SPINE LECTURE - James - St. Mary`s Medical Center

Randall H. James, DO, FAAPMR
Randall H. James, DO, FAAPMR
ST MARY’S PHYSICAL MEDICINE &
REHABILITATION
2828 First Ave. Ste 504
Huntington, WV 25702
Tel: 304-399-7212
Fax: 304-399-7215
Randallhjames@st-marys.org
1. Purpose and function of a spine center
2. Epidemiology of back pain
3. Comorbidities in WV, OH, and KY
4. Pain definition and prevalence
5. Common types of back injuries and pathology
6. Diagnostic guidelines for neck & back pain
7. Treatment options for spine pain and disease
8. Indications for referral to specialists
9. Summary: Questions and Answers
2012--HealthGrades: 5 Star rating for both
Fusion and Non-fusion spine surgery
Reasons for development of
Regional Spine Centers
MEDICAL COMORBITIES CONTRIBUTE TO BACK PAIN AND
DISABILITY.
WEST VIRIGINIA HAS AMONG THE STATES WITH THE
HIGHEST DISABILITY AND MEDICAL COMORBIDITES.
WEST VIRGINIA PATIENTS AVERAGE 17 PRESCRIPTIONS
PER PATIENT.
Predictors of disability include: high baseline disability,
greater medication use, greater cigarette smoking, older
age, being single, high blood pressure, arthritis, less
physical activity, high body mass index(BMI). High activity
level is one of best predictors of non-disability.
Hubert, HB, Fries, JF, Predictors of physical disability after age 50, ANN EPIDEMIOLOGY 1994 Jul : 4(4) 285-94.
Key Points
$80 billion in lost
work and productivity
175 million working
days are lost annually
due to chronic back
pain
Significant
improvement in
outcomes in past
decade
12 Million Impaired
by Back Pain
45 Million
with Back Pain
Definitions:
Obesity: Body Mass Index (BMI) of 30 or
higher.
Body Mass Index (BMI): A measure of an
adult’s weight in relation to his or her height,
specifically the adult’s weight in kilograms
divided by the square of his or her height in
meters.
BMI = Weight (kg)
Height (m2)
BMI (kg/m2)
Risk of
Comorbidities
Healthy weight
18.5 – 24.9
Normal
Overweight
25.0 – 29.9
Increased
Obese Class I
30.0 – 34.9
High
Obese Class II
35.0 – 39.9
Very High
Obese Class III
> 40.0
Extremely High
Adapted from the World Health Organization. Obesity: Preventing
and Managing the Global Epidemic. Geneva: WHO; 2000.
Obesity Trends* Among U.S. Adults
BRFSS, 1990, 1995, 2005
(*BMI ≥ 30, or about 30 lbs overweight for 5’4” person)
1995
1990
2005
No Data
<10%
10%–14%
15%–19%
20%–24%
25%–29%
Centers for
Disease
Control &
Prevention
≥30%
1.
2.
3.
4.
5.
30-50% increased probability of hypertension
Increases risk of heart disease
Increases risk of diabetes
Increases risk for obesity
Increases risk for colon cancer via obesity
E Giovannucci et al. 1 March 1995 | Volume 122 Issue 5 | Pages 327327-334, annals
of Internal medicine
6.
Increased risk of heart attack
American Journal of Epidemiology Vol. 142, No. 9: 889-903
The Johns Hopkins University School of Hygiene and Public Health
7.
Increased risk of chronic disease
http://www.oxha.org/knowledge/backgrounders/riskhttp://www.oxha.org/knowledge/backgrounders/risk-factorsfactors-exercise
8.
Increased Risk for Disability
1. WEIGHT LOSS & MANAGEMENT
2. IMPROVES MOOD, AFFECT, DECREASES
DEPRESSION & ANXIETY
3. COMBATS CHRONIC DISEASE: OSTEOPOROSIS,
HYPERTENSION, HYPERLIPIDEMIA,
CARDIOVASCULAR DISEASE, LUNG DISEASE,
DIABETES
4. IMPROVES SLEEP
5. IMPROVES ENERGY LEVEL
6. IMPROVES SEXUAL INTEREST AND ENDURANCE
cardio: 2 ½ HOURS( 150 minutes) moderate
exercise (e.g. brisk walking) per week AND
Strengthening: 2 or more days per week on all
muscle groups (legs, hips, back, abdomen,
chest, shoulders, and arms).
