MASTERCLASSCompensationandtheSpine

PaulLicina

disc herniation

discogenic pain

spinal stenosis

WHATCAUSESIT?

WHOYOUARE

WHATYOUDO

WHATHAPPENED

genetics

weight

fitness psychology

age

WHOYOUARE

WHATCAUSESIT?

WHATYOUDO

occupation

pastimes

WHATCAUSESIT?

previousinjuries

smoking

WHATHAPPENED

injury

repetitive load

WHATCAUSESIT?

WHOYOUARE

WHATYOUDO

WHATHAPPENED

WHATCAUSESIT?

WHATCAUSESIT?

The once commonly held view that disc degeneration is primarily aresult of aging and “wear and tear” from mechanical insults andinjuries was not supported by this series of studies. Instead, discdegeneration appears to be determined in great part by geneticinfluences. Although environmental factors also play a role, it is notprimarily through routine physical loading exposures (eg, heavy vs.light physical demands) as once suspected.

Previously, heavy physical loading was the main suspected risk factorfor disc degeneration. Recent research indicates that heredity has adominant role in disc degeneration, explaining 74% of the variance inadult populations studied to date.

WHOYOUARE

WHATYOUDO

WHATHAPPENED

WHATCAUSESIT?

HOWDOWEDECIDEIFITISWORK-RELATED?

mechanismofinjury

• wasthereaspecificevent?• wasitanunusualevent?• couldthatinjuryhavecauseddamage?

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1 2 3 4 5

1 2 3 4 5

mechanismofinjury

relationshiptoonsetofpain

• howsoondidthepainstart?• howsimilarwasthepainatthestarttothepainnow?• whenwasthelinkmade?

1 2 3 4 5

1 2 3 4 5

1 2 3 4 5

mechanismofinjury

relationshiptoonsetofpain

preexistingproblems

• havetherebeensimilarproblems?• howlongago?• howmuchdegenerationispresent?

1 2 3 4 5

1 2 3 4 5

1 2 3 4 5

1 2 3 4 5

mechanismofinjury

relationshiptoonsetofpain

preexistingproblems

currentpathology

• istheresomethingobjectivewrong?• doesitexplainthepain?• istraumaafactorinthatcondition?

1 2 3 4 5

1 2 3 4 5

1 2 3 4 5

1 2 3 4 5

1 2 3 4 5

mechanismofinjury

relationshiptoonsetofpain

preexistingproblems

currentpathology

consistencyofpresentation

• abnormalillnessbehaviour• painbehaviour• credibility

1 2 3 4 5

1 2 3 4 5

1 2 3 4 5

1 2 3 4 5

1 2 3 4 5

1 2 3 4 5

mechanismofinjury

relationshiptoonsetofpain

preexistingproblems

currentpathology

consistencyofpresentation

TOTAL

HOWDOWEDECIDEWHETHERTOAPPROVESURGERY?

1 2 3 4 5conditionbeingtreated

• isthesurgeryaimedattheacute injuryorthepreexistingcondition?

• isthereasimplerprocedurethatjustaddressestheacuteinjury?

1 2 3 4 5

1 2 3 4 5

conditionbeingtreated

nonoperativetreatment

• isthereaneffectivenonoperativetreatmentatthistime?

• hasnonoperative treatmentbeencompletedproperly?

1 2 3 4 5

1 2 3 4 5

1 2 3 4 5

conditionbeingtreated

nonoperativetreatment

effectivenessofsurgery

• issurgerynormallyeffectiveforthisdiagnosis?

• inthiscircumstanceissurgerylikelytobemoreorlesseffective?

1 2 3 4 5

1 2 3 4 5

1 2 3 4 5

1 2 3 4 5

conditionbeingtreated

nonoperativetreatment

effectivenessofsurgery

likelihoodofreturntowork

• isreturntoworkusuallyfeasibleafterthistypeofsurgery?

• inthiscircumstanceisreturntoworkmoreorless likely?

1 2 3 4 5

1 2 3 4 5

1 2 3 4 5

1 2 3 4 5

1 2 3 4 5

conditionbeingtreated

nonoperativetreatment

effectivenessofsurgery

likelihoodofreturntowork

capabilityofsurgeon

• aretheiroutcomesusuallyfavourable?

• istherequestreasonable?

1 2 3 4 5

1 2 3 4 5

1 2 3 4 5

1 2 3 4 5

1 2 3 4 5

1 2 3 4 5

conditionbeingtreated

nonoperativetreatment

effectivenessofsurgery

likelihoodofreturntowork

capabilityofsurgeon

TOTAL

mechanismofinjury

relationshiptoonsetofpain

preexistingproblems

currentpathology

consistencyofpresentation

• abnormalillnessbehaviour• painbehaviour• credibility

• istheresomethingobjectivewrong?• doesitexplainthepain?• istraumaafactorinthatcondition?

• havetherebeensimilarproblems?• howlongago?• howmuchdegenerationispresent?

• howsoondidthepainstart?• howsimilarwasthepainatthestarttothepainnow?• whenwasthelinkmade?

• wasthereaspecificevent?• wasitanunusualevent?• couldthatinjuryhavecauseddamage?

conditionbeingtreated

nonoperativetreatment

effectivenessofsurgery

likelihoodofreturntowork

capabilityofsurgeon

• aretheiroutcomesusuallyfavourable?• istherequestreasonable?

• isreturntoworkusuallyfeasibleafterthistypeofsurgery?• inthiscircumstanceisreturntoworkmoreorless likely?

• issurgerynormallyeffectiveforthisdiagnosis?• inthiscircumstanceissurgerylikelytobemoreorlesseffective?

• isthereaneffectivenonoperative treatmentatthistime?• hasnonoperative treatmentbeencompletedproperly?

• issurgeryaimedattheacuteinjuryorthepreexistingcondition?• isthereasimplerprocedurethatjustaddressestheacuteinjury?