Evaluation and Management of Select Spine Conditions

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Felicity Greer
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Back Pain Second most frequent primary care complaint 80 90% of adults - at least once in their life Leading cause for visits to: Orthopedist, Neurosurgeon, Occupational medicine Bad News Leading

1 Evaluation and Management of Select Spine Conditions Michael E. Zychowicz, DNP, ANP, ONP, FAAN, FAANP Professor & Director, MSN Program Lead Faculty, Orthopedic NP Specialty Director, Duke-Durham VA Nursing Academic Partnership Duke University School of Nursing Back Pain Second most frequent primary care complaint 80 90% of adults - at least once in their life Leading cause for visits to: Orthopedist, Neurosurgeon, Occupational medicine Bad News Leading cause of work disability 4% of patients have symptoms > 6 months Good News Symptoms are usually self limiting 85% of patients improve within 1 month Even without treatment Back Pain Back pain is not always just back pain!!!!!!! Many differentials Strain/ sprain, degenerative disc disease, arthritis Spondylolisthesis, fibromyalgia, spinal stenosis Cancer pain, infection, cauda equina, fracture Abdominal aortic aneurysm, disc herniation, spinal tumor Pyelonephritis, renal calculi, endometriosis Spinal TB, Paget s disease, etc, etc, etc 1

2 Common Causes of Back Pain Sprain/strain/ nonspecific low back pain Usually low back pain +/- leg discomfort Decreased range of motion Possible guarding or muscle spasm Degenerative disease/ Arthritis back pain +/- leg pain Decreased range of motion Pain with activities May or may not have neuro deficit Cancer Prior Hx of CA Unexplained weight loss +/- change in appetite Night or rest pain > 50y/o and <20y/o Failure to improve with therapy Spinal infection Fever Hx of IV drug use Recent bacterial infection Immunocompromised state Steroid, organ transplant, diabetes, HIV Pain at rest Back Pain: Red Flags Fracture Use of corticosteroids Age greater than 70 History of osteoporosis Recent significant trauma Back Pain: Red Flags Cauda equina syndrome Urinary retention or incontinence Saddle anesthesia Anal sphincter tone decrease or fecal incontinence Lower extremity weakness, numbness or progressive neurologic deficit Usually bilateral IMMEDIATE surgical consultation!!! 2

Imaging X-ray Fractures, bony tumors, arthritis, disc height Consider if unimproved in 6-8 weeks or trauma Consider if suspicious for red

$myelopathy, infection, neoplasm Trauma bone edema from fractures Radicular sx w/ motor/ reflex deficit Radicular sx unimproved in 6-8 weeks$ $Osteomyelitis, neoplasm, metastatic disease, occult fracture Back Pain Treatment First visit Physical Exam Consider referral if red flags$ exercise Walking, stationary bike, gentle pool movement Medication management NSAIDS inflammation and pain Muscle relaxers muscle spasm (Non)

exercise Walking, stationary bike, gentle pool movement Medication management NSAIDS inflammation and pain Muscle relaxers muscle spasm (Non)

3 Imaging X-ray Fractures, bony tumors, arthritis, disc height Consider if unimproved in 6-8 weeks or trauma Consider if suspicious for red flag problems MRI Very good for imaging soft tissues Disc herniation, tumor, infection, cord or nerve compression Consider if suspicious for myelopathy, infection, neoplasm Trauma bone edema from fractures Radicular sx w/ motor/ reflex deficit Radicular sx unimproved in 6-8 weeks Imaging CT Scan Good for imaging cortical bone fractures arthritis Bone Scan Useful if plain x-rays are normal and suspicious for: Osteomyelitis, neoplasm, metastatic disease, occult fracture Back Pain Treatment First visit Physical Exam Consider referral if red flags present Treat low back pain/ radicular symptoms Activity modification No heavy lifting, pushing or pulling Progressive ROM and light aerobic exercise Walking, stationary bike, gentle pool movement Medication management NSAIDS inflammation and pain Muscle relaxers muscle spasm (Non) Narcotic analgesics pain Treatment Guideline: Modified from American Academy of Orthopedic Surgeons (2002) Adult Patients with Low Back Pain/ Sciatica [Acute] 3

