1 spinal disorders (or how do i deal with these back pain patients)
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Spinal disorders Spinal disorders (or how do I deal with these back pain patients)(or how do I deal with these back pain patients)
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Neck and Back PainNeck and Back Pain
85% with no specific diagnosisLook for red flagsbed rest beyond 4 days not advised80-90% improve within six to eight weekswith or without treatment, 80% of patients
with sciatica eventually recover
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History and PhysicalHistory and Physical
History, history, history – the patient will tell you what is wrong almost ALWAYS!
Neurological exam– Motor– Reflex– Sensory– Other
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Red FlagsRed Flags
Cancer or infectionspinal fracture- trauma, prolonged steroids,
age greater that 70yrscauda equina syndrome- acute onset of
retention or incontinence, saddle anesthesia, weakness, fecal incontinence or loss of sphincter tone
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Motor ExamMotor Exam
5/5 Normal4(+-)/5 Some resistance3/5 Overcome gravity2/5 Able to move but not overcome gravity1/5 muscle flicker0/5 No movement
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Motor ExamMotor Exam
C5 -- Deltoids
C6 -- Biceps
C7 -- Triceps
C8/T1 -- Grip
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Motor ExamMotor Exam
L1/L2 -- Hip flexors
L3/L4 -- Leg extensors
L5 -- Dorsiflexion
S1 -- Plantarflexion
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ReflexesReflexes
Biceps -- C6Triceps -- C7
Knee Jerk -- L3/L4Ankle Jerk -- S1
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OtherOther
Spurlings Maneuver
Hoffman’s Sign
Straight Leg Raise or Crossed SLR
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Radiculopathy vs. Radiculopathy vs. MyelopathyMyelopathy
Radiculopathy -nerve root pressure
– back or neck pain radiating to extremity
– motor, sensory, reflex >>>>> decreased
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Radiculopathy vs. MyelopathyRadiculopathy vs. Myelopathy
Myelopathy -- spinal cord pressure– history of gait disturbance, numbness,
weakness, Lhermitte’s phenomenon– URINARY URGENCY or INCONTINENCE– motor and sensory >>>>>decreased– REFLEXES INCREASED
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Neck and Back Pain Neck and Back Pain w/wow/wo RadiculopathyRadiculopathy
(No Red Flags)(No myelopathy)History and physicalNo radiographs necessary for first month
unless weakness presentTreat with NSAIDS, Flexeril, Limited Use
of narcotics (no refills)
How can you treat?How can you treat?
Rest is not the same as limited duty or “don’t do anything” – Don’t aggravate!
PT – health maint., stretch, therapiesChiropractics - Manipulate, therapiesAcupuncture – Auricular, scalp, pplus,
protocols (systemic)Pain clinic – ESI, Facet blocks, spinal stim
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Persistent PainPersistent Pain
Neurosurgery-Okinawa Dogma
– SM/Dep/VIP with persistent Low Back Pain without radicular pain has pars defect until proven otherwise
– WRONG
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Persistent Pain Work-upPersistent Pain Work-up
Plain X-rays- AP, Lat, Obliques, Flex/Ext– In civilian community, 3 views may be enough
MRI
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Persistent PainPersistent Pain
If normal xray and mri– conservative pain management– PT– Limdu– If no improvement after 6-12 mos, refer to
MED BOARDIf normal xray and mri
– Neurosurgery has nothing to offer
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Other problemsOther problems
Myelopathy, Weakness, Pars defect– Refer to Neurosurgery
If persistent pain with failed conservative treatment and HNP, Stenosis, or fracture on x-ray / mri– Refer to (Tele)Neurosurgery
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Neurosurgery ClinicNeurosurgery Clinic
For weakness, myelopathy, pars defect- surgery recommended (considered)
For persistent pain-- options offered– PT, Pain clinic, Chiro, Acupuncture, – Surgery– Med Board
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Neurosurgery ClinicNeurosurgery Clinic
Use the clinic staff when possible
Always available
Clinical Practice Guidelines\Low Back Pain
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