When to get worried: Missed pathology in the pain clinic - Dr Andrew Crockett

Assessment Issues in Chronic Pain Spring Scientific Meeting 16 th May 2008 www.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 Assessor Why diagnose? Back pain when to worry Conclusion Questions

Causes of missed diagnosis Assessor Patient Diagnosis Institution/philosophy

CONSEQUENCES OF MISSED DIAGNOSIS patient illness professional institution

Assessment Role of initial assessor Who performs initial assessment? Triage Single vs. team assessment Goals of assessment Diagnosis vs symptom management

Reasons to pursue diagnosis? Serious illness Treatable diagnosis Disease progression Onward referral Patient anxiety Ability to progress Therapeutic investigation

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

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 tenderness Non-mechanical pain (capsular) (Thoracic pain) PMHx: Ca, steroids, HIV Unwell, wt loss Structural deformity Persistent night pain Widespread neurology bilateral leg signs Saddle anaesthesia Sphincter disturbance

Back Pain 1) Non specific low back pain 2) Back pain potentially associated with radiculopathy or spinal stenosis. 3) Back pain associated with another specific spinal cause Look for differentiating factors American College of Physicians 2007

Breakdown of Back pain Group 1 >85% non specific. Group 2 Spinal stenosis 3%, radiculopathy 4% Cauda equina syndrome 0.04% Group 3 Compression fracture 4% Cancer 0.7%, spinal infection 0.01% Ankylosing spondylitis 0.3-5% Other

Radiculopathy Typical sciatica history Location Motor assessment Straight leg raise, crossed SLR

Spinal Stenosis Pseudoclaudication Radiating leg pain Downhill treadmill Pain relieved by sitting Age >65

Cauda equina syndrome Rapidly progressive, severe neurological deficit Motor deficits >1 level Faecal incontinence Bladder dysfunction

Malignancy risk factors History of cancer* Unexplained weight loss Failure to improve after 1 month >50 year old

Vertebral infection Fever IV drug use Recent infection Specific Risk factors

Fracture Age Young: traumatic Older: osteoporotic Steroid use

Ankylosing spondylitis Young, male Morning stiffness Improvement with exercise Alternating buttock pain Wakening with pain in the second part of the night

Psychosocial factors Depression Passive coping strategies Job dissatisfaction High disability levels Disputed compensation Somatisation Catastrophising

Group 1 No routine imaging or tests required. Assess psychosocial overlay

Investigation of 2) and 3) Signs of progressive/severe neurological deficits Serious underlying disease Deciding on further treatment (symptoms > 1 month) MRI CT XRay

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 Pain Spring Scientific Meeting 16 th May 2008 www.nbpa.org.uk Queen Mother Conference Centre