1. Unusual Findings in the Patient with Spine Pain Sayed E Wahezi, MD Department of Rehabilitation Medicine Program Director, Pain Medicine Fellowship Montefiore Medical Center Albert Einstein College of Medicine

2. Outline Case – Introduction History (1-2 slides) Physical Exam (1-2 slides) – Images (3-4 slides) – Ask the audience (1 slide) Interventional Procedure? Refer to surgery? Send for PT? Medication management? More tests? – What did I do? ( 1 slide) – Evidence (1 slide; 2-3 references)

3. History Case#1 76 yo R handed female with history of HTN, hypercholesterolemia Presents with R neck > arm pain x 8 weeks Insidious onset. Gradual worsening. “Dull and achy.” Temporal Radiation. Moderate AM stiffness. Worse with R neck rotation and R lateral flexion. Improves with L neck lateral flexion and Ibuprofen (transient: 2-3 hours). Pain is 6/10 Refractory to Tylenol, Flexeril, and 10 sessions of PT

4. Physical Exam Case#1 Appears stated age 1+ DTR BC and BR on right, otherwise 2+ in UE 5/5 MMT UE Spurling (-) Shoulder exam unremarkable

5. Images Case#1 Will be revealed at conference

6. What would you do? Case#1 Interventional Procedure? Refer to surgery? Send for PT? Medication management? More tests?

7. Images Case#1 Will be revealed at conference

8. Evidence Case#1 Will be revealed at conference

9. History Case#2 65 yo male with history of HTN, DM, hypercholesterolemia Presents with LBP and R lateral anterior thigh and lateral leg pain x 4 weeks Sudden onset while attempting to lift 25lb bag of mulch when gardening. Gradual worsening x 1 week; stable x 2 weeks. “Achy and sharp.” Temporal Radiation. Minimal AM stiffness. Worse with truncal flexion and R truncal rotation. Improves with lying supine. Pain is 9/10. Refractory to Tylenol, Flexeril, NSAIDs, Medrol Dose pack. Cannot tolerate PT due to pain

10. Physical Exam Case#2 Appears stated age Normal mood and affect Significant discomfort. Not anxious. Mildly pressured speech. Focused thoughts; non-tangential. Normal eye contact. Antalgic gait with L sided lean – Decreased cadence – No AD – Mild foot slap on R 1+ DTR L patella tendon on left, otherwise 0 in LE 4/5 MMT R DF, otherwise 5/5 No UMN signs.

11. Images Case#2 Will be revealed at conference

12. What would you do? Case#2 Interventional Procedure? Refer to surgery? Send for PT? Medication management? More tests?

13. Evidence Case#2 Will be revealed at conference

14. History Case#3 20 yo male presents with mother Student in college No significant medical history Presents with R>L LBP x 4 months Insidious onset. Gradual worsening x 3 months. Stable x 4 weeks. “Dull and deep.” Radiation to bilateral posterior thighs. AM stiffness x 10minutes, but “mattress is 7 years old.” Worse with truncal flexion, extension, rotation, and sitting > 30minutes in class. Pain is 10/10. Refractory to Tylenol, NSAIDs, refractory to PT.

15. Physical Exam Case#3 Appears younger than stated age Anxious affect and concordant mood. Appears comfortable when observed in waiting area and during history. Mildly pressured speech. Focused thoughts; non-tangential. Poor eye contact. Normal gait and cadence Normal Neuromuscular Exam Maneuvers to ellicit discogenic, radicular, SI pain (-) Hamstrings mod-severe tight bilaterally when patient laid supine and hips passively flexed/knees passively extended

16. Images Case#3 Will be revealed at conference

17. What would you do? Case#3 Interventional Procedure? Refer to surgery? Send for PT? Medication management? More tests?

18. Evidence Case#3 Will be revealed at conference

19. End