with low-back pain. van der Windt DAvan der Windt DA, Simons E, Riphagen II, Ammendolia C, Verhagen AP, Laslett M, Devillé W, Deyo RA, Bouter LM, de Vet HC, Aertgeerts B.Simons ERiphagen IIAmmendolia CVerhagen APLaslett MDevillé WDeyo RABouter LMde Vet HC

12. Accuracy of EMG Utility of electrodiagnostic testing in evaluating patients with lumbosacral radiculopathy: An evidence-based review. Charles Cho S, Ferrante MA, Levin KH, Harmon RL, So YT. Muscle Nerve. 2010 Aug;42(2):276-82. Review.

13. Accuracy of CT Eur Spine J.Eur Spine J. 2012 Feb;21(2):228-39. Epub 2011 Sep 14. Computed tomography for the diagnosis of lumbar spinal pathology in adult patients with low back pain or sciatica: a diagnostic systematic review. van Rijn RMvan Rijn RM, Wassenaar M, Verhagen AP, Ostelo RW, Ginai AZ, de Boer MR, van Tulder MW, Koes BW.Wassenaar MVerhagen APOstelo RWGinai AZde Boer MRvan Tulder MWKoes BW

14. Accuracy of MRI Eur Spine J.Eur Spine J. 2012 Feb;21(2):220-7. Epub 2011 Sep 16. Magnetic resonance imaging for diagnosing lumbar spinal pathology in adult patients with low back pain or sciatica: a diagnostic systematic review. Wassenaar MWassenaar M, van Rijn RM, van Tulder MW, Verhagen AP, van der Windt DA, Koes BW, de Boer MR, Ginai AZ, Ostelo RW.van Rijn RMvan Tulder MWVerhagen APvan der Windt DAKoes BWde Boer MRGinai AZOstelo RW

15. Summary of Literature Extensive studies show inaccuracy regarding history, physical, and diagnostic studies Studies relate a lack of gold standard

16. Research Proposal Problem – Anamnesis and PE findings are inconsistent for diagnosis. – Role and efficacy of MRI/CT imaging, and EMG is controversial. – There is a lack of consensus in defining a gold standard.

17. Research Proposal Objectives and specific aims – Hypothesis: Natural History is the best available gold standard for the diagnosis of LR at this time. – Long term goal: Identify a set of diagnostic criteria with high positive likelihood ratio for the diagnosis of lumbar radiculopathy.

18. Research Proposal Specific aims – Evaluate accuracy of anamnesis, PE, Imaging, and EDX evaluation (diagnostic factors) for the diagnosis of LR – Evaluate accuracy of anamnesis, PE, Imaging, and EDX evaluation (diagnostic factors) for the diagnosis of LR. – Identify best combination of diagnostic factors for the diagnosis of LR. (Best positive likelihood ratio)

19. Research Proposal Methods – Study Design: Cohort study – Population: Patients seen at Lexington VAMC from 2009-2011 – Inclusion Criteria: Acute back and leg pain with symptoms less than 6 months. Follow up data for at least 1 year. – Exclusion Criteria: Previous spinal surgery.

20. Research Proposal Methods – Natural History: Age, gender, race/ethnicity, occupation. Pain characteristics (Onset, trigger event, quality, location, distribution, exacerbating/alleviating symptoms, response to conservative and or surgical management). > 12 month follow up (pain level, pain distribution, pain radiation, neurological symptoms, red flags, timing of symptoms)

21. Research Proposal Methods – Findings/Symptoms Back pain radiating to lower extremity (unilateral or bilateral Numbness in LE Muscle Weakness Precipitous factors (sneezing, coughing, standing, sitting) Location of pain

22. Research Proposal Methods – Findings/PE Muscle Strength Reflex asymmetry SLR/XSLR Muscle Atrophy Sensation

23. Research Proposal Methods – MRI findings Pathology causing nerve compression – CT findings Pathology causing nerve compression – EDx findings H-Reflex, EMG

24. Research Proposal radiculopathy, mononeuropathy back pain back ache lumbago back sprain back disorder VAMC pts from 2009-2012 with Back Pain Back Pain with leg pain natural hx (1 year) radiculopathy non-radiculopathy chronic NM involvementRadicular sx that improved within a year and no relapseSurgical response with no relapse compare accuracy of dx factors per Hx, PE, EMG, CT, MRI (Dx/ICD9 codes)

25. Research Proposal Methods – Data will be compiled based on + or – presence of a factor – Likelihood ratios will be identified for each factor. – Multivariate regression analysis will be used to identify group of factors that best correlate with diagnosis of radiculopathy.

26. Research Proposal Safety and Ethical considerations – No intervention will be performed

27. Questions