OR
CARDIO 1 ¼ Hour (75 minutes) of vigorousintensity aerobic activity (i.e., jogging or running)
every week AND
Strengthening: 2 or more days per week on all
muscle groups (legs, hips, back, abdomen,
chest, shoulders, and arms).
1. NO TIME: You have to make time and schedule
your exercise.
2. NO COMMITMENT: Chose exercise that you
enjoy, do with friends, family or partners.
3. EXERCISE HURTS: choose exercise best for you
and build up to it. Correct underlying medical
problems.
4. DO NOT HOW: Learn, begin by taking classes.
Hire a personal trainer, ask a friend for help.
Injured employees require an average of 19 therapy
visits (Workers Compensation Research Institute).
A work-related injury results in a loss of $38,000
including wages, productivity loss and medical
expenses (National Safety Council, 2005)
The National Safety Council documented that the
longer you wait to treat workers' compensation
injuries, the greater the cost.
Research regarding value of early referral to physical
therapy for injured workers with low back injuries has
indicated that patients who receive early physical
rehabilitation had fewer physician visits, fewer
restricted workdays, fewer days away from work, and
shorter case durations (Zigenfus, Giang, & Fogarty,
2000)
Zigenfus, G. C., Yin, J., Giang, G. M., & Fogarty, W. T.
(2000). Effectiveness of early physical therapy in the
treatment of acute low back disorders. Journal of
Occupational and Environmental Medicine, 42(1),
35-39.
Pain 76.2 million
Diabetes 23.6 million people
MI/ chest pain 23.3 million
Cancer 11 million
70
60
50
40
%
30
20
10
0
One
Two
Three
Household Size
Four
Five
Seven
50
45
40
% in 35
Pain
30
25
20
15
10
5
0
Males
Females
15 - 30
31 - 40
41 - 50
51 - 60
Age
>60
34
35
30
25
%
21.4
19.7
18.8
20
15
10
5
3.4
2.6
0
t Su
Pos
cal
rgi
Spo
rts
e
cid
Ac
nt
er
Oth
us
rk
neo
Wo
nta
Spo
70
67
60
50
%
40
30
20
17.1
10
0
2.6
3.3
2.6
1m
1 - 3m
3 - 6m
6.8
6 - 12m
1 - 3y >3 years
39
40
35
%
30
25
23
20
15.4
15
13
9.4
10
5
0
d
Mil
Dis
35
c om
ing
fort
g
rible
iatin
Ho r
ruc
Ex c
sing
tr es
Dis
33
30
24.2
25
%
22.3
20
15
10
7.6
4.6
5
4.2
3.5
Hip
Arm
0
Back
%
80
70
60
50
40
30
20
10
0
Head
Leg
Chest Other
80
2.5
5.5
7.5
er
is t
i st
ct
ur
ap
ra
ct
er
p
n
h
o
u
t
ir
io
up
ys
Ch
Ac
Ph
4.5
O
er
th
c
Do
r
to
Pain prevalence for households was one in three
Pain prevalence for individuals was one in five
As age increases pain prevalence increases
Females more than 30 years old have more pain than
males
Back pain most common problem
Cause of pain usually spontaneous or unknown
45% severe pain, 55% mild - discomforting pain
The majority experienced pain, daily or continuously, for
three or more years.
The majority received care from a medical practitioner
The results of this survey are consistent with overseas
studies.
USA
MAKES UP 4% OF
THE WORLD’
WORLD’S
POPULATION BUT
CONSUMES 96% OF THE
WORLD’
WORLD’S NARCOTICS.
