Compression fx workup

[Pain Applicant1]

If you have a 50 yo F with two level mid tspine compression fx do you work it up. Fx is 9 months old and found on xray. It is not causing significant discomfort. Pt is without osteoporosis/penia and pt is with no known reason for fx. Dexa normal. She does not remember any inciting event for compression fx. Do you look for pathology and if so, how extensive? MRI, CT?

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[Jcm800]

If you have a 50 yo F with two level mid tspine compression fx do you work it up. Fx is 9 months old and found on xray. It is not causing significant discomfort. Pt is without osteoporosis/penia and pt is with no known reason for fx. Dexa normal. She does not remember any inciting event for compression fx. Do you look for pathology and if so, how extensive? MRI, CT?

Yes work it up. Get MRI. If it looks funny go from there. Get simple labs also, CBC, chemistry, all phos maybe. I'm no weight loss,cor fevers or chills, could skip labs I think at first.

 

[lobelsteve]

Yes work it up. Get MRI. If it looks funny go from there. Get simple labs also, CBC, chemistry, all phos maybe. I'm no weight loss,cor fevers or chills, could skip labs I think at first.

SPEP, UPEP, Alk phos, ESR.

How do you know Fx is 9 mo old?

Why is patient in front of you today?

Get a bone scan. Now.

 

[Pain Applicant1]

Thanks for the quick response!

Sorry, fracture at least 9 months old because Xray was that old. Plus some osteophytes present. Here with some minor muscle strain over tspine paraspinals.

Tspine fracture was anterior wedging at two levels in mid thoracic spine. Slight compression of approximately 10%. I called radiologist. He said this was essentially normal and he sees it all the time. Degenerative in nature. Pt essentially asymptomatic minus above complaint. I ordered CBC,CMP,SPEP, UPEP, Alk phos, and ESR. Neuro exam normal. No sign of mid or posterior elements noted on xray. No sign of retropulsion on xray. Radiology recommends holding off on additional imaging for now.

Will hold off on bone scan/MRI unless something borderline shows up on labs. Any opinions?

 

[lobelsteve]

43 y/o male with no significant trauma.

Fell off couch, was lifting tree limbs.
Fx on STIR T7, L1, L5. Pain more L1 or L5.

SPEP, UPEP, Alk phos, ESR. Bone scan.

What else?



Why is patient in front of you today?

Get a bone scan.

 

[Ducttape]

tell him to move couch inside, so he doesnt have to lift tree limbs to sit on it? then again, in Geooogaa, maybe those trees grow inside houses...

not in jest - get chemistries, check renal function, check calcium and albumin, ? heme-onc referral early on...

is skeletal survey or bone scan best first test?

 

[emd123]

43 y/o male with no significant trauma.

Fell off couch, was lifting tree limbs.
Fx on STIR T7, L1, L5. Pain more L1 or L5.

SPEP, UPEP, Alk phos, ESR. Bone scan.

What else?



Why is patient in front of you today?

Get a bone scan.

Either there's a gap in history or something else going on like a pathological fracture. Some of these say, "I never fell" because they don't want to admit or don't remember the time they were drunk and had trauma, fell down stairs, crashed while driving while drunk, got the crap kicked out of him, etc. I've seen that one hundred ten umpteen times.

Either he had trauma and won't/can't remember/admit it or there's some badness going on that you need to dig for until you find.

 

[Agast]

If you have a 50 yo F with two level mid tspine compression fx do you work it up. Fx is 9 months old and found on xray. It is not causing significant discomfort. Pt is without osteoporosis/penia and pt is with no known reason for fx. Dexa normal. She does not remember any inciting event for compression fx. Do you look for pathology and if so, how extensive? MRI, CT?

No, I would not do the work up myself. Presumably she was referred to me for pain and kyphoplasty work up by someone with a background in internal medicine, and they should be the ones ordering and interpreting the labs. I can do a biopsy for path and cement augmentation. I'm not going to take responsibility for diagnosing the cause of her pathology because referral to oncology or other specialist should come from her PCP.

 

[lobelsteve]

No, I would not do the work up myself. Presumably she was referred to me for pain and kyphoplasty work up by someone with a background in internal medicine, and they should be the ones ordering and interpreting the labs. I can do a biopsy for path and cement augmentation. I'm not going to take responsibility for diagnosing the cause of her pathology because referral to oncology or other specialist should come from her PCP.

9 mo post Fx, kypho not indicated. Not in pain.

 

[Agast]

9 mo post Fx, kypho not indicated. Not in pain.

Then why is she seeing a pain doctor? Advise her that she has increased risk of future fractures and send back to her PCP for work up.

 

[lobelsteve]

Then why is she seeing a pain doctor? Advise her that she has increased risk of future fractures and send back to her PCP for work up.

