Pre-Trial Testimony of an Orthopedic Surgeon-NY Medical Malpractice Case
By ROBERT H. BELDING MD Orthopedic Surgeon Columbia, SC, USA.
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Transcript of By ROBERT H. BELDING MD Orthopedic Surgeon Columbia, SC, USA.
By
ROBERT H. BELDING MD
Orthopedic Surgeon
Columbia, SC, USA
2nd most common cause for office visit 60-80% of population will have lower back
pain at some time in their lives Each year, 15-20% of people will have back
pain Most common cause of disability for
persons < 45 years Costs to society: $20-50 billion/year 80% to 90% Resolve in one month 20% to 30% Become chronic 5% to 10% Become disabling
“One would have thought by now that the problem of diagnosis and treatment would have been solved, but the issue remains mysterious and clouded with uncertainty.”
Rosomoff HL, Rosomoff RS. Low back pain: Evaluation and management in the primary care setting. Med Clin North Am 1999;83:643-62.
ANATOMY
ANATOMY
ANATOMY
ANATOMY
ANATOMY
ANATOMY
ANATOMY
DEEP LUMBARMUSCLES
ANATOMY
SUPERFICIALLUMBARMUSCLES
ANATOMY
ANATOMY
SPINAL NERVES, ARTERIESAND VEINS
ANATOMY
Lumbar “strain” or “sprain” – 70% Degenerative changes – 10% Herniated disk – 4% Osteoporosis compression fractures –
4% Spinal stenosis – 3% Spondylolisthesis – 2%
Spondylolysis, other spinal instability – 2%
Fracture - <1% Congenital disease - <1% Cancer (primary, metastatic)– 0.7% Inflammatory arthritis (RA, lupus, etc.)
0.3% Infections – 0.01%
1. HISTORY2. PHYSICAL EXAM3. PLAIN X-RAYS4. DIFFERENTIAL DIAGNOSIS5. SPECIAL STUDIES
HOW DID IT BEGINWHAT AGGRIVATES ITWHEN IS IT WORSEWHERE IS THE PAIN LOCATEDDOES IT RADIATE TO THE LEGARE THERE ASSOCIATED NEUROLOGICAL SIGNSWHAT TREATMENT HAVE YOU HADWHAT OTHER CONDITIONS HAVE YOU HADIS THERE A FAMILY HISTORY OF BACK PAINHAVE YOU MISSED WORKIS IT WORK RELATEDIS CLAUDICATION PRESENT
HISTORY
History of cancer Unexplained
weight loss Intravenous drug
use Prolonged use of
corticosteroids Older age
Major Trauma Osteoporosis Fever Back pain at rest
or at night Bowel or bladder
dysfunction
HISTORY
RANGE OF MOTION TENDERNESS MUSCLE SPASM STRAIGHT LEG RAISING TEST SI JOINT STRESS TEST TRENDELENBURG SIGN LEG LENGTH SPINE DEFORMITIES ERYTHEMA OR HEAT BIRTH MARKS
Waddell's signs are a group of physical signs, first described by Waddell et al in 1980, that may indicate non-organic or psychological component to chronic low back pain. Historically they have been used to detect "malingering" patients with back pain.
One or two Waddell's signs can often be found even when there is not a strong non-organic component to pain. Three or more are positively correlated with high scores for depression, hysteria and hypochondriasis on the Minnesota Multiphasic Personality Inventory.
Superficial tenderness – skin discomfort on light palpation. Nonanatomic tenderness – tenderness crossing multiple
anatomic boundaries. Axial loading – eliciting pain when pressing down on the top
of the patient’s head. Pain on simulated rotation - rotating the shoulders and
pelvis together should not be painful as it does not stretch the structures of the back.
Distracted straight leg raise - if a patient complains of pain on straight leg raise, but not if the examiner extends the knee with the patient seated (e.g. when checking the Babinski reflex).
Regional sensory change - Stocking sensory loss, or sensory loss in an entire extremity or side of the body.
Regional weakness - Weakness that is jerky, with intermittent resistance (such as cogwheeling, or catching). Organic weakness can be overpowered smoothly.
Overreaction - Exaggerated painful response to a stimulus, that is not reproduced when the same stimulus is given later.
RADIOLOGY
RADIOLOGY
AP LATERAL
SPOT LATERAL L-5
RADIOLOGY
RADIOLOGY
RADIOLOGY
RADIOLOGY
RADIOLOGY
DIFFRENTIAL
1.Back exercise for strengthening and flexibility2.Education about sitting, lifting, bending3.Proper surface for sleeping4.Weight reduction5.Smoking cessation6.Good mental health7.Back school
PREVENTION
Treat the underlying cause first:Tumor, Fracture, Arthritis, Infection, Osteoporosis ,
Congenital deformity, etc.
Treatment of Lumbar strain , spinal stenosis, diskogenic pain, spinal instability, degenerative disease symptomatically as long as there
are no progressive neurologic findings
TREATMENT
1.MEDICATION2.REST3.BRACES & SUPPORTS4.PHYSICAL THERAPY6. STEROID INJECTIONS7. ACCUPUNCTURE
TREATMENT
TREATMENT
TREATMENT
LUMBOSACRALCORSETTE
EXTENTION BACKBRACE
PREVENTIVE WORKBRACE
1.BACK EXERCISE2.MESSAGUE3.ELECTRIC STIMULATION4.HEAT/COLD5.PELVIC TRACTION6.ULTRASOUND7.MANIPULATION
TREATMENT
1.EPIDURAL2.FACET JOINT3.TRIGGERPOINT4.INTRAMUSCULAR
TREATMENT
1.Progressive Neurologic Findings2.Unstable Spine 3.Some Congenital Deformities4.Infection With Abscess Or
Osteomylitis5.Symptoms That Are Unresponsive
To Conservative Treatment6.Tumors7.Fractures
TREATMENT
THANK YOU