Poor muscle tone caused by lack of
exercise
Poor posture
Faulty body mechanics
Stressful living and working habits
Loss of strength and flexibility, aging
Excessive weight
Anatomical pathology
Injury or accidents
Functions of the Spine
Protection
Spinal cord and nerve roots
•
Internal organs
Spinous Process
Superior Articular
Facet
Transverse
Process
Lamina
Pedicle
Spinal Cord
in
Spinal Canal
Spinal Canal
(Intravertebral
Foramen)
Body
Intervertebral disc
• End plate
• Cartilaginous
• Bony
• Apophyseal
ring
Superior
Articular
Process
Articular processes
Pars
• Pars interarticularis
Zygapophyseal
Joint
(Facet Joint)
Inferior
Articular
Process
Vertebral Structures
Body
Pedicle
Transverse
Process
Vertebral
Foramen
Lamina
Spinous
Process
Superior
Articular
Process
Functions of the Spine
Flexibility of motion in six degrees
of freedom
Flexion and Extension
Left and Right
Side Bending
Left and Right Rotation
Annulus
Fibrosus
Annulus fibrosus
Outer portion of the disc
• Made up of lamellae
• Layers of collagen fibers
• Arranged obliquely 30°
• Reversed contiguous
layers
•
Great tensile strength
Bands or sheets of tough,
fibrous tissue that connect
bones, cartilage, or other
structures
Become active when
stressed to maximum range
of motion
Protect the joints from being
hyperflexed
Lamellae
Bands or sheets of tough,
fibrous tissue that connect
bones, cartilage, or other
structures
Become active when
stressed to maximum range
of motion
Protect the joints from being
hyperflexed
Posterior
longitudinal
ligament
Anterior
longitudinal
ligament
Ligamentum flavum
Nucleus pulposus
•
•
•
•
Inner structure
Gelatinous
High water content
Resists axial forces
Nucleus
Pulposus
Spinal muscles can be
classified into anterior and
posterior groups
Subclassified into superficial,
middle, and deep layers
Attached to bone by tendons
Active structures that provide
motion
Spinal Cord
Contained in epidural space
Network of sensory and motor
nerves
Firm, cord-like structure
Extends from foramen
magnum to L1
Terminates at conus medularis
Cauda equina below L1
Filum terminale
After learning about all of the functions
the discs are tasked with performing,
it’s likely become no surprise that discs
can eventually tire, weaken, and break
down. More specifically, the annuli
fibrosi become frail and brittle and the
nuclei pulposi lose water content. These
changes make the discs less able to
perform their responsibilities, and make
the discs prone to become herniated
and bulging.
Though degenerative disc disease in the back is
quite common among older individuals, receiving a
diagnosis can still come as a shock for many
individuals. As an individual approaches middle
age, his or her body begins to react to the wear and
tear that has been placed on it over the years. The
spine is no exception, which is why so many older
individuals experience chronic back pain and lower
body discomfort. Still, assigning a name to what
was previously considered just a “bad back” can
be shocking, worrisome, and even depressing. By
learning more about the condition, many patients
come to learn that the term “degenerative disc
disease” isn’t nearly as nefarious as it sounds.
Occurs at all levels of
the spine
Asymptomatic
degeneration in majority
of the population
Normal
The spinal structures most
affected by degenerative
disease are
Intervertebral discs
Articular facet joints
These conditions are similar to
osteoarthritis and
degenerative disease of the
spine, which is often referred
to as “osteoarthritis of the
spine,” or spondylosis
Degenerative
A diagnosis of spondylosis
usually requires confirmation
by radiologic examination, but
biochemical and histological
changes occur long before
symptoms or identifiable
anatomic changes are present
Based on radiologic findings,
degenerative disc disease
(DDD) may be classified into
stages of progression
Thompson criteria
Loss of cells
Loss of H20/ ↓
proteoglycans
↓ Type II/ ↑ Type I collagen
Annular fissures
Mechanical incompetence
Bony changes
I
II
III
IV
V
The process is thought
to begin in the annulus fibrosis
with changes
to the structure and chemistry
of the concentric layers
Over time, these layers suffer
a loss of water content and
proteoglycan, which changes
the disc’s mechanical
properties, making it less
resilient
to stress and strain
V
Degenerative
Anatomy
Changes in disc structure
and function can lead to
changes in the articular
facets, especially
hypertrophy (overgrowth),
resulting from the
redirection of
compressive loads from
the anterior and middle
columns to
the posterior elements
There may also be
hypertrophy of the
vertebral bodies adjacent
to the degenerating disc;
these bony overgrowths
are known as
osteophytes
(or bone spurs)
Discogenic pain is pain
originating from the disc
itself; an internally
disrupted disc may result
in disc material causing
chemical irritation of
nerve fibers
Cause
Pathology
Painful and tender back, stiffness and muscle guarding
Treatment
Aging wears away discs along with back posture, muscle weakness
or old injury
Disc dries out causing nerve pressure
Warm moist packs, flexibility exercises to back and leg,
anti-inflammatory medications, steroid injections, physical therapy
and muscle strengthening
Largest avascular structure
Blood supply by diffusion
through end plates
Damage to the blood
supply leads to
degradation of the disc
As we age, the water and protein content of
the spinal discs changes. This change
results in weaker, more fragile discs that
become dehydrated and flatten out.
