back pain

Tuesday, October 28, 2014

Fans always want to know the ins and outs of NFL injuries. Understanding what happens on the sidelines or in the locker room may help their fantasy football predictions or perhaps satisfy their prurient interest, like slowing down when driving by an accident, but it also engenders a false expectation of what the real world can bring to medical care. If technology was used on every person with a back injury like it was on the Cowboy’s Tony Romo, Medicare would be in a deeper financial hole than it already is.

Admittedly, even for an elite athlete, Mr. Romo’s case is special. Last year, he required surgery to repair a ruptured disc in his back and he has had to limit his practice time so that he could play on Sundays. Still, the Cowboy nation held its breath when he lay on the turf after taking a knee to his low back when being tackled. After x-rays in the locker room were negative for broken bones, he came back to play. But physical exam, those x-rays and clinical judgment weren’t enough. Technology and an MRI was required to confirm the decision as to whether he could return to play.

More than 85% of the United States population will experience low back pain in their lifetime and almost all will have it resolve within a couple of weeks without doing much special. Still, mechanical back pain is the most common cause of disability for those younger than 45 and falls only to number three for those who are older. Almost all are work related, especially for people who use their body as a tool or machine. While a single traumatic event can be the cause of the low back pain, often it is a series of minor traumas that add up to cause the pain. The numerous structures that make up the low back, the bones, ligaments, tendons, discs and nerves, all have to work together to allow the back to function. An injury and subsequent inflammation to any one structure can lead to pain.

The back has many responsibilities including maintaining an erect or upright posture. But perhaps, its most important job is to protect the spinal cord its nerves from damage. Most often the cause of back pain arises from the muscles, tendons and ligaments. The decision point for the care provider is to decide whether the spinal cord or nerves are at risk. If the answer is no, then imaging the back with plain x-rays, CT or MRI is a waste of time, radiation and resources.

Most often, the diagnosis is made by talking to the patient and performing a detailed physical exam. When the pain started is important. Was it acute onset with movement? Or did it arise hours later, perhaps after laying down or getting up in the morning. Understanding the mechanism…was it rotation or torsion of the lower back, or the lumbar spine? or was it flexing or bending forward. That information can help point to what stabilizing structure of the back might be damaged. If the physical exam isn’t exciting and the diagnosis made that it’s all soft tissue (muscle, tendon, ligament), there’s not much to do, except pain control, activity as tolerated and perhaps physical therapy or chiropractic manipulation.

Perhaps the questions that are directed to the potential for nerve impingement or irritation are most important. Is there sharp pain radiating into the buttock or down the leg. Is there numbness or tingling in part of the foot? Nerves that run from the spinal cord can present with pain that follow predictable dermatome patterns and can help determine at what level in the spine damage has occurred. The sciatic nerve is the accumulation of all those nerve roots that supply the leg. Inflammation of any one root can cause significant pain called sciatica. Still, there is little to be gained by x-ray or MRI. The treatment remains pain control and activity as tolerated.

lowerlimbdermatomes

It’s only when signs of impending spinal cord damage does imaging become and urgency. Has the patient lost control of their bowel and perhaps become incontinent of stool? Has he or she lost the ability to empty their bladder and urinate? Is there numbness around the anus or vagina? The questions may seem unrelated to the back but are harbingers of spinal cord disaster and emergent MRI is required.

For most other patients, the best diagnosis and care for low back pain is time and support. Often, symptoms resolve in 2-4 weeks with a combination of rest, ice, heat and anti-inflammatories. Activity as tolerated is always better in mending a back than lying in bed. In some patients, back pain is progressive and further diagnosis and treatment is required, but as opposed to Tony Romo’s x-ray within a few minutes and MRI within 48 hours, the time frame is a lot slower. To be fair, one indication for plain x-rays is in a trauma victim and suspicion of fracture, and being hit by a linebacker qualifies. For most people, however, their trauma is bending over or twisting to pick up a box and that isn’t enough to break bones. (There are always exceptions in medicine and we’ll offer one to little old ladies with osteoporosis who can get compression fractures with little or no trauma).

The stakes are high in the NFL and with player salaries in the millions, there is a want to return the player to the field of play as soon as possible. It causes doctors and trainers yo use technology to bolster their medical opinion. In the real world, the stakes for o every patient are just as high, but it is just as reasonable to trust high touch instead of high tech in caring for their back. If the 85% of the population that will one day experience back pain demand the Tony Romo level of care, unemployment in this country will fall to zero. Somebody will have to build all those MRI machines.

