Patient cases

1. Practical guidelines for the management of
back pain and sciatica
Brisbane
24 March 2018

2. Dave is a 38 year old factory worker on a production line. He
comes to see you as a new patient, complaining of back
pain. He tells you he has a long history of intermittent back
pain which started about 10 years ago. Previous episodes
have usually settled with a few days of rest. These episodes
have become frequent and severe over the years.

3. The most recent episode started 4 weeks ago and is getting
worse. Dave does not recall a particular injury or incident
but remembers doing some heavy lifting at about the time
the pain started. Dave reports that the current pain is not
settling and he has missed time from work using his sick
leave. He is unable to return to work now.
He wants advice about
• what is wrong
• what painkillers to take
• submitting a WorkCover claim

4. Your first step is to assess him clinically. Dr Angus Forbes is now
going to run through a concise history and examination for back
pain.
1. What to ask in the history
2. What to look for in the examination
Assessment

5. HISTORY
Past history of back problems
• How long ago
• How similar to current pain
• How often
Current episode
• Gradual or sudden
• Precipitating event
• Evolution
Current symptoms
• Location and severity
• Lower limb pain/weakness/parasthesia
• Relationship to activity and position
Current treatment
• Medication type and frequency
• Active and passive therapies
SOFT TISSUE SPRAIN
AGGRAVATION OF DEGENERATION
DISCOGENIC PAIN
FACET PAIN
REFERRED LOWER LIMB PAIN
RADICULAR PAIN
FRACTURE
TUMOUR
INFECTION
CAUDA EQUINA
SPONDYLOARTHRITIS

6. EXAMINATION
Look
• Alignment
• Wasting
• Gait (heel/toe/squat)
Feel
• Tenderness
• Percussion
• Wasting
Move
• Flexion (finger-floor) / Extension
• Rotation / lateral flexion
• SLR / hip / knee / SI joint
Neuro
• Strength / sensation / reflexes
DISCOGENIC FLEXION PAIN
FACET EXTENSION PAIN
HIP JOINT / SI JOINT
RADICULAR / REFERRED PAIN
SUPERFICIAL TENDERNESS
PAIN ON AXIAL COMPRESSION
PAIN ON SIMULATED ROTATION
SLR DISCREPANCY
GIVING WAY ON MOTOR TESTING
REGIONAL SENSORY LOSS
NEUROLOGICAL DISORDER
SPONDYLOLARTHRITIS
INCAPACITATING PAIN
FRACTURE
TUMOUR
INFECTION

7. What to watch for in 5 specific pathological causes of back pain:
Vertebral fracture
• Minimal trauma vertebral osteoporotic fractures rare in patients <50 years.
• Risk factors are: being female; age>70; severe trauma; and long-term glucocorticoids.
• If three risk factors are present, probability of a minimum trauma vertebral fracture is 90%.
Axial spondyloarthritis
• Peak onset between 20-40 years.
• Only a slight male predominance.
• Morning stiffness that improves with exercise, but not with rest.
• Prevalence of radiological disease between 0.3 and 0.8%.
• Often a 5-year delay between reporting pain and diagnosis.
• Effective treatments exist, so early referral to a rheumatologist advised.
Malignancy
• 97% of spinal tumours are metastases.
• Vertebral metastases occur in 3-5% of people with cancer.
• Past history of malignancy, particularly adenocarcinomas, most useful indicator.
Infections
• Either pyogenic (patients 59-69 years) or granulomatous (immigrant populations).
• Rare, but have significant mortality.
Cauda equina syndrome
• Very rare. Most GPs will not see a case in a working lifetime.
• Urinary retention and overflow incontinence are cardinal clinical features.
• Consider if new onset perianal sensory change, bladder symptoms or bilateral severe radicular pain
with low-back pain of any duration.

8. Dave has not had any previous imaging of his back. He advises he
would like a scan to see “what damage work has done”. Dr Greg
Cowderoy will now discuss the best imaging to order and how to
interpret and explain the findings to Dave.
1. When should imaging be ordered?
2. What imaging should be ordered?
3. How should the results be interpreted?
Imaging

9. 1. When should imaging be ordered?
2. What imaging should be ordered?
3. How should the results be interpreted?

