Good morning, it's 10.15. Welcome for our session number 309, which is about a problem-based learning experience to evaluate and treat low back injuries. I am the moderator. My name is Saj Savul, and I am, I would say I'm here local. I work at the, okay, I'm sorry, I'm told that it's not streaming yet, so we'll just pause for a second. Okay, well, I'll do it again. Good morning, and welcome to our session number 309, which is about learning experience to evaluate and treat low back injuries, and this is session number 309. I have a little housekeeping sheet here, but I'm sure, like today being day three, you know, you've been to these sessions, and you've been in this area, and you're familiar with where everything is. I am Saj Savul, and I am here at Penn as the Residency Program Director for Occupational and Environmental Medicine. I'll be the moderator for today's session, as will be two of our Penn residents, Josh Stevens and Zun Huang, who you will be meeting here up on the stage in a couple minutes. Our speaker is Dr. Adrian Popescu. Dr. Popescu is Director of Spine Service, Department of Physical Medicine and Rehabilitation here at the University of Pennsylvania. He's been related to Penn for a good 20 years. He did his residency in PM&R, anesthesia, then his fellowship in interventional pain, and now he's actually the Fellowship Director for Interventional Spine and Musculoskeletal Medicine. He also co-leads the Neuroscience Spine Service Line, Associate Professor of Clinical Physical Medicine and Rehab, and also Associate Professor of Anesthesiology and Critical Care. So the way we have set up is like it's meet the professors, we'll have two residents come and talk to us about a case, they'll give a brief HPI, a little bit of what they found on the exam, and then they will be asking the professor on how Professor Popescu would approach the case. And I will invite Dr. Josh Stephens and Dr. Ziyun Huang to come and present their case. All right, thank you. Thank you, Saj. I appreciate you asking us to be here in this intimidatingly large room. I'm going to skip directly to the case here. So lower back pain after a fall onto the left buttock. So this was a case, Doc. I slipped and fell on the floor in the hospital, hit my right buttock hard, had some bad pain initially, but I thought it was going to get better. That was two weeks ago. It's not getting any better, though, and it affects my job, I cannot take care of my mother at home. More of the history. This is a 62-year-old man, he works in the hospital as a case manager, slipped, fell in the hallway, we said about two weeks ago, visited with his primary care physician prior to coming to occupational health, has had right buttock pain with sitting, some pain with changing positions from sitting to standing. Pain is somewhat better when active walking with short distances, but more pain at work, pain at night that wakes him from sleep, and pain actually radiates into the bilateral buttocks and thighs at times. No falls after the injury, no other interval injury there. No bowel or bladder incontinence, some night pain, nocturia. Pain is 8 out of 10 at the worst, it's in the right lower back, some thigh radiation, no numbness below the knee, though. He has pain getting in and out of his car, and he did receive an x-ray of the right hip post-fall which showed no fracture or dislocation, has bilateral total hip arthroplasties without evidence of dislocation, he said. He did start physical therapy, first session he described as rough, painful. Past medical histories, hypertension, hyperlipidemia, nocturia, some new onset, kidney insufficiency, my doctor is ordering a bunch of labs. Some back pain on and off for years, but did not rise to the level of needing to see a physician at any point previously, and is an otherwise fit and healthy guy, played Division I athletics and other competitive sports. All right, I'll turn this over to Zune here. Good morning everyone, good morning Prof. So Josh was called away, and so I was in charge of doing the physical exam, and after receiving turnover over the patient's history, I certainly observed that he was walking with an antalgic gait, with kind of a short stride, he was kind of favoring the left hip, both standing as well as sitting. He tended to offload the right buttock, and when he was sitting, and for prolonged periods or when he initiated walking, he would complain of exacerbation of his pain. Just doing kind of a general range of motion exercise, when he had lateral bending, he complained of just mild pain that seemed to worsen a little bit in the thigh and the leg as well. On extension, he did not notice any improvement of his pain. When he laid supine, he noticed that it improved the pain, and he noticed pain when transitioning from the sitting to the standing position. So certainly in terms of thinking where to go after the initial impression, I'd have you consider the same things I would consider in terms of what type of exam elements would need to be added to this exam. If you have a proactive coder in your office, they may say, oh, are you thinking about the elements that would be required, perhaps five elements to get to a target or a problem-focused exam? Thinking about those things. I was thinking, do we need to get imaging for this gentleman? Is there an indication for it, and what type of imaging? Any additional labs? He talked about the kidney, a possible renal insufficiency. Is there going to be some, will that be an importance