The document discusses factors that contribute to spinal compensation issues and determining whether back pain is work-related or requires surgery. It notes that genetics play a dominant role in disc degeneration, explaining 74% of cases, rather than physical loading as previously thought. When evaluating work-relatedness, multiple factors are considered like the injury mechanism, pain onset relationship, preexisting issues, current pathology, and presentation consistency. For surgery approval, considerations include the treated condition, nonoperative treatment effectiveness, surgery effectiveness, return to work likelihood, and surgeon capability.

1. MASTERCLASS
Compensation
and the Spine
Paul Licina

2. disc herniation
discogenic pain
spinal stenosis

4. WHAT CAUSES IT?
WHO YOU
ARE
WHAT YOU
DO
WHAT
HAPPENED

5. genetics
weight
fitness psychology
age
WHO YOU ARE
WHAT CAUSES IT?

6. WHAT YOU DO
occupation
pastimes
WHAT CAUSES IT?
previous injuries
smoking

7. WHAT HAPPENED
injury
repetitive load
WHAT CAUSES IT?

8. WHO YOU
ARE
WHAT YOU
DO
WHAT
HAPPENED
WHAT CAUSES IT?

9. WHAT CAUSES IT?
The once commonly held view that disc degeneration is primarily a
result of aging and “wear and tear” from mechanical insults and
injuries was not supported by this series of studies. Instead, disc
degeneration appears to be determined in great part by genetic
influences. Although environmental factors also play a role, it is not
primarily through routine physical loading exposures (eg, heavy vs.
light physical demands) as once suspected.
Previously, heavy physical loading was the main suspected risk factor
for disc degeneration. Recent research indicates that heredity has a
dominant role in disc degeneration, explaining 74% of the variance in
adult populations studied to date.

10. WHO YOU
ARE
WHAT YOU
DO
WHAT
HAPPENED
WHAT CAUSES IT?

12. HOW DO WE DECIDE IF IT IS WORK-RELATED?

13. mechanism
of injury
• was there a specific event?
• was it an unusual event?
• could that injury have caused damage?
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14. 1 2 3 4 5
1 2 3 4 5
mechanism
of injury
relationship to
onset of pain
• how soon did the pain start?
• how similar was the pain at the start to the pain now?
• when was the link made?

15. 1 2 3 4 5
1 2 3 4 5
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mechanism
of injury
relationship to
onset of pain
preexisting
problems
• have there been similar problems?
• how long ago?
• how much degeneration is present?

16. 1 2 3 4 5
1 2 3 4 5
1 2 3 4 5
1 2 3 4 5
mechanism
of injury
relationship to
onset of pain
preexisting
problems
current
pathology
• is there something objective wrong?
• does it explain the pain?
• is trauma a factor in that condition?

17. 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
mechanism
of injury
relationship to
onset of pain
preexisting
problems
current
pathology
consistency of
presentation
• abnormal illness behaviour
• pain behaviour
• credibility

18. 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
mechanism
of injury
relationship to
onset of pain
preexisting
problems
current
pathology
consistency of
presentation
TOTAL

19. HOW DO WE DECIDE WHETHER TO APPROVE SURGERY?

20. 1 2 3 4 5
condition
being treated
• is the surgery aimed at the acute injury
or the preexisting condition?
• is there a simpler procedure that just
addresses the acute injury?

21. 1 2 3 4 5
1 2 3 4 5
condition
being treated
nonoperative
treatment
• is there an effective nonoperative
treatment at this time?
• has nonoperative treatment been
completed properly?

22. 1 2 3 4 5
1 2 3 4 5
1 2 3 4 5
condition
being treated
nonoperative
treatment
effectiveness
of surgery
• is surgery normally effective for
this diagnosis?
• in this circumstance is surgery
likely to be more or less effective?

23. 1 2 3 4 5
1 2 3 4 5
1 2 3 4 5
1 2 3 4 5
condition
being treated
nonoperative
treatment
effectiveness
of surgery
likelihood of
return to work
• is return to work usually feasible after
this type of surgery?
• in this circumstance is return to work
more or less likely?

24. 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
condition
being treated
nonoperative
treatment
effectiveness
of surgery
likelihood of
return to work
capability of
surgeon
• are their outcomes usually
favourable?
• is the request reasonable?

25. 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
condition
being treated
nonoperative
treatment
effectiveness
of surgery
likelihood of
return to work
capability of
surgeon
TOTAL

26. mechanism
of injury
relationship to
onset of pain
preexisting
problems
current
pathology
consistency of
presentation
• abnormal illness behaviour
• pain behaviour
• credibility
• is there something objective wrong?
• does it explain the pain?
• is trauma a factor in that condition?
• have there been similar problems?
• how long ago?
• how much degeneration is present?
• how soon did the pain start?
• how similar was the pain at the start to the pain now?
• when was the link made?
• was there a specific event?
• was it an unusual event?
• could that injury have caused damage?

27. condition
being treated
nonoperative
treatment
effectiveness
of surgery
likelihood of
return to work
capability of
surgeon
• are their outcomes usually favourable?
• is the request reasonable?
• is return to work usually feasible after this type of surgery?
• in this circumstance is return to work more or less likely?
• is surgery normally effective for this diagnosis?
• in this circumstance is surgery likely to be more or less effective?
• is there an effective nonoperative treatment at this time?
• has nonoperative treatment been completed properly?
• is surgery aimed at the acute injury or the preexisting condition?
• is there a simpler procedure that just addresses the acute injury?