A Surgeon s Perspective for the Primary Care Physician Stephen Curtin M.D. Tucson Orthopeadic Institute

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1 A Surgeon s Perspective for the Primary Care Physician Stephen Curtin M.D. Tucson Orthopeadic Institute 26th Annual Southwestern Conference on Medicine

2 AXIAL MUSCULO- SKELETAL PACK PAIN: Common Self-limited 2 weeks 50% Better 6 weeks 90% Better Mild Analgesics Exercise/Stretching/PT Activity modification

3 Recognize Surgical Emergent/Urgent Spinal Conditions Know the Principles of Surgical Treatment of Spinal Conditions Review Outcomes of Surgical Treatment for Common Spinal Conditions

4 Cauda Equina syndrome is Characterized by: A. Common Condition that should be seen by a Specilist at First Available appointment B. Hyperreflexia and Increased Tone in the Lower Extremities C. Saddle Anesthesia, LE weakness, Diminished /Absent Rectal Tone D. None of the Above

5 Myelopathy is Characterized by: A. Hyperreflexia, pathologic reflexes B. Gait Disturbance C. Bilateral hand Symptoms D. All of the Above

6 As Defined in this Talk, an Unstable Spine Under Physiologic Load Could: A. Develop Progressive deformity B. Develop Neurologic Deficit C. Have Incapacitating Pain D. All of the Above

7 Traumatic Infectious Tumor Congenital/Developmental Degenerative

8 60 y.o. Male RHD, 2 Week Hx left Shoulder and back pain referred to Shoulder Surgeon Pain Severe Enough that he was unable to work. First time he had ever missed work as a mason PMH: NIDDM P.E.: Afebrile, positive Spurling s Test, Mild tricep weakness

9 Suspected Cervical Etiology and referred for MRI an infiltrative process such as lymphoma is a consideration. An infected facet joint with epidural phlegmon is also a possibility recommend clinical correlation, appropriate lab test and MRI post contrast imaging

10 Refused to be admitted Repeat MRI with contrast: atypical infectious process, with septic facet joint and epidural phlegmon with tiny abscesses

11 Admitted P.E. : Afebrile, No Position of Comfort, Tricep 4/5, WF4/5, Intrinsics & FF3/5 Labs: WBC 10.8 (nl) ESR 45 CRP12.5 Bld Clx: MSSA Treatment Surgical decompression and Drainage with multilevel hemilaminectomies

12 Severe Pain without Position of Relief Rapidly Progressive Neurological Deterioration Risk Factors Afebrile

13 CAUDA EQUINA SYNDROME Severe LBP Saddle Anesthesia Bowel and Bladder Dysfunction Lower Extremity Weakness Rare: 1 in 33,000 to 1 in 100,000 LOWER MOTOR NEURON INJURY

14 CAUDA EQUINA SYNDROME Overflow Incontinence Patulous Rectal Tone Surgery within 48 hours

15 MYELOPATHY Cord Level Injury Weakness, Spasticity, Hyperreflexia, Pathologic Reflexes, Clonus Gait Disturbance Bilateral Hand Symptoms UPPER MOTOR NEURON INJURY

16 Trauma with Neurologic Injury High Energy Impending Fracture Tumor Infection Rapid/Progressive Neurologic Deficit Disc/Bone Tumor Puss

17 Decompression Relieve the Neural Elements Stabilization Restore Alignment Stop Motion Protect Neural Structures

18 Instability the loss of the ability of the spine under physiological loads to maintain its pattern of displacement so that there is no initial or additional neurologic deficit, no major deformity, and no incapacitating pain Panjabi et al

19 Stable Spine No Neurologic Deficit No Major Deformity No Incapacitating Pain Physiologic load

20 INFECTIOUS TRAUMATIC

21 TUMOR CONGENITAL/DEVELOP MENTAL

22 DEGENERATIVE DEGENERATIVE AND DEVELOPMENTAL

23 Biologic Fusion Bone to Bone Lots of Temporary Fixation Trade Off: Loss of Physiologic Motion for Relief of Pain and Deformity