10. Ineffectiveness of imaging for
nonspecific LBP
• Favourable natural Hx
– Most improve by 4 weeks; unaffected by imaging
• Nonspecificity: loose association between
findings and symptoms
– ‘Abnormalities’ or normal aging?
• Potential harms:
– Radiation
– ‘Labelling’
– Incidental findings
Ann Intern Med 2011;154:181-190

11. LOW BACK PAIN GUIDELINES
Diagnostic triage
1. Non-specific LBP
2. Radiculopathy
3. Specific LBP
• ‘Red flags’
‘Red Flags’
• Cauda equina syndrome
• Known 10 tumour
• Weight loss
• Severe symptoms, not
settling
• Fever
• Recent infection or Sx
• Osteoporosis
• Steroid use
• Non-mechanical pain
• Child*

12. 1. When should imaging be ordered?
2. What imaging should be ordered?
– Radiographs (X-rays)
– Scintigraphy (bone scan)
– CT
– MRI
3. How should the results be interpreted?

13. Imaging modalities
• Radiographs (X-rays)
• Scintigraphy (bone scan)
• CT
• MRI

14. MRI
What you see
• Bony anatomy and
alignment
• Bone pathology
• Multiplanar view of spinal
canal and foramina
• Disc: hydration and
structure
• Neural structures: cord,
nerve roots

15. 1. When should imaging be ordered?
2. What imaging should be ordered?
3. How should the results be interpreted?
– Carefully!
– Clinical correlation

16. Degenerative changes on imaging
• Ubiquitous and nonspecific
Brinjikji AJNR 2015;36:811 ystematic literature review of imaging features of spinal degeneration in asymptomatic populations
Imaging Finding
Age (yr)
20 30 40 50 60 70 80
Disk degeneration 37% 52% 68% 80% 88% 93% 96%
Disk signal loss 17% 33% 54% 73% 86% 94% 97%
Disk height loss 24% 34% 45% 56% 67% 76% 84%
Disk bulge 30% 40% 50% 60% 69% 77% 84%
Disk protrusion 29% 31% 33% 36% 38% 40% 43%
Annular fissure 19% 20% 22% 23% 25% 27% 29%
Facet degeneration 4% 9% 18% 32% 50% 69% 83%
Spondylolisthesis 3% 5% 8% 14% 23% 35% 50%
Brinjikji AJNR 2015;36:811

23. Pre-op imaging

24. L4/5 L5/S1

26. Dave has taken only over the counter medication for his previous
episodes of back pain. However, his wife had Endone in the
cupboard which she was prescribed after some recent surgery.
Dave has taken that for the last few days but advises that it is not
helping and he needs something stronger. Dr Brendan Moore will
now discuss Dave’s medication plan.
1. Comprehensive medication plan
2. What to do with a flare of pain
3. Other pain management options

27. Dave recalls seeing a physiotherapist in the past. He didn’t think
anything really helped. You note that he is avoiding all physical
activity for fear of making things worse. He has become quite
anxious and frustrated about his situation. He is happy to see
someone again at your suggestion. Stephen Boyd will discuss the
place for physical therapy.
1. Role of physiotherapist and what to ask for
i. Role of active therapy eg exercise physiology
ii. Role of passive therapy eg massage

28. Dave tells you that he wants to open a WorkCover claim and would
like a certificate backdated to when the pain started. He tells you
that he now thinks that work caused the problem in the first place.
Dr Angus Forbes will discuss the implications of WorkCover in the
process.
1. Your ethical obligations to the patient and the insurer
2. What to put on the certificate
3. Meaning of significant contributing factor and aggravation
WorkCover

29. WORKCOVER
• your ethical obligations
• to the patient
• to the insurer
• what to put on the certificate
• relationship to employment
• capacity vs total incapacity
• meaning of
• significant contributing factor
• aggravation vs exacerbation

