evaluation of lower back and neck pain/media/files... · • obesity • smoking • sedentary...
TRANSCRIPT
![Page 1: Evaluation of Lower Back and Neck Pain/media/files... · • Obesity • Smoking • Sedentary lifestyle • Physically or psychologically strenuous work ... –foot drop, extremity](https://reader034.vdocuments.us/reader034/viewer/2022050605/5fac7ce7511fb551c8727d09/html5/thumbnails/1.jpg)
Evaluation of
Lower Back and Neck Pain
David F. Antezana, MD
Neurosurgery Division, The Oregon Clinic
Chair, Department of NeurosurgeryProvidence Portland Medical Center
Portland, Oregon
![Page 2: Evaluation of Lower Back and Neck Pain/media/files... · • Obesity • Smoking • Sedentary lifestyle • Physically or psychologically strenuous work ... –foot drop, extremity](https://reader034.vdocuments.us/reader034/viewer/2022050605/5fac7ce7511fb551c8727d09/html5/thumbnails/2.jpg)
Epidemiology
• Back pain is hard to truly understand and even harder to treat
• Second most common chief complaint for clinician visits in USA
• Estimated 80+% of adults experience significant back pain in a lifetime
• ~ 25% of adults report back pain lasting a whole day in the past 3 months
• Accounts for 15 million, or 2.5% of PCP visits
2
![Page 3: Evaluation of Lower Back and Neck Pain/media/files... · • Obesity • Smoking • Sedentary lifestyle • Physically or psychologically strenuous work ... –foot drop, extremity](https://reader034.vdocuments.us/reader034/viewer/2022050605/5fac7ce7511fb551c8727d09/html5/thumbnails/3.jpg)
Cost of Pain
• Over $100 billion/year
• 75% of cost due to only 5% of patients
• Deyo, et al, 2009, report the following increases in the last decade, translating to $$$$$$$:
629% ↑ in Medicare expenditures for ESIs
423% ↑ in expenditures for opioids for back pain
307% ↑ in the number of lumbar MRIs among Medicare beneficiaries
220% ↑ in spinal fusion surgery rates
3
![Page 4: Evaluation of Lower Back and Neck Pain/media/files... · • Obesity • Smoking • Sedentary lifestyle • Physically or psychologically strenuous work ... –foot drop, extremity](https://reader034.vdocuments.us/reader034/viewer/2022050605/5fac7ce7511fb551c8727d09/html5/thumbnails/4.jpg)
Risk Factors
• Age
• Obesity
• Smoking
• Sedentary lifestyle
• Physically or psychologically strenuous work
• Job dissatisfaction
• Gender: more females experience back pain
• Worker’s compensation or legal claim
• Low education level
• Psychosocial variables
• Somatization disorder
• Twin study found genetic factors more important than we previously thought
4
![Page 5: Evaluation of Lower Back and Neck Pain/media/files... · • Obesity • Smoking • Sedentary lifestyle • Physically or psychologically strenuous work ... –foot drop, extremity](https://reader034.vdocuments.us/reader034/viewer/2022050605/5fac7ce7511fb551c8727d09/html5/thumbnails/5.jpg)
Prognosis - Acute Back Pain
• 80%+ recover within 6 weeks
• Less than 5% will have serious systemic pathology
• Thus many different interventions appear to be
effective for acute back pain
5
![Page 6: Evaluation of Lower Back and Neck Pain/media/files... · • Obesity • Smoking • Sedentary lifestyle • Physically or psychologically strenuous work ... –foot drop, extremity](https://reader034.vdocuments.us/reader034/viewer/2022050605/5fac7ce7511fb551c8727d09/html5/thumbnails/6.jpg)
Acute - Management
• Short term activity modification
• Resume normal activity ASAP
• Walking, swimming especially helpful
• NSAIDs
• Tramadol may be comparable to codeine
• Chiropractic, acupuncture, massage, heat
• Opioids/narcotics: avoid, limit
6
![Page 7: Evaluation of Lower Back and Neck Pain/media/files... · • Obesity • Smoking • Sedentary lifestyle • Physically or psychologically strenuous work ... –foot drop, extremity](https://reader034.vdocuments.us/reader034/viewer/2022050605/5fac7ce7511fb551c8727d09/html5/thumbnails/7.jpg)
And now . . .