The discs that lie between the vertebrae
normally have a high water content and are
subject to wear and tear over time,
resulting in narrowing of the disc space.
This gradual deterioration of the disc
between the vertebrae is called Disc
Degeneration or Degenerative Disc Disease
Pedicle notches
• Intervertebral
foramen
Slight
Notch
Deep
• Nerve roots exit Notch
Intervertebral
Foramen
www.spineuniverse.com/conditions/degenerative
-disc/degenerative-disc-disease-animation
Cause
Pathology
Narrowing of the canal and spinal cord compression
Pathology
Flexibility and stretching exercises
Physical therapy
Cause
Ligaments become thick and inflexible
Attempts to move the joint result in pain
Stiffness retards circulation
Treatment
Sprain or strain healing without normal movement
Longstanding poor posture
Bony spurs and aging spine
Treatment
Anti-inflammatory medications, steroid injections,
physical therapy
If it doesn’t improve, surgery may be necessary
Neck
Numbness or tingling in your
arm or hand
Weakness in your arm or
hand
Pain that shoots down your
arm
Pain that shoots up towards
your head
Pain when you move your
head
Frequent headaches
Dizziness & Nausea
Back
Pain in low back
Pain in hips
Pain that shoots down the
leg
Numbness or tingling in your
leg or foot
Weakness in leg or foot
Burning sensation down
leg/foot
Difficulty walking
Difficulty with bowels or
bladder
UPPER MOTOR NEURON
INJURIES: EG CVA, SCI
GAIT: NORMAL TO ATAXIA
PARESIS TO PLEGIA
TONE: NORMAL TO
INCREASED
REFLEXES: NORMAL TO
INCREASED
+ BABINSKI, + CLONUS
ATROPHY: NORMAL TO
SLOW PROGRESSIVE
INCOMPLETE LOSS
LOWER MOTOR NEURON
INJURIES: EG RADICULOPATHY,
POLIO
GAIT: NORMAL TO ATAXIA
PARESIS TO PLEGIA
TONE: NORMAL TO
DECREASED OR ABSENT
REFLEXES: NORMAL TO
DECREASED
NEG. BABINSKI
ATROPHY: MAY BE RAPID
AND MODERATE TO
COMPLETE LOSS
• Non-surgical treatments such as:
• Oral Pain Medications
• Ergonomics and Change of occupation
• Physical Therapy and Occupational Therapy
• Acupuncture & Massage
• Manual medicine(e.g. OMT)
• Exercise to alleviate neck and back pain.
•Traditional Open spine surgery
•Minimally Invasive spine surgery
•Interventional steroid injections
•Implantable pain pumps
Arthritis
Pinched Nerve
Ruptured Disc
Cause:Improper lifting, twisting, falls or other
injuries
Pathology: Tearing, bleeding and/or irritation
of muscles or ligaments
Treatment:
If minor injury, a few days of rest
NSAIDS, MUSCLE RELAXANTS
PT, MASSAGE, MANUAL MEDICINE,
MODALITIES.
