Pain specialist Conor W. O’Neill, MD, director of the UCSF Nonoperative Spine Program, presents a straightforward approach to assessing low back pain in primary care, including how to efficiently rule out serious causes and how to recognize the multiple factors – biological, psychological and social – that contribute to pain. Learn to perform more useful physical exams, order MRIs wisely, and make treatment plans that serve patients in the long run.
mm. Um let's see if I can advance. Can you see that 1? Yeah, looks good. Okay, great. So anyways, um, this is a famous corpus from Sir William Osler. I'm pretty sure that he didn't spend a lot of time taking care of back pain patients because I can listen to them all day long and I have no idea what's what's causing their pain. Ah, there are some exceptions. Of course. This was a gentleman that I saw many years ago now who came in with literally his chief complaint was he felt like he had a knife in his back. And sure enough, he actually did. This is a little piece of metal down here in his back. You've been in a altercation that involves someone stabbing in the back and the tip was broken off. He was carrying this around. So in that case, I guess William we probably got the diagnosis, but that's that's the rare exception. The reason is so difficult. This because pain is such a complicated condition. I think everyone here is familiar with the bio psychosocial model of back pain. So, we know that there's biological factors, but probably as important. In fact, probably more important are the psychological and social factors and trying to untangle and you need a particular patient, you know, which of these things is primary is it's pretty difficult. Um, and it is a general rule, the treatments we have for low back pain just are not very effective and that leads to patients turning to potentially harmful treatments. This is a good example that this is actually UCSF faculty member who would develop low back pain. It wasn't clear at all where it was coming from Uh surgeons she saw thought that was probably coming from her L- 34 discs. So it just replacement there a year later. She is no better. In fact she's now she's going to work half time. She saw another surgeon who said it's coming from the L five S 1 disk. So he plays that disk. Now she's worse. She's not working. She's two years post up. She finally went to Germany and they said, well we'll just use just replaced them all. So that's what they did. They replace the other two that and being operated on yet. And now she's basically completely disabled from pain. And it's a real tragedy. Uh, so that's maybe a bit extreme. But we see stories like this all the time. And I'm sure many of you have seen patients like this in your clinics. The other harmful treatment that people turn to of course is our opioids. And everyone's familiar with the the opioid epidemic. Uh this this data from 2019. But it's gotten worse actually over the past couple of years in the pandemic opioid jungle roses as a whole. And and the percentage or proportion that are related to opioids have increased even more. So in response to this in 2019 or there about congress actually allocated billion dollars to try and solve this opioid epidemic. So what they did was they created this program called hell and I am hoping to end addiction long term. And as part of that, they create a number of different programs. one was a program called Backpack. Nice catchy name. Uh, there was really devoted to finding new ways are better ways to treat back pain. So a lot of the money that went into hell was, has been focused around opioid use disorders and, you know, finding ways to avoid opioids or treat opioid use disorder. But they also put a pretty big chunk of money into trying to find better ways to treat back pain. And in our department, we, Our cut of that $1 billion $30 million. We were lucky enough to secure that to define our own research on back pain. I don't want to tell you just a little bit about that, just so you have an idea Hopefully where we're gonna be in the next five to maybe 10 years, even though we're not there now. Mhm. So what we're doing is what we're taking all the different factors that we know are associated with back pain and and measuring them and trying to uh define particular Fiona types and also how patients with different combination of these factors. We're going to respond in different treatments. So it's essentially trying to find personalized medicine for, for back pain. Um, and we're using a number of, of uh, you know, tools that we're developing to do this, looking at different aspects of pain, for example, uh some members of our team have developed a really innovative way to measure body biomechanics using an off the shelf. It's not an Xbox, it's some other video game thing Um that's like $150, but with some a lot of dance software and and artificial intelligence and so on, You can can actually uh allow it to give some pretty sophisticated biomechanical biomechanical analyses. Uh We're also looking a number of novels and rye methods uh including this is an image here from what we call em R. Spectroscopy. So it's a way to actually visualize