. . . the 5%
Who Need Further Intervention
7
![Page 8: Evaluation of Lower Back and Neck Pain/media/files... · • Obesity • Smoking • Sedentary lifestyle • Physically or psychologically strenuous work ... –foot drop, extremity](https://reader034.vdocuments.us/reader034/viewer/2022050605/5fac7ce7511fb551c8727d09/html5/thumbnails/8.jpg)
But first, a friendly reminder:
Oregon Health Plan
and Medicaid
require spinal fusion candidates
to be
smoke-free for
6 months prior to surgery.
8
![Page 9: Evaluation of Lower Back and Neck Pain/media/files... · • Obesity • Smoking • Sedentary lifestyle • Physically or psychologically strenuous work ... –foot drop, extremity](https://reader034.vdocuments.us/reader034/viewer/2022050605/5fac7ce7511fb551c8727d09/html5/thumbnails/9.jpg)
Physiatrist—Rehabilitation Medicine
• A possible alternative or bridge to seeing a
neurosurgeon
• Highly competent at evaluating neck and back
problems, and treating non-operative cases
9
![Page 10: Evaluation of Lower Back and Neck Pain/media/files... · • Obesity • Smoking • Sedentary lifestyle • Physically or psychologically strenuous work ... –foot drop, extremity](https://reader034.vdocuments.us/reader034/viewer/2022050605/5fac7ce7511fb551c8727d09/html5/thumbnails/10.jpg)
Pathology
Conditions causing neck and back pain
• Scoliosis/kyphosis
• Neoplasms
• Infections
• Degenerative disease
• Spondylosis
• Osteoarthritis
• Inflammation
10
![Page 11: Evaluation of Lower Back and Neck Pain/media/files... · • Obesity • Smoking • Sedentary lifestyle • Physically or psychologically strenuous work ... –foot drop, extremity](https://reader034.vdocuments.us/reader034/viewer/2022050605/5fac7ce7511fb551c8727d09/html5/thumbnails/11.jpg)
Pathology
• Normal aging process
• ↓ fluid content in nucleus pulposus – less efficient
shock absorbers
• Degeneration of the posterior ligament
• Hypertrophy of facet joint and ligamentum flavum
11
![Page 12: Evaluation of Lower Back and Neck Pain/media/files... · • Obesity • Smoking • Sedentary lifestyle • Physically or psychologically strenuous work ... –foot drop, extremity](https://reader034.vdocuments.us/reader034/viewer/2022050605/5fac7ce7511fb551c8727d09/html5/thumbnails/12.jpg)
Degenerative Spine
12
![Page 13: Evaluation of Lower Back and Neck Pain/media/files... · • Obesity • Smoking • Sedentary lifestyle • Physically or psychologically strenuous work ... –foot drop, extremity](https://reader034.vdocuments.us/reader034/viewer/2022050605/5fac7ce7511fb551c8727d09/html5/thumbnails/13.jpg)
Etiology
• Trauma
• Poor mechanics
• Valsalva
• Overuse/repetition
• Genetics
• Age
13
![Page 14: Evaluation of Lower Back and Neck Pain/media/files... · • Obesity • Smoking • Sedentary lifestyle • Physically or psychologically strenuous work ... –foot drop, extremity](https://reader034.vdocuments.us/reader034/viewer/2022050605/5fac7ce7511fb551c8727d09/html5/thumbnails/14.jpg)