Spondylosis: spinal osteoarthritis 729.10, Dr. H. An
Spondylolysis: fracture at pars inarticularis
without displacement. Lumbar 721.3
Spondylolisthesis: fracture at pars inarticularis
with slippage.i
slippage.i aacquired:
aacquired: 738.4
Meyerding Grading for Spondylolisthesis:
Spondylolisthesis Grade 1: 0-25%,
Spondyloptosis: : >100% slippage off vertebra 738.4
grade 2:25-50%, grade3: 50-75%, grade 4: 75-100%.
Types:
DysplasticDysplastic true congenital spondylolisthesis that occurs
from malformation of the lumbo-sacral junction with small
incompetent facet joints.
IsthmicIsthmic- (aka spondylotic spondylolisthesis or acquired) is
the most common with a prevalence 5-7% is acquired
from ages 6-16 years of age. Males 2-3 x > females.
DegenerativeDegenerative disease of aging that develops from facet
arthritis and facet remodeling causing sagital orientation
which allows slippage. Common, 30% whites, 60% black
women over age 65. can cause neuro compromise,
TYPES continued
TraumaticTraumatic- rare and may be associated with acute
fracture of the inferior facets or pars interarticularis.
PathologicPathologic rare. Follows damage to posterior elements
from metastases or metabloic bone disease. Diseases
associated include pagets disease of bone, tuberculosis,
giant cell tumors, and tumor metastases.
SYMPTOMS: pain, stiffening of back, tightening of
hamstrings, change in posture and gait, forward leading,
waddle gait if advanced, referred pain, sciatica,
paresthesias, increased pain with valsalva pressures.
Gradation of
spondylolisthesis
Meyerding’s Scale
Grade 1 = up to 25%
Grade 2 = up to 50%
Grade 3 = up to 75%
Grade 4 = up to 100%
Grade 5 >100%
(complete dislocation,
spondyloloptosis)
Spondylolisthesis
Retrolisthesis
Lateral listhesis
Axial and rotational
displacement
Forward displacement
Backward displacement
Sideways displacement
Segmental hypo- and hyperkyphosis or lordosis
DIAGNOSIS:
1. XRAYS: lumbar AP & LAT, W OBLIQUES
2. add flexion/extension views if known
spondylolysis or high suspicion to check slippage.
3. Consider MRI if radicular symptoms or if
positive xray for spondylolisthesis.
CONSERVATIVE TREATMENT
1. 80-90% never need surgery
2. NSAIDS, REST, BRACING, PT, WT. LOSS
INDICATIONS FOR SURGERY
1. Progressive slipping
2. intractable pain
3. neurological deficits
4. failed conservative measures with symptoms
SURGERY
1. Two major types: insitu fusion or reduction
2. latest: Minimally invasive techniques(stealth)
Spondylolysis
Also known as pars defect
Also known as pars fracture
With or without
spondylolisthesis
A fracture or defect in the
vertebra, usually in the
posterior elements—most
frequently in the pars
interarticularis
Symptoms
Low back pain/stiffness
Forward bending
increases pain
Symptoms get worse
with activity
May include a stenotic
component resulting in
leg symptoms
Seen most often in athletes
Gymnasts at risk
Caused by repeated strain
SPINAL STENOSIS: narrowing of the spinal canal
most commonly in the lumbar or cervical spines.
ETIOLOGY: Aging is the most common cause with
degenerative changes including hardening and
thickening of spinal ligaments, herniated or
bulging discs, osteophyte(bone spur) formation.
SYMPTOMS: Pain, paresthesias, leg weakness,
increased pain with standing/walking, decreased
with sitting, leaning forward. Gait problems.
DIAGNOSIS:
Xrays: identifies associated pathology of spinal stenosis.
MRI: Diagnostic test of choice.
CT: valuable especially in those when MR contraindicated.
CONSERVATIVE TREATMENT: always try first if possible.
Physical therapy, Yoga, Pilates, epidural steroid
injections, ergonomic education, oral steroids, NSAIDS.
SURGICAL TREATMENT:
Laminotomy, foraminotomy, facetectomy, lumbar
disectomy and fusion, cervical corpectomy.