in evaluating this back pain? And finally, any prescription medications that he had. So in terms of the exam elements that we did, we assessed that he could do a heel-toe walk, and he could stand, rise from sitting to standing position on one leg. So at good strength. Manual motor testing was grossly intact, 4 to 5 over 5 in proximal and distal groups. His sensory exam, not particularly remarkable, at least a gross light-touch testing. Focusing on the hip, he did notice pain in the posterior buttock on the right, a little bit on the left. And so we certainly did some targeted maneuvers to try to elucidate whether the pain generator was in the hip versus in the SI or in the lumbar spine by doing the FABR, the F-A-D-I-R distraction test and compression test of the pelvis, and then the GANSLESS test. So again, thinking from here in terms of what type of preferential direction we were going, if he had a preference in his direction, the single direction of movement that decreased or centralized or abolished his symptoms, we couldn't identify any specific one. So one of the things we did was we did a targeted test by having him lay on his right side up, which was the symptomatic side. We flexed the right hip, and with the knee resting from the table, asked him to abduct or kind of both externally rotate and abduct the knee, and he noticed that buttock pain was produced against resistance. And he also noticed pain with resisted hip flexion and also some pain with the femoral stretch test. So first thing I would have you think about is what's in your differential. And I don't know if you want to present that. Thank you. So I tried to keep it fun and not boring. We all see back pain, some of us more than others, and this is a real case of actually not a social work, but the physician that came to our office, and sure, I'm afraid for the echo. So what I didn't give you as a physical exam, I didn't give you the location of the pain aside from buttock, and location of the pain more specifically with provocative maneuvers. When we do a physical exam or a provocative maneuver, ask the patient, you will be surprised how many times when they exhibit pain is not in the location that you expect. Ask where is the pain? Is the knee? Is the toe? Is your headache? Is your eye? Is your back? Is the buttock? Is the groin? All those provocative maneuvers should have a location of the pain. So why the history is more important than the physical exam? Because the location and mechanism of injury is number one for me, for this patient. Any position that worsens symptoms, any associated weakness, any specific time of the day or activity, right? We all know that early in the morning, discogenic pain is worse. And in terms of physical examination, I failed to have 100 pages of physical exam compressed in 10-minute lecture, but I strongly recommend this book, which is an evidence-based approach to physical exam for lower back and the hip. Inspection, why do you look at the patient to see if there's any coronal imbalance, any scoliosis? Percussion, you want to make sure that the patient does not have pain with spinous processes, percussion so you don't miss a compression fracture. Those are elements of a three-minute physical exam that we all need to learn not to miss big things, right? The range of motion and provocative maneuvers. Any maneuver that we do, we need to ask, where is the pain? And that's my favorite question, did you have this pain before? If the patient had the same pain, then you might look back in history of imaging or other things that happened in the past and understand the proximity of structures. All the lower back structures are within a couple of inches of each other, SI joint, facet joint, L5S1, L5S1 disc. Our two-point discriminatory accuracy is about this much, it's about four inches on the back. So sometimes we think that we can diagnose with a physical exam, a good physical exam, but sometimes we cannot. So directional preference is important for patients with a herniated disc, why? Because if the patient has a movement that decreases, centralizes, or abolishes symptoms, they will do well with physical therapy. And I've never had this patient that everything hurts, every movement hurts, nothing makes it better. Did you? Okay, good. So the purpose of this slide is to know that if there's something, some movement, for example extension that helps or seating that helps, you can actually point to a structure. If everything hurts, physical therapy might not help, might only gain time for you. So this is a study that was done by Long in 2003 and showed clearly that the red graph decreased in back pain and leg pain for patients that have a preferential direction that had a disc herniation and improved the pain by three points or more on a numerical analog scale. Yellow flags. Do you see this in your clinic? Yes, we do, right? Anxiety, pain behaviors, history of depression, and some secondary gain sometimes. So we're thinking about differential. What can this be? This is a colleague of yours that just came to see you. And can be a discogenic pain, yes, lower back, right side. Can be a Z joint, a facet joint, yes, it can be. Can be a sacroiliac joint, giving the trauma and fall, yes, it can. So what are the elements of a discogenic pain syndrome? Pain in the morning, pain with seating, pain is better with walking, pain usually is better with extension, pain with coughing and sneezing, pain with coming from a sitting position to a standing