GP Education Evening Spine Update 26 March 2014

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Jasper Stevens
6 years ago
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1 GP Education Evening Spine Update 26 March 2014 In partnership with:

2 Dr Michael Bryant Guidelines for low back pain management & Dr Steven Yang Neck and arm pain In partnership with:

3 About Us Founded in 2005 Union of 3 surgical practices Now 7 surgeons 5 Neurosurgeons and 2 Orthopaedic Spine Surgeon Originally 3 sites Now 11 sites all across Queensland and Northern New South Wales Sunshine Coast Brain & Spine our first permanent practice outside Brisbane Expanded Clinical Services Neuro-oncology Nurse Practitioner Research Newro Foundation In partnership with:

4 About Us Founded in 2005 Union of 3 surgical practices Now 7 surgeons 5 Neurosurgeons and 2 Orthopaedic Spine Surgeon Originally 3 sites Now 11 sites all across Queensland and Northern New South Wales Sunshine Coast Brain & Spine our first permanent practice outside Brisbane Expanded Clinical Services Neuro-oncology Nurse Practitioner Research In partnership with:

5 Our Surgeons Dr Frank Tomlinson Neurosurgeon Dr Terry Coyne Neurosurgeon Dr Geoff Askin Orthopaedic Spinal Surgeon Dr Richard Kahler Neurosurgeon Prof David Walker Neurosurgeon Dr Michael Bryant Neurosurgeon Dr Steven Yang Orthopaedic Spinal Surgeon In partnership with:

6 Our Locations Operating Hospitals Sunshine Coast Private Hospital and Sunshine Coast University Private Hospital (Nov 2013) Brisbane Based Hospitals: The Wesley Hospital, Auchenflower St Andrew s War Memorial Hospital, Spring Hill Holy Spirit Northside, Chermside Mater Private Hospital, South Brisbane Clinic Locations Consult in 11 medical centres in QLD & Northern NSW Auchenflower Chermside Toowoomba Sunshine Coast Lismore South Brisbane Spring Hill North Lakes Ipswich Mackay Rockhampton In partnership with:

7 Weekend Conference 14 & 15 June 2014 Sheraton Noosa Resort Earn 40 Category 1 RACGP Points

8 Guidelines for low back pain management Dr Michael Bryant Neurosurgeon & Spinal Surgeon MBBS, FRACS In partnership with:

9 Up to 80% of Australians will have back pain

11 Special Consideration Back Pain that s not from the back PUD AAA Renal Pathologies etc. History and Examination

12 Red Flags Cancer Pain History of Cancer Weight Loss Night Pain

13 Red Flags Infection Discitis or Osteomyelitis Fever IV Drug use Immunocompromise Rest Pain

14 Red Flags Cauda Equina Syndrome Enough said

15 Red Flags Fracture Osteoporosis Steroid use Traumas

16 Red Flags Ankylosing Spondylitis

17 1-2% of presentations

18 Pts with Radiculopathy 5-6% of presentations Reduced power Reduced reflexes Altered sensory perception Pain

19 2/3 improve without intervention 2-3 month time frame Pain considerable Painkillers NSAIDs Neuromodulators Benzos

20 Physical/Alternative Therapies Physiotherapy / Acupuncture / Massage / Hydrotherapy / Osteopathy / Bowen Therapy / Chiropractors / Pilates / Yoga / Exercise Physiology / Gym / Hypnotherapy / Myotherapy etc etc etc

21 Nerve Root Blocks Occasionally better as a diagnostic investigation

22 Surgery

23 Non-Specific Low Back Pain 94-96% of presentations Guidelines for their care

24 Recommendations 1 - Don t image 2 Start simple Panadol Activity 3 Persisting pains Increasing pain killers Physical alternate therapies

25 Persisting Low Back Pains Greater than 6 weeks Imaging now Increase pain killers Physical therapies Interdisciplinary rehab

26 Discogenic Pain

27 Degenerate Spondylolisthesis

28 Pars Defects/Spondylolisthesis

29 Questions? In partnership with:

30 Neck and arm pain Dr Steven Yang Hand and Spine Surgeon BHB, MbChB, FRACS In partnership with:

31 Neck Pain Common complaint- up to 90% of population has intermittent neck pain. Vast majority self limiting Sedentary/computer work Poor posture/ overuse

