Neck and Back Pain. Spinal Assessment for Primary Care 10/1/2012

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Anastasia Crawford
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1 35th Annual Nurse Practitioners of Oregon Education Conference Oct 2012 Spinal Assessment for Primary Care Todd Kuether M.D. Background of Spinal Conditions Diagnostic Workup Testing Results When should a patient be referred for a surgical opinion Case Reviews Neck and Back Pain 50% adults report pain in the last 3 mo 15% of population will visit their doctor for back pain 1

2 Missing Work 2nd most common reason for missed workday Most common cause of disability #1 occupational hazard COST 2005 $85.9 billion relief from back/neck pain Cost of pain meds Increased 423% Cervical Condition Symptoms» Neck pain, shoulder blade pain, stiffness» Arm complaints (pain, numbness, weakness)» Dexterity, coordination, walking Signs» Weakness, atrophy» Numbness» Reflex changes 2

3 Cervical Exam 0 - No muscle contraction 1 - Muscle contracts but is not able to move the joint/limb 2 - Muscle is able to move the joint/limb, but not against gravity 3 - Muscle is able to move the joint/limb against gravity, but not through a full ROM 4 - Muscle is able to move the joint/limb through a full ROM, but the strength against resistance is not equal to the opposite limb (if normal) 5 - Muscle strength is normal (equal to the opposite, normal limb) Cervical Exam C5 radiculopathy Weakness: shoulder abduction Test: Have patients hold their shoulders in abduction, against downward force by the examiner. C6 radiculopathy Weakness: elbow flexion, wrist extension Test: Have patients lift their arm against resistance by the examiner. C7 radiculopathy Weakness: elbow extension, wrist flexion Test: Have patients push with their arm away from their chest against resistance by the examiner. C8 radiculopathy Weakness: thumb extension, wrist ulnar deviation Test: Have the patients hold their extended fingers together against the examiner's attempts to open the fingers. Sensation Reflexes Cervical Exam Spurlings - foraminal compression test Lhermitte sign 3

4 Back Pain Back Pain Causes Muscles Sudden, awkward movement, strained back muscles and ligaments, lifting heavy objects, or using improper form when lifting objects Nerves Pressure or impingement of nerve roots in the spinal canal can be caused by: Herniated discs Collapsed disc spaces Arthritic conditions Bone spurs Displacement of vertebrae Lumbar Condition Symptoms» Leg complaints (pain, numbness, weakness)» Dexterity, coordination, walking» Loss of bowel and bladder control» Fever, night sweats Signs» Weakness, atrophy» Numbness» Reflex changes Back Pain Strain - muscular 3 mo Ligamentous mo Facet Disc Fracture Instability 4

5 Lumbar Exam Dermatomes L1 - IP minor L2 - IP L3 - Adductor L4 - quad L5 - DF S1 - gastroc - PF Wadell s Signs Tenderness tests: superficial and diffuse tenderness and/or nonanatomic tenderness Simulation tests: these are based on movements which produce pain, without actually causing that movement, such as axial loading and pain on simulated rotation Distraction tests: positive tests are rechecked when the patient's attention is distracted, such as a straight leg raise test Regional disturbances: regional weakness or sensory changes which deviate from accepted neuroanatomy Overreaction: subjective signs regarding the patient's demeanor and reaction to testing Xrays 5

6 MRI CT-Myelogram EMG-NCS Evidence of nerve irritation Localize level Differentiate with a peripheral neuropathy or entrapment neuropathy 6

7 Provocative Testing Facet injections Nerve root blocks Discography Marcaine Referral for surgery Most patients respond well to nonsurgical treatments Less than 5% of patients with neck pain need surgery What s important? Muscle weakness» Deltoids, DF,atrophy Severe pain Myelopathy» Hyperreflexia, ataxia Bowel/bladder symptoms Progressive symptoms 7

8 Contraindications to Surgery Labs Comorbidities Medications Weight Other options Pain management» Pharmacologic» Stimulator/pump Chiro Acupuncture PT Chiropractic Care A 2011 Cochrane review found strong evidence that there is no clinically meaningful difference between spinal manipulation and other treatments for reducing pain and improving function for chronic low back pain. A 2010 Cochrane review found no current evidence to support or refute a clinically significant difference between the effects of combined chiropractic interventions and other interventions for chronic or mixed duration low back pain 8

9 Spinal Decompression There is very limited evidence in the scientific literature to support the effectiveness of nonsurgical spinal decompression therapy. This intervention has never been compared to exercise, spinal manipulation, standard medical care or other less expensive conservative treatment options which have an ample body of research demonstrating efficacy. Considering the cost-benefit relationship, many better researched and less expensive treatment options are available to the clinician. $4000 Steroid Injections ESI Only 10-15% long term relief Facet Injections SI Injections Difference in Spinal Surgery Cervical» ACDF/fusion vs foraminotomy vs arthroplasty» Laminectomy Lumbar» Microdisc» Laminectomy» Fusion vs arthroplasty Thoracic 9

10 Anterior Surgery of the Cervical Spine Primary Treatment Goals Eliminate pain Neck pain Arm pain Preserve or enhance neurological function Radiculopathy Myelopathy Provide segmental stability ACDF with instrumentation Higher fusion rates Improved lordosis Reduced immobilization requirements Adjacent segment disease 2.9% per year incidence requiring surgery 25% predicted at 10 years 10

11 PRESTIGE Cervical Disc Clinical Experience Largest prospective randomized medical device study in the cervical spine ever conducted and completed Demonstrated: Safety Effectiveness The PRESTIGE Cervical Disc was proven to be statistically superior in Overall Success at 24 months; statistically superior in Neurological Success at 24 months; and similar in NDI results XLIF Surgical Approach extreme Lateral Interbody Fusion (XLIF) Advantages: Does not require entry through sensitive back muscles, bones, or ligaments or the retraction of major blood vessels anteriorly Made safe with the use of nerve monitoring technology 11

12 CASE REVIEWS 5 XLIF Patient Benefits Source: *Wright N, XLIF the United States experience , International Meeting on Advanced Spine Techniques, 2005, Banff, Canada. * Source: *Wright N, XLIF the United States experience , International Meeting on Advanced Spine Techniques, 2005, Banff, Canada. XLIF indication Symptoms Pain in the back, buttocks, or leg XLIF Correction Reduces motion between the vertebrae Corrects alignment Restores proper disc height Alleviates pain 12

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