position, discogenic pain. Vertebrogenic pain, if you have a compression fracture, you can have some abnormalities on the MRI, modic changes, type one or two. You can have pain with bending forward, you have pain with percussion of the posterior elements. Facet joint pain, you can have pain with lateral bending and rotation. Everybody talks about facet loading test, right, that's very sensitive, but it's not very specific. The most specific test, believe it or not, is no pain with transitioning from sitting to standing, and patient cannot stand straight. So those are elements that are part of the history and part of the physical exam with the gold standard for facet-generated pain being dual diagnostic blocks. I'm not going to talk about injections because I believe that you should question your injectionist and see if everybody gets diagnosed with something, or in fact, your injectionist or the referral source has the sighted prevalence for facet joint pain, which is fairly low, it's 10% to 15%, maybe 20% in certain age groups. Sacroiliac joint pain, it's a condition that I think we as physiatrists diagnose very often, and sometimes it's not that prevalent. I'm really convinced by this condition when I see high intensity on the MRI T2 star image, and the gold standard is an SI joint injection with lidocaine with a perfect arthrogram, which my colleague, Dr. Tingan, will tell you probably is the most difficult injection that we do because the access to the joint is not easy, okay? Some trauma or stretch prior to pain will point to that also. The maneuvers, again, I refer you to the book, but if you do distraction, which is laying the patient supine and pressing on both ASIS pelvic bony landmarks, you should provoke pain in the SI joint area in the back. Distraction, compression, compression is the test where you lay the patient on the side and you compress on the pelvis, and you should reproduce the pain in the SI joint area. Sacral thrust and thigh thrust. Ganslins didn't have much of a diagnostic validity in this study by Leslet, and again, they provoked pain with provocative maneuvers for SI joint, and then they diagnosed the condition doing an SI joint injection with lidocaine. So this is kind of evidence-based physical exam. If more than three tests are negative, the negative predictive value for those negative tests is 87%, and least we can tell is not SI joint. Piriformis syndrome. We tried to go through all these physical exam maneuvers, and my colleagues presented a physical exam that is classic for piriformis muscle pain, where you have the patient on the side, you bend the knee, you apply pressure on the knee, and the patient has pain in the buttock area. Only that this patient had other tests that were positive in addition to that. So for me, I need to confirm the piriformis muscle pathology, some type of imaging to show me inflammation of the muscle, edema of the muscle, atrophy of the muscle, or a good ultrasonographer, and I'm going to take a pause here. I'm going to repeat it. A very good ultrasonographer. A two-day course or a two-month fellowship will not make you a very good ultrasonographer. Okay? It's actually difficult. These slides are for you to take home and have an algorithm in place in terms of diagnosing lower back pain, radicular lumbar sacral pain, and possible etiologies. Again, these are just slides for you to take home and be very efficient in your clinic. Time for weakness. Toe walk, heel walk. And look at the patient's gait. Does he hold the cane and does not use the cane, just keeps the cane under his arm? Or he actually uses the cane appropriately. Does he have any weakness with single leg sit to stand, single leg raise, pathological reflexes, preferential directions, spinous process percussion, as I mentioned. So what's the next step? We send the patient to physical therapy, he's a very reliable guy, he's a physician, very motivated to come to work every day, started physical therapy, very painful sessions, the primary care ordered an MRI, and surprise, surprise, got approved. What's the next step? What's our differential here? Severe buttock pain, it wakes him up at night. He didn't have pain prior to this fall. Functional interventions, okay, how do we write a physical therapy script to make the patient better? Well, this is an example for lower back and radicular leg pain. The most important element here is actually the last line. Transition to home exercise program and monitor for weakness. Tell your physical therapist to monitor for that, because you'll be surprised that patient can have pain and the pain can transition to weakness. And if you are not aware of that, it's not good for the patient, because then the patient's gonna be upset. What is one intervention that we can do for patients that might have a one disc herniation to reduce the discogenic pain? Just tell them to avoid bending in the morning, and they're gonna feel better. According to this study, this 86 volunteers with chronic lower back pain that avoided the first hour in the morning flexion reduced the pain days by 18%, so almost 20%. One in five days, less pain than their counterparts. All right, let's go to imaging, because our second objective is imaging. When do we order imaging? So if we order an x-ray of the lumbar spine, four views, or three views, lateral, obliques, AP, that tells us that the patient has a spine. Well, I knew that. Maybe we need to tell something else to the x-ray tech. Maybe we need to tell the x-ray tech that