EVALUATE, TREAT AND WHEN TO REFER RED FLAGS Mid Atlantic Occupational Regional Conference and Environmental Medicine October 6, 2018
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1 EVALUATE, TREAT AND WHEN TO REFER RED FLAGS Mid Atlantic Occupational Regional Conference and Environmental Medicine October 6, 2018 Marc J. Levine, MD Rothman Institute Director Spine Surgery Program RWJUH/Hamilton President Elect Medical Society of New Jersey Vice President Eastern Orthopaedic Association
2 Where Are We Going Anatomy Exam/History Treatments Common Pathologies Surgical Options/Advances
3 CERVICAL SPINE ANAOTOMY
4 CERVICAL SPINE ANATOMY
5 CERVICAL SPINE ANATOMY
6 CERVICAL SPINE ANATOMY
7 Cervical Spine Neural Anatomy
8 Spinal Cord Anatomy
9 Spinal Cord Anatomy
10 PLAIN XRAYS
11 COMPUTED TOMOGRAPHY CT SCANS
12 CT SCANS C1 C2 NORMAL
13 MRI VS CT
14 MRI AXIAL CERVICAL NORMAL
15 LUMBAR SPINE ANATOMY Lumbar Spine: Lateral View Intervertebral Disc
16 LUMBAR SPINE ANATOMY BUILDING BLOCKS OF THE LUMBAR SPINE
17 INTERVERTEBRAL DISC Annulus Fibrosus Nucleus Pulposus
18 Ligaments: Lumbar Spine Lateral View sagittal cortical bone cancellous bone
19 Lumbar Spine Neuroanatomy Neuroforamen Lateral view Spinal Cord/Conus/Cauda Equina
20 Lumbar Spine XRAYS
21 Computed Tomography CT
22 Computed Tomography CT
23 MRI Sagittal
24 MRI SAGITTAL
25 MRI AXIAL
26 Myelograms Post myelogram CT scans Discograms Contrasted MRIs Standing MRIs Bone Scans EMG/NCS OTHER IMAGING TESTS
27 Treatment of Acute Low Back Pain OUT OF ORDER
28 MANAGEMENT OF ACUTE BACK PAIN
29 Management of Acute Back Pain NO RED FLAGS DOOR NUMBER 1 Activity Modification Oral Steroids NSAIDS Muscle Relaxants Physical Therapy Pain Medications/Opioids RE ASSURANCE!!
30 Management of Acute Back Pain NO RED FLAGS Door Number 2 Pain Management Epidural Steroids Facet Injections Medial Branch Blocks SI Joint Injections Trigger Point Injections Occipital Nerve Injections
31 Management of Acute Back Pain Door Number 3 Spinal Surgeon When to Refer Failure to respond to Door Number 1 Failure to respond to Door Number 2 RED FLAGS
32 ACUTE NECK/BACK PAIN HISTORY AND PHYSICAL
33 HISTORY FOR ACUTE BACK PAIN HISTORY OF INJURY MVA FALL IMPACT TWIST LIFTING/STRAIN IMPACT ENERGY of INJURY PAST HISTORY Malignancy, infections, surgery, medical, osteoporosis HISTORY OF SYMPTOMS Onset to event Severity 0 10 Weakness Lhermittes Gait Bowel Bladder Saddle Paresthesias Unilateral/Bilateral
34 HISTORY FOR ACUTE BACK PAIN HISTORY OF INJURY MVA FALL IMPACT TWIST LIFTING/STRAIN IMPACT ENERGY of INJURY PAST HISTORY Malignancy, infections, surgery, medical, osteoporosis HISTORY OF SYMPTOMS Onset to event Severity 0 10 Weakness Lhermittes Gait Bowel Bladder Saddle Paresthesias Unilateral/Bilateral
35 Motor Vehicle Accident Neck Pain GET XRAY NORMAL LATERAL
36 CERVICAL SPINE XRAY RED FLAGS Soft Tissue Swelling
37 CERVICAL SPINE XRAY RED FLAGS ALIGNMENT AND SOFT TISSUE
38 Compression Fracture Lumbar Spine Xray Red Flags Energy of Injury Superior/Inferior INTACT Posterior Cortex
39 Lumbar Spine Xray Red Flags Energy of Injury Burst Fracture Pedicle Widening Bone Retropulsion
40 CHANCE FRACTURE MVA seat belt injury Compression/Flexion Boney/Soft Tissue Lumbar Spine Xrays Red Flags Plain Xrays
41 HISTORY FOR ACUTE BACK PAIN HISTORY OF INJURY MVA FALL IMPACT TWIST LIFTING/STRAIN IMPACT ENERGY of INJURY PAST HISTORY Malignancy, infections, surgery, medical, osteoporosis HISTORY OF SYMPTOMS Onset to event Severity 0 10 Weakness Lhermittes Gait Bowel Bladder Saddle Paresthesias Unilateral/Bilateral
42 History of Symptoms Red Flags Lhermitte s Symptom/Exam Spinal Cord Sign I feel electrical shocks
43 History of Symptoms Red Flags Gait and Clumsiness Symptom/Exam I am falling over when I walk I am dropping things Cervical Myelopathy