27 ANTERIOR INTERBODYAPPROACH POSTERIOR INTERBODY APPROACH

28 TRENDS AND VARIATIONS IN CERVICAL SPINE SURGERY IN THE UNITED STATES: MEDICARE BENEFICIARIES, 1992 TO 2005 WANG, MARJORIE C. MD, MPH*; KREUTER, WILLIAM MPA ; WOLFLA, CHRISTOPHER E. MD*; MAIMAN, DENNIS J. MD, PHD*; DEYO, RICHARD A. MD, MPH SPINE: 20 APRIL VOLUME 34 - ISSUE 9 - PP % increase in cervical fusions Medicare Age > 65 Spondylosis with Myelopathy 36% UNITED STATES TRENDS IN LUMBAR FUSION SURGERY FOR DEGENERATIVE CONDITIONS DEYO, RICHARD A. MD, MPH* ; GRAY, DARRYL T. MD, SCD ; KREUTER, WILLIAM MPA ; MIRZA, SOHAIL MD ; MARTIN, BROOK I. MPH SPINE: 15 JUNE VOLUME 30 - ISSUE 12 - PP % increase in Lumbar fusions Age > 60 saw most rapid increase Excluded trauma, Cancer and Infections

29 Herniated Disc Degenerative Spondylolisthesis Spinal Stenosis

SPORT Outcomes: Herniated Disc "Surgery Vs Non-Operative Treatment for Lumbar Disk Herniation: The Spine Patient Outcomes Research Trial: A Randomized Trial" JAMA 296(20):2441-2450, 2006.

30 SPORT Outcomes: Herniated Disc "Surgery Vs Non-Operative Treatment for Lumbar Disk Herniation: The Spine Patient Outcomes Research Trial: A Randomized Trial" JAMA 296(20): , "Surgery Vs Non-Operative Treatment for Lumbar Disk Herniation: The Spine Patient Outcomes Research Trial Observational Cohort" JAMA 296(20): , "Surgery Vs Non-Operative Treatment for Lumbar Disk Herniation: Four-Year Results from the Spine Patient Outcomes Research Trial (SPORT)" Spine 33(25): , "Surgical versus Non-Operative Treatment for Lumbar Disk Herniation: Eight-year Results for the Spine Patient Outcomes Research Trial (SPORT)" Spine 39(1):3-16, 2014.

31 Conclusion. Carefully selected patients who underwent surgeryfor a lumbar disc herniation achieved greater improvement than nonoperatively treated patients; there was little to no degradationof outcomes in either group (operative and nonoperative) from 4 to 8 year

32 SPORT Outcomes: Degenerative Spondylolisthesis "Surgery Vs Non-Operative Treatment for Lumbar Degenerative Spondylolisthesis" NEJM 356(22): , "Surgical Compared With Non-Operative Treatment for Lumbar Degenerative Spondylolisthesis: Four-Year Results in the Spine Patient Outcomes Research Trial Randomized and Observational Cohorts" JBJS 91: , 2009.

33 Conclusions: Compared with patients who are treated nonoperatively, patients in whom degenerative spondylolisthesis and associated spinal stenosis are treated surgically maintain substantially greater pain relief and improvement in function for four years.

34 SPORT Outcomes: Spinal Stenosis "Surgical Vs Nonsurgical Therapy for Lumbar Spinal Stenosis" NEJM 358(8): , "Surgical versus Non-Operative Treatment for Lumbar Spinal Stenosis: Four-Year Results of the Spine Patient Outcomes Research Trial (SPORT)" Spine 35(10), 2010.

35 Conclusion. Patients with symptomatic spinal stenosis treated surgically compared to those treated nonoperatively maintain substantially greater improvement in pain and function through 4 years

36 We Treat Patients Not MRI s Does Patho-Anatomy fit Symptoms? Host factors Comorbidities Psycho/Social Motivation

37 1. There are Spinal Conditions That Require Surgical Intervention Emergently/Urgently 2. Spinal Stabilization/Fusion When Necessary is a Good but Imperfect Solution 3. Spine Surgery in Properly Selected Patients and Conditions Offers Good Long Term Results

38 Cauda Equina syndrome is Characterized by: A. Common Condition that should be seen by a Specilist at First Available appointment B. Hyperreflexia and Increased Tone in the Lower Extremities C. Saddle Anesthesia, LE weakness, Diminished /Absent Rectal Tone D. None of the Above

39 Myelopathy is Characterized by: A. Hyperreflexia, pathologic reflexes B. Gait Disturbance C. Bilateral hand Symptoms D. All of the Above

40 As Defined in this Talk, an Unstable Spine Under Physiologic Load Could: A. Develop Progressive Deformity B. Develop Neurologic Deficit C. Have Incapacitating Pain D. All of the Above

Comprehension of the common spine disorder.

Objectives Comprehension of the common spine disorder. Disc degeneration/hernia. Spinal stenosis. Common spinal deformity (Spondylolisthesis, Scoliosis). Osteoporotic fracture. Anatomy Anatomy Anatomy