maybe we should get some dynamic views with flexion and extension, and see if there's any shift of the lumbar spine. And it's very important to think about the differential diagnosis when you order these studies. So these are the x-rays for our patients, okay? And what do you think we have here? We have scoliosis, awesome, okay? So we do have a spinal deformity in the lumbar spine that has the convexity, the C, to the left of the patient, right? So if this is me, this is convexity to the left. Patient has more pain to the right, but that's a reason for the patient to have back pain. Doesn't have any instability. And these are the x-rays from a different patient, not from the same patient, but kind of trying to drive the point home to look at the x-rays and see if we can see anything. And this is the lateral x-ray for this patient. This is a 37-year-old patient with back pain, cannot get out of bed for two hours in the morning, successful manager at Comcast here in Philadelphia. Very successful woman, cannot get out of bed. These were the x-ray that we received. What do you think? Anything that catches your attention? Not much, pretty aligned, very nicely, okay. Let's see, how about this one with extension? Not much, okay. Kind of, what I did, I made a phone call to the x-ray tech, I said, please retake these x-rays. And they were upset, of course, because it's time of their day and so on and so forth. But they retook the x-rays. Do you see anything different now? Pretty significant finding, right, that L5-S1, we see the L5 vertebral body in front of the S1. It's a spondyloptosis, it's more than a grade four list this is there, right? So the patient has a basically surgical condition. Last time she had back pain and was seen was four years ago. Nobody followed up with any x-ray. And at that time, she had a grade two spondylolisthesis. Now she has a grade four spondylolisthesis. So important to follow up with your patients and you can see that, right? It's pretty profound. She was still walking, she had no neuro deficits, just severe pain. This is our patient. We got x-rays, the x-rays were read as everything is in anatomic alignment, everything is good. But somebody mentioned some spinal deformity. And we went over an MRI. And this MRI, I put a video to see how you go lateral to medial. Now you see the spinal canal, very nice, no spinal stenosis, you see my arrow there. And you go back and then you go up and down and you assess for the spinal canal there. And you see the disherniation there in the foramen on the right. Very wide open, beautiful canal. And then you will see central spinal stenosis at L2-3, which is severe. Then you see some disc changes and modic changes at L1, L2, you see that. And on the right side, on the left side of the patient. And then central spinal stenosis, moderate at least, which can cause buttock pain, can cause pain in the legs. And you see that disc, foraminal disc on the right side that can cause pain. Anything else that catches your attention? We've had about four pain generators and we know that the MRI can be untelling, about 30, 40% of asymptomatic individuals have findings. So then, this is another video of the MRI. And in the middle you have the STIR sequence of the MRI, which shows bright edema, or bright CSF, or bright blood vessels. And you see some things there that are fairly bright near the SI joints. The radiology read was degenerative changes and everything else that I told you about. You see some bright signal there, right? Bright signal, edema. And it's right at the edge of the field, so sometimes they will say, oh, because it's at the edge of the field, it's not that accurate, retake it. Good luck with the insurance company. So, what's the purpose of getting an MRI? How common is the disease that you're looking for? And how often we see something really, really bad? And it's rare. Metastatic disease, 0.7%. Spine infection, 0.01%. 4% osteoporotic compression fracture, or 0.3% AS. And MRI is really good to detect cancer or infection with excellent likelihood, positive likelihood ratio, negative likelihood ratio. Unfortunately, low prevalence of a systemic disease implies most finding will be degenerative. And you can find degenerative changes in asymptomatic individuals and then they're gonna come to you and say, hey, I have a disc herniation. You might have had a disc herniation before or a while ago and asymptomatic before your fall. And we need to learn the sensitivity and what can we predict with that imaging, right? So, what are the recommendation? If you look at the American College of Radiology, no imaging for lower back pain. Can you tell your patients that? I'm just curious. Anybody of you work on patient experience? I don't think they like that. No imaging is a no-go. But anyway, recent significant trauma is an indication for imaging, right? This guy had a fall, pretty hard fall, so we can justify that. Minor trauma in age over 50. Fever, weight loss, immunosuppression, steroid use, focal progressive neuro deficits. And again, this is a good study where it shows the high prevalence of this degeneration and disc herniation, different studies in asymptomatic individuals, okay? Was the utility of ultrasound as imaging of the lower back and posterior buttock. I think you have a good utility done by a person that is experienced and preferably he does that every day in and out, starting at eight o'clock in the morning and finishing at three o'clock in the afternoon because radiologists, they