Patients with Back Pain Dr Nick Pendleton TIMELINE

Patients with Back Pain Dr Nick Pendleton TIMELINE

Patients with Back Pain Dr Nick Pendleton TIMELINE About this presentation The scenarios in this slide presentation are based wholly or partly on real patients who have presented to GP surgeries. They have been anonymised for use as

a teaching tool for GPs in Training. For realism the patients have been given fictional names, ages and professions. David Morris

39 years old Works at a Hotel as a Waiter Infrequent attender Usually well No diagnosed conditions of note Married , son aged 12 First Consultation 20 March 2013 Saw Doctor A (GP Partner) Accidental Fall Slipped at work on a greasy kitchen floor. Fell on right side. Got up and carried on. Stiffness and bruising 48 hours later. Still has niggle of

pain R loin. Examination normal. Continue nsaids should settle with time Second Consultation 9 May 2013 Saw Doctor B (GP Partner) Hip pain esp nocte following a fall onto R hip 4-5/52 ago. Refer to physiotherapist Third Consultation 7 June 2013 Doctor B again

Back pain appt at physio end of June! Expedite letter Rx Tramadol Entry in notes 10 June 2013 Urine dipstick test NEGATIVE. No sign of infection Fourth Consultation June 17 2013 Spoke to Dr C (ST3 Trainee), TRIAGE CALL Hip pain since fall. Also now back pain.

Suspect it is to do with walking because of hip pain. No red flags. Taking paracetamol/codeine/tramadol regularly. Works as a waiter and looks after son. Struggling. Physio next week.... Fourth Consultation June 17 2013 Continued... Wants sick note/examination as insisting on scan. Dont think will need it but reassess and see what u feel. c/o muscle spasms. ? Diazepam for a few days. Outcome appt given for same day

Fifth Consultation June 17 2013 Saw Dr D (FY2 Trainee) Hip pain since fall 5/52 ago. Now c/o pain in lower back. Altered gait to compensate for R hip pain. No red flags. No neuro symptoms. Tramadol stopped, didnt help. cant sleep due to pain. Fifth Consultation June 17 2013 Examination tender ant joint line R hip. Feels like there is a deep haematoma in R thigh. No SIJ tenderness. SLR ok, good ROM,

some lower back spasm. No neurology. Keen for scan explained why this is not appropriate. Rx Codeine 30 mg, diazepam (2 mg x 28). Aware of red flags. To return if present. MED3 2/52 ACUTE BACK PAIN RED FLAGS? A search of the literature has shown that 163 Red Flags for sinister back pain have been identified!

Referred pain that is segmental or band-like Escalating pain which is poorly responsive to treatment (including medication) Different character or site to previous symptoms Funny feelings, odd sensations or heavy legs (multisegmental) Lying flat increases pain Agonising pain causing anguish & despair Gait disturbance, unsteadiness, especially on stairs (not just a limp) Sleep grossly disturbed due to pain being worse at night RED FLAGS FOR METASTATIC SPINAL CORD COMPRESSION Greenhalgh & Selfe 2009 Past Medical History of Cancer (but note

25% of patients do not have a diagnosed primary) A Combination of Red Flags increases suspicion (the greater number of red flags the higher the risk and the greater the urgency) Sixth Consultation June 26 2013 Saw Dr E (GP Partner) Back pain weakness right leg, sensation loss laterally and reduced knee jerk. Needs scan, if worsens for immediate review, bowel

and urinary function ok and no sensation loss in perineal area. Rx Co-codamol, Naproxen MRI SCAN REFERRAL (Lumbar spine) Seventh Consultation July 1 2013 Spoke to Dr F (ST3 Trainee) Needs MED3, saw Dr E last week. No bladder or bowel symptoms, no numb bum. MED3 2 weeks Back pain Eighth Consultation July 4 2013 Spoke to Dr G (GP Partner)

Leg pain worse, numbness spread round from top of leg from lateral aspect to inner. No bowel, bladder symptoms, no parasthesia or weakness other than this. Already referred MRI Scan. Advised re cauda equina symptoms Management plan is sound CAUDA EQUINA SYMPTOMS ? Spinal Cord Anatomy