4 Back Pain Treatment Treatment options cont. Physical therapy/ home exercise ROM, stretching, strengthening, heat/ cold, ultrasound, TENS, traction, massage Adjuncts conflicting evidence Shoe inserts, back belts, lumbar corsets, biofeedback, chiropractor, acupuncture Bed rest 2 days at most Prolonged may lead to deconditioning Treatment Guideline: Modified from American Academy of Orthopedic Surgeons (2002) Adult Patients with Low Back Pain/ Sciatica [Acute] Back Pain Treatment Follow-up 1-3 weeks as indicated by pain and injury If unimproved or worsening symptoms Continue or modify plan for up to 4-6 wks Reassurance/ patience is helpful Refer as needed If improved Off meds/ Return to activities Maintain stretching/ strengthening program Treatment Guideline: Modified from American Academy of Orthopedic Surgeons (2002) Adult Patients with Low Back Pain/ Sciatica [Acute] Back Pain Treatment At 4-6 weeks If the patient is unimproved or worse Repeat psychosocial and physical assessment Reconsider red flag differentials Obtain AP and Lateral lumbar spine x-ray Consider MRI and referral: neurologic deficit Modify meds/ treatment as needed If improved Off meds/ Return to activities Maintain stretching/ strengthening program Treatment Guideline: Modified from American Academy of Orthopedic Surgeons (2002) Adult Patients with Low Back Pain/ Sciatica [Acute] 4

Back Pain Treatment Follow up at 8-12 weeks If unresolved or worse Repeat psychosocial and physical assessment Reconsider red-flag differentials Consider MRI Modify meds/ treatment as needed Consult

Orthopedic Surgeons (2002) Adult Patients with Low Back Pain/ Sciatica [Acute] Lumbar Radiculopathy AKA: Sciatica Neurogenic pain Nerve root compression or chemical irritation Mostly leg pain across

5 Back Pain Treatment Follow up at 8-12 weeks If unresolved or worse Repeat psychosocial and physical assessment Reconsider red-flag differentials Consider MRI Modify meds/ treatment as needed Consult ortho or neuro for further evaluation/treatment If resolved Off medications/ Return to activities Maintain stretching/ strengthening program Treatment Guideline: Modified from American Academy of Orthopedic Surgeons (2002) Adult Patients with Low Back Pain/ Sciatica [Acute] Lumbar Radiculopathy AKA: Sciatica Neurogenic pain Nerve root compression or chemical irritation Mostly leg pain across dermatome May have some back pain Causes Disc herniation Spinal stenosis Primary or metastatic tumor Lumbar Radiculopathy A 38 y/o male comes to the office c/o constant left lateral thigh and calf pain. He had a sudden onset of pain yesterday after lifting a heavy object at home. The pain is worsening. He is having difficulty finding a comfortable position. NSAIDS have not helped the pain. No bowel or bladder dysfunction. 5

Lumbar Radiculopathy Physical exam May have thoracic shift (+) straight leg raise or femoral stretch test Evaluate weakness, reflexes, sensation Differentials Disc herniation, stenosis Femoral

6 Lumbar Radiculopathy Physical exam May have thoracic shift (+) straight leg raise or femoral stretch test Evaluate weakness, reflexes, sensation Differentials Disc herniation, stenosis Femoral cutaneous nerve entrapment Trochanteric bursitis and ITB syndrome Primary or metastatic tumor Lumbar Radiculopathy Diagnostics X-ray Evaluate for structural pathology MRI Evaluate for herniation, stenosis, tumor EMG May help clarify clinical picture Treatment Relative rest and reassurance NSAIDS, pain meds, consider oral steroids Consider Physical therapy or chiropractic Possible epidural steroids See treatment for herniation and stenosis Nucleus pushes partly or fully through annulus Pressure on nerve root or ligament Radicular symptoms Possible back pain Usually from disc degeneration Trauma or repetitive loading Most commonly at L4-5 Men > Female Smoking increases risk Lumbar Disc Herniation 6

Lumbar Disc Herniation A 46 y/o male presents to the office c/o sudden onset of severe right lateral leg pain, numbness and tingling with mild back pain.