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ranking doctors and quarterbacks

Monday, October 20, 2014

Once upon a time, sports pages reported about the game. Analysis was more than just the numbers. Reporters and columnists wrote about the ebb and flow of the action, along with the turning points that might had led to that one defining moment where victory or defeat was defined. And then came fantasy football. Instead of team, the focus changed to individual player statistics and who won the game was of secondary importance. Welcome to the same reality that has inched itself into grading doctors and hospitals.

Sometimes statistics are helpful in deciding the quality of care provided to a patient and sometimes those numbers can be deceiving. The latest version of www.healthgrades.com went live this week and it advises that there is a “right way to find the right doctor.” And their philosophy and advice is absolutely correct. Being able to assess a physician’s experience, patient satisfaction and the hospital quality all will give guidance, but too often that guidance presumes a level playing field and that is not always the case. Ratings need to be taken with a grain of salt because context is everything.

This week in the NFL, the Panther’s Derek Anderson and the 49ers Blaine Gabbert placed in the top half of quarterback rankings. Both are backups who came into the game after the outcome had been decided. Johnny Hekker of ranked #7 this week for his one pass completion on a fake punt. However, the cream does rise to the top, as Peyton Manning and Aaron Rogers ranked #1 and #2 for the week, but not every team gets to have a superstar.

In medicine, it’s all about context. Hospitals are not necessarily equipped to care for every medical situation. Some have developed programs with special expertise in trauma, heart attack or stroke. Fewer can care for major burn victims or can perform organ transplants. Hospitals are ranked on patient outcomes and many have to do with complications that might occur during or after a patient hospitalization. Post-operative infections, blood clots, wound healing problems and bed sores are a few parameters that are monitored. The problem with blindly comparing hospital data has to do with patient distribution. Some hospitals are not equipped to care for the sickest, most complicated patients and when they present to their doorstep, the patients are transferred to hospitals that have the capability to provide them care. This is the right thing to do for the patient but the sickest patients also have the highest complication rates, even with the best of care.

Similarly, some physicians and their nursing teams take on the most challenging patients, knowing that some are destined to have reportable complications. Patients with diabetes and patients who smoke have high rates of wound infections and may not heal properly. The risk/benefit analysis for some patients skews to the risk side and yet, sometimes, operations are potentially unavoidable because the alternative is death.

Mayo Clinic in Rochester is a world renowned center of medical excellence. Two hospitals care for their patients. Healthgrades has ranked St. Mary’s Hospital with 34 five-star rankings and 15 five-star awards. Methodist, its sister hospital has but 14 five-star rankings and 9 five-star awards. St. Mary’s has worse than average complication rates for a few of the monitored surgical complications while Methodist is ranked above average. With the same physician and nursing staff, it is likely that one hospital is geared to care for the most injured and ill and is to be expected that their complication rate will be higher. The same type of dichotomy is also found at Massachusetts General Hospital in Boston, the flagship for Harvard Medical School, highly ranked and awarded and yet with worse than expected complication rates.

When it comes to patient satisfaction, only in Lake Wobegon can all the physicians be above average. There are times when the physician must answer “no” to a patient or family demand. Having a less than satisfactory interaction with the patient, may cause a Healthgrades rating to decline, regardless of the soundness of the medical decision making.

The question then remains: how should one find a doctor or choose a hospital? It starts with asking people you know and trust.

  • Family and friends are the first resource to recommend a doctor that they trust.
  • Next comes the hard work. Your doctor should be board certified in their specialty, meaning that they have not only graduated medical school, but also completed post graduate training and have passed their exams. http://certificationmatters.org/
  • Now it’s time to check whether any red flags for discipline or malpractice are flying. A very useful link from Consumer Reports

Once the preliminary screening is done, it’s time to decide whether you like that doctor as a person and to see whether you are compatible. You should feel comfortable not only with the science, but also with the communication skills. Bedside manner is important in increasing the likelihood that a patient will follow their doctor’s advice.

And finally make a plan for emergencies. For some, there may be only one hospital in town, but in larger cities, numerous hospitals vie for your business. Knowing which hospital is best for stroke emergencies or heart attack or trauma may be life-saving. Paramedics and EMTs know and are trained to take the patient to the proper facility, even if it means bypassing a hospital that is closer. But when it’s family that’s driving, you need to know where to go.

Statistics are more than looking at the raw numbers. Understanding how a doctor or hospital ranks is sometimes no different than the process needed to understand quarterbacks and wide receivers. No disrespect meant, but Blaine Gabbert may not be a better quarterback than Joe Flacco or Russell Wilson, regardless of what the numbers say.

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