L1/L2 Cauda Equina Syndrome Cauda Equina syndrome is caused by compression of nerve roots distal to the level of spinal cord termination (Usually L1/ L2) Trauma, vertebral fracture or displacement, disc herniation, a tumour or metastatic deposit or an abscess Permanent neurological damage can occur Cauda Equina Syndrome

Low back pain and: Bladder dysfunction, usually retention. Sphincter disturbance Saddle anaesthesia Lower limb weakness Gait disturbance The symptoms and signs depend on the level of compression Pain and Deficits Associated with Specific Nerve Roots Nerve Root Pain

Sensory Deficit Motor Deficit Reflex Deficit L2 Anterior medial thigh

Upper thigh Slight quadriceps weakness; hip flexion; thigh adduction Slightly diminished suprapatellar L3 Anterior lateral

thigh Lower thigh Quadriceps weakness; knee extension; thigh adduction Patellar or suprapatellar L4

Posterolateral thigh, anterior tibia Medial leg Knee and foot extension Patellar L5

Dorsum of foot Dorsum of foot Dorsiflexion of foot and toes Hamstrings S1-2 Lateral foot

Lateral foot Plantar flexion of foot and toes Achilles S3-5 Perineum Saddle

Sphincters Bulbocavernosus; anal Ninth Consultation July 15 2013 Spoke to Dr E MED3 back pain with neurological involvement, 2 weeks Tenth Consultation with Dr E 31st July MED3

Eleventh Consultation August 12 2013 Spoke to Dr H (GP Partner) MED3 back pain with neurology, 2 weeks 22 August 2013. Dr A, logged on at home reading routine letters MRI REPORT LUMBAR SPINE 14 August 13 Diffuse abnormal signal of the bone marrow and large right and paravertebral soft tissue masses. Consistent with tumoural process. Consider lymphoma. Encasement of right L3 and L4 nerve roots

Encasement of the right ureter with secondary hydronephrosis Did the Scan result fit with the clinical symptoms? Nerve Root Pain Sensory Motor Deficit Deficit Reflex

Deficit L3 Anterior lateral thigh Lower thigh Patellar or suprapatellar L4

Posterolateral Medial leg thigh, anterior tibia Quadriceps weakness; knee extension; thigh adduction Knee and foot Patellar

extension Consultation with Dr A, 23 August 2013 12th consultation, was asked tci urgently Breaking bad news, at end of morning clinic Came with his wife

Possibly lymphoma This is a type of cancer Already spoken to Haematology Consultant and arranged appt next week Next step is a biopsy Consultation with Dr A, 23 August 2013 David: So all this has been caused by a slipping in the kitchen?! Summary of Timeline Date and Doctor

Diagnosis Code Outcome 20 March, Dr A Accidental Fall Should settle with time 9 May, Dr B

Hip Pain Physio referral 7 June, Dr B Back Pain 17 June, Dr C Hip Pain Expedite Physio, Rx

Given appt tci 17 June, Dr D Hip Pain Analgesia, request for scan declined 26 June, Dr E Back Pain MRI SCAN lumbar spine referral

1 July, Dr F Back Pain MED3 4 July, Dr G Leg Pain Advice re: cauda equina symptoms

15 July, Dr E Back Pain MED3 31 July, Dr E Back Pain MED3

12 August, Dr H Back Pain 14 August HAD MRI SCAN

MED3 Faxed to surgery 22 August, Dr A Read report Appt next day to discuss result

Letter from Haematologist 1 Oct 2013 Well, paresthesia on thigh has resolved No lymphadenopathy CT-Guided Biopsy Result Diffuse Large BCell Lymphoma Treatment To have Chemotherapy Victor Parker

66 Moderate COPD, borderline DM On Seretide and Spiriva inhalers Ex-smoker Retired Joiner Lives with wife Consultation No. 1