Manifestations: Back
• Aching pain low back, buttocks
• Sciatica: sharp, radiating pain down entire leg
• Pain ↑ with valsalva
• ↑ pain with prolonged sitting
14
![Page 15: Evaluation of Lower Back and Neck Pain/media/files... · • Obesity • Smoking • Sedentary lifestyle • Physically or psychologically strenuous work ... –foot drop, extremity](https://reader034.vdocuments.us/reader034/viewer/2022050605/5fac7ce7511fb551c8727d09/html5/thumbnails/15.jpg)
Manifestations: Neck
• Usually older adults
• Lower cervical area
• Herniation may be lateral or central
• Cervical disc protrusion can cause root and cord compression
15
![Page 16: Evaluation of Lower Back and Neck Pain/media/files... · • Obesity • Smoking • Sedentary lifestyle • Physically or psychologically strenuous work ... –foot drop, extremity](https://reader034.vdocuments.us/reader034/viewer/2022050605/5fac7ce7511fb551c8727d09/html5/thumbnails/16.jpg)
Helpful Tests That You Can Do
• Sensation
• Reflexes
• Balance, Romberg
• Gait
• Heel/toe
• Cranial loading
• Specific physiological tests, below:
16
![Page 17: Evaluation of Lower Back and Neck Pain/media/files... · • Obesity • Smoking • Sedentary lifestyle • Physically or psychologically strenuous work ... –foot drop, extremity](https://reader034.vdocuments.us/reader034/viewer/2022050605/5fac7ce7511fb551c8727d09/html5/thumbnails/17.jpg)
Lasegue’s Sign, a.k.a. Straight Leg Lift
While patient is supine, lift patient’s straight leg.
Positive Lasegue’s = pain or spasm in posterior thigh
or back.
17
![Page 18: Evaluation of Lower Back and Neck Pain/media/files... · • Obesity • Smoking • Sedentary lifestyle • Physically or psychologically strenuous work ... –foot drop, extremity](https://reader034.vdocuments.us/reader034/viewer/2022050605/5fac7ce7511fb551c8727d09/html5/thumbnails/18.jpg)
Trendelenberg’s Sign
Patient stands on
affected leg.
Positive: pelvis
droops on the
unaffected side.
18
![Page 19: Evaluation of Lower Back and Neck Pain/media/files... · • Obesity • Smoking • Sedentary lifestyle • Physically or psychologically strenuous work ... –foot drop, extremity](https://reader034.vdocuments.us/reader034/viewer/2022050605/5fac7ce7511fb551c8727d09/html5/thumbnails/19.jpg)
Hoffman’s Sign
Hold patient’s wrist. Firmly flip the middle fingernail.
Positive Hoffman’s sign elicits reflexive contraction of the thumb and index finger.
19
![Page 20: Evaluation of Lower Back and Neck Pain/media/files... · • Obesity • Smoking • Sedentary lifestyle • Physically or psychologically strenuous work ... –foot drop, extremity](https://reader034.vdocuments.us/reader034/viewer/2022050605/5fac7ce7511fb551c8727d09/html5/thumbnails/20.jpg)
Spurling’s Sign
Patient extends the neck and rotates and laterally bends the head toward the symptomatic side.
Compress the top of the patient's head. Positive when the maneuver elicits radicular arm pain.