have a shorter schedule than us. So, you can scan the piriformis muscles, you can scan the gluteus muscle, you can assess for false positives and they will tell you. And we have to think what is the utility of ultrasound and was the cost, and was the utility of an MRI and was the cost. And the MRI costs got significantly better recently, like an out-of-pocket MRI probably is four or $500, okay? If you want to pay for it and you don't want to use insurance. So, in this case, it's pretty interesting. The MRI of the hip showed this things. And on the right-hand side of your screen is the left side of the patient. And the blue circle shows the piriformis muscle on the left, that one, okay? Pretty nice, okay? On the other side, you don't see it. It's actually degenerated. There's lots of fat around it. And if you look on the star image, you see a little bit of inflammation. Interestingly enough, this patient got a piriformis injection prior to this MRI, which clearly caused muscle necrosis. Was that under ultrasound? Do we need to do that? Probably not, okay? So the MRI report confirmed what we just discussed with clear piriformis atrophy with associated edema and mild arthritis. This is how the piriformis will be assessed under ultrasound. I think it's a great modality. Now, keep in mind, that scan is the width of a credit card. And I'm not sure about you, but my hands are not that precise to get exactly that location on both sides and have the patient in absolute perfect location. It's almost impossible. On the MRI, you can go back and forth. You know you take the same scan, which is perpendicular to the muscle. In ultrasound, unless it's really obvious, it's probably harder. And it's a deep structure. So I'm not sure about you, but in Philadelphia, we have our challenges due to body habitus sometimes. It's hard to see even a good shoulder exam. That might be a lot more difficult with ultrasound. So again, much easier to see on the MRI, right? Let's go back to our patient. And this is a more focused MRI. And on the left-hand side, I have the STIR image of the MRI, which is a T2 special sequence that takes out the fat so you don't see fat posterior to the spine. And on the right-hand side of the screen, you do see posterior fat. On the left side, you don't see subcutaneous fat. So it takes the fat out, and everything you see is bright signal if there is anything there. What do you think? What should we do for our patient? He's a colleague of ours. He has pain with sitting, pain with going from sitting to standing. He has full strength, but he has pain when he goes on one leg from seat to stand. He has pain with piriformis stretch. He has pain with all these hip maneuvers, but his pain is not in the groin. It's in the posterior buttock, kind of both sides. And he has this pain after a fall. The x-rays showed no fracture. The x-ray showed spinal deformity. That happens to be on the opposite side, but it's spinal deformity, so that can cause pain. What do you think? Pain generator, okay? We're trying to think. So I'm trying to formulate my diagnosis. What advice do I give my colleague? Don't worry about it. I can say that. Anybody can say that. Can you say again? Spasm of the piriformis muscle. Spasm of the piriformis muscle. Let's say yes. I am not able to assess that, but let's say it really feels painful and the piriformis muscle fires up. And that's a response to pain, okay? So spasm of the piriformis muscle, yes. So what advice do I give him? What should I do, doc? It really hurts. It wakes me up at night when I turn a certain way. Can I take some NSAIDs? Yes, you can. Your creatinine is 1.1, three days, I think it's fine. But this is the diagnosis. And I'm not sure about you, but I was surprised that the MRI read did not mention it. So as you can see at the bottom of the screen, you see that bright signal on the left-hand side when I go through the SI joint area and sacral area. And again, you saw the MRI. Anything could have been the cause for this, right? We had a disc herniation on the right. We had the spinal stenosis at L2-3. This is a reliable guy that wants to go to a doctor. L2-3, this is a reliable guy that wants to go to work every day. But you see bright, bright signal in the sacral area. And yes, the piriformis is spasming because he has pain, and the pain can generate spasm of the muscle as a protective mechanism. Okay? So what's the follow-up? This is your patient. What would be the follow-up for a patient that has sacral insufficiency fracture, feels a little better after four weeks? What do you counsel him? Do you give him a brace? Do you say, don't worry about it? Do you need further workup? What if this is some type of cancer? You know what I do? I over-order ESRs, sed rates. You know why? Because if it's cancer, you're gonna see something there. I over-order CRPs, CBCs. Maybe I follow up with a CT scan, because the CT scan will clearly tell me if the bone structure is healing or not. And you do that, give or take six weeks after the injury. If it's not healing, and if you see trabeculae that are destroyed by osteolytic or osteoblastic lesion, you will see that on the CT scan. There's no question about it. And I think the patient will feel better if you tell him that we might be able to tell if it's healed or not. Make sense? And again, our differential was broad for this case, and I picked it on purpose, because we always have a broad differential for every patient that we see. So we could have said it's