the chemicals inside the disk. And you can see this graph down here that shows a spike here is lactic acid. So we've found that in patients that have really symptomatic disc as opposed to just asymptomatic, the general gist disease. They have a particular chemical signature in their disk. And we think that this can be a way to help us sort out patients better in the future. And we're looking at special these are these are some of the special muscle sequences and we're also doing functional MRI because, you know, pain ultimately is is a cortical phenomenon that's really perceive pain. Uh There's actually evidence now that in some people anyways that the cortex actually gets reorganized in chronic pain and it probably d couples paying from from the periphery. So these these are important tools that we're using in our studies and then we're doing some sophisticated measurements of pain sensitivity because that's a really key part of all this, which we'll talk about in just a moment. So this this is our vision. We're going to develop all these fancy new tools where we have um connecting some big observation of studies where we're gathering across the country is part of a consortium that will have Data on probably 10,000 or so patients. And then we're going to be using, you know, the modern analytic methods of machine learning and artificial intelligence and hopefully, you know, ultimately be able to provide precision back pain management. So that's our goal. There's there's a lot of money behind this from from congress and uh it's gone to a number of different centers around the country and we're also working very closely together trying achieve this goal but we're not there yet. We're a long ways away. In the meantime, you and I each have to see back pain patients in our clinics every day and try to figure out all right how to get them better release something cope. So the tool that I alluded to in the very beginning is called the clinically organized relevant exam. Core actual and I put a link web link down at the bottom uh to the organization that developed this which is actually in Canada uh and it's called the Center for effective practice. It's it's um a basically an organization that's devoted to evidence based medicine and to try and try and provide clinicians with tools to implement evidence based medicine into their practices. And they had a whole bunch of really useful resources there, including videos and so on. So if you really want to, you know, do a deep dive into this, they can keep you busy for hours looking all the material. Did you have one specific handout, which is this core back tool? They actually have a very similar one for neck pain and one for headache, which which are the tools that I give to our residents to to make sure that they at least get these these uh principles internalized and now they care for back pain patients. Some of this is pretty straightforward, some of its you know, it has developed in Canada. So they have a different system there and they do have put a little bit more emphasis on on perhaps the primary care physician actually directing therapy then I think we do here. So what I want to do is just sort of boil this down to the very basics and talk about that for a couple minutes and then provide some examples of of how this may be used in practice. So this is what got, I'm going to call the core of the core approach, the first one here be alert for red flag conditions. I don't think any of you have any her familiar with all that. Um But but there's two things that you may not be doing in your practice which I think are really important and super easy to do. One is to assess what we call yellow flags. And these are questions that can identify uh negative thoughts and emotions around team that patients have that are a definite indicator that they're vulnerable to developing chronic pain or are at risk for, they have chronic pain for for persistence and bad outcomes. And I think these are really important to emphasize and to incorporate into practice. Um And I think can really help in terms of identifying patients that need to that'd be referred early. The other is is just very simple assessment of spine movement. And it's amazing to me even in this flying clinic at UCSF patients all the time go through there and they see surgeons and they've never asked them to actually then there's fine. Um And you know that's one of the that's one of the key functions of the spine is to move. So I think you know, if you're going to examine the spine, you definitely have to assessed movement uh and really be able to just differentiate the two categories mechanical amount of mechanical. We'll talk about that. You just do that. This last bullet point is not part of the core approach officially because not in their tool but it's something that that you know I feel quite strongly about. Um mris reports are one of the banes of my existence. I spend so much time every day talking to patients about how their reports don't mean anything. Uh and um before a patient gets an MRI, they really should be prepped in advance that they're going to have bulging discs, they're going to have arthritis, they're