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Spinal disorders Spinal disorders (or how do I deal with these back pain patients)(or how do I deal with these back pain patients)

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Neck and Back PainNeck and Back Pain

85% with no specific diagnosisLook for red flagsbed rest beyond 4 days not advised80-90% improve within six to eight weekswith or without treatment, 80% of patients

with sciatica eventually recover

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History and PhysicalHistory and Physical

History, history, history – the patient will tell you what is wrong almost ALWAYS!

Neurological exam– Motor– Reflex– Sensory– Other

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Red FlagsRed Flags

Cancer or infectionspinal fracture- trauma, prolonged steroids,

age greater that 70yrscauda equina syndrome- acute onset of

retention or incontinence, saddle anesthesia, weakness, fecal incontinence or loss of sphincter tone

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Motor ExamMotor Exam

5/5 Normal4(+-)/5 Some resistance3/5 Overcome gravity2/5 Able to move but not overcome gravity1/5 muscle flicker0/5 No movement

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Motor ExamMotor Exam

C5 -- Deltoids

C6 -- Biceps

C7 -- Triceps

C8/T1 -- Grip

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Motor ExamMotor Exam

L1/L2 -- Hip flexors

L3/L4 -- Leg extensors

L5 -- Dorsiflexion

S1 -- Plantarflexion

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ReflexesReflexes

Biceps -- C6Triceps -- C7

Knee Jerk -- L3/L4Ankle Jerk -- S1

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OtherOther

Spurlings Maneuver

Hoffman’s Sign

Straight Leg Raise or Crossed SLR

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Radiculopathy vs. Radiculopathy vs. MyelopathyMyelopathy

Radiculopathy -nerve root pressure

– back or neck pain radiating to extremity

– motor, sensory, reflex >>>>> decreased

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Radiculopathy vs. MyelopathyRadiculopathy vs. Myelopathy

Myelopathy -- spinal cord pressure– history of gait disturbance, numbness,

weakness, Lhermitte’s phenomenon– URINARY URGENCY or INCONTINENCE– motor and sensory >>>>>decreased– REFLEXES INCREASED

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Neck and Back Pain Neck and Back Pain w/wow/wo RadiculopathyRadiculopathy

(No Red Flags)(No myelopathy)History and physicalNo radiographs necessary for first month

unless weakness presentTreat with NSAIDS, Flexeril, Limited Use

of narcotics (no refills)

How can you treat?How can you treat?

Rest is not the same as limited duty or “don’t do anything” – Don’t aggravate!

PT – health maint., stretch, therapiesChiropractics - Manipulate, therapiesAcupuncture – Auricular, scalp, pplus,

protocols (systemic)Pain clinic – ESI, Facet blocks, spinal stim

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Persistent PainPersistent Pain

Neurosurgery-Okinawa Dogma

– SM/Dep/VIP with persistent Low Back Pain without radicular pain has pars defect until proven otherwise

– WRONG

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Persistent Pain Work-upPersistent Pain Work-up

Plain X-rays- AP, Lat, Obliques, Flex/Ext– In civilian community, 3 views may be enough

MRI

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Persistent PainPersistent Pain

If normal xray and mri– conservative pain management– PT– Limdu– If no improvement after 6-12 mos, refer to

MED BOARDIf normal xray and mri

– Neurosurgery has nothing to offer

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Other problemsOther problems

Myelopathy, Weakness, Pars defect– Refer to Neurosurgery

If persistent pain with failed conservative treatment and HNP, Stenosis, or fracture on x-ray / mri– Refer to (Tele)Neurosurgery

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Neurosurgery ClinicNeurosurgery Clinic

For weakness, myelopathy, pars defect- surgery recommended (considered)

For persistent pain-- options offered– PT, Pain clinic, Chiro, Acupuncture, – Surgery– Med Board

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Neurosurgery ClinicNeurosurgery Clinic

Use the clinic staff when possible

Always available

Clinical Practice Guidelines\Low Back Pain

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