dyscogenic. We had a right side, far lateral disherniation. It could be SI joint, could be facet joint, could be compressive joint, could be any of these things. It could be SI joint, could be facet joint, could be compression fracture, could be neurogenic claudication secondary to L2-3. And 10% of the cases of severe central stenosis manifest themselves just with back pain, not leg pain. And the surgeon doesn't want to operate on that. Piriformis syndrome, or of course, no clue. No clue is a diagnosis, because this guy has seen actually two other colleagues, and radiology did not mention that. So it's always tough to be a provider, because you will have something special. I'm not sure if you experienced that, but I can experience, I can tell you my experience, that every time you have an appendicitis, you end up with a pelvic abscess, because you're a provider. Anyway, this was the other study. This was the CT scan that we did, about six weeks, and showed very nicely healed sacrum. And mind you that the x-rays miss consistently the sacral insufficiency fractures that have no displacement. So it's a good thing to get an x-ray, but does not rule out sacral insufficiency fractures. Okay? So what would be the take-home message? The mystery is in the history. Everything that has to do with the initial injury, mechanism of injury, timing of injury, timing of pain is very important. Focus, neuro, and MSK exam. Compare side to side. Know your anatomy and have a broad differential. So remember what we did. We toe walk him, we heel walk him, we ask him to sit to stand on one leg. Just that exam, if he has no weakness, he has no weakness, and we ask him, where is your pain? Is it in the groin? That's a hip pathology. Is it in the back? It's a back pathology, and then we broaden the differential. We did more provocative maneuvers for the back and for the hip. And everything pointed to something in the sacral area, sacroiliac joint area, lower facet joint. Did we need to order an MRI? I think we did. Even based on the American College of Radiology. He had a trauma. He was over 50. He had night pain with changing in bed, and I think that's also one of my favorite questions. Like, do you have night pain? What makes it worse? Does it wake you up when you move? And so on and so forth. What else we did, physical exam-wise? Pretty much every maneuver. Not sure about you, but we usually, I try to tell the fellows, you should be able to do a focus exam in five minutes. And time yourself for that exam. How fast can you do a very good exam without missing anything? And all the elements that I gave you, you will be able to do it close to five minutes, I would say, because that's important in nowadays environment to be very focused. Know your anatomy. Have a broad differential. Know the diagnostic yield for the study that you'll order. And more importantly, follow up with a patient. If you don't know what's happening, that's normal. If you don't have a diagnosis of the first visit, that is normal. You think it's the SI joint, it's possible. You think it's the disc, it's possible. So lower back pain, it's an interesting topic that probably cannot be covered in one hour. I hope you are not like this guy that I absolutely love. And I acknowledge my patients and our patients because I think that's the reason we wake up in the morning and we feel good about ourselves at the end of the day, that we make a difference. And I thank you and I'm taking any questions that you have. Thank you. It was an informative talk. I just had a question. Insurance adjusters, insurance companies, as an op doc, the MRI comes back normal or degenerative disease and they pressure me, I'm giving you real world, they pressure me, the MRI shows degenerative disease, close the case down and say follow up with your family doctor. I don't know if you understand my question. I understand your question. The insurance company pressures you to close the case for a normal MRI under the circumstances that they think there's absolutely nothing wrong with a patient and the patient continues to report pain. And again, it's, I think we need to understand or they need to understand that we are the physician, we are the provider. And I'll give you an example. And this is another real life example because I like those better than those book examples. I am privileged to take care of a professor of radiation oncology at Penn. And he had an event where he had two compression fractures on the MRI, documented. He couldn't sleep, he couldn't work, but he went to work every day. He couldn't take medications, pain medications because it would affect his other problems, mentation and everything else, decision making, driving. And the insurance company denied his vertebral augmentation. There's a pill put in by neuro interventional radiology, denied. Very complex discussion between the payer and the institution to get this approved got denied. And what I said, I started the phone calls and I called, I said, okay, can you tell me your name? Because I want you to be part of this case. If you want me to close the case, no problem, I'll close the case. But I want to make sure that you as a director of the insurance company or the payer, you're part of this case. And surprise, surprise, when the CMO of that insurance company name got in the chart, the study got approved and he got a vertebral augmentation. Thank you. You're very welcome. Hello, I'm Srivani Ganamuri. I'm coming from Washington state. I'm an occupational medicine