going to have stenosis, you know, all these things that just come with natural aging that don't have nothing to do with their pain. Um so just real quick about red flags. There was a really nice paper published a few years ago in the Journal Born Joint Surgery that took a critical look at red flags and, and to really try to figure out how how, how useful they really are Because I think we're all familiar with, you know, all the different questions that one can ask about fevers chills 19 et cetera. It turns out that there's, there's some very specific ones that, that are probably helpful that may help to identify a red flag for neurological, it's really urinary retention genital numbness. Um, one thing that I do in every single back pain patient is just having feeling to walk if they can do that, the chance that they have some, you know, impending neurologic catastrophe or need urgent treatment is really minimal. It's just such a simple ST ng tool and I do it on every back pain patient essentially, every time I see them. Her infection is recent infection, not fevers, chills, Fracture, it's trauma an age over 70 years. obviously the older the worse, but 70 seems to be sort of a cut point for tumors, personal history of cancer and inflammatories, typical inflammatory back pain, symptoms of young onset morning stiffness, better with exercise and nighttime pain. So those are really the things for the red flag conditions. Um the probably the most important red flag I think, which to me anyways is a failure to respond to conservative care. So I don't think there's unless someone has a really obvious neurologic dysfunction or there's a strong suspicion of cancer or something like that. Um there's, most people should have conservative care before the MRI scan. Um, but the key is followed, but making sure that they get better and if they don't, that's when it's time to think about the MRI. This is a young gentleman, 28 year old who fell while snowboarding came in with what seemed like classic, you know, muscle strain. Uh he went to PT didn't get better after about 23 weeks. We got the MRI. And yes, these marrow replacing lesions here, which turned out to be a lymphoma and he ended up doing well with the bone marrow transplant, but that's obviously a serious condition you wouldn't want to miss. This is another patient who came in again with, you know, sort of right leg symptoms. It seems like a very classic, ridiculous pattern. Uh but she had an MRI scan which showed Pretty normal disks. A little bit degeneration here at L 4, 5 little bit of stenosis here. This is the nerve root, this is fat around the nerve. So as long as the nerd bird has fat around it, it's probably not going to be a major source of pain. So when you see em I reports and see mild, moderate, severe, etcetera. It's those terms are not the helpful. There's a huge variation. Radiologists, what they call mild, moderate or severe. The real key thing is, do they have fatter on the nerve? Which case is protected? But if you look up here, she has a a little something here that shouldn't be there. And that ended up being a a drop metastases from a brain tumor. So again, she went to conserve care, She didn't respond. And then that's where the worker and we found serious condition. There's a woman who came in with thoracic pain uh seemed sort of mechanical, but it wasn't really classic in the I didn't have a strong relationship to active your posture. She had the similar I scan, which was pretty remarkable. There's the spinal cord, you know, there's no obvious lesions going on there. And uh but so that led to a chest ct of donald chest ct. And she had this big turn out to be a part of someone carcinoma. This is an infection. This I hardly ever see. Um But this is just an example of what infected this looks like it gets super white on MRI scan. All this whitish stop here you see is the demon adjacent bones. Um This is an extra free time and also in degenerative disease. We'll look at some examples of that in just a little bit. So this by itself is not so concerning. But this super intense collection in the desk certainly indicates a disc itis. Here's a patient with a vertebral fracture. I don't think these are too much of a diagnostic one in most cases. This one Actually is uh called retrieval plain. And it's just basically a pancake at this point. This is I think the L. one. Um She had an MRI scan and you see some retro pulse bone here started binging on the on the corners and galleries right at or close to it. But she was totally asymptomatic from this, which is pretty much the case. I don't recall seeing a patient with one of these that's had a serious neurologic wow. Oh dysfunction from that. And then finally just rounding out our tour of serious rare conditions, there's a young gentleman who came in with classic, it's mandatory back pain. So morning stiffness and all the things that go along with it. And this is an MRI scan showing that the demons take really I joined when he had the uh you know, appropriate geologic work out which confirmed the diagnosis. So those are all things that obviously have to be aware of it. But they're rare primary practice Somewhere