Symptoms
Back pain
Pain, dysthesias,
anesthesias in the
buttocks, thighs,
and legs
Unilateral or bilateral
Symptoms occur while
walking or standing,
and remit when sitting
May start in the buttocks
and traverse
to the legs or vice versa
DIAGNOSIS:
History: get a good history including bowel and bladder
function, radicular symptoms, severity of pain, aggravating
factors, history of trauma or incidents.
PHYSICAL EXAM: Have patient point to and describe pain
General: Reflexes, Palpation, ROM, motor strength, sensation
Lumbar: Straight leg test, FABERS
Cervical: Spurlings, Roos, Tinels, Phalens, Compression.
X-rays: identifies associated pathology, possible etiology,
MRI: Diagnostic test of choice.
CT: valuable especially in those when MR contraindicated.
Add contrast with history or surgery or suspected cancer, infxn.
Varying degrees
Disc bulge
Mild symptoms
Usually go away with
nonoperative treatment
Rarely an indication
for surgery
Extrusion (herniation)
Moderate/severe
symptoms
Nonoperative treatment
Without compression of a spinal nerve, many
individuals can be afflicted with degenerative disc
disease in the back without even knowing it.
However, when the affected disc ruptures or
protrudes and comes into contact with a neural
structure, the condition can certainly make itself
known. Symptoms can include pain, numbness,
tingling, and muscle weakness, which will appear in
different locations depending on which area of the
spine is affected. If the bulging or herniated disc is
located in the cervical spine, the patient can
experience symptoms in the neck, upper back,
shoulders, arms, and/or hands. Compression of a
nerve in the lumbar spine can lead to discomfort in
the lower back, hips, buttocks, legs, and/or feet.
In simplest terms, bulging discs are
misshapen and appear to balloon or bulge
outwardly. This occurs when the annulus
fibrosus weakens to the point that it can
no longer keep the nucleus pulposus
within its normal boundaries. The annular
wall does not rupture in the case of a
bulging disc, nor does the nucleus
pulposus seep into the spinal canal.
Rather, the misshapenness of the disc is
what can cause neural compression.
When a disc becomes herniated, its
nucleus pulposus has seeped through a
crack or tear in the disc’s annular wall.
The outer portion of the annulus fibrosus
contains nerve fibers, which can become
aggravated when the wall ruptures. This,
combined with the fact that the nucleus
pulposus contains inflammation-causing
proteins, can lead to significant pain and
discomfort. Symptoms can become even
more intense if the extruded disc
material presses against a spinal nerve,
a nerve root, or the spinal cord itself.
Degenerative/traumatic:
annular teartear- anular fissures, are separations between annular
fibers, avulsion of fibers from vertebral insertions, or breaks
through fibers.
Degeneration: may include dessication, fibrosis, narrowing of disc
space, diffuse bulging of annulus, defects & sclerosis of
endplates, & osteophytes.
Herniation: localized displacement of disc material beyond the
limits of intervertebral disc space. Localized/focal < 25% of disc
circumference, generalized > 50%. Presence of disc
circumferentially(50-100%) beyond ring apophyses may be called
bulging. Protrusions & extrusions are types of herniations.
CONSERVATIVE TREATMENT: always try first if possible.
Physical therapy, Yoga, Pilates, manual medicine(e.g. OMT),
ergonomic education, medications: muscle relaxants, oral
steroids, NSAIDS. Use narcotic sparingly unless severe pain.
Screen for drug use if any suspicion.
SURGICAL TREATMENTS:
Newest: minimally invasive techniques(aka
microdisectomy, percutaneous disectomy)
open disectomy, laminotomy, laminectomy, fusion,
DIAGNOSIS: Gold StandardStandard- Electrodiagnostic studies
including nerve conduction studies(NCS) &
electromyography(EMG). MRI identfies anatomical pathology,
EMG identifies pathophysiology. Confirms and identifies specific
nerve roots and differentiates from other pathology(
monononeuropathies, polyneuropathies, myopathies, or rules
out neurological injury.
CONSERVATIVE TREATMENT: always try first if possible.
Physical therapy, manual medicine(e.g. OMT), medications:
muscle relaxants, oral steroids, NSAIDS.