Lumbar Disc Herniation Physical exam Weakness, loss of DTR, or decreased sensation Gait abnormality or drop foot Straight leg raise Femoral stretch test Cauda

Lumbar Disc Herniation Imaging X-ray and MRI Symptoms lasting > 6 weeks Trauma or suspected pathology Weakness and/ or loss of reflexes Cauda equina syndrome Most

7 Lumbar Disc Herniation A 46 y/o male presents to the office c/o sudden onset of severe right lateral leg pain, numbness and tingling with mild back pain. He was at work yesterday lifting a heavy object when he developed the pain. No difficulty ambulating. No bowel or bladder dysfunction. Lumbar Disc Herniation Physical exam Weakness, loss of DTR, or decreased sensation Gait abnormality or drop foot Straight leg raise Femoral stretch test Cauda equina syndrome (Emergency) Saddle anesthesia or bowel/ bladder change Loss of rectal tone Differentials Degenerative disc disease, spinal stenosis Back strain Lumbar Disc Herniation Imaging X-ray and MRI Symptoms lasting > 6 weeks Trauma or suspected pathology Weakness and/ or loss of reflexes Cauda equina syndrome Most improve without surgery Proper lifting, Activities as tolerated NSAIDS, muscle relaxer, narcotics, oral steroids Physical therapy, chiropractic, acupuncture Epidural steroids or selected nerve root block 7

Lumbar Disc Herniation Surgery Emergent with Cauda equina Consider if unimproved in 6-8 weeks Consider if weakness, loss of reflexes intractable pain Post op Disc degeneration Recurrent HNP Epidural

heredity, smoking Disc dehydrates and looses height Ligaments not as tight Increased abnormal motion causing tears Foraminal stenosis Facet degeneration Spurring and inflammation Onset 30 60 years

8 Lumbar Disc Herniation Surgery Emergent with Cauda equina Consider if unimproved in 6-8 weeks Consider if weakness, loss of reflexes intractable pain Post op Disc degeneration Recurrent HNP Epidural fibrosis and chronic pain Infection and discitis Lumbar Degenerative Disc Disease Degeneration of intervertebral disc Frequently asymptomatic Intermittent or chronic pain Aging, trauma, infection, heredity, smoking Disc dehydrates and looses height Ligaments not as tight Increased abnormal motion causing tears Foraminal stenosis Facet degeneration Spurring and inflammation Onset years old Men sooner than women Lumbar Degenerative Disc Disease A 45 year old male presents to the office for low back pain. He has had intermittent low back pain for the past 5 years lasting 1 week at each episode. His 4/10 pain is now constant for the past 6 weeks. He reports no trauma or injury. The pain radiates to the buttocks and upper posterior thighs. No other pain, numbness or tingling into the lower extremities. No reported weakness of the legs. No difficulty ambulating. No bowel or bladder dysfunction. The pain is aggravated with bending and lifting activities. Also worse with transition from a seated to standing position. NSAIDS and chiropractic have not helped. He feels he is unable to perform his job as a mechanic at this time due to the pain. 8

Lumbar Degenerative Disc Disease Physical exam Discomfort with ROM Usually no neuromuscular deficit Possible

Non-spinal cause of back pain Inflammatory or seronegative arthropathy Secondary gain, work place issues Drug seeking

Disease Diagnostics X-ray not improving, trauma, suspected pathology MRI Not improving, suspected pathology Rule out

management specialist Physical therapy and home exercises Weight reduction as needed Activity as tolerated

9 Lumbar Degenerative Disc Disease Physical exam Discomfort with ROM Usually no neuromuscular deficit Possible discomfort with palpation Muscle spasm or trigger points Consider complicating psych conditions Differentials Non-spinal cause of back pain Inflammatory or seronegative arthropathy Secondary gain, work place issues Drug seeking behavior Fracture, Potts disease Disc or vertebral infection Primary or metastatic tumor Lumbar Degenerative Disc Disease Diagnostics X-ray not improving, trauma, suspected pathology MRI Not improving, suspected pathology Rule out differentials Lumbar Degenerative Disc Disease Treatment NSAIDS, Pain medication Pills, patches and creams Pain management specialist Physical therapy and home exercises Weight reduction as needed Activity as tolerated Chiropractic or acupuncture may help Address radicular component Possible steroids injections Associated trigger points or facet pain Surgical fusion last resort 9

