eck and Low ack pain: ddressing he Surgical valuation

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1 eck and Low ack pain: ddressing he Surgical valuation KI FOX, DO T WORTH BRAIN & SPINE

2 Goals Review anatomy Identify sources of pain Imaging: the good, the bad, and the ugly PE: findings to determine source of pain Significance of Imaging Case presentations

3 Why Is This Important? Determining appropriate referral destination: PMR vs. surgeon Big picture of assessing patients with neck and low back pain VALUE: My role Get patients in sooner, avoiding backups with surgeons Provide treatment options including conservative options prior to surgery Setting and managing patient expectations

Cervical Region omy of neck: has no body or spinous process -C2/ rotation- C3-C7 sidebening cet joints tervertebral discs amentous structure: supraspinous, interspinous, amentum Nuchae rtebral artery

4 Cervical Region omy of neck: has no body or spinous process -C2/ rotation- C3-C7 sidebening cet joints tervertebral discs amentous structure: supraspinous, interspinous, amentum Nuchae rtebral artery runs adjacent to nerves bilaterally nerves e roots C2, C3, C4 innervation to upper and lower region. e distribution C5-T1 combines in upper axillary n forming brachial plexus innervating upper mities.

5 Brachial Plexus

6 Dermatomes/Myotomes

7 Axial vs Radicular Neck Pain Axial causes: Muscular --Palpation identify trigger points in musculature. Pain w/palpation. Facet: Pain: Lateralization of spine w/sidebend and palpation in lower spine ~C3-C7= facet loading. Typically overall decrease ROM Ligament- stiffness with prolonged posture, achy- usually hx trauma or cumulative trauma Spondylosis visible on Xray/MRI. Stiffness, cracking sound with motion Radicular causes: Herniations likely produce pain into extremities SPURLING: extension, rotation, compression of head: produces sx into UE opposite of lateralization Sensory or weakness correlating to dermatome/myotome Hyporeflexia more rare cancer related

8 X-ray comparison Facet arthropathy/ddd/listhesis

9 Herniation vs Normal: saggital view

$fluid/widening between spinous process playing pinous muscle edema w/o nce of fracture rmal disc signal with$

10 Ligamentous Injury rmal vertebral body or facet lignment of Xray/MRI entous disruption with a joint fluid/widening between spinous process playing pinous muscle edema w/o nce of fracture rmal disc signal with disc widening

11 Referral Patterns: axial vs radicular

12 Physical Exam : Axial pain vs. Radicular BIG PICTURE Identifying facet related pain: Assess AROM Flex/extend for occipito-atlanto joint- articulation between occiput and atlas Rotation for C2-C3- atlanto-axial C3-C7 lateralization/sidebending of neck with palpation of facets as this is done. Spurlings: Extension, rotation, compression Lhermitte's: flexion of neck forward causing shock sensation down spine from cervical down to thoracic and/or lumbar spine. *DEMONSTRATION

13 Myelopathy Myelopathy on PE : Pathology compromising spinal cord. More common in the elderly population and is a slow process. Symptoms include incoordination in the hands, a heavy feeling in the legs, or numbness and tingling in the legs. It is generally a slowly progressive condition. Assessed with reflex exam, sensory (SX may be diffuse), strength, gait/coordination. SX would be B/L- likely UE and LE (+) hoffman in UE; (+) babinski LE, (+) clonus

14 What Has Been Discussed We have reviewed anatomy, normal vs pathology. Types of pain: causes, distribution of pain due to possible causes. Physical exam specifics Lets put it together with simplified guidelines

15 CERVICAL: Simplified guidelines to consider surgical referral Application of findings on PE: simply finding (+) facet loading or Spurlings is not enough for direct referral to neurosurgery. (1)*Myelopathy on exam: unsteady gait, (+) hoffmans, (+) clonus, (+) increased reflexes again will likely be UE and LE MRI Imaging: Canal diameter <~7mm in sagittal plane WHY? The canal is ~17mm, cord is ~12 to 13mm. Disc material is likely compressing cord at this diameter. X-ray dynamic views: listhesis with instability of ~4 to 5mm in C- spine with motion is considered pathologic. Occlusion of foramen due to protrusion. Foramen ~4mm diameter

