Evaluation of Lower Back and Neck Pain David F. Antezana, MD Neurosurgery Division, The Oregon Clinic Chair, Department of Neurosurgery Providence Portland Medical Center Portland, Oregon

Epidemiology • Back pain is hard to truly understand and even harder to treat • Second most common chief complaint for clinician visits in USA • Estimated 80+% of adults experience significant back pain in a lifetime • ~ 25% of adults report back pain lasting a whole day in the past 3 months • Accounts for 15 million, or 2.5% of PCP visits 2

Cost of Pain • Over $100 billion/year • 75% of cost due to only 5% of patients • Deyo, et al, 2009, report the following increases in the last decade, translating to $$$$$$$: 629% ↑ in Medicare expenditures for ESIs 423% ↑ in expenditures for opioids for back pain 307% ↑ in the number of lumbar MRIs among Medicare beneficiaries 220% ↑ in spinal fusion surgery rates

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Risk Factors • • • • • • • • • • • •

Age Obesity Smoking Sedentary lifestyle Physically or psychologically strenuous work Job dissatisfaction Gender: more females experience back pain Worker’s compensation or legal claim Low education level Psychosocial variables Somatization disorder Twin study found genetic factors more important than we previously thought 4

Prognosis - Acute Back Pain

• 80%+ recover within 6 weeks

• Less than 5