Ive got pain in my back! It came on over the weekend I had been stretching up to paint the ceiling Its really sore Its next to my right shoulder blade Examined: no bony tenderness Conclusion: likely to have strained back by painting ceiling Analgesia Rx. Co-codamol 30/500 See again if worsens

Consultation No. 2 later that week The doctor said to come back if it got worse It has got worse, the co-codamol are not helping Examined: tenderness over the right side of upper thoracic vertebra Outcome: Rx Tramadol. Refer for MRI Scan of thoracic spine Differential diagnosis ? This Dr ordered an MRI scan to investigate, but what would you do? Myeloma: 2008-2010

Average Number of New Cases Per Year and Age-Specific Incidence Rates per 100,000 Population, UK Please include the citation provided in our Frequently Asked Questions when reproducing this chart: http://info.cancerresearchuk.org/cancerstats/faqs/#How Prepared by Cancer Research UK - original data sources are available from http://www.cancerresearchuk.org/cancer-info/cancerstats/ What is Multiple Myeloma? Plasma cell in Bone Marrow becomes malignant Plasma cells are a type of WBC Plasma cells usually produce immunoglobulins (antibodies) Plasma cell clones multiply and accumulate in bone marrow

Immunoglobulins (antibodies) are also known as paraproteins The malignant plasma cells make vast quantities of Igs = paraproteinaemia Myeloma Disease Process The type of paraproteinaemia depends on the type of plasma cell which became malignant Commonest is IgG Myeloma The plasma cell tumours are known as plasmacytomas, they spread and damage bone affecting multiple areas of the

skeleton This causes hypercalcaemia The paraproteins cause renal damage Myeloma can lead to.....

Pathological fractures Nerve compression Renal failure Bone pain Hypercalcaemia symptoms Anaemia Thombocytopaenia Serious infections (only 1 type of Ig) Hyperviscosity MYELOMA SCREEN

Full blood count ESR or plasma viscosity Urea, Creatinine, Calcium, Albumin Electrophoresis of serum and concentrated urine including 24 hour Urine for Bence-Jones Protein light chains (typical antibody = 2 light chains + 2 heavy chains) +/- Xray of painful region, lytic lesions, pathological fractures Dr Henry Bence-Jones developed a light chain protein urine test in 1847

A crystal of BJ Protein: Ig light chains leak into urine due to renal failure Chemist and Physician. 1813- 1873. What is the Treatment for Myeloma? Young patients who can tolerate aggressive treatment Stem Cell Transplant (autologous or

allogeneic) Following 6-9/12 treatment with: Chemotherapy + Steroids +Thalidomide Older patients >70: mephalan, pred & thalidomide (MPT) Treatment for 12-18 months, 80% respond, well for 2-3 years and then relapse Thalidomide Recently approved for use in combination with steroids for the treatment of newly diagnosed Multiple Myeloma Interferes with signals affecting myeloma

cell multiplication and spread Inhibits new blood supply (angiogenesis) Patients must not become pregnant or father children on treatment with thalidomide Victor Parker Home Visit Request 2 weeks later at 11:30am His wife rang: Can you come and see Vic, He tried to get up to go to the loo this morning and he says his legs are too weak! He stumbled on the stairs yesterday and hes got pain in the bottom

of his back Victor Parker Home Visit Request The Doctor visits straight away: Back Pain: Unable to stand due to weakness of legs. Unable to pass urine into container by bed, ?bladder palpable. no ankle reflexes and loss of sensation to perineum/perianally. Poor anal tone. Spoke to Neurosurgeons at Hope ? Cauda Equina Syndrome Victor Parker - Outcome Radiology report in hospital

L5 vertebral collapse causing compression of cauda equina, partial compression fracture of T6 noted, no cord compromise at this level, multiple lytic lesions of spine and ribs, consider myeloma as first differential. report phoned to neurosurgery team for urgent decompression at L5/S1 Victor Parker - Outcome