32 Neck pain-history Differentiate serious from self limiting conditions Trauma? Red Flags- Sepsis -history of cancer -increasing pain> 6 weeks -neurological signs/symptoms

33 Neck pain-history Location of pain: -neck (central/side) -occipital headaches -trapezial/periscapular pain

34 Neck pain Radiation? -Arm -Forearm -Hand/digits -Gait disturbance -Bladder/bowel/sexual dysfunction

35 Differential diagnosis Neck pain only Arm/Forearm pain Hand paraesthesia/numbness

36 Diagnosis Neck pain only May have associated headaches Trapezial and periscapular radiation NO nerve involvement

37 Neck pain Muscle spasm- wry neck much -not able to move neck Muscle ache- knots /Trigger points -tender or hard areas

38 Neck pain Aggravation of degenerative spondylosis Aging/wear of disc & facet joints Stiffness Reduced range of motion

39 Management Analgesics-paracetamol, NSAID s if severe spasm or pain short term tramadol/opiods, limited role for benzodiazepines -Physiotherapy/remedial massage -May need recurrent management

40 Investigations Only if trauma/red flags If no better after 6 weeks Xrays +/- CT Relevant blood test (FBC,ESR,CRP and others depending on suspicion)

41 Further treatment Persistent severe neck pain Facet arthritis? Facet blocks/medial branch blocks(radiologist or pain specialist) Radiofrequency ablation for facet pain(pain specialist)

42 Neck with shoulder/arm pain May be difficult to sort out Middle aged/elderly- multiple pathology Subacromial impingement/rotator cuff tear

43 Neck with shoulder pain Can t sleep on painful shoulder Painful lifting arm Clinical examination- R.O.M. -impingement test

44 Neck with shoulder pain If suspect shoulder: -Ultrasound scan -Subacromial steroid and L.A. injection If confirmed- Physiotherapy for shoulder

45 Shoulder/arm pain Can be C5 or C6 root irritation/compression May be electric shock, pins & needles or unpleasant numbness rather than pain Shoulder R.O.M. pain free Investigate-Xrays, MRI Nerve root injection-diagnostic and therapeutic

46 Quick Guide to Assessing Neck, Arm & Hand Symptoms In partnership with:

47 Neck pain and hand symptoms Usually radicular pain Sometimes peripheral nerve syndrome and neck muscle ache Carpal tunnel syndrome(median nerve) Cubital tunnel syndrome(ulnar nerve at medial elbow)

48 Carpal tunnel syndrome Hand/wrist only Worse at night Heavy, numbness, pins and needles, burning/cold sensation rather than pain. Thumb and radial digits Phalen s,tinel s and raised arms

49 Quick Guide to Assessing Neck, Arm & Hand Symptoms In partnership with:

50 Cubital tunnel Syndrome Aching in medial forearm and arm Ulnar 2 digits or little finger only. Worse at night Aggravated by pressure on medial elbow

51 Peripheral nerve compression Clinical findings Nerve conduction studies Surgical decompression if permanent numbness /wasting or night splinting ineffectual

52 Neck Pain with arm/forearm radiation Shooting sensation into forearm or digits Forearm/hand symptoms: shooting intermittent sensations, paraesthesia/numbness rather than pain Dermatomal pattern

53 Early management 70% will settle within 6 weeks. Severe pain in 1 st. 2 weeks Strong analgesics to buy time NSAID s, tramadol,oxycontin/targin(long acting preferred) Pregabalin, Amitriptyline- will take 2 days to work.

54 Early management If doesn t improve: MRI to confirm which nerve root Option of CT guided nerve root injection

55 Surgery <20% will come to surgery Maybe due to acute disc herniation, ostephytes from arthritis or combination Occassionally may have central/spinal cord compression(cervical myelopathy)

56 Surgery Involves decompressing the relevant nerve root(s) Followed by either fusion or disc replacement Cervical myelopathy may involve operating on more than 1 level

61 Questions? In partnership with:

EVALUATION AND MANAGEMENT OF CERVICAL SPINE DISORDERS

CERVICAL SPINE EVALUATION AND MANAGEMENT OF CERVICAL SPINE DISORDERS Gregory M Yoshida MD Supports the skull Allows movement of the head Houses the spinal cord CERVICAL SPINE Unique anatomy Upper C spine