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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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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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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# of patients

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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

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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