44 History of Symptoms Red Flags CAUDA EQUINA
45 Cauda Equina Syndrome History Low Back Pain Saddle Hypoesthesia Bowel/Bladder Dysfunction
46 HISTORY FOR ACUTE BACK PAIN HISTORY OF INJURY MVA FALL IMPACT TWIST LIFTING/STRAIN IMPACT ENERGY of INJURY PAST HISTORY Malignancy, infections, surgery, medical, osteoporosis HISTORY OF SYMPTOMS Onset to event Severity 0 10 Weakness Lhermittes Gait Bowel Bladder Saddle Paresthesias Unilateral/Bilateral
47 Inflammatory Arthritis Malignancy Previous Spine Surgery Infection History Osteoporsis Past History Red Flags Awareness Suspicion
48 Where Are We Going Where Have We Been Anatomy Exam/History Treatments Common Pathologies Surgical Options/Advances OFF WE GO
49 Lumbar Spine Exam Red Flag Weakness
50 Signs and Symptoms Radicular Pain Weakness Numbness Back Pain Straight Leg Raise AXIAL BACK AND/OR RADICULAR PAIN
51 Cauda Equina Syndrome Exam Decreased Perineal Sensaton Decreased Rectal Tone Depressed Reflexes Knee Ankle BC Reflex REFER
52
53 Cauda Equina Syndrome Pathology Compression of Cauda Equina Disc Tumor Trauma Epidural Process Hematoma Abscess NOT THE SPINAL CORD REFER
54 EXAM Cervical Spine Innervations Refer for Weakness
55 Deep Tendon Reflexes Red Flags Asymetry Brisk
56 Physical Exam Red Flags RADICULOPATHY VS. MYELOPATHY REFER
57 Upper Motor Signs Myelopathy Red Flags Hoffman Babinski Clonus
58 Where Are We Going Where Have We Been Anatomy Exam/History Treatments Common Pathologies Surgical Options/Advances OFF WE GO
59 Cervical Disc Herniation
60 Cervical HNP Clinical Radiculopathy or Myelopathy Neck Pain Plain xrays often normal MRI Best Myelo/CT option
61 ACDF ANTERIOR CERVICAL DECOMPRESSION AND FUSION
62 Anterior Cervical Decompression and Fusion ACDF
63 ACDF
64 CERVICAL DISC ARTHROPLASTY
65 Lumbar HNP MRI L5 S1 Sagittal L5 S1 Axial
66 Lumbar Spine Discectomy
67 Lumbar Discectomy Schematic
68 Lumbar Stenosis Normal 3D Schematic Stenosis =Narrowing
69 Lumbar Stenosis MRI Sagital
70 Lumbar Stenosis MRI Axial Normal Stenosis
71 Lumbar Stenosis Laminectomy
72 Vertebral Body Compression Fracture (VCF) Depressed endplate(s) Wedgeshaped Spine shorter, tilted forward Normal Fractured
73 KyphX Introducer Tool Kit Allows precise, minimally invasive access to the vertebral body and provides a working channel
74 KyphX IBT Inflation Reduces the fracture, compacts the bone, and may elevate the endplates
75 KyphX IBT Removal Leaves a defined cavity within the vertebral body
76 Case Study Patient: Diagnosis: Fracture Reduced: 55 YO Male Secondary osteoporosis L-1, 3 day old
77 LUMBAR FUSION WE HAVE COME A LONG WAY
78 GOALS OF LUMBAR FUSION Stabilize Spine Take Away Motion Re Create Anatomy Nerve Decompression **TAKE AWAY PAIN** Prevent Recurrent Problems
79 Traditional Lumbar Open Fusions Still Has a Place
80 Minimally Invasive TLIF/PSF Transforaminal Interbody Fusion/Posterior Spinal Fusion
81 MIS TLIF/PSF vs. OPEN
82 X treme Lateral Interbody Fusion XLIF
83
84 Caudal Left Lateral UP Cranial
85 Retractor Placement Important AP/Lat Flouro Views
86 XLIF Large Implant Large Surface Area
87 Degenerative Disc Disease
88 Anterior Lumbar Interbody Fusion ALIF
89 MIS Advantages Clinical Less Blood Loss Less Transfusions Less Pain Med Requirements Less Muscle Dissection Clinical Benefits 1 2 years Similar Long Term Benefits LESS PHYSICIAN WEAR AND TEAR
90 SUMMARY ACUTE Back Pain RED FLAGS AND WHEN TO REFER Cauda Equina Syndrome: saddle paresthesias, bowel/bladder, Cervical Myelopathy: hyper reflexia, upper motor signs, Energy of Injury: fractures Motor Weakness and Progression Radicular Pain relative sooner than axial back pain Beware of concomitant medical issues Failure to respond to non operative treatment When in doubt NOT A SIGN OF WEAKNESS
91 THANK YOU
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