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EVALUATE, TREAT AND WHEN TO REFERRED FLAGS
Mid‐Atlantic Occupational Regional Conference andEnvironmental Medicine
October 6, 2018
Marc J. Levine, MDRothman Institute
Director Spine Surgery Program‐RWJUH/HamiltonPresident Elect‐Medical Society of New JerseyVice President‐Eastern Orthopaedic Association
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Where Are We GoingAnatomyExam/HistoryTreatmentsCommon PathologiesSurgical Options/Advances
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CERVICAL SPINE ANAOTOMY
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CERVICAL SPINE ANATOMY
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CERVICAL SPINE ANATOMY
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CERVICAL SPINE ANATOMY
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Cervical Spine Neural Anatomy
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Spinal Cord Anatomy
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Spinal Cord Anatomy
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PLAIN XRAYS
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COMPUTED TOMOGRAPHY CT SCANS
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CT SCANS C1‐C2
NORMAL
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MRI VS CT
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MRI AXIAL CERVICAL NORMAL
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LUMBAR SPINE ANATOMY
Lumbar Spine: Lateral View Intervertebral Disc
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LUMBAR SPINE ANATOMYBUILDING BLOCKS OF THE LUMBAR SPINE
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INTERVERTEBRAL DISC‐Annulus Fibrosus‐Nucleus Pulposus
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Ligaments: Lumbar SpineLateral View
‐sagittal‐cortical bone‐cancellous bone
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Lumbar SpineNeuroanatomy
Neuroforamen• Lateral view
Spinal Cord/Conus/Cauda Equina
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Lumbar Spine XRAYS
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Computed TomographyCT
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Computed TomographyCT
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MRI Sagittal
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MRI SAGITTAL
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MRIAXIAL
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OTHER IMAGINGTESTS
• Myelograms• Post myelogram CT scans• Discograms• Contrasted MRIs• Standing MRIs• Bone Scans• EMG/NCS
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Treatment of Acute Low Back Pain“OUT OF ORDER”
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MANAGEMENT OF ACUTE BACK PAIN
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Management of Acute Back Pain“NO RED FLAGS”
DOOR NUMBER 1• Activity Modification• Oral Steroids• NSAIDS• Muscle Relaxants• Physical Therapy• Pain Medications/Opioids• RE ASSURANCE!!
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Management of Acute Back Pain“NO RED FLAGS”
Door Number 2• Pain Management• Epidural Steroids• Facet Injections• Medial Branch Blocks• SI Joint Injections• Trigger Point Injections• Occipital Nerve Injections
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Management of Acute Back Pain
Door Number 3• Spinal Surgeon
When to Refer• Failure to respond to Door
Number 1• Failure to respond to Door
Number 2• RED FLAGS
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ACUTE NECK/BACK PAINHISTORY AND PHYSICAL
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HISTORY FOR ACUTE BACK PAIN
HISTORY OF INJURY• MVA• FALL IMPACT• TWIST• LIFTING/STRAIN• IMPACT• “ENERGY of INJURY”
• PAST HISTORY• Malignancy, infections, surgery,
medical, osteoporosis
HISTORY OF SYMPTOMS• Onset to event• Severity 0‐10• Weakness• Lhermittes• Gait• Bowel Bladder• Saddle Paresthesias• Unilateral/Bilateral
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HISTORY FOR ACUTE BACK PAIN
HISTORY OF INJURY• MVA• FALL IMPACT• TWIST• LIFTING/STRAIN• IMPACT• “ENERGY of INJURY”
• PAST HISTORY• Malignancy, infections, surgery,
medical, osteoporosis
HISTORY OF SYMPTOMS• Onset to event• Severity 0‐10• Weakness• Lhermittes• Gait• Bowel Bladder• Saddle Paresthesias• Unilateral/Bilateral
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Motor Vehicle Accident‐Neck PainGET XRAY
• NORMAL• LATERAL
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CERVICAL SPINEXRAY RED FLAGS
Soft Tissue Swelling
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CERVICAL SPINEXRAY RED FLAGS
ALIGNMENT AND SOFT TISSUE
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Lumbar SpineXray Red Flags
“Energy of Injury”
• Compression Fracture
• Superior/Inferior• INTACT Posterior Cortex
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Lumbar Spine XrayRed Flags
“Energy of Injury”
• Burst Fracture• Pedicle Widening• Bone Retropulsion
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Lumbar Spine XraysRed FlagsPlain Xrays
• CHANCE FRACTURE• MVA‐seat belt injury• Compression/Flexion• Boney/Soft Tissue
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HISTORY FOR ACUTE BACK PAIN
HISTORY OF INJURY• MVA• FALL IMPACT• TWIST• LIFTING/STRAIN• IMPACT• “ENERGY of INJURY”
• PAST HISTORY• Malignancy, infections, surgery,
medical, osteoporosis
HISTORY OF SYMPTOMS• Onset to event• Severity 0‐10• Weakness• Lhermittes• Gait• Bowel Bladder• Saddle Paresthesias• Unilateral/Bilateral
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History of SymptomsRed FlagsLhermitte’s
• Symptom/Exam• Spinal Cord Sign• “I feel electrical shocks”
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History of SymptomsRed Flags
Gait and Clumsiness• Symptom/Exam• “I am falling over when I walk”• “I am dropping things”• Cervical Myelopathy
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History of SymptomsRed Flags
“CAUDA EQUINA”