between 1 to 40%. A much bigger issue, which affects at least half the patients that have low back pain are these uh, negative thoughts and emotions around back pain. And the main ones are catastrophizing, which is basically feeling like nothing is ever going to get better fear avoidance, which is a fear that movement is going to hurt your spine and you do damage to yourself. And of course, anxiety and depression. So, you know, most of time these are pretty apparent just from talking to the patient from what they offer to you. I mean, there are some specific questions you can ask, um, to, to sort of tease out a little bit, which these different factors may be playing a role. Um, but you know, I would, I think these are much more important than the red flags to be honest. Um, and really do influence how we're going to treat patients. The other thing that's very important, addition to the assessing the yellow flags is to assess the movement of the spine. Um, if we take, you know, low back pain as a whole, I take out all the red flag conditions. What we're left with is the diagnosis of non specific, low back people. Um, that can really be divided into two buckets. One is non mechanical pain. You know, there is mechanical, mechanical is pain that's do, that's worsened with movement or loading. And usually the patient has some some type of identifiable position of comfort and mechanical pain is going to be due to some tissue dysfunction or irritation or inflammation in the back. Um That was almost always gonna respond to some type of mechanical therapy, whether that be physical therapy, chiropractic care, um surgery for that matter. Uh So patients that have a mechanical pain pattern, we usually have ways to treat them. Maybe not ideal, but we have ways uh huh If they're non mechanical then you accept a sense are thinking about a lot of different things. Um You know, if they have primarily leg pain, could this be some type of neurologic syndrome, public sympathy, disastrous trapping et cetera, visceral pain. Of course the kidney and the uterus are probably the most common vascular uh particular patients that have clarification noises have to check their pulses obviously. Uh, musculoskeletal pain is a big, it's a big one because a lot of patients that have extremity pain, you may well have some other problems such as arthritis and my super cypress. So all of these none of these conditions are going to be influenced by by his fine movement. So it's really important to at least start thinking of these. Probably the most important one, the one that is going to be the most common. It's just patients with a a generalized increase in pain sensitivity and that's what we refer to as central pain, there's a number of other ways to describe it but that's that's sort of how most people refer to it. And and basically that's just they're paying tentative, that's just the way they are. Um and things, you know, little aches and pains that the rest of us may shrug off in patients that have an elevated pain sensitivity. Uh They become like faltering. There's basically two categories of of uh increased pain sensitivity, altered pain processing is another way to think of it. Uh There's certainly it can be constitutional uh And this is a there's a syndrome of what we call chronic overlapping pain conditions that include migraines, your mobile syndrome, uh industrial societies, etcetera. And these these um syndromes co associate with each other and they probably have a common underlying path of physiology which is probably uh and elevated pain sensitivity. We kept 100% sure about that, but these conditions definitely occur together and any one of these is a very bad prognostic indicator for recovery from from back pain. Um And then some pain sensitivity is also gonna be acquired. Just chronic themed itself, can increase sensitivity through complex effects on the nervous system psychologic distress, that the fear avoidance and kind of catastrophe. Ization we talked about and find narcotics um that's something we've become really a lot more aware of in the last several years that that the narcotics themselves. Oftentimes induced paradoxical hypersensitivity uh and um uh you know, that once that gets uh going and the only cure is to get off the narcotics, which is, I'm sure you all know, not not easy to do. So, you know, in addition to creating problems for patients and doctors, you know, chronic low back pain also creates problems for health systems, Including ours at UCSF. So in 2018 we sort of did a survey of our primary care practices to to understand how many patients we were seeing per year with chronicle of acting. It turned out to be a little bit over 1000 patients per year. Um And then we looked at the at the financials, we found that we were spending a lot and losing, you know, consider a lot. Um and we had no data on improvement in quality of life. We had some data from our spine clinic, which is a different population uh because the patients are coming in, a lot of them have surgery and salon. But even that data suggested that we weren't really making a lot of headway mm in our back pain patients, but really not not good. David, we just