31. WORKCOVER
• the treating doctor is a key and critical stakeholder in the RTW process
• WorkCover highly values communication with the treating doctor
• direct contact with case manager very useful
• the more information available in the medical certificate, the easier it is for
WorkCover to support the injured worker
• provide as much information as possible
• esp. for subsequent certificates (rather than just extending dates)
• focus on capacity and what the injured worker can do, not incapacity
• assists with goal of supporting return to appropriate employment
• the more time the injured worker is off work, the harder it is to return
to work

32. Dave returns, saying that nothing is helping his pain. He has
stopped doing the exercises prescribed and didn’t return to the
psychologist as he feels that he isn’t crazy. He went to see an after
hours doctor and has been prescribed Targin and Endone, as the
medications that the pain physician prescribed weren’t working. His
WorkCover claim has been rejected and he has seen a solicitor. He
wants an operation to fix the problem. You organise a referral.
Dr Paul Licina will talk about the role of surgery in back pain.
1. Who is a good candidate for surgery?
2. What type of surgery?
3. Does surgery work and does it lead to further problems?
Surgery

34. Are they eligible for surgery?
IMAGING
• Isolated disc degeneration
• Marked narrowing
• End-plate reactive changes
• Specific conditions
• Isthmic spondylolisthesis
• Revision or lateral disc herniation

36. Are they suitable for surgery?
PATIENT

37. SUITABLE CANDIDATE
• Self-employed
• Successful business
• No specific injury
• No compensation or litigation
• Works with some difficulty
• Has given up some of more active sports
• Uses intermittent over-the-counter analgesics
• Non-smoker
• Normal body weight
• Goal is to be able to return to active lifestyle
• No abnormal illness behaviour

38. UNSUITABLE CANDIDATE
• Employee undertaking manual work
• Dissatisfied with employment
• Unremitting pain after lifting at work
• Unresolved WorkCover claim with civil action
pending
• Failed attempts at return to work
• Has given up all social activities
• Uses regular narcotic analgesia
• Smoker
• Unfit and overweight
• Goal is for someone to get rid of their pain
• Abnormal illness behaviour on examination

39. What type of surgery?
SURGEON
• Fusion
• Posterior or anterior
• Disc replacement

44. Peta is a 32 year old accountant. She has a 3 week history of
left sciatica. Peta recalls no accident or injury; she just woke up
with the pain. She managed to continue working through the
busy tax time but three days ago woke with excruciating pain,
together with numbness and weakness, involving her whole
leg. She was taken by ambulance to the Emergency
Department, where a lumbar CT scan was performed, and she
was given analgesics and sent home with advice to see her GP
for followup.

45. You see Peta and review her results. Dr Greg Cowderoy will
discuss the imaging.
1. MRI characteristics of disc herniations
2. Other causes of radiculopathy
Imaging

46. 1. MRI characteristics of disc herniations
2. Other causes of radiculopathy

47. 1. MRI characteristics of disc herniations
2. Other causes of radiculopathy

48. • Disc bulge
• Herniation
• Extrusion
• Sequestration

49. • Disc bulge
• Herniation
• Extrusion
• Sequestration

50. • Disc bulge
• Herniation
• Extrusion
• Sequestration

51. • Disc bulge
• Herniation
• Extrusion
• Sequestration

52. 1. MRI characteristics of disc herniations
2. Other causes of radiculopathy
– Spinal stenosis: osteophyte +/- disc
– Synovial cyst
– Tumour

54. 2015 2016

56. You then clinically assess Peta. Dr Simone Headrick will focus
on the neurological assessment.
1. Clinical assessment of radiculopathy
2. Differential diagnosis of foot drop
3. Specialised nerve studies
Neurology

