Post on 29-Jan-2016
description
A Practical Approach to the Official Disability Guidelines
ODG477 Pages of Fun
MICHAEL WRIGHT, M.D.
OSSO SPINE AND HAND CENTER
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
Direct Medical Costs 10-40 Billion
Disability Payments 30-40 Billion Absenteeism
Lost Productivity 20-25 Billion Presenteeism
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55 60 65 70 75 80 85 90 95
Million Days
Year
Million Days
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US pop Allcauses
Heart Schtiz LBP
Percent increase
Medical costs are 3x higher in WC
30% of WC claims receive TTD
4% of non-WC claims receive TTD
Injury, TD
Non-Injury, TD
WC TD
86%
11%
3%
30% of WC claims responsible for 90% of total costs
WC TD 4.5x longer than Non-WC injury
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WC Non WC
PT Consumption
Filing a claim for LBP
Previous History p<.001 Smoker p<.001 MMPI p<.0001 Job Satisfaction p<.00001
Weight, Co-morbid (DM), Sedentary
Early DiagnosisEffective Health CareEfficient Use of ResourcesEliminate Attorney Litigation (50%
incr. cost)Early Return To Work
It is helpful to distinguish early between Lumbar Strain (DDD) vs. Radiculopathy (HNP).
Lumbar Strain Back Pain Pred.
Radiculopathy Leg Pain Pred.
History and Exam
X-rayMRIEMGCT MyelographyDiscogram
Not all MRI’s are created equalOpen 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.
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
Injection of Saline and Contrast into Disc
Radiographic Identifiable PathologyPain Response to Disc Distension
▪ Pain response most predictive.
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
Predominance of Leg PainNerve Tension signsMotor WeaknessSensory DeficitAsymmetrical ReflexesRadiographic Pathology
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
NSAIDSMedrol dose packMuscle Relaxers/Narcotics (short
term)Physical Therapy (early vs. delayed)Chiropractic Manipulation (3 visits)
Many studies to suggest effectiveness of ESI
LBP 20% effectiveLeg Pain 50% effective
Indications Large Disc Herniation
Severe Pain Neurologic Deficit(foot drop, Cauda Eq) Failure of Non-operative Treatment
Wide Geographic Variation
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60
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120
Calif Sweeden Tulsa
Rate of discsurg/100K
personl comm
Spengler – J Spinal Disorders, 1998Compare patients with same D/OCompare patients with different
comp involvementEvaluate effect of legal involvement
on clinical outcome.
Private, non-workers’ compensationWorkers’ compensationWorkers’ compensation plus
attorneyThird party liability
Age SexOccupationLength of symptomsOPES (objective patient eval score)Outcome
32 Males38 Labor27 Non comp37 Non legal
22 Females16
Management27
Compensation17 Legal
Neurological signs 25 pts
Sciatic Tension Signs 25 pts Personality factors (drawing) 25
pts Imaging studies 25 pts
100 pts
50 Points desired to recommend a lumbar Discectomy procedure
No negative explorations were observed (All patients had pathology)
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Good Fair Poor
# of patients
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Good Fair Poor
no legal
legal
%
All patients had proven Disc herniation
Claimants had poorer outcomes than non claimants
Outcomes progressively worsened as legal involvement increased
Moskovitz – 1998Mehta Analysis9 Papers
1160 pts Claimant 2.8x more likely to have
fair/poor outcome as a non-claimant
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.
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.
Marketing frequently exceeds Science
Smaller is not always better Percutaneous Discectomy IDET Laser
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)
Makes my job easier
Acupuncture (NR)Vax D traction table. (NR)PT guidelinesSpine Injections (ESI)
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
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.
LBP WITH Radiculopathy
LBP WITHOUT Radiculopathy
Identify Radicular SignsMedical HistoryDermatologic sensory LossPain below the kneeReflexesTension SignsMotor Weakness
Visit 1, Day 1
Rx Activity modificationsNSAIDS, MR if muscle
spasmsStretchingRTW in 72 hours Except
severe(Pain Meds ?)
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 (?)
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.
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
MRI Prior surgeryMyelopathy ( cord compression)Spine Trauma (Fall from height, MVA)Red Flags - Cancer, infection, Cauda Equina SyndromeUncomplicated LBP with Radiculopathy after 1 month of TXProgressive Neuro Deficit.
