when to get worried: missed pathology in the pain clinic - dr andrew crockett
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Assessment Issues in Chronic PainSpring Scientific Meeting
16th May 2008www.nbpa.org.uk
Queen Mother Conference Centre
NBPA May 2008
When to get worried?Missed pathology in the pain clinic
Outline
Causes and consequences Role of AssessorWhy diagnose? Back pain when to worryConclusionQuestions
Causes of missed diagnosis
Assessor Patient DiagnosisInstitution/philosophy
CONSEQUENCES OF MISSED DIAGNOSIS
patient
illness
professional
institution
Assessment
Role of initial assessorWho performs initial assessment? TriageSingle vs. team assessmentGoals of assessmentDiagnosis vs symptom management
Reasons to pursue diagnosis?
• Serious illness• Treatable diagnosis• Disease progression• Onward referral• Patient anxiety• Ability to progress • Therapeutic investigation
Problems with pursuing diagnosis
• No diagnosable illness• Anxiety and catastrophising• Fuels cure searching• Cost• Duplication of investigations• False positives• Use of resources
Age under 20 or over 55 Bony tendernessNon-mechanical pain (capsular)(Thoracic pain) PMHx: Ca, steroids, HIVUnwell, wt loss Structural deformity Persistent night painWidespread neurology bilateral leg signs Saddle anaesthesiaSphincter disturbance
Back Pain
1) Non specific low back pain2) Back pain potentially associated with radiculopathy or spinal stenosis.3) Back pain associated with another specific spinal cause
Look for differentiating factorsAmerican College of Physicians 2007
Breakdown of Back pain
Group 1>85% non specific.
Group 2Spinal stenosis 3%, radiculopathy 4%Cauda equina syndrome 0.04%
Group 3Compression fracture 4%Cancer 0.7%, spinal infection 0.01%Ankylosing spondylitis 0.3-5%Other
Radiculopathy
Typical sciatica historyLocationMotor assessmentStraight leg raise, crossed SLR
Spinal Stenosis
PseudoclaudicationRadiating leg painDownhill treadmillPain relieved by sittingAge >65
Cauda equina syndrome
Rapidly progressive, severe neurological deficitMotor deficits >1 levelFaecal incontinenceBladder dysfunction
Malignancy risk factors
History of cancer*Unexplained weight lossFailure to improve after 1 month>50 year old
Vertebral infection
FeverIV drug useRecent infectionSpecific Risk factors
Fracture
AgeYoung: traumaticOlder: osteoporoticSteroid use
Ankylosing spondylitis
Young, maleMorning stiffnessImprovement with exerciseAlternating buttock painWakening with pain in the second part of the night
Psychosocial factors
DepressionPassive coping strategiesJob dissatisfactionHigh disability levelsDisputed compensationSomatisationCatastrophising
Group 1
No routine imaging or tests required.Assess psychosocial overlay
Investigation of 2) and 3)
Signs of progressive/severe neurological deficitsSerious underlying diseaseDeciding on further treatment (symptoms > 1 month)MRICTXRay
Resources
Diagnosis and Treatment of Low Back Pain: A Joint Clinical Practice Guideline from the American College of Physicians and the American Pain Society. 2007 American College of Physicians
International Headache Society Classification Subcommittee. The International Classification of Headache Disorders. 2nd edition. Cephalalgia 2004; 24 (Suppl 1): 1-160
Descriptions of Chronic Pain Syndromes and Definitions of Pain Terms, Second Edition, IASP
Assessment Issues in Chronic PainSpring Scientific Meeting
16th May 2008www.nbpa.org.uk
Queen Mother Conference Centre