Evaluation and Examination

Evaluation and Examination

Evaluation and Examination
Transcript

So there are many different conditions that cause low back pain and part of the evaluation and determination of the cause of the low back pain and the diagnosis is based on the examination, the history, the studies, which might include an x-ray or an MRI. And once you have a diagnosis or potential diagnoses, you then determine a treatment plan for that patient that is custom made for that individual patient.

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Evaluation and Examination

Doctor Visits

If the back pain and the pain down the leg doesn't get better, that's called a visit to the doctor. And the reason is is that a nerve is being pinched and you need to be at the doc because now this is a situation in which you need a diagnostic study. The major diagnostic study, here's what we talk in this day and age, is an MRI of the lumbar spine, which is done without contrast. It's a big huge electromagnet that excites water molecules and then the water molecules give off the energy. And so that energy then is read by things that say, ooh, where those water molecules are. And so it gives you much the same as light gives you a photograph, it gives you a picture. And we can slice people almost any way we want. And so MRI is a huge advance over CT, which was x-rays done in a similar, although non-excitatory manner. So ruptured discs, synovial cysts, maybe stenosis and there are a whole host of other things. But if you're having pain down the leg and it's acute and it's getting worse and you're not happy and anti-inflammatories aren't making you better, it's a trip to the doc. Now, once you see the doctor and you may or may not get an imaging study, some doctors will go ahead and start you on a steroid burst and there are many different steroids and steroid burst sometimes come in packs. We take five pills the first day, three pills the second day, two pills, the third, et Cetera, and then there are other ones where you may be on a steroid burst where you're on the same dose three times a day, four times a day for a week. Generally that's a first line treatment for excruciating back and leg pain. Then if the patient isn't better than it may be time for the MRI. Then after that depends on what the pathology is. So let's finish up on the potential treatments of acute low back pain. We've talked about brace, ice, anti-inflammatory and that's really the treatment. The vast, vast majority of acute muscular tenderness, low back pain is going to get better that way. If it doesn't get better, then the next step may be physical therapy. It may be Chiropractic, or it may be even a stiffer brace, or ultimately maybe injections. Surgery for acute muscular tenis, low back pain really doesn't have any place in terms of management. There's nothing surgical to do. You're only going to make a patient worse with that, and not any better.

What To Bring With You

Preparing For Your Appointment

Dissecting a Diagnosis

So now that you've gone to see your doctor, you're probably asking yourself, well, how's he going to sort this all out? How are we going to get to the bottom of things? How are we going to really get a diagnosis? And there's probably a good place to say that sometimes we don't always have exactly the diagnosis. Sometimes people do have pain and we don't come to it numerical diagnosis as it were, and that can be frustrating. But the patient shouldn't necessarily always come to the diagnosis. The doctor is going to often come to the diagnosis and how's he going to do that? Number one is the history is hugely important. Second part is being a good examiner. The things that we do, people come in and always wonder about my reflex hammers. Am I going to get a stick that somewhere? And the reality is is I'm very interested in their reflexes. I'm very interested in their strength and very interested in their sensation and I'm very interested in their backs. I think stepping up on a, maybe not a soapbox, but something like that, that there was a interesting article that looked at people who went to practitioners for their backs and only 45% of the time did somebody put their hands actually physically on the back. And there are things to be gained there feeling muscle spasms, feeling if people can actually reverse their curvature when they lean over, march in place does do things relax, seeing where it really hurts. Sometimes patients will be very far off. They'll say, oh, well I know this. It hurts it L1-2, and it really doesn't, it's not really L1-2 at all. It's it's either way above that are way below. So history physical, that's going to get you about 90% of your diagnoses. The last 10% you're going to get probably 6% of those, the MRI's going to help you with the next 2% the EMG is going to help you with in the last 2% maybe that's why we lose our hair. Maybe that's way we scratch our heads, but we may never have exactly a diagnosis. It may be worthwhile to have a second look months later, maybe worthwhile to have someone else take a look. Clearly, experience and facility, ability examination really helps to get to the right diagnosis straightaway.