20
![Page 21: Evaluation of Lower Back and Neck Pain/media/files... · • Obesity • Smoking • Sedentary lifestyle • Physically or psychologically strenuous work ... –foot drop, extremity](https://reader034.vdocuments.us/reader034/viewer/2022050605/5fac7ce7511fb551c8727d09/html5/thumbnails/21.jpg)
Wadell’s Signs
21
![Page 22: Evaluation of Lower Back and Neck Pain/media/files... · • Obesity • Smoking • Sedentary lifestyle • Physically or psychologically strenuous work ... –foot drop, extremity](https://reader034.vdocuments.us/reader034/viewer/2022050605/5fac7ce7511fb551c8727d09/html5/thumbnails/22.jpg)
22
Diagnostic Work-up
• MRI – gold standard for neural and soft
tissue problems
• CT scan – standard for bone imaging
• Nerve conduction studies
• Lab work – sedimentation rate/ESR, CBC,
urinalysis
• Bone scan – if tumor or infection suspected
• Lumbar spine films – fracture, alignment
• Scoliosis series films
![Page 23: Evaluation of Lower Back and Neck Pain/media/files... · • Obesity • Smoking • Sedentary lifestyle • Physically or psychologically strenuous work ... –foot drop, extremity](https://reader034.vdocuments.us/reader034/viewer/2022050605/5fac7ce7511fb551c8727d09/html5/thumbnails/23.jpg)
One More Friendly Reminder
Oregon Health Plan
and Medicaid
require spinal fusion candidates
to be
smoke-free for
6 months prior to surgery.
23
![Page 24: Evaluation of Lower Back and Neck Pain/media/files... · • Obesity • Smoking • Sedentary lifestyle • Physically or psychologically strenuous work ... –foot drop, extremity](https://reader034.vdocuments.us/reader034/viewer/2022050605/5fac7ce7511fb551c8727d09/html5/thumbnails/24.jpg)
Complex Spinal Deformity Conference
– Surgeon
– Anesthesiologist
– Neuroradiologist
– OR Nurse
– Floor Nurse
– Physical Therapist
– Nutritionist
– Other Specialists
All meet monthly
to discuss our most
complex spinal
deformity cases
PPMC is the only community
hospital doing this in the NW
24
![Page 25: Evaluation of Lower Back and Neck Pain/media/files... · • Obesity • Smoking • Sedentary lifestyle • Physically or psychologically strenuous work ... –foot drop, extremity](https://reader034.vdocuments.us/reader034/viewer/2022050605/5fac7ce7511fb551c8727d09/html5/thumbnails/25.jpg)
Complex Spinal Deformity Conference
Example #1
• 78 y/o f, BMI 27, c/o LBP and scoliosis
• LBP worse on left side; occasional numbness in L great toe; no radicular pain down leg
• Exacerbated by using kickboard while swimming; standing or walking 15+ min; sleeping; mopping; vacuuming
• Ameliorated by sitting
• Comorbidities include osteoporosis; RAD w/ persistent cough; hypertension; ankle swelling; unhealed iliac fracture; paroxysmal supraventricular tachycardia/PSVT; hypothyroid
• PMH: cervical pain ESI resolved, breast CA, hyperglycemia, anemia, gout
![Page 26: Evaluation of Lower Back and Neck Pain/media/files... · • Obesity • Smoking • Sedentary lifestyle • Physically or psychologically strenuous work ... –foot drop, extremity](https://reader034.vdocuments.us/reader034/viewer/2022050605/5fac7ce7511fb551c8727d09/html5/thumbnails/26.jpg)
Complex Spinal Deformity Conference
Example #1
• DEXA scan T-score
10/7/2014: -2.8
10/30/2009: -1.9
• 61° scoliotic curve along
lumbar spine
• Compensatory thoracic curve
• Left lateral listhesis of L2 on L3
and L3 on L4
26
![Page 27: Evaluation of Lower Back and Neck Pain/media/files... · • Obesity • Smoking • Sedentary lifestyle • Physically or psychologically strenuous work ... –foot drop, extremity](https://reader034.vdocuments.us/reader034/viewer/2022050605/5fac7ce7511fb551c8727d09/html5/thumbnails/27.jpg)
Complex Spinal Deformity Conference
Example #2
• 30 y/o m, BMI 23, originally presented to
pulmonologist c/o dyspnia
• FVC 1.83; 52%
