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Mechanical Low Back Pain (Sciatica)

Case 3: Karen

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Objectives

When working with CPP, you will be able to:

Identify abnormal neurological signs and symptoms

List 3 assessment tools that may be useful

Address patient expectations for diagnostic imaging and surgical referral

Indications for Opioid Use

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Mechanical Low Back Pain

“Karen”, 35 year old female, Nurse, presenting with 6 week history of right leg dominant pain

She first noticed it after having difficulty with a patient transfer and experience immediate low back and right posterior leg pain.

She tried to maintain work but found it increasingly difficult and was advised by her therapist to stop work since she was not responding to treatment.

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What are your Key Questions?

How do you determine if this is mechanical back pain ?

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On History, we found…

She rates her pain as 9/10 and finds that sitting and walking are difficult and aggravate her symptoms

She experiences increased pain with coughing and sneezing

Morning stiffness is 30 minutes

There are no changes in his bowel and bladder habits

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Physical Exam

What physical examination techniques would you use?

We found:Flexion and Extension aggravated low back painDifficult to find any comfortable position Positive SLR causing reproduction of leg painDecreased right Achilles reflex Decreased myotomal strength of right toe extension Hypersensitivity over lateral calf & intermittent tingling.

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Pain History

What would you ask to determine optimal pain management strategy ?

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We found

Lives with husband and 7 year old daughter in Richmond

Tried over-the-counter meds initially but found that she was taking 12-14 tablets per day of acetaminophen and ibuprofen.

Has been put on Codeine based analgesia for 3 weeks and is experiencing constipation with little relief

Has asked about using Lyrica or Percocet which her colleagues have suggested

Mood is “anxious and stressed” Concerned that she will not be able to go back to

work due to pain

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Management Tools

How would you determine if investigations were appropriate ?

We used:

a) Is there poor or no response to appropriate treatment?

b)Are pain levels unmanaged with best medications?

c) Are there prolonged neurological deficits greater than 6 week ?

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Understanding symptoms of neurological origin

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Imaging Options ?

XRAY suspected trauma or fragility fracture

Bone Scan infection, metastases, systemic inflammatory

process

MRI Progressive neurological deficits, unresponsive

radicular syndrome, neurogenic claudication, cauda equina

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Facilitating recovery through home based exercise and recovery postures

What would you suggest ?

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Facilitating your patient to set Goals

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No Improvement noted

Despite best efforts for therapy and medication, Karen is not improving and she has had increasingly more pain and withdrawal from activities.

The MRI demonstrated a right large paracentral disc herniation with nerve compression.

Would you refer to a surgeon or not ?

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Referral to a Specialist

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Clinical Impression

Pattern 3 –Leg Dominant Pain Leg dominant and flexion continually increases

pain Positive Neurological exam

She is anxious and apprehensive of pain Her pain management has not been

successful although she is compliant, may need opioids

Should have a trial of conservative therapy but may need referral for surgical opinion

Appropriate for MRI investigation

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Key Clinical Information

What are the key criteria for MRI investigation? Lack of treatment response Evolving Neurological tests Leg Dominant Pain Syndrome

What Medication may be best for her ? Short acting opioids for best treatment.

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Summary

When working with Mechanical Leg Dominant Pain, it is important to:

1. Take a targeted history 2. Do a full neurological examination 3. Refer for goal oriented rehab treatment and

evaluate4. response. 5. 4. Consider MRI if no response to appropriate

therapy and escalating leg dominant pain.6. 5. Consider short term opioid management.

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References

Alberta TOP (Towards Optimizing Practice) Low Back Pain Guideline http://www.topalbertadoctors.org/cpgs/885801

The Opioid Manager http://nationalpaincentre.mcmaster.ca/opioidmanager/