physician there. My question, yeah, I see a lot of low back injuries. So when you fall from a ground level, do you think that can cause spondylolisthesis? Very good question. I always like to look in the record. I'm very privileged. I work at Penn, so we have many years of records usually and I look back. Can that cause a spondylolisthesis? Depending on how hard you fall, did you have a parse defect to start with? If you had a parse defect in a prior x-ray and you didn't have spondylolisthesis and now you have spondylolisthesis, it's reasonable to say yes. If you have no prior x-rays and you have a spondylolisthesis grade 1, is that reasonable to think that it's caused by the fall? Again, I didn't witness the fall. It's a hard question. If it's not unstable, it's not unstable. It doesn't require surgery. It doesn't require injections. The causality part is a very complex question. I would focus on laser point history. Tell me how you fell, when you fall, did you fall before, did you have back pain before, and stuff like that. Those are my comments. If you have a prior x-ray, I think it helps. If you have a prior x-ray with evidence of parse defect, it helps to say yes, it's possible. Thank you. You're welcome. I just wanted to say, if you don't want to get out of your chair to ask a question or for people who are following along at home, you can ask questions on the app and we'll read them aloud. Thank you. Two brief questions. Is the Nadler book still available? He died 20 years ago. He died. Nadler and Dr. Malanga, both of them. It's still in print? It's still on Amazon. I have no conflict of interest, no benefits from that book yet. The second is, are handouts available for this? Should be. It's official. Hi, sir. Thank you so much. A great presentation. Of course. It's very difficult, I think, to get follow-up studies. About six weeks later, we just got a big study. It showed the issue. Obviously, the majority won't show any issue, but I'm the ones that do. Is there any benefit to doing a follow-up CT scan a year and a half later? Will it show sort of those calcifications? Will it show the remodeling or it just doesn't? I just don't have experience in that. Very good, awesome question, I think. Because people are used to order the CT scan six to eight weeks prior, after the initial injury. Was the value of a CT scan a year after? If the patient has no pain, I would not order the CT scan. If the patient continues to have pain, probably I would order a CT scan at six months. If the patient, the question is, would the CT scan show remodeling? Usually, the CT scan will show sclerosis of those areas, like our CT scan showed, if it's just a sacral insufficiency fracture, non-displaced. Again, thank you for a great lecture. I would like your recommendations, if any, and I think I'm not the only med doc here, where a person, an employee comes in and clearly has signs of neurological deficits, such as a significant herniated disc, and there's delay after delay of getting the person the proper care, and as you know, with neurological cases, there's an expiration time before it becomes a permanent disability. So, like the person's out of work, so it's affecting their mental health, they're in agony 24-7 because of a bad herniated disc, there's not denial, not saying to close the case, but just taking forever just to see either, even just do an MRI, or seeing a neurosurgeon or an orthopedist. Do you have any recommendations in those cases where you're in limbo and you've done a very thorough note that's like, okay, this is what needs to be done, hurry up about it, and nobody's answering you, nobody's following up? When you say nobody's following up, the patient does not get care for two weeks, or three weeks, or six weeks? No, I'm remembering a vivid case of a gentleman, I followed up with him every two weeks, I had comparable data. Oh, so it's not two days, it's reasonable. No, it's every two weeks to make sure that somebody's seeing this person, but the people who are supposed to pay for these tests are taking forever, and this poor person is giving up. So I just wondered if you had any suggestions of what can be done in such circumstances. Two things, pain and neurological weakness, two different things. So I usually document, look really hard for neuro deficits. Is it the EHL, is it the foot drop, is it the patient walking like that? All those things, yep. Walking like that. I see. Or if the patient cannot do one heel raise off the floor. So all those neurological deficits qualify you for advanced imaging. And all those neurological deficits should qualify the patient to be seen by a specialist, not necessarily to have surgery, but to have an opinion. Was the natural history of a foot drop? Was the natural history of weakness secondary to a disc herniation? What is appropriate to wait, is it appropriate to wait six weeks to see if it's better? If it's not better in six weeks, you have to have something done. Does the patient have any preference? Q word is should. Yeah, Q word, yeah. Truly, 100%. And again, I think we don't know what, you know, this comes also with a major stress at home, because it can result in losing the house, losing the kids because you cannot support those kids, and so on and so forth. So it's a lot more complex than we see it as a disc herniation. Well, it's more than a disc herniation, okay? And usually I ask for names when things get denied. Just say, can I have your name so you're part of the chart? And we are all