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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Too many tests

Monday, August 25, 2014

In our mind’s eye, we could all throw it like Peyton, hit like big Papi and be like Mike. But while we aspire to their greatness, we should not ask to have their medical testing inflicted upon us. Today’s elite athletes can no longer be content with medical opinion, rather they or their team management expect that the latest technology be used to help make the diagnosis.

The latest victim of this syndrome is Carolina Panther quarterback, Cam Newton, whose rib injury during a preseason game might have been diagnosed with a brief history and physical examination. Mere mortals might have needed a plain chest x-ray but Mr. Newton also got a CT and MRI of his chest. The verdict? He had a nondisplaced rib fracture. And how did those extra tests affect his care and treatment? They didn’t.

Medicine has gone high tech with imaging tests that can peer inside every nook and cranny of the body to find things that may or may not matter. Chest wall injuries area prime example of what if gone wild. The ribs and muscles that make up the chest wall serve a couple of purposes. Most importantly, they act as a bellows, swinging up and out to suck air into our lungs to help us breathe and then again squeezing back in to make us exhale. It doesn’t matter if a rib is bruised or broken, the pain of either injury makes it difficult to take a deep breath and that interrupts the mechanism of breathing. When the lung does not adequately expand with inspiration, the patient runs the risk of getting pneumonia, an infection of the lung, and that is the great complication of a rib injury. The ribs also protect those organs that are located beneath. The lungs are obvious but the lower ribs also protect the spleen and liver in the abdomen and lower chest trauma can cause damage to the upper abdomen.

This is where the art of medicine comes in. Taking a history allows the doctor or other care provider to understand how much force was inflicted upon the patient and understanding the patient appreciates how much force they can withstand. A frail elderly patient who falls against a countertop and injures ribs is perhaps more likely to have underlying damage than a padded quarterback being hit by a linebacker. The physical examination can help decide whether a small area of the rib cage is damaged or whether numerous ribs are injured. The larger the injured area, the more likely that the breathing mechanism is compromised and the potential for complication increases. For most patients, a plain chest x-ray is adequate to look not for rib fractures but for a pneumothorax (collapsed lung) or pulmonary contusion (a bruised lung). Ordering rib x-rays to look for a fracture is a waste of time, money and radiation. Physical exam will also tell you whether there is enough abdominal tenderness to us CT to look for internal bleeding.

But the art of medicine is not infallible and perhaps that is feeds the fear of missing an injury. Green Bay Packer center TJ Tretter hurt his knee early in the game against Oakland but played on after doctors evaluated him on the sideline and cleared him. Unfortunately, he had a fracture that will sideline him for the next many weeks. The same fear also feeds the use of CT to routinely evaluate concussions when there are clinical guidelines that can help decide who needs a scan and who doesn’t.

One can appreciate the high medical tech approach to those athletes whose salaries run into the tens millions of dollars and those teams who market the player to their maximum advantage, yet the general population takes their cue from what they see on the field, on the sideline and in the training room. Ideally, regular folk should ask the doctor why a test is being ordered and what benefit it will bring. Sometimes, tests are ordered just because with little thought. Other times, the decision as to what test to perform takes great thought. Sometimes, there is risk management involved. The doctor doesn’t want to miss a diagnosis, not only for the patient’s sake but also for fear of being sued. In many situations, if the patient were asked, they might agree the risk of missing the diagnosis was not enough to perform an expensive or painful test.

This shared risk happens routinely when a diagnosis has been made and treatment options are being contemplated. The patient often helps decide if they want aggressive or more conservative treatment options or perhaps an operation now or later. There is no reason that the process of involving the patient cannot happen earlier in the diagnosis phase as well. The key is communication is to allow the patient to become a partner in the all decision making process and not the object of it.

For Mr. Newton, his ribs are going to hurt for the next few weeks, regardless of whether they are broken or bruised. It will hurt to take a deep breath or to twist to throw or hand off the ball. It won’t matter that it took a CT scan or MRI to make the diagnosis of the broken rib. A good physical exam might have been enough, but it wouldn’t have been perfect…but even the best rarely are.

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