1. Clinical Case Studies Developed by Dr. David Hunt

2. www.pspbc.ca Acute and Chronic Low-Back Pain: Case of Mr. M.B. Setting The Stage

3. 3  49, Overweight, Married, Self Employed Movie Set Special Effects Technician.  March 2005 – fell off ladder at home › Landed and twisted to left › No Head Injury › Shortly Developed Burning Non Radiating Pain in Neck, Mid Back and Low Back Case of Mr. M.B. Non Specific Mechanical Low Back Pain

4. 4  2 days post accident – Saw F.P. › Burning Pain and Stiffness at Injury Sites › Moderate Restricted ROM, Muscle Tenderness and Spasm › Has to Work because of Deadlines and Lucrative Contract › 00100 Case of Mr. M.B. Non Specific Mechanical Low Back Pain

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6. 6  2 weeks post injury – Saw F.P. › Continuing to Work With Pain and Stiffness › Unable to Sit for Very Long › Difficulty Sleeping, Feeling Anxious  00100 even if visit more than 20 min Case of Mr. M.B. Non Specific Mechanical Low Back Pain

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10. 10  6 MONTHS POST injury – F.P. › Daily Severe Low Back Pain … “11/10” › LBP Aggravated by Activity › Pain No Longer Relieved by Chiro › Stopped Work as Soon as Contract Ended – Has Disability Benefits › Feeling Helpless, Hopeless, Avoiding Family and Friends, “Moody” › 00100 even if visit more than 20 minutes Case of Mr. M.B. Non Specific Mechanical Low Back Pain

11. 11 Case of Mr. M.B. Non Specific Mechanical Low Back Pain

12. 12 Case of Mr. M.B. Non Specific Mechanical Low Back Pain

13. 13 Case of Mr. M.B. Non Specific Mechanical Low Back Pain

14. 14 Case of Mr. M.B. Non Specific Mechanical Low Back Pain

15. 15  7 MONTHS POST INJURY – F.P. › Fell Asleep in Small Loveseat in Hyperflexed Lumbar Position for Several Hours › Awoke in Severe Low Back Pain and Mixed Left L5 + S1 Nerve Root Pain to the Foot › Pain Worse with BM’s › “Can’t Sleep”, Angry and Irritable, anxiety and depression worse › Disability Payments Ceased, High Marital distress › Neuro Intact : Positive Nerve Root Tension on Left › 00100 even if more than 20 minutes Case of Mr. M.B. Mixed Discogenic And Neuropathic Pain

16. 16  8 months post INJURY – F.P. › Requiring More and More Opiate for Only Partial Relief of Back and Leg Pain › Current Dose-HMContin 9mgm Q8h:HM-IR 8mgm/24hr Having Back Muscle Spasms and Calf Cramps › Started Drinking Alcohol and Smoking Pot for the Pain and Insomnia › Anxious and Depressed-Catastrophizing – referred for MH&A counselor › Back and Lower Extremity Exam Unchanged On urgent list to see Neurosurgeon › 00100 Case of Mr. M.B. Mixed Discogenic And Neuropathic Pain

17. 17  10 months post INJURY. › Assessed by the Neurosurgeon › Exam:  Positive Nerve Root Tension Signs with Crossover  Mild Sensory Deficits in Distal Left L5 and S1  Severe Pain Not Responding to Conservative Therapy  Imaging Correlates with Clinical › Recommends Surgery › 00100 Case of Mr. M.B. Mixed Discogenic And Neuropathic Pain

18. 18  13 months post Injury. › L4-5 and L5-S1 Discectomies with Bilateral L4-5 and L5-S1 Foramenotomies › Post Op Pain Medication Orders do Not Factor in the High Presurgical Dose of Opiate › Surgeon on Holiday-Covering Surgeon Unaware of Medication History › Patient in Severe Post OP Pain-Accused of Drug Seeking/Addiction › Depression/Anxiety continuing › Patient Self discharges AMA at Post Op Day 4 › 15300 (now 50 yrs old) CASE of MR. M.B. Mixed Discogenic And Neuropathic Pain

19. 19 Questions