Workshop. Eric M. Massicotte, MD, MSc, MBA, FRCSC Associate Professor University of Toronto

Transcription

1 Workshop Eric M. Massicotte, MD, MSc, MBA, FRCSC Associate Professor University of Toronto

2 Copyright 2017 by Sea Courses Inc. All rights reserved. No part of this document may be reproduced, copied, stored, or transmitted in any form or by any means graphic, electronic, or mechanical, including photocopying, recording, or information storage and retrieval systems without prior written permission of Sea Courses Inc. except where permitted by law. Sea Courses is not responsible for any speaker or participant s statements, materials, acts or omissions.

3 Objectives Review case presentations to illustrate teaching points in presentations. Cases from Participants

4 Neck Pain presentation Questions you want to ask? location Onset Radiation Associate symptoms (Numbness, weakness, clumsiness, incontinence and gait instability) Past medical history

5 Neck Pain presentation What is the initial treatment? What do you need to see before you order imaging?

6 Case Illustration 76 Yr-Old Male 10 year history 2 yr decline in function Florid spastic gait Generalized quadriparesis ASIA C C1-2 stenosis atlanto- subluxation axial Procedure: PCDF C1/2 laminectomy occiput to C2 reconstruction

7 Case Illustration Baseline 6 Months 12 Months Nurick (0-5) MJOA (0-18) BBS (0-56) MWT Cadence/Seco nds Dynamometry Kg/F 0/0 60/51 sec /46 sec

8 Literature Support

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10 Clinico-anatomical Correlation

11 Cervical Radiculopathy

12 Surgical Management Clinical Details: 71 Yr-old man Case Illustration Presenting complaint: can t finish 18 holes of golf Pain in both legs after a few holes, getting worse over the last year However, wife adds he now loves to come grocery shopping and pushes the cart Physical exam is normal, no deficits

13 Surgical Management Case Illustration CT MRI axial MRI T2 sagittal

14 Take Home Messages 1- Look for Red Flags 2- Neurological deficits dictate indications for imaging & consultation 3- Not all treatment algorithms end with surgery 4- Surgical intervention for a select group of patients is very effective

15 Take Home Message IWPkXQn3JYYYsPnpGlIg

16 Surgical Management Case Illustration Spondylolisthesis Clinical Details: 48 yr-old nurse Back dominant pain failure of conservative management (8 mths of core strengthening) L4-5 retrolisthesis Grade II Motion on flexion extension x-ray

17 Surgical Management Case Illustration Cage L4 vertebral body L5 vertebral body Sacral promontor Spondylolisthesis

18 Surgical Management Case Illustration L4-5 Intra-operative L4-5 Post-operative L4-5 coronal L4-5 Sagittal Spondylolisthesis

19 Surgical Management Literature Support May 31, 2007

20 Case illustration 56 Year-old Man, Bed Ridden from Back Pain, Neurologically Intact

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22 Stereotactic Body Radiation Treatment (SBRT) Spinal Cord dose kept under 10 Gy

23 Neoplastic: Importance of Pathology Survival by Type of Proportion alive Primary Cancer Time (Days)

24 Neoplastic: Surgery over Radiation Lancet 2005; Patchell et al. Primary end-point Ambulatory time after Treatment Surgery + radiation S+RT median post treatment ambulation = 122 days RT median post treatment ambulation = 13 days

25 MASS for Mets Our experience with combination MASS and SBRT First 10 cases BREAST CANCER: SURGERY ON THE SPINE Technology in cancer Research & Treatment Feb JUNE 12, 2009 VALERIE SWANN WAS DIAGNOSED WITH BREAST CANCER IN 1987 AND IT HAS SINCE SPREAD TO HER SPINE - SOMETHING THAT HAPPENS IN CLOSE TO HALF OF ALL BREAST CANCER CASES. WATCH AS DR. MASSICOTTE PERFORMS A MINIMALLY INVASIVE PROCEDURE TO REMOVE A TUMOUR AND... WATCH VIDEO

26 Surgery Adjunct to Radiation Table 3. A summary of the Bilsky epidural disease grading classification Bilsky Grade Description 84% local control 0 No epidural disease 1a Epidural disease impinging the thecal sac but without deformation 1b Epidural disease deforming the thecal sac but not the spinal cord 1c Epidural disease deforming the thecal sac and spinal cord contact 2 Epidural spinal cord compression with CSF visible 3 Epidural spinal cord compression and no CSF visible Al-Omair et al 2013

27 MASS for Mets The role of minimally invasive techniques in the management of spinal neoplastic disease: a review JOURNAL OF NEUROSURGICAL SCIENCES Journal of Neurosurgical Sciences 2013 September;57(3):

28 Case presentation 15 year-old girl is struck by the ball during a soccer match Immediately is taken off the field of play with headache and neck pain. What are you next steps?

29 CONSENSUS STATEMENTS MANAGEMENT B. Later Management The 6-step Graduated Return to Play Protocol Step 1 - physical and mental rest. No return to activity until all symptoms have resolved, and do not recur even after provocative exercise during Steps 2-5. If any Symptoms or Signs Return, Stop the Process, and Return to Step 1. Never return to play if symptoms persist or recur with exercise!

30 CONSENSUS STATEMENTS MANAGEMENT Step 2 - Light aerobic exercise, such as walking or stationary cycling. Monitor for symptoms and signs. No resistance training or weight lifting. Step 3 - Sport specific activities and training (e.g. skating). Step 4. Drills without body contact. May add light resistance training and progress to heavier weights. Step 5. Begin drills with body contact. Step 6. Game play.

31 MANAGEMENT CLINICAL SUMMARY The return to play process is gradual, and begins after a doctor has given the player clearance to return to activity. If any symptoms/signs return during this process, the player must be re-evaluated by a physician. No return to play if any symptoms or signs persist. Remember, symptoms may return later that day or the next, not necessarily when exercising! Each step should take at least one day. Therefore, the minimum time for return is one week, and double that for children

32 Questions? Thank you.