Spinal Stenosis Narrowing of the canal and/or foramina Cauda Equina, roots and vascular compression Worse with extension Neural root ischemia and neurogenic

$fractures, tumor Ligamentum flavum hypertrophy, synovial cysts Spinal Stenosis A 68 y/o male presents with pain, numbness and weakness in the lower extremities while$ He notices the pain is improved with sitting and leaning forward or leaning over a shopping cart while grocery shopping. No bowel or bladder dysfunction.

He notices the pain is improved with sitting and leaning forward or leaning over a shopping cart while grocery shopping. No bowel or bladder dysfunction.

10 Spinal Stenosis Narrowing of the canal and/or foramina Cauda Equina, roots and vascular compression Worse with extension Neural root ischemia and neurogenic claudication Improved with flexion Opens canal and foramen Relieves nerve pressure Contributing causes: Degenerative disc, facet joint arthropathy Spondylolisthesis, fractures, tumor Ligamentum flavum hypertrophy, synovial cysts Spinal Stenosis A 68 y/o male presents with pain, numbness and weakness in the lower extremities while walking a short distance. This has been gradually worsening over the past 2 years. He has occasional back pain. He notices the pain is improved with sitting and leaning forward or leaning over a shopping cart while grocery shopping. No bowel or bladder dysfunction. Physical exam Neurovascular examination Motor exam Straight leg raise Phalen test to reproduce symptoms Differentiate from vascular problem Differentials Disc herniation Tumor or space occupying lesion Peripheral vascular disease Spinal Stenosis 10

Spinal Stenosis Imaging X-rays Evaluate for disk space narrowing and instability Osteophyte formation, ligament calcification Myelogram, CT scan, MRI Evaluate the soft tissue, bone,

$fractures Primary osteoporosis Secondary osteoporosis Drug-induced (corticosteroids, tobacco, etc) Endocrine (hyperparathyroidism, diabetes) Miscellaneous (renal failure, COPD,$ y/o osteoporotic female presents with a sudden onset of midback pain. No trauma. She has no complaints of shortness of breath. No pain, numbness or tingling into the extremities.

y/o osteoporotic female presents with a sudden onset of midback pain. No trauma. She has no complaints of shortness of breath. No pain, numbness or tingling into the extremities.

11 Spinal Stenosis Imaging X-rays Evaluate for disk space narrowing and instability Osteophyte formation, ligament calcification Myelogram, CT scan, MRI Evaluate the soft tissue, bone, canal and foramen Nonsurgical treatment Possible epidural steroids Stretching and strengthening exercises Surgical Treatment Decompression and possible fusion Lumbar compression fractures Primary osteoporosis Secondary osteoporosis Drug-induced (corticosteroids, tobacco, etc) Endocrine (hyperparathyroidism, diabetes) Miscellaneous (renal failure, COPD, rheumatoid, hepatic disease or transplant) Osteolytic lesions Multiple Myeloma Bone metastases Paget s disease Trauma Usually vertical compression Lumbar compression fractures A 88 y/o osteoporotic female presents with a sudden onset of midback pain. No trauma. She has no complaints of shortness of breath. No pain, numbness or tingling into the extremities. She has had prior back pain the she has not been evaluated for. It seemed to dissipate over time. She has noticed a definite loss of height and her clothes are not fitting the way they used to. 11

$Lumbar compression fractures Physical exam Pain on palpating the spinous process Kyphosis Loss of$ $Imaging X-ray to visualize fracture MRI or Bone scan Evaluate for occult fracture Determine acute vs$ $relaxers +/- pain meds Jewett brace, LSO or TLSO Lumbar compression fractures Surgical treatment Not$ $fracture without reduction Kyphoplasty Stabilize and reduces the Fracture Bone cement in a reduced$