57. Radiculopa
thy
• Radicular pain
• Sensory loss-
dermatomal
• Myotomal
weakness
• +/- Reflex loss
KJ = L3 & 4
AJ = S1

58. Common Clinical Presentations in Patients with Lumbosacral Radiculopathies
Pain Radiation Sensory
Impairment
Provocative Tests Weakness Hypo/Areflexia
L1 To groin Inguinal region None None None
L2 To groin and anterior thigh Anterolateral thigh Reversed straight leg test Hip Flexion None
L3 To anterior thigh and knee Groin and medial thigh Reversed straight leg test Hip flexion and
adduction, and knee
extension
Knee Jerk
L4  anterior thigh,
knee, and medial
foreleg
Anterior thigh and
medial leg
Reversed straight leg
test
Knee extension,
hip adduction, and
ankle dorsiflexion
Knee Jerk
L5  buttock, lateral
thigh and leg, and
dorsal foot
Lateral leg, dorsal
foot, and big toe
Straight leg test Toe and ankle
dorsiflexion,
inversion and
eversion
None
S1 buttock,
posterior thigh and
leg, and lateral foot
Posterior thigh, lateral
foot, and little toe
Straight leg test Plantar flexion,
toe flexion
GMaximus HExt
Ankle Jerk
Katirji, B. (2007). Electromyography in Clinical Practice. United States of America: Mosby Elsevier.

59. Common Peroneal Nerve
Sciatic nerve
Lumbosacral plexus
L4 nerve root
L5 nerve root
FOOT DROP
S1-3

60. Common Peroneal Nerve
- Motor weak ankle DF & eversion
- Reflexes normal
- Sensation anterolateral leg & dorsum foot
- Pain is rare
Sciatic nerve
Lumbosacral plexus
L4 nerve root
L5 nerve root FOOT DROP
S1-
3

61. Weakness isolated to peroneal nerve
Recognisable compression episode 
observe 2/12 +/- AFO
if progressive then investigate  MRI EMG
Most common cause of foot
drop – peroneal at fibular
head
Recent surgery TKR? ICU?
“Strawberry picker palsy”
“Slimmer’s palsy”

62. Common Peroneal Nerve
- Motor weak ankle DF & eversion, inversion spared
- Reflexes normal
- Sensation anterolateral leg & dorsum foot
- Pain is rare
Sciatic nerve
Lumbosacral plexus
L4 nerve root
L5 nerve root
FOOT DROP – weak Ankle inversion
 beyond territory of Peroneal
nerveS1-
3
Ankle inversion = Tibialis Posterior = L5

63. Sciatic nerve
L4 nerve root
L5 nerve root
Upper motor neuron signs?
CENTRAL causes  Foot drop  Peripheral causes
Parasagittal meningioma, stroke
MND
+ Mixed UMN + LMN signs ….
progressive weakness with time
(painless & no sensory symptoms)
Common Peroneal Nerve
Lumbosacral plexus

64. NCS & EMG
• Stimulate over skin &
record
• record electrical
potentials generated in
muscle belly

65. NCS
Peroneal motor study – EDB
Stimulate @ankle
Stimulate at Fibular
head
Above fibular head

66. •NCS & EMG  Diagnostic sensitivity overlaps  MRI
Physiologic information
AnatomicAims of NCS & EMG in radiculopathy:
• 1. Exclude distal Mononeuropathy or
generalised PN
• 2. Confirm nerve root compression
- Localise to single or multiple roots
- Time course (distant past vs active ongoing)
- Severity
Challenging cases…
• Inconsistent clinical & MRI findings yet persistent disabling
symptoms of radiculopathy
• Motor deficit absent or uncertain  EMG objective
evidence of denervation
• Persistent weakness evaluation – most useful > 3wks
• MRI Normal identify non-structural radiculopathy mimics
(DM, infective, malignant)
• MRI multiple abnormalities  precisely localise if
neuroimaging findings are causing the specific neurologic
deficits
• Non-specific spinal pain: distinguish pain-related reduced
muscular effort vs true neurogenic weakness
• Pain only or sensory loss only – NCS EMG = low yield

67. You refer Peta to see a spine surgeon. He recommends surgery.
She undergoes a left L5-S1 microdiscectomy as a day patient.
She is working from home two days after surgery, having
stopped her analgesia.
Two weeks after surgery Peta contacts the practice nurse to
advise she has been experiencing the pain in her leg again.

68. She is referred to see a pain specialist. Dr Brendan Moore will
now discuss his plan for Peta’s postoperative flare of pain.

69. At the three week clinic review, Peta’s leg pain has settled. She
has minimal back discomfort and no residual weakness.