16 Approach to assessment Assess complaints of patient: Ask yourself, is this axial w/o radicular SX? if axial --- X-ray dynamic view look for facets, spondylosis, DDD, instability Remember quick guidelines: 1) Are they myelopathic? 2) On imaging is canal ~<6-7mm (MRI) ; Xray: is it unstable. If no imagingget it. --Dynamic X-ray if axial pain only is ok, try some PT --if radicular: MRI warranted

17 When in Doubt? If simplified guidelines not met: what to do? Referral to Physical Medicine & Rehabilitation (PM&R) What does PMR do? PMR specialists mirror the profession of neurology, sports medicine, as well as spine and brain injury specialists. We are here to evaluate, diagnose, and facilitate healing through physical education, or interventions whether it be pre or post surgery.

18 Case Presentation t: 73 years old, history of cervical pain, fusion several years ago. Presents with returning SX. ing to right arm. Pain at night and with AROM. History of renal cancer treated with surgery 3 t states followed yearly and has been found to be ok. Presents for evaluation. t has no recent imaging. Last MRI many years ago. x: renal carcinoma hx: smoker for >30yrs but has quit at this time hx: father with prostate cancer ) B/B ited cervical ROM) extension~20, lateralization 20. Rotation even more minimal mans B/L, (-) spurlings, (+) Lhemerrites. Reflexes UE ¾ throughout as well as LE. ould you do next? Xray Images dynamic to assess fusion and stability of previous surgery. d surgery so order MRI with and w/o contrast.

19 Sagittal MRI patient JB

20 Normal MRI vs patient JB

21 Mid and Low back : T1-S1 Dimensions of canal consistent with ~16mm with cord ending L1-L2. Axial SX localized along spine: Facets Annular tears* Pars defects Spondylosis/lysis Ligament strains Ankylosing spondylitis Again more rare: mets Radicular SX Typically disc herniations Disc degeneration causing central vs foramen stenosis Osteophytes/ and or spondylosis that contact nerve Listhesis/lysis Cauda Equina

22 Comparison pathy, Spondylosis, Listhesis 1) Normal

23 Annular Tear

24 Pars defect and spondylolisthesis grade 1-2

25 Comparison MRI L-SPINE

26 DDD/ Osteophytes

27 ar Distribution/Referral patterns

28 Pertinent for Physical Exam Axial 1. Facet generated pain extension and facet loading. 2. Annular tear- worse with sitting, bending forward, coughing (stays in relation to axial region) 3. Strain/sprain pain with twisting/pushing/pulling movement 4. Pars- worse w/ hyperextension Radicular 1. Produced with SLR both seated and lying position Herniations will be seen MRI Listhesis seen easily Xray or MRI 2. Reflexes: hyporeflexic with radiculopathy. 3. Babinski (-)

29 Lumbar imaging Typically will need X-ray and/or MRI. Axial pain obviously can be caused by soft tissue pathology (annular tear) With X-rays: dynamic** just as cervical always good to get these. Previous hx surgery MRI w and w/o contrast

30 LUMBAR: General guidelines for surgical referral 1. Myelopathic: weakness, unable to tandem walk, noticeable hyper-reflexia ¾* cord compression will produce hyper-reflexic response. 2. Diagnostics: protrusion of 5mm or >. AP of lumbar canal ~15 to 16mm. Although cord has ended, compression of nerve rootlets at approximately this value. 3. (+) Babinski= compression of cord 4. (+) instability on dynamic views of >5mm 5. Cancerous findings (obvious) 6. Cauda Equina

31 Case Presentation CR HPI: 81 yr old patient. Pain in low back forever. Previous hx of Cervical fusion. SX. Right LE pain L5 dermatome, that has been steadily increasing over time. Pain increases with prolonged sitting/standing/driving/ walking very far. Denies weakness. Pain 8/10 70%back; 30% right leg. Last MRI 2011 PE: (+) SLR right. No weakness. B/L S1 ~1+/4 (-) babinski, (-) hoffmans. (+) tandem walk

32 Case Presentation : Patient CR id I do? How did he do? RI If MRI 6 months or > s get new imaging. TFESI L5-S1;S1-S2 with t 100% pain relief.

33 Discussion QUESTIONS AND DISCUSSION

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