12 Lumbar compression fractures Physical exam Pain on palpating the spinous process Kyphosis Loss of height Negative straight leg raise Normal neuro exam Protuberant abdomen Lumbar compression fractures Imaging X-ray to visualize fracture MRI or Bone scan Evaluate for occult fracture Determine acute vs old Evaluate for pathology Treatment Usually 3 months length Medical management of osteoporosis Muscle relaxers +/- pain meds Jewett brace, LSO or TLSO Lumbar compression fractures Surgical treatment Not responding to conservative tx Neurologic deficit or intractable back pain Progressive loss of vertebral height Open Surgical Treatment Only if neurologic deficit Instrumented fusion Vertebroplasty Freezes fracture without reduction Kyphoplasty Stabilize and reduces the Fracture Bone cement in a reduced vertebral fracture 12

Cervical Degenerative Disc Disease (DDD) Neck pain with motion Limited motion Grinding or popping sensation Muscle spasm and headaches May have symptomatic stenosis Spurs or osteophyte disc complex

creams Lidoderm patches Surgical fusion is last option Axial neck pain, cervical radiculopathy, or noncomplicated whiplash Initial Treatment (No red flags suspected) Medication NSAIDS/Tylenol/Muscle

13 Cervical Degenerative Disc Disease (DDD) Neck pain with motion Limited motion Grinding or popping sensation Muscle spasm and headaches May have symptomatic stenosis Spurs or osteophyte disc complex Normal disc space Decreased disc space Bone Spur Cervical DDD Symptoms may last or come and go NSAIDS, Tricyclics or other pain meds Pillow or neck roll PT, chiropractic may help Topical arthritis creams Lidoderm patches Surgical fusion is last option Axial neck pain, cervical radiculopathy, or noncomplicated whiplash Initial Treatment (No red flags suspected) Medication NSAIDS/Tylenol/Muscle Relaxers/ Opioids May consider Medrol dose pack for radiculopathy Consider PT/ chiro/ acupuncture Many conflicting studies Varied effectiveness of modalities Relative rest Return to activities as early as possible Clinical Guideline: Douglas & Bope (2004) Journal of the American Board of Family Medicine 13

14 Axial neck pain, cervical radiculopathy, or noncomplicated whiplash Follow-up visit Consider F/U in 1-2 weeks Repeat exam Dependent on pain, return to work, clinical concern, etc Consider PT/chiro, acupuncture if unimproved Adjust meds as needed Encourage patient Consider neuro/ortho referral if loss of reflex or motor strength Clinical Guideline: Douglas & Bope (2004) Journal of the American Board of Family Medicine Axial neck pain, cervical radiculopathy, or noncomplicated whiplash Follow-up visit 4-6 weeks Repeat exam Adjust meds as needed Encourage patient Consider PT/chiro, acupuncture if unimproved X-ray neck if pain unimproved If radicular symptoms persist Consider MRI Consider antidepressant or anticonvulsant Consider ortho/ neuro referral Clinical Guideline: Douglas & Bope (2004) Journal of the American Board of Family Medicine Whiplash with Neuro Symptoms Physical exam Pain meds NSAIDS, (non) opioid meds, muscle relaxers X-ray neck Immobilize neck and refer if fracture No fracture treat same as radiculopathy Clinical Guideline: Douglas & Bope (2004) Journal of the American Board of Family Medicine 14

15 Suspected infection, neoplasm, myelopathy Physical examination X-ray and MRI of C-spine Labs (CBC, CRP, ESR) Ortho/neuro referral Clinical Guideline: Douglas & Bope (2004) Journal of the American Board of Family Medicine Summary 15

외래에서흔히접하는 요통환자의진단과치료 울산의대서울아산병원가정의학과 R3 전승엽

외래에서흔히접하는 요통환자의진단과치료 울산의대서울아산병원가정의학과 R3 전승엽 Index Introduction Etiology & Type Assessment History taking & Physical examination Red flag sign Imaging Common disorder Management Reference Introduction Pain