Medical Treatment Guidelines
Washington State Department of Labor and Industries
Clinical featuresPreadmissionevaluation andtreatmentHospital admissioncriteriaPost-admissionmanagementGroup 2Acute major backtrauma not suspected;patient has neurologicfindings suspected tobe active orprogressive
A) No history of recentmajor injury.
B) Patient complains of symptoms suggestingacute or progressiveneurologic deficit.Typically these include:1)
Progressive weakness ornumbness in one leg(and occasionally both legs).
Loss of control of bowel or bladderfunction.
Progressivenumbness in theperineal region.
C) The examiningphysician indicates thatthe patient has (orprobably has) an acute orprogressive neurologicdeficit. A) Outpatient setting:Evaluation andtreatment isindividualized.B) Emergency Department Setting:1) Advanceddiagnostic imagingmay be indicated when a patient inGroup 2 comes to theEmergency Department.2) An attempt toreach the patient’sattending physicianshould always bemade before anemergency department MDdecides to orderadvanced imagingstudies. (Theattending physician isin the best position toevaluate the patient’sclinical presentationand judge theusefulness of imagingstudies).3) If an imagingstudy is done and doesNOT demonstrate anacute, lesion, for which surgery isindicated, the patientshould be managedlike a patient in Group3. The patient should be discharged unlesshe/she is unable toperform ADLs athome. A) If a patient has a new orprogressive neurologicdeficit, he/she may behospitalized in order tofacilitate surgical decision-making, to provide closeobservation of furtherprogression or to help thepatient compensate forneurological deficits (e.g. todetermine whether thepatient needs to learnintermittentcatheterization).B) If a patient does NOThave a new or progressiveneurologic deficit, he/sheshould be treated like apatient in Group 3. The only valid reason forhospitalization is thathe/she cannot manage basic ADLs at home.C) If a patient is admittedthrough an emergency department, the decision toadmit should be made withthe concurrence of theattending physician, unlessthe attending physiciancannot be reached. A)
Duration of hospitalizationshould be brief
. The greatmajority of Group 2 patients whoare admitted to a hospital can bedischarged in 1-3 days (if spinesurgery is not performed).B) Treatment Plan Goals1) General Strategy – It iscrucial to assess the patients’ability to perform ADLs and toidentify environmental barriersto return home.a) An assessment of thesefactors should begin immediately upon admission. A list of barriersto discharge should be noted inthe patient record. b) The ability of the patientto perform ADLs should bemeasured serially, e.g., can thepatient ambulate to the bathroom?c)
Discharge planningshould begin immediately, forexample: the patient’s significantother should be contacted andproblem solving should beundertaken regarding practicalproblems such as the ability toget food and ambulate to the bathroom in the home.2) Pain Management – Review potential to benefit fromnonsteroidals, antidepressants,opiates.
TheDepartment of Labor andIndustries does not coverepidural or intrathecaladministration of opiates exceptin the peri-operative period.3) Management of NeurologicalDeficits – a patient may needhelp with bladder catheterizationor may need a brace for his/herleg.C) Diagnostic Imaging,Physician Consultants andSurgical Planning –Individualized.D)
Prolonged bed restusually does more harm thangood in a patient with low back pain. Admission for the purposeof bed rest is not acceptable.