INTERVENTIONAL TREATMENT: Cervical & lumbar epidural steroid
injections(ESI). Diagnostic, Therapeutic, prognostic.
SURGICAL;
SURGICAL Disectomies, foraminotomies etc.
27% of patients with lumbar
radiculopathy were diagnosed with
polyneuropathy of the lower
extremities.
UP TO 19% OF RADICULOPATHIES ARE
PRESENT WITHOUT SIGNIFICANT MRI
FINDINGS
1.
2.
3.
4.
1. EMG IS GOLD STANDARD FOR RADICULOPATHY
EVALUATION
2. ALWAYS CORRELATED WITH CLINICAL EXAM AND
HISTORY.
3. EMG is 97% sensitive for diagnosing radiculopathies
The lumbosacral electromyographic screen: revisiting a classic paper Clinical Neurophysiology
Volume 111, Issue 12 , Pages 2219-2222, December 2000 Top of FormTimothy R. Dillingham
et all
From Wikipedia, Sciatica
( /saɪˈætɪkə/; sciatic neuritis)
neuritis [1] is
a set of symptoms including pain that
may be caused by general
compression or irritation of one of
five spinal nerve roots that give rise
to each sciatic nerve, or by
compression or irritation of the left or
right or both sciatic nerves. The pain
is felt in the lower back, buttock, or
various parts of the leg and foot .
It may be pinched in lumbar or hip
region. Hip OA mimicks sciatica.
Exam: SLR, DIAGNOSTICS: EMG
Cervical DDD: 722.4
Cervical herniated disc w/o myelopathy: 722.0
Cervical radiculopathy: 723.4
Cervical spinal stenosis: 723.0
Cervical sprain: 847.0
Lumbar DDD: 722.52
Lumbar herniated disc w/o myelopathy: 722.10
Lumbar radiculopathy 724.4
Lumbar spinal stenosis: 724.02
Lumbar sprain: 846.0
Physicians also often recommend physical therapy
for individuals who have been diagnosed with
degenerative disc disease. This type of treatment
can strengthen the muscles in the back and
abdomen, which may provide the spine with
additional support and relieve some of the strain
that is placed on the intervertebral discs. Physical
therapy may also entail the use of other treatment
techniques, such as cryotherapy (cold therapy),
thermotherapy (heat therapy), therapeutic
ultrasound, transcutaneous electrical nerve
stimulation (TENS), massage therapy, and posture
modification exercises, among others.
Alternative therapies are also becoming
increasingly popular among patients who have
degenerative disc disease in the back. Herbs and
dietary supplements, acupuncture, hypnotism, and
chiropractic manipulation have helped many
individuals reduce their pain and increase their
quality of life. That being said, many members of
the medical community continue to eschew
alternative therapies due to questions regarding
their efficacy and credibility.
Ruptured
Disc
Tubular
Access
Nerve Root
Compression
Rods and Screws Placed
Percutaneously
Skin Line
Tubes
Rods and Screws
Cages
• Cervical plates
Decompression
Lumbar laminectomy
Discectomy
Interbody fusion
Interbody fusion with cages
Minimally invasive discectomy
Screws and rods
Bone dowels or
wedges
Allograft or
autograft
Implant = medical device
New ICD 9 code = 84.52
Used with an interbody device = 84.51
ESI’
ESI’s treat radicular pain more than “back pain”
pain”.
Indications for Lumbar Epidural Injections
By: Richard Staehler, MD
Several common conditions that cause severe acute or chronic low
back pain and/or leg pain (sciatica
(sciatica)
sciatica) from nerve irritation can be
treated by steroid injections. These conditions include:
A lumbar disc herniation, where the nucleus of the disc pushes
through the outer ring (the annulus) and into the spinal canal where
where it
pressures the spinal cord and nerves. Read Lumbar herniated disc for
more information on diagnosis and treatments.
Degenerative disc disease, where the collapse of the disc space may
impinge on nerves in the lower back. See Lumbar degenerative disc
disease.
disease.
Lumbar spinal stenosis, a narrowing of the spinal canal that literally
literally
chokes off nerves and the spinal cord, causing significant pain. See
Spinal stenosis symptoms, diagnosis and treatment.
treatment.
