QUESTION: How would you diagnose Edna?
Edna's Diagnosis, Explained
Dr. Weiner diagnoses Edna with hip osteoarthritis, which causes Edna’s chronic low back pain.
Dr. Weiner describes the following to explain the diagnosis of hip osteoarthritis to Edna:
“What we have to think of is the way the spine functions. And by that I mean the spine, the pelvis, and the hip move together as a unit. And so because your hip isn’t moving normally it’s irritating your spine. But if you didn’t have that hip arthritis and your hip moved normally, that arthritis in your back and the stenosis in your back likely wouldn’t be causing you any symptoms at all. So the way you can think of it is the back is your weak link, but it’s not the treatment target. The thing that we need to target with treatment is your hip.”
QUESTION:: What options would you offer Edna for treatment?
Edna's Preferred Treatment
Edna says she's not interested in using pain medication, but would like to try the anti-inflammatory shot. She adds she tried physical therapy in the past and it didn't help her pain.
QUESTION: Edna told you her treatment preferences. Do you think you should encourage her to try anything specific?
Physical Therapy Target
Dr. Weiner wants to encourage Edna to try physical therapy that targets her hip. In the past, Edna tried physical therapy targeting her back. Dr. Weiner discusses with Edna the difference between a treatment target of the hip and the past treatment target of the back.
Previous Doctor's Recommendation
A previous doctor told Edna she might need spinal surgery if her pain didn’t improve. Edna’s now suffered from back pain for three years. As she speaks with Dr. Weiner, she describes the following about the medical advice given to her by a previous doctor:
“Well, the doctor that I went to before had taken an MRI. He said that I have arthritis and spinal stenosis. And he said that if the pain didn't improve, that I was going to have to…might have to have spinal surgery.”
Edna said a previous doctor told her she has arthritis and spinal stenosis.
QUESTION: Which of the following features in Edna’s case support a diagnosis of lumbar spinal stenosis?
QUESTION: If Edna's MRI showed spinal stenosis, should it be treated along with her hip osteoarthritis?
If you see spinal stenosis on an MRI, it doesn’t mean it’s causing symptoms. Studies show twenty percent of older adults will have evidence of spinal stenosis on MRI, but be asymptomatic. Even if a patient has symptomatic stenosis, an adequate course of pharmacological and non-pharmacological treatment options should be considered before making a surgical referral. However, the 2008 Cochrane Review shows no strong evidence that an epidural spinal injection would help symptomatic stenosis.
Imaging isn’t routinely recommended to diagnose the cause of low back pain. It may be needed if red flags come up, but you should rely instead on the history and physical for diagnosis.