Difficulties With Diagnosis

MRIs and Back Pain

CT Scans and Back Pain

Functional Studies

One thing that doesn't have to do with imaging because those are structural studies, how things are put together. So MRI and CT are both structural studies. You may want a functional study and it's called EMG/NCV and we have lots and lots of initials in medicine. But EMG is electro electric, myo, muscle, gram, study. NCV as nerve conduction studies, nerve conduction velocity. So we can look at nerves and we can tell how well they're functioning was certain limits. The tests have their limits, but you stimulate, one thing you can do is you can see, gee, how fast the nerve travels. In other words, this is like going out with a radar gun on I-10 and see, gee, some of the nerves are traveling at 70 meters per second. Some are traveling at 50 meters per second. Some are traveling at 30 meters per second. And so it's a function of telling you how fast that nerve is conducting. That's one part of it and that's a gross oversimplification but is still useful for patients to understand. The second part is the needle exam where needles are actually put into muscles. We know that just like highways that end in streets that end in particular places that the nerves and in particular places. Gee, that C6 nerve root that comes out of our neck is going to come down and is going to go to a muscle called the pronator which twists our hand in. I'm not a tennis player, but twist your arm in at the end of that. Maybe in golf someone pronates, I don't know. But if you put a needle in that muscle and ooh, you see particular changes called fibs or positive waves and it's not important what they're called, but you see those changes that can tell you that that nerve root is irritated. And if you see one nerve root irritated, that may tell you one diagnosis. If you see lots of nerve roots that light up, it may tell you a different diagnosis and then used in conjunction with the nerve, conductions can tell you whether this is really peripheral neuropathy or whether this is a pinched nerve or whether this patient avulsed some of their nerves and their fall off of the truck. And so it was really helpful too, and it's a functional study as opposed to a structural study.

Jonathan Nissanoff, MD

Orthopedic Surgeon

Certified by the American Board of Orthopaedic Surgery
A leading orthopedist, specializing in Orthopedic minimally invasive sports medicine
Recognized nationally as a top healthcare provider

Jonathan Nissanoff, MD

Orthopedic Surgeon

Certified by the American Board of Orthopaedic Surgery
A leading orthopedist, specializing in Orthopedic minimally invasive sports medicine
Recognized nationally as a top healthcare provider

Kurt Schroeder, MD

Neurosurgeon

Certified by the American Board of Neurological Surgery
Chief of Neurosurgery at St. Joseph’s Hospital
Former Chief of Surgery at Tucson Medical Center

Kurt Schroeder, MD

Neurosurgeon

Certified by the American Board of Neurological Surgery
Chief of Neurosurgery at St. Joseph’s Hospital
Former Chief of Surgery at Tucson Medical Center

Jonathan Nissanoff, MD

Orthopedic Surgeon

Certified by the American Board of Orthopaedic Surgery
A leading orthopedist, specializing in Orthopedic minimally invasive sports medicine
Recognized nationally as a top healthcare provider

Kurt Schroeder, MD

Neurosurgeon

Certified by the American Board of Neurological Surgery
Chief of Neurosurgery at St. Joseph’s Hospital
Former Chief of Surgery at Tucson Medical Center

Kurt Schroeder, MD

Neurosurgeon

Certified by the American Board of Neurological Surgery
Chief of Neurosurgery at St. Joseph’s Hospital
Former Chief of Surgery at Tucson Medical Center

Kurt Schroeder, MD

Neurosurgeon

Certified by the American Board of Neurological Surgery
Chief of Neurosurgery at St. Joseph’s Hospital
Former Chief of Surgery at Tucson Medical Center

Kurt Schroeder, MD

Neurosurgeon

Certified by the American Board of Neurological Surgery
Chief of Neurosurgery at St. Joseph’s Hospital
Former Chief of Surgery at Tucson Medical Center

Kurt Schroeder, MD

Neurosurgeon

Certified by the American Board of Neurological Surgery
Chief of Neurosurgery at St. Joseph’s Hospital
Former Chief of Surgery at Tucson Medical Center

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