An epidural steroid injection delivers steroids directly into the
the epidural space
in the spine. Sometimes additional fluid (local anesthetic and/or
and/or a normal
saline solution) is used to help ‘flush out’
out’ inflammatory mediators from
around the area that may be a source of pain.
Epidural injections are often used to treat radicular pain, also called sciatica,
sciatica,
which is pain that radiates from the site of a pinched nerve in the low back to
the area of the body aligned with that nerve, such as the back of
of the leg or
into the foot. Inflammatory chemicals (e.g. substance P, PLA2, arachidonic
arachidonic
acid, TNFTNF-α, ILIL-1, and prostaglandin E2) and immunologic mediators can
generate pain and are associated with common back problems such as
lumbar disc herniation or facet joint arthritis. These conditions,
conditions, as well as
significant
cant nerve
many others, provoke inflammation that in turn can cause signifi
root irritation and swelling.
Steroids inhibit the inflammatory response caused by chemical
chemical and
mechanical sources of pain. Steroids also work by reducing the activity
activity of the
immune system to react to inflammation associated with nerve or tissue
damage.
.
RISKS
FEMALES > MALES
INCREASED WITH AGE
FAMILY HISTORY
RACE: HIGHER IN CAUCASIANS & ASIANS
SMALL FRAME SIZE & INACTIVITY
EXPOSURE TO SYSTEMIC STEROIDS
EARLY MENOPAUSE OR OVARIES REMOVEAL
SYMPTOMS
PAIN
FRACTURES
LOSS OF HEIGHT
CHRONIC LOW BACK PAIN
DIFFICULTY WALKING & LOSS OF INDEPENDENCE
POOR POSTURE & RESPIRATORY DEPRESSION
THINNING & WEAKENING OF BONES THROUGH
DECREASED MINERAL CONTENT.
The presence of one vertebral fracture increases the risk
of any subsequent vertebral fracture 5-fold. Of women
who have had a recent osteoporosis vertebral fracture, it
is estimated that approximately 20% will sustain a new
fracture within the next 12 months.
Osteoporotic fractures cost $13.3 billion annually. (3)
Vertebral compression fractures cost approximately $1.5
billion and result in 150,000 patient hospitalizations per
year. On average, vertebral compression fractures
necessitate an eight-day hospital stay
1. Xrays all areas of pain
2. MRI confirmation diagnostic test of choice but
nuclear bone scans can be helpful for aging.
A spine center offers a Board certified
Physiatrist or similar specialist to meet with
the patient to examine, review, or order
additional diagnostics and testing.
Recommends the proper avenue of
consultation or treatment and refers the
patient to the proper physician, surgeon, or
service.
Documents the history/injury, diagnostics and
treatments for the primary to review.
Offers an inter-disciplinary team approach
to spine care
Combines the expertise of surgeons,
radiologists, primary care physicians,
pain and rehabilitation specialists, &
many highly trained therapists and
nurses.
Provides comprehensive education to the
patient and family throughout the entire
Spine Center experience.
Unique care model of wellness
Preoperative education class with
comprehensive notebook
Nurse navigator to guide patients through the
process
Dedicated, specially trained staff members
Dedicated Neuroscience Spine Unit
Shorter hospital stays
SMMC has provided the TriTri-State with brain and
spine surgery since 1948.
Features board certified Neurosurgeons who
perform hundreds of spine surgeries each year
Our neurosurgeons are well known & trusted
and have over 50 years of combined
experience in spine care.
Utilize the latest, most advanced computerized
image guided and minimally invasive
techniques including Cyberknife technology
1.
2.
MAKING A REFERRAL
1. Perform a history and exam on the patient
to determine if any emergency referral is
necessary. If a true emergency refer to the
emergency room. If urgent, refer to service or
specialist you feel must see the patient
directly. Speak to a doctor or nurse if needed.
2. All other referrals please refer to the
Physical Medicine & Rehabilitation
department with Dr. James who will perform or
complete all necessary diagnostics, testing,
and make the most appropriate referral.
Thank You for Coming!