Probably for the workup for the Fx so she doesn't get another one. Funny was just listening to Dannemiller for my 10 year MOC. I think it was Ferrante talking about the workup for Fx of the spine. Guess some of us are pain docs and some of us just want to make a buck by doing unnecessary care. If you bothered to read the clinical info provided she was not in any significant discomfort.

 

[Ducttape]

I believe Dr. Ferrante did internal medicine before pain. i guess his background in IM would encourage him to work up the etiology of the fracture, as opposed to a symptom management focus.

 

[NJPAIN]

I believe Dr. Ferrante did internal medicine before pain. i guess his background in IM would encourage him to work up the etiology of the fracture, as opposed to a symptom management focus.

He is fellowship trained In ID

 

[lobelsteve]

I believe Dr. Ferrante did internal medicine before pain. i guess his background in IM would encourage him to work up the etiology of the fracture, as opposed to a symptom management focus.

The point is it is on our boards and we should be the ones to do this work.

 

[Ducttape]

i misinterpreted your last 1 1/2 sentences, steve. my apologies. and NJ, ID is an ABIM subspecialty...

 

[NJPAIN]

i misinterpreted your last 1 1/2 sentences, steve. my apologies. and NJ, ID is an ABIM subspecialty...

As I am aware. I was just confirming that you are correct that he is an internist.

 

[PainDrain]

The point is it is on our boards and we should be the ones to do this work.

Absolutely true. Some people only seems to remember where to put the needle and what codes to bill. Last I check we were physicians, not mid levels; do the work up and rule out the bad stuff.

Had a 50ish guy, very active, construction worker come in with new onset thoracic pain after stepping awkwardly off a curb. initial X-ray by PCP showed compression fractures at T9 and T11. He was sent to us and we got an MRI which showed acute fx and radiologist wrote malignancy cannot be excluded. Guy refused our workup and didn't want any follow up. My guess is he just doesn't want to hear the bad news. I would have started with Cbc, Esr, CRP and bone scan.

 

[clubdeac]

Absolutely true. Some people only seems to remember where to put the needle and what codes to bill. Last I check we were physicians, not mid levels; do the work up and rule out the bad stuff.

Had a 50ish guy, very active, construction worker come in with new onset thoracic pain after stepping awkwardly off a curb. initial X-ray by PCP showed compression fractures at T9 and T11. He was sent to us and we got an MRI which showed acute fx and radiologist wrote malignancy cannot be excluded. Guy refused our workup and didn't want any follow up. My guess is he just doesn't want to hear the bad news. I would have started with Cbc, Esr, CRP and bone scan.

you forgot one of the most important ones - SIF

 

[epidural man]

Absolutely true. Some people only seems to remember where to put the needle and what codes to bill. Last I check we were physicians, not mid levels; do the work up and rule out the bad stuff.

Had a 50ish guy, very active, construction worker come in with new onset thoracic pain after stepping awkwardly off a curb. initial X-ray by PCP showed compression fractures at T9 and T11. He was sent to us and we got an MRI which showed acute fx and radiologist wrote malignancy cannot be excluded. Guy refused our workup and didn't want any follow up. My guess is he just doesn't want to hear the bad news. I would have started with Cbc, Esr, CRP and bone scan.

I disagree.

We ARE CERTAINLY NOT physicians.

Anyone that only has 10 minutes with a patient is NOT really being a physician. I know many of you see 40-50 patients a day.

that is not being a physician in my book.

 

[PainDrain]

Yikes. 40-50 patients a day? That's nuts. It's nice to be busy but that is not good care, no matter how you justify it to yourself.

 

[clubdeac]

they justify it with the benjamins

 

[lonelobo]

they justify it with the benjamins

Who are these Benjamins you speak of?

 

[lobelsteve]

Who are these Benjamins you speak of?

Big Ben, Parliament..

 

[lonelobo]

Big Ben, Parliament..

Ahhh Bach....

 

[Ducttape]

im sure some use these instead of benjamins - too messy and bulky...
http://www.ebay.com/itm/like/201409731814?item=201409731814&lgeo=1&vectorid=229466&rmvSB=true

 

[Papa Lou]

I think the appropriate thing to do is stop being egotistical and narcissistic. It may be "in our boards" therefore we shoulder certainly be thinking along these lines, and starting the workup, but there should be a conversation with his PCP (the central hub of care for all of that pt's potential specialist referrals) about it, and he should be the one who spearheads the rest of that mission. The captain of the ship is in the middle. So is the quarterback and the pitcher. We need to be good doctors and be diligent, but also realize we're in left outfield, as we are specialist consultants. Always think outside the box and be thorough, but know your role and respect the system. THAT'S good doctoring.