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

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

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

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

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

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

And now . . .

. . . the 5%

Who Need Further Intervention

7

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

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

Pathology

Conditions causing neck and back pain

• Scoliosis/kyphosis

• Neoplasms

• Infections

• Degenerative disease

• Spondylosis

• Osteoarthritis

• Inflammation

10

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

Degenerative Spine

12

Etiology

• Trauma

• Poor mechanics

• Valsalva

• Overuse/repetition

• Genetics

• Age

13

Manifestations: Back

• Aching pain low back, buttocks

• Sciatica: sharp, radiating pain down entire leg

• Pain ↑ with valsalva

• ↑ pain with prolonged sitting

14

Manifestations: Neck

• Usually older adults

• Lower cervical area

• Herniation may be lateral or central

• Cervical disc protrusion can cause root and cord compression

15

Helpful Tests That You Can Do

• Sensation

• Reflexes

• Balance, Romberg

• Gait

• Heel/toe

• Cranial loading

• Specific physiological tests, below:

16

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

Trendelenberg’s Sign

Patient stands on

affected leg.

Positive: pelvis

droops on the

unaffected side.

18

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

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

Wadell’s Signs

21

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

One More Friendly Reminder

Oregon Health Plan

and Medicaid

require spinal fusion candidates

to be

smoke-free for

6 months prior to surgery.

23

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

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

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

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

Complex Spinal Deformity Conference

Example #2

28

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

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

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

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