Had decompression surgery Spent 3 weeks in hospital Still has leg weakness but normal bladder function Myeloma was confirmed chemo, steroids, thalidomide Whilst in hospital appointment came through for MRI arranged by GP Shortly after discharge his wife (and main carer) had a sudden episode of drooping of left side of mouth with an irregularly irregular pulse... Mr Bob Peters 83, Type 2 DM

23 June 2014 left-sided low back pain and hip pain (chronic) Examination of hip and back normal No bony tenderness OA lumbar spine likely Analgesia advice add codeine to paracetamol 21 July 2014

Diarrhoea symptoms 1 month Loss of appetite Loss of 1 stone in weight in 1 month PR normal Abdo exam normal FH Bowel Cancer Referred for colonoscopy 2WW

13 August 2014 Colonoscopy normal 17 August Attended OOH GP fever, malaise, dysuria No urine to dip, T 37.8, tender suprapubically Suspected UTI

Trimethoprim 200mg bd 7 days 22 August 2014 Reviewed following OOH GP attendance Symptoms better but feels drained

Urine dipstick normal, T 36.9 No signs of ongoing infection Antibiotics finish today Recovering from illness 8 September Still not fully recovered from UTI, feels lethargic Still has back pain, slightly worse. Bloods arranged inc PSA , Bone profile, CRP, UE eGFR, FBC, HbA1c, LFT 24 September 2014

Blood results PSA 47 (< 6.70 ug/L) Hb 12.7 HbA1c 48 ALT 37.4 (<5) CRP 37.4 (<5) eGFR 63, creatinine 110 (62-124) ALP 141 (<130) Other blood tests parameters normal 26 September 2014 Results discussed with patient Prostate Cancer likely

Referred Urology 2WW 3 October Emergency appointment Severe left-sided back pain, loin to groin, colicky Apyrexial, abdomen soft, feels pain in renal angle Referred surgeons ? Renal colic

CT Scan during Admission Suggestive of prostate cancer with nodal involvement Filling defect in left sided renal pelvis Diagnosis: Ureteric obstruction secondary to prostate cancer Biopsy done Started on Cyproterone and to have Zoladex in clinic Managing Neuropathic Pain NICE GUIDELINE CG96 (Health Technology Appraisal) 1. Amitriptyline or Pregabalin 2. Pregabalin (if 1st used was Amitriptyline or other TCA) 3. Refer to Pain Team and add or change to Tramadol

Dont start opoids other than Tramadol without specialist assessment LOCAL GMMMG GUIDELINE 1. Amitriptyline 2. Nortriptyline/imipramine to maximum doses 3. Gabapentin 4. Pregabalin (if started 1st and not effective go back to step 1) 5. Carbamazepine or other anticonvulsant GMMMG Guidance GMMMG met and considered the NICE guideline CG96. (without access to the evidence NICE considered)

NICE places products equally in the guideline when there is an acquisition cost difference of 20 60 times difference per month. Implementation of the guideline would have lead to an additional financial pressure of 12.8 million Drugs licensed for treatment of neuropathic pain Amitriptyline Not licensed for neuropathic pain Duloxetine

Licensed for painful diabetic neuropathy Imipramine Not licensed for neuropathic pain Lidocaine (topical) Licensed for post-herpetic neuralgia Nortriptyline

Not licensed for neuropathic pain Gabapentin Licensed for neuropathic pain Pregabalin Licensed for central and peripheral neuropathic pain Tramadol

Licensed for moderate and severe pain Response from NICE NICE is aware that there have been concerns about the associated costs that pregabalin may bring to the NHS as one of the first line treatment options for adults with neuropathic pain Therefore, NICE will fully update its clinical guideline in order to address ongoing uncertainties regarding the cost effectiveness of some of the recommended treatment options Until a further announcement is made, the original

guideline (CG96) continues to represent best practice for the NHS The Back Book (RCGP) http://www.wsib.on.ca/files/Content/ DownloadableFileTheBackBook/BackBookEnglish.pdf Upcoming Sessions 11th November 2014: Confidentiality and Consent (MDDUS) 25th November 2014: TBC 9th December 2014: COPD (Michaela Bowden)

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