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Cauda EquinaSyndrome‐HistoryLow Back PainSaddle HypoesthesiaBowel/Bladder Dysfunction
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HISTORY FOR ACUTE BACK PAIN
HISTORY OF INJURY• MVA• FALL IMPACT• TWIST• LIFTING/STRAIN• IMPACT• “ENERGY of INJURY”
• PAST HISTORY• Malignancy, infections, surgery,
medical, osteoporosis
HISTORY OF SYMPTOMS• Onset to event• Severity 0‐10• Weakness• Lhermittes• Gait• Bowel Bladder• Saddle Paresthesias• Unilateral/Bilateral
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Past History Red Flags
Awareness‐Suspicion
• Inflammatory Arthritis • Malignancy• Previous Spine Surgery• Infection History• Osteoporsis
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Where Are We Going“Where Have We Been”AnatomyExam/HistoryTreatmentsCommon PathologiesSurgical Options/Advances
OFF WE GO
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Lumbar Spine ExamRed Flag‐Weakness
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Signs and SymptomsRadicular PainWeaknessNumbnessBack PainStraight Leg Raise
AXIAL BACK AND/ORRADICULAR PAIN
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Cauda EquinaSyndrome‐ExamDecreased PerinealSensaton
Decreased Rectal Tone
Depressed ReflexesKneeAnkleBC Reflex
REFER
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Cauda EquinaSyndrome‐PathologyCompression of CaudaEquina
DiscTumorTraumaEpidural Process‐Hematoma‐Abscess
NOT THE SPINAL CORD
REFER
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EXAMCervical Spine Innervations
Refer for Weakness
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Deep Tendon ReflexesRed Flags
• Asymetry• Brisk
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Physical ExamRed Flags
RADICULOPATHY VS. MYELOPATHYREFER
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Upper Motor SignsMyelopathyRed Flags
HoffmanBabinskiClonus
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Where Are We Going“Where Have We Been”AnatomyExam/HistoryTreatmentsCommon PathologiesSurgical Options/Advances
OFF WE GO
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Cervical Disc Herniation
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Cervical HNPClinical ‐Radiculopathy or MyelopathyNeck PainPlain xrays often normalMRI BestMyelo/CT option
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ACDFANTERIOR CERVICAL DECOMPRESSION AND FUSION
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Anterior Cervical Decompression and FusionACDF
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ACDF
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CERVICAL DISC ARTHROPLASTY
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Lumbar HNPMRI
L5‐S1Sagittal
L5‐S1Axial
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Lumbar SpineDiscectomy
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Lumbar DiscectomySchematic
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Lumbar Stenosis
• Normal 3D Schematic • Stenosis =Narrowing
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Lumbar StenosisMRI Sagital
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Lumbar StenosisMRI Axial
• Normal Stenosis
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Lumbar StenosisLaminectomy
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Vertebral Body Compression Fracture (VCF)
Normal Fractured
Wedge-shaped
Depressed endplate(s)
Spine shorter, tilted forward
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Allows precise, minimally invasive access to the vertebral body and provides a working channel
KyphX® Introducer Tool Kit
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KyphX® IBT Inflation
Reduces the fracture, compacts the bone, and may elevate the endplates
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Leaves a defined cavity within the vertebral body
KyphX® IBT Removal
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Case Study
Patient: 55 YO MaleDiagnosis: Secondary osteoporosisFracture Reduced: L-1, 3 day old
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LUMBAR FUSIONWE HAVE COME A LONG WAY
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GOALS OF LUMBAR FUSION
• Stabilize Spine• Take Away Motion• Re‐Create Anatomy• Nerve Decompression• **TAKE AWAY PAIN**• Prevent Recurrent Problems
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Traditional Lumbar “Open” FusionsStill Has a Place
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Minimally Invasive TLIF/PSFTransforaminal Interbody Fusion/Posterior Spinal Fusion
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MIS TLIF/PSF vs. OPEN
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X‐treme Lateral Interbody FusionXLIF
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Caudal –Left Lateral UP‐Cranial
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Retractor PlacementImportant AP/Lat Flouro Views
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XLIF
Large Implant Large Surface Area
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Degenerative Disc Disease
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Anterior Lumbar Interbody FusionALIF
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MIS AdvantagesClinical
• Less Blood Loss• Less Transfusions• Less Pain Med Requirements• Less Muscle Dissection• Clinical Benefits 1‐2 years• Similar Long Term Benefits• LESS PHYSICIAN WEAR AND TEAR
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SUMMARY ACUTE Back Pain
RED FLAGS AND WHEN TO REFER
• Cauda Equina Syndrome: saddle paresthesias, bowel/bladder, • Cervical Myelopathy: hyper‐reflexia, upper motor signs,• Energy of Injury: fractures• Motor Weakness and Progression• Radicular Pain‐”relative”‐sooner than axial back pain• Beware of concomitant medical issues• Failure to respond to non‐operative treatment• When in doubt—”NOT A SIGN OF WEAKNESS”
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THANK YOU