in the same boat. We all look for the patient. I love that. Thank you. Yeah, you're welcome. For legitimate reasons, prostate PSA screening dropped in the last 10 or 15 years due to screening protocol changes, and now theoretically we're seeing more advanced cases than we were previously. Would that cause you to lower your age of x-ray from 70 down to perhaps 60 because of a concerned increased rate of unknown cancer? So the question is, one is about PSA screening, right? And one is about imaging as a screening tool? No, because the PSA screening rate went down, your older male population may have undiagnosed prostate cancer, which might have changed your calculus in ordering an x-ray. So I have, so the x-ray, when you see the cancer on x-rays, it's usually advanced because the cortex is done. So I would have no, I don't think the PSA is a very expensive test. I don't know, but I don't think it is. And I think if you believe that that should be ordered, for me, history of night pain and history of chronically elevated PSA will allow me to order a study. And usually things that you document in your note, for example, six weeks of conservative treatment, no improvement in pain, no improvement at night pain, that would qualify you for an advanced study, I think. Neurological deficit with no improvement at four weeks would qualify you. Again, night pain is a big one. History of cancer, out of all that HPI, is one element that is the most significant and the most predictive of defining a metastatic disease in the patient. So history of cancer can be a skin cancer, remote melanoma, 40 years ago. If the patient has back pain, new back pain, unexplained, you should document that history of melanoma, rule out recurrence metastatic melanoma. I've seen that. And I'm glad that the insurance company didn't give me a hard time. It was metastatic melanoma, yeah. Yes. Yes, Mark Boto from Seattle. Oh, okay. I've been doing IMEs for the last 12 years. I've seen well over 10,000 IMEs. What I am impressed by is that I see the problem cases for Beck, and there's like generalized pain, a totally grossly non-physiologic exam with multiple Waddell's findings in so many cases. The AP has let this go on for years, yet they don't pick up on this thing. I think it's very important to be cognizant and do these tests so that these people may have issues that are super-tentorial as opposed to neuromusculoskeletal. It's just not being done or documented well. One hundred percent. So what the point made is that, if I understand correctly, patients that have anxiety can have real problems, and despite having suspected non-organic findings, they might have a problem that is missed, like a foot drop or some other finding. No, I do very detailed neurologic exams, and these people are just grossly non-physiologic. It should have been picked up years ago by the treating provider. I understand that. So a physical exam, unfortunately, is a dying art. Truly is. Thank you. We're just going to take one more question from the floor, and there are a couple of questions coming in online that I just wanted to say that the professor will get to those in the chat. Perfect. Excellent. Thank you. Thank you, and since you're from UPenn, I'll be easy on you. I'm a grad. Can you comment on the value of performing electrodiagnostics for low back pain that is radicular-like but no hard findings of radiculopathy as a pretest to the MRI? Awesome. This is a great question, and of course I didn't want to get into the lecture. For us, all of us in the room and physiatry, the electrodiagnostics are the extension of a good physical exam. If your physical exam did not show any weakness, it's very unlikely that the electrodiagnostics will show a lot. It can show peripheral neuropathy that is totally unrelated to the back. It can show other conditions, but will be less likely to show a lot. If your physical exam shows weakness, and if your physical exam, more importantly, shows weakness in different myotomes at different limbs, make sure that that patient is seen by neurology and roll out ALS. It's not very often, but if it doesn't make sense to you, please make sure the patient does get an electrodiagnostic study. The second part of the question, would an electrodiagnostic study allow you to get an MRI, or if positive findings on an electrodiagnostic study will allow you to, or it will be easier for you to get an MRI if you have that. I do not know, actually, because I think the MRI criteria is solely based on duration of treatment, response to treatment, and neurological findings, versus prior surgery, concern for infection, or concern for quadriacline. Thank you. Thank you, Dr. Popescu. Excellent stepwise approach, and as you were telling me earlier, that this particular healthcare worker went back to work eight weeks after the diagnosis, and after they had their healing period. Adrian, he sees quite a few of our work injuries, and I really like his approach on not just treating the patient, but also that sense of an Achmed doc, of sending them back to their pre-injury level of activity as soon as they can. Thank you so much. The chat questions will be answered a little later, and also for those who were, and the audience here, too, the handouts will be updated later today. Thank you so much. Thanks for your attention. Thank you. Thank you. Thank you. Thank you.

low back pain

fall

62-year-old man

case manager

hospital

severe pain

night pain

radiating pain

herniated disc

piriformis syndrome