• Pulmonologist referred patient to Dr. Yost because
pulmonary function compromised by 140+°
kyphoscoliosis in upper thoracic spine
• early myelopathy, as well
• Latent TB w/o evidence of active TB
27
![Page 28: Evaluation of Lower Back and Neck Pain/media/files... · • Obesity • Smoking • Sedentary lifestyle • Physically or psychologically strenuous work ... –foot drop, extremity](https://reader034.vdocuments.us/reader034/viewer/2022050605/5fac7ce7511fb551c8727d09/html5/thumbnails/28.jpg)
Complex Spinal Deformity Conference
Example #2
28
![Page 29: Evaluation of Lower Back and Neck Pain/media/files... · • Obesity • Smoking • Sedentary lifestyle • Physically or psychologically strenuous work ... –foot drop, extremity](https://reader034.vdocuments.us/reader034/viewer/2022050605/5fac7ce7511fb551c8727d09/html5/thumbnails/29.jpg)
Surgical Interventions
• Discectomy – removal of nuclear disc material
• Hemilaminectomy – part of lamina and posterior arch removed
• Laminectomy – lamina removed
• Foraminotomy – intervertebral foramen is enlarged to reduce pressure on nerve root; usually performed in the cervical area
• Spinal fusion – immobilize and stabilize vertebral column
• Fusion with bone chips/graft or plates and screws
29
![Page 30: Evaluation of Lower Back and Neck Pain/media/files... · • Obesity • Smoking • Sedentary lifestyle • Physically or psychologically strenuous work ... –foot drop, extremity](https://reader034.vdocuments.us/reader034/viewer/2022050605/5fac7ce7511fb551c8727d09/html5/thumbnails/30.jpg)
Complications
• Hematoma
– severe incisional pain, decreased motor function,
urinary retention
• Nerve root injury
– foot drop, extremity weakness
• CSF leak
– abnormal connection between the subarachnoid
space and incision, dressing damp, possible
infection/meningitis
30
![Page 31: Evaluation of Lower Back and Neck Pain/media/files... · • Obesity • Smoking • Sedentary lifestyle • Physically or psychologically strenuous work ... –foot drop, extremity](https://reader034.vdocuments.us/reader034/viewer/2022050605/5fac7ce7511fb551c8727d09/html5/thumbnails/31.jpg)
Postoperative Management
• Vital signs
• Neurological assessment: weakness, numbness, pain could indicate nerve root compression
• Monitor urinary function for retention or overflow
• Monitor GI function – possible ileus
• Pain assessment and management
• Fluid and electrolyte balance
• Blood loss replacement
• Prevention of deep vein thrombosis– Thigh-high thrombosis embolic deterrent, TED
– Sequential compression devices, SCDs
31
![Page 32: Evaluation of Lower Back and Neck Pain/media/files... · • Obesity • Smoking • Sedentary lifestyle • Physically or psychologically strenuous work ... –foot drop, extremity](https://reader034.vdocuments.us/reader034/viewer/2022050605/5fac7ce7511fb551c8727d09/html5/thumbnails/32.jpg)
References
1. Deyo, RA, et al. Descriptive epidemiology of low-backpain and its related medical care in the United States. Spine (Phila Pa 1976) 1987; 12:264.
2. Hart LG, Deya RA, Cherkin DC. Physician office visits for low back pain. Frequency, clinical evaluation and treatment patterns from a US national survey. Spine (Phila Pa 1976) 1995; 20:11.
3. Katz JN. Lumbar disc disorder and low-back pain: socioeconomic factors and consequences. J Bone Joint Surg Am 2006; 88 Supl 2:21.
4. Battié, Michele C. et al., The Twin Spine Study: Contributions to a changing view of disc degeneration. The Spine Journal 2008; 9:1, 47-59
32
![Page 33: Evaluation of Lower Back and Neck Pain/media/files... · • Obesity • Smoking • Sedentary lifestyle • Physically or psychologically strenuous work ... –foot drop, extremity](https://reader034.vdocuments.us/reader034/viewer/2022050605/5fac7ce7511fb551c8727d09/html5/thumbnails/33.jpg)