didn't really know. So this uh initiated. Oh, the other thing I just want to mention is that uh, you know, in in serving how our care was delivered. You know, not, I mean not dissimilar to most places, that one would go, maybe, I'm not sure if one medical group, there's an exception or not, but at least at UCSF, you know, there was no coordinated path for patients. So primary care doctor, you know, would have any one of a number of different places to make decided to refer the patient, where they go, depends on what treatment to get. And a lot of times they bounce around between multiple places and they come out at the other end and you know, there's really not a whole lot better. Um so our response to this was to create what we call uh creative spine service which were developed as a collaboration between primary care physicians, physical therapists, physical society tree and obviously orthopedics and neurosurgery and we uh put together, you know, uh an evidence based program based on the bio psychosocial model that we wanted, that we instituted to provide this sort of integrated path for patients, the geared towards difficult patients uh to follow through the through the course of the illness and hopefully get them better. So our concept basically was to create a medical home essentially for for back pain. Uh We don't, I tend to think that we're going to get everybody better, but we at least think that we can help them cope and hopefully get out of that cycle bounced around to different places. Uh This is our team, I won't worry with all those details, we put uh put together, you know, some patient education materials, a website which honestly we're not really using that much mom. But we we tried to really map out what we consider the the uh appropriate program for back pain patients. Um So these are our goals. We wanted to reduce direct costs by 10%. We achieve that. So down 14.6%. Not for sharing but not bad. Um We did as part of this program uh start a uh outcome assessment program where we looked at uh promised measures we use the global Short form. So it's relatively easy to compromise. 10 questions. I mean, as you probably know, giving any kind of an outcomes assessment program going, it is not easy, but we were able to demonstrate that we were able to improve physical health By 10% and mental health by 12%. One could argue with that. That's frankly meaningful, but at least it's a step in the direction. This is a tool that we use, which is, you know, basically it's it's sort of a yellow flags uh on steroids I guess you'd call it. Um it's called the start back tool. Some of you may be familiar with. It has become pretty popular over the last 10 years or so since it was introduced and asked some very specific questions that that identifies uh patients that are at a high risk for a bad outcome. Uh primarily focused around these negative thoughts and emotions, but also some questions about physical dysfunction. Uh so patients with higher pain levels and and more disability than others and using this tool. Uh There's risk stratified treatment pathways that have been defined and and validated a number of different settings and we we sort of use a um uh a variation of this. It's hard to get it. Exactly right. Um But we try to every patient that we see is a ministry start back tool. If they're low risk, they basically just get some home exercise instructions if they're medium risk because supervised exercise, if they're high risk, these are the patients that really half those psycho social conditions that we know are going to affect their their outcomes. They get the full court press use a CBT Here is not really CBT because it's you can't do CBT unless you're licensed therapist. So it's psychologically informed. Physical therapy is the correct term. So if patients uh you know, they go through this treatment program. If they're successful, of course, then there's always a maintenance of some kind. If not, that's when we get the MRI uh the MRI is for two reasons. One is of course, if the patients feel conservative care, we have to make sure they don't have a serious condition. The second is to figure out if there's an interventional treatment that's appropriate. And I put an asterisk here because that's appropriate, is an extremely vague term. Some people they you know, they have a very, very low threshold for doing injections or surgery. Some people, it's higher. It's really hard to know what the right approaches and it obviously has to be influenced by patient factors, patient preferences, et cetera. Um This is uh as I mentioned earlier before we get memory in a patient, we make sure we prep them. Uh this is a patient that I saw once upon a time who had gotten in their primary care physician ordered the MRI scan and then sent them this message by my chart describing all the bad stuff in their spine. Smeared narrowing. You see a spine surgeon and this explains your pain. You don't need to go to physical therapy, which is basically the exact opposite what we tell them what I would tell them. Which is that there's fine shorts of normal ages structurally. It sounds like they need to be active. Surgery is not going to help