? What if LBP w/o radiculopathy? Discussion
Cauda Equina Syndrome Lumbar Spine Trauma, w Neuro deficit Lumbar Spine Trauma, fracture LBP, Red flags (cancer, Infection) LBP radiculopathy, 1 month TX LBP prior surgery LBP Myelopathy, (cord compression)LBP without the above not addressed
MRI - no rec for uncomplicated LBP Valuable aside from treatment issues.
▪ Causation▪ Apportionment▪ Impairment▪ RTW restriction▪ Objective ? ( value of a NL MRI)
▪ Discussion ?▪ Can you close a litigated WC case without an MRI?
Injections ESI
▪ Radiculopathy must be documented▪ Failure of conservative treatment, NSAIDS, MR, PT▪ No more than 2 Root levels injected, or 1 Intra Lam▪ No more than 2 ESI▪ Additional injections if initial injection/s produce pain
red by 50% for 6-8 weeks
▪ Max of 4 ESI / year.
Injections Facet injections / Medial Branch Block
▪ Diagnostic tool Facet Radiofrequency Rhizotomy
▪ Under Study▪ Conflicting evidence
Facet syndrome dx , from ODG
Tenderness to palpation Normal Sensory Exam Absence of radicular findings Normal Straight leg raising exam Large dose of Common Sense.
Under Study, conflicting evidence
My opinion Weak science to support Over utilized in our community MBB relief based upon Narcotics vs MBB? Person evaluating success of MBB is same person to
determine if the next procedure in indicated (RFA). Biased ?
Literature suggest 25% conversion of MBB to RFA. My observation is closer to 90%
Some role in recalcitrant LBP with diffuse degenerative changes in the discs and facets.
Results decay w time 1x / year maximum
One MBB, NOT 2 No evidence of radicular pain No more than 2 joint levels may be
blocked an any one time Formal plan with additional evidenced
based approach. (PT, NSAIDS) Pain relief from MBB not narcotic related. Should not be repeated unless initial
procedure produces >50% for > 12wks Max 3/year. (Costly, unending?)
OSSO Spine experience 6700 patient office visits 2011 47 patients referred for a MBB 09 patients treated w RFA 00 patients referred for a repeat RFA Minimal sedation if any given during MBB MHW evaluated all patients post MBB Decision to proceed to RFA not made by the
same physician that ultimately performed the RFA
Attempt to reduce internal bias.
Meds (NSAIDS, pain, MR, Neurontin, Cymbalta) PT ESI Facet disease Home therapy, stretching, weight loss, Activity modification Devils Claw. (herbal medicines - ODG rec)pg
86/477
Continued severe pain?
Fusion should not be considered for LBP within the first 6 months, except
▪ Fracture▪ Dislocation▪ Progressive neurologic loss▪ Science vs Practical approach ▪ Discussion
Indications Neural Arch Defect (Spondylolisthesis) Segmental Instability Primary Mechanical Back Pain
▪ 2 levels
Revision Surgery Infection 2 failed LLD
IndicationsAll pain generators identified and TXAll Phys med and PT completedX-ray, MRI, discogram correlate w
SXsSpine pathology limited to 2 levelsPsychological Screening6 wks nonsmoker
After screening for psychosocial variables, outcomes are improved and fusion may be recommended for degenerative disc disease with spinal segment collapse with or without neurologic compromise after 6 months of compliance with recommended conservative therapy.
4 wks (NSAIDS, PT, Stretching, MR) MRI? 8 wks PT - Total of 10/ 8 wks, ESI ? 12 wks Facet Injections ? Home ex
program? 16 wks ? 20 wks ? 24 wks ? 30 wks ? Off work, Light duty, TTD cost ? Different for BC than WC ?
Few patients with LBP are surgical candidates
Evidence based medicine does support the use of spinal fusion in a minority of patients with 1 and 2 level disc pathology
Ideal timing of a surgical decision 6 months ? Pain level back vs leg pain. Neurologic exam and complaints Level of confidence in outcome Overall patient presentation
MICHAEL WRIGHT, M.D.OSSO SPINE AND HAND CENTER