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MULTI-DISCIPLINARY APPROACH TO THE

SPINE PATIENTMARC D. MOISI, MD

CHIEF OF NEUROSURGERY DETROIT RECEIVING HOSPITAL

COMPLEX/MINIMALLY INVASIVE SPINE SURGERY AND SPINAL ONCOLOGY

DISCLOSURES

• Globus- Consultant

GOALS

•When to refer a patient to a Neurosurgeon

THE SPINE

• Cervical

• Thoracic

• Lumbar

• Sacral

• Coccyx

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“BACK PAIN”

• At one time or another, back pain affects an estimated 80 percent of Americans.

• The degree of pain and duration vary greatly. It could come from the lower, middle or upper back.

• Common back pain causes include nerve and muscular problems, degenerative disc disease and arthritis.

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“More than 465,000 spinal fusions were performed in the United States in 2011, according to government data, and some experts say that a portion of them — perhaps as many as half — were performed without good reason”

Washington Post 2013

GOALS

•When to refer a patient to a Neurosurgeon

•Development of a Multi-Disciplinary Patient-centric Spine Treatment Team

MULTI-DISCIPLINARY APPROACH• Who Should be Involved:

• Patient and Patient Family• Internal Medicine• Pain Specialists

• Medications• Injections• Pain Pump trials• Stimulators/Simulator Trials

• Radiology• Interventional Radiology• PMR

• MD• PT/OT

• Surgeons• Complex Spine Specialists

• Multi Disciplinary Spine Conference

MULTI-DISCIPLINARY CONFERENCE

• All spine care services present

• Discuss all spine cases• Conservative management

• PT

• Other options including Injections and pain management

• Surgical options

• Should be last resort

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PRE-HAB

• Strengthening

• Core Strengthening• Planks

• HydroTherapy

• Massage Therapy

• Stretching and Range of Motion

PAIN SPECIALISTS

• Pain Medication Management

• Injections• Foraminal

• Epidural

• Facet

• Trochanter

• Spinal Cord Stimulators• Trials and Or Placement

• Pain Pumps

PUMPS

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SPINAL CORD STIMULATORS

RADIOLOGY

SPINE SURGEONSWHAT DO WE DO?

Back Pain/Neck

PainDisc

Herniations Deformity Stenosis

Spinal Cord Injury Trauma

Tumor• Primary• Metastatic

MORE URGENT SURGICAL CONSULTATIONS

• Cervical/Thoracic Myelopathy

• New Neurological Deficits• Motor

• Bowel/Bladder

• Myelopathy

• Spinal Metastasis

• Osteomyelitis

• Spine Trauma

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Technique Description

Stabilization

Fusion (spondylodesis) Uniting portions of the spine via instrumentation and/or graft materials. A variety of approaches can be implemented (anterior, lateral, posterior, etc.)

Distraction Halo, traction, interfacet or interspinous process devices to provide distractive force to vertebral column

Decompression

Laminotomy Partial removal of the lamina

Hemilaminectomy (unilateral laminectomy) Removal of a single lamina with exposure limited to one side of the interspinous ligament with decompression of one or both sides of the spinal canal

Total laminectomy Removal of the bilateral lamina along with the spinous process

Laminoplasty Expansion of the spinal canal while preserving the dorsal laminar arch

Pediculectomy Removal of the pedicle, usually along with the facet as a transpedicular approach and often combined with hemi or total laminectomy

Corpectomy Complete or partial removal of the vertebral body

Vertebrectomy (spondylectomy) Complete or partial removal of the vertebra

Foraminotomy Expansion of the neural foramen, usually via resection of part or all of the facet

Facetectomy Resection of part or all of the facet

Discectomy/microdiscectomy Removal of herniated disc material

Miscellaneous

Disc and nucleus pulposus replacement Dynamic reconstruction of the intervertebral disc with artificial disc or nucleus pulposus

Dynamic stabilization Various devices inserted into the disc space, interspinous space, or facet joints

Vertebroplasty, kyphoplasty, skyphoplasty, sacroplasty Minimally invasive injection of cement into vertebrae, or sacrum,

Nucleoplasty Radiofrequency ablation of herniated disc

SPINE SURGERY • Complex Spinal Instrumentation

• Occipital-Cervical Fusions• C1-2 Fusions, Odontoid Screws• Anterior/Posterior Cervical Fusions or

Corpectomies• Costotransversectomy • Thoraco-Lumbar Fusions• Pelvic Fixation

• Adult Deformity Correction

• Back Pain Diagnostic / Interventional Procedures

• Minimally Invasive Approaches• Lateral Surgery• Percutaneous Fusions

• Motion Preservation Techniques

• Disc Arthroplasty

• Spinal Oncology and Trauma

• Management of Complex / Failed Fusions/Re-do Surgery

PATIENT HISTORY

• 44 year old female s/p MVC with severe neck pain. MRI shows some STIR changes in the posterior elements of the cervical spine. No neurological deficits. Told at OSH needs 3 level fusion.

• Came for second opinion.

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CERVICAL MYELOPATHY

• 44 yo F getting progressively weaker in her hands and multiple falls because of gait ataxia

• Motor exam significant for Grip and Hand Intrinsic at 3/5 bilateral. Bilateral IP 4/5

• Positive Hoffman, Hyper-reflexive.

ANTERIOR CERVICAL DISCECTOMY AND FUSION

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LAMINOPLASTY

• 24 year old construction worker with acute right C5 radiculopathy after lifting a box at work. Underwent injections and PT for 6 weeks with minimal improvement. Wanted to undergo surgical intervention to be able to return to work. Offered Anterior Cervical Discectomy and Fusion versus cervical discectomy versus Disc Athroplasty

PRESTIGE (MEDTRONIC)

FLEXION/EXTENSION

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PRODISC-L (SYNTHES) CHARITE (DEPUY)

• 54 year old Male with acute LLE S1 radicular pain.

• Underwent PT with Aquatic therapy and 3 transforaminal injections.

• Pain Free went back to normal activities

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5 YEARS LATER

• 77 year old male with difficulty walking more than half a block with out stopping to take a rest. In the supermarket he leans over the shopping cart in order to help him be able to shop. He is neurologically intact on exam. MRI of the Lumbar Spine shows severe stenosis at L3-4, L4-5.

• Dx: Neurogenic Claudication

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• 54 yo M with groin pain and left leg pain.

SPINE TRAUMA • 62 yo F s/p ground level fall

• ASIA A

• Disease Process• Ankylosing Spondylitis

• Fracture Dislocation

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CONCLUSIONS

• Aim to Develop a Patient-centric Multi-Disciplinary Spine Team

• Be a Minimalist

• Take care of todays problems today, Tomorrows problems tomorrow

THANK YOU