once a patient has this message and they're already predisposed to fear avoidance and ken astronomy trash topic thinking, I mean it's really Deimel unless you spend a lot of time de programming. They are going to just we're going to go find a surgeon or something and it's it's really difficult can reverse them. Some of the radiologists help us a lot. These are the group from cp M. C. Does this uh think of cp M. C. And all those others also that put in this epidemiologic information. There's actually a really nice study done not too long ago, a randomized trial showing that that includes this information actually decreases opioid prescriptions. Um So again it because patients, I'll read their reports and they see these words and if there's not some context they assume that you know there's finest crumbling. Uh and uh so it's really help to do this. Our radiologists at UCSF won't do this. We asked them wonder why um this is uh a lumbar spine. This is a cuba body. Here's disk. This is the dreaded bulging disk which so many patients are can this is causing their pain. Uh This down here is the natural discrimination. So you see the difference just a little bulge here. This is a discrimination that's poking outside the disk. And you see here it is, it's um actually this is a commercial nerve root right here. These are pretty dots. My stuff is CSF so it's actually deflecting and maybe even compresses. And um these are extremely common in asymptomatic people. So just this finding by itself obviously it has to be really correlated with with clinical findings, they don't cause back pain because like I mean, so when a patient went back in only they're really pretty meaningless uh this is diffused disc degeneration. Again, very little coalition with backbeat. This is final thesis, Greenland's final thesis. This is again very low correlation back green. If you're looking at a population level. Uh This over here is final stenosis. This is um and actually obviously the disk here's the facet joint very arthritic. Here's the spinal canal, the white stuff is the CSF and the little dots are the nerve would so you see it's compress quite a bit and you would think that well gee if none of which are compressing that this has to cause pain. But it turns out that At least 10% of people of asymptomatic people have severe stenosis. Uh and uh there's very little correlation between the severity of snow sys symptoms and the real graphic uh no radiographic severity of stenosis. So there's something more going on there. This probably relates to inflammation. Uh One other thing that you'll see here that people don't pay much attention to is that these are the spinal, these the stabilizing muscles of the spine. This dark stuff here means nice healthy muscle. See all this right here, this fat replacement, so fatty muscles and poor muscle quality probably play a big role in pain every night. Really paying attention to right now. That's one of the outputs one of the focus points of our research project. Um Make sure your time. I think I have 10 minutes left. So I think we're okay. There are some findings in the MRI scandal that are helpful. This is uh this is again an attribute of the spine. These are set joints. You see these fluid collections which are really pretty dramatic. These are for such joint effusions. These are much more likely to be associated with pain with everyday degeneration. So this is something we definitely look for and pay attention to. Um this is these are some, some information in the bone marrow. This is these are what are called motive changes. Uh they also, at one point we thought they indicated uh inflammation that probably is a little more complicated than that. And there's a lot of fat in there too. So it's sort of fiber vascular. But this is definitely more common in symptomatic populations and probably is a marker effect of symptomatic disc degeneration in some patients. But we're still a lot more work to do on yet. This is a good example of patient who had completely normal disks. She had Some really mild uh cassandra through apathy at all. 45, but she had this little effusion on the left side and that fit extremely well with her symptoms. So that's a that's key with all these things. These findings and MRI scan is we need to correlate those symptoms. In her case, she had mechanical pain, there was worse with extension, which sort of suggests that there's some poster structure in the spine is getting stressed in people and point tenderness over that joint. In her case, I'm not quite sure why she end up having this, but she end up getting a spect scan was also showed intense uptake right there when this patient everything fits. She didn't need to have this study. I'm not sure why she did, but that's just a good example of all uh what an otherwise age related degeneration in the spine can actually in this case would be a source of pain that's indicated by this inflammatory finding. So just to sort of wrap up a little bit, I just want to go through a few cases of patients just to show how, you know, once they get beyond the get to the MRI stage and we've ruled out everything else and they are a candidate for interventions. Some of the some of the things approaches we might take. So this is a woman by wildlife biologists, really super healthy, super active person. She failed all conservative care. She had pretty localized back pain. So she's got back pain. So we're thinking, you know that the problem is in the disks that joints the muscles, not the nerves because nerve pain usually causes like pain, but not always. There are some patients that can have nerve pain is confined to the back. You get your radiates out a little bit on hers. There's a little bit of the census radiating that much for the moment. So since she, this is some sort of music studies. So she has some story Alexis. Uh it's pretty mild actually. Um This is your memory scan. Just just just pretty good except these two right here, L- 2334. And those research to generate. And that's why she's talking over at those two levels. You can see that that's what her tilt is occurring. So she's got to generate desk, she's got these fiber vascular changes which may be a education information. She's got joints are degenerated. Can appreciate it well but they are degenerating. And then because she's because she's clapped over on that side, there's some narrowing around the nerves in the framing. She still got some fat around them but not abundant. And this potentially could be a source of pain to so sort of the normal progression is to first of all because it's back pain, it's more likely to be disks or joints. You don't really have good treatments from disk pain in general to treat the joints first in this case the cassette joints. And she did not get any better. So then I did some epidural injections. The thought that this could be ridiculous back pain. These are needles going in the framing or on the nerves that could be getting irritated. She had no better. Uh So then moving on to something that uh don't do very commonly but because she had these uh inflammatory changes on the MRI scan it put steroids into a disc at L. 23 and out 34 and shouldn't having a great great response. Um So in this case and this is pretty typical. It's really hard to know. We sent MRI and clinical findings in most cases with the source of pain. And so we're not going back and forth and trying things and making educated guesses and keep going until we either fail or find find the right answer. This is my last one here. This is a really nice lady. She has in this case it's very different. She has primarily like pain. So now we're thinking about nerve symptoms. You're not thinking that she has a back disk, your joint or muscle problem. She's super active, she wants a fix. Which is always a bad sign because they usually you know are they sort of do conservative care just to satisfy you. But they really just want surgery. Um So here's the MRI scan because they're just the generation all over all kinds of bulging guests again from anything because she doesn't have back pain. This is a real 45 level. Uh These are the facet joints, you have some fluid here in the joint but again, no back feet. So it's probably not relevant. She has a fair bit of stenosis. Uh this these are all the nerves side of sort of bunched together. So in this case because she has a clinical presentation that's consistent analysis and she has an MRI scan demonstrates that that's sort of the leading diagnosis. So she had a couple of epidural steroid injections. Usually like to just do one that someone has, you know a definite response But its partial will sometimes do a 2nd 1 and she did great after that she went off climbing all over the sierra and then she came back seven years later, she had the same pain, but the other side. So well your MRI scan, They're really interesting in this case. The all 45 level looks basically the same. So it's just an indication that when it comes to cyanosis, it's not the narrow, there's some other issue, probably inflammatory that are causing his patients to become symptomatic. So you hear a lot of occasions they'll say why stenosis and nothing's to make that better except surgery. Well not necessarily. Um So anyways uh this was not a problem. She had this at L. five S. 1. She had developed this little cyst. This little area of fluid is poking out and you can see the nerve here. Yes, when nerve getting pushed, there's one on the opposite side. So this was causing the pain down the right leg. So she had in this case what I did was actually pop the cyst. Uh so this is a needle, a joint to some contrast, There's a cyst being film there and it was a little more fluid, the material this just pops and then it all just sort of decompress into the epidural space. Um It was just to wrap up uh summary the core of the core approach. We talked about, the red flags, the yellow flags, the movement and loading patterns and if you're really interested the, what's that? A reference to earlier goes into some detail about some of the different patterns you can identify if if you really want to try and get into that. Um And then finally, the MRI is just, I think it is really important to to prep patients before we order them. That just prevents a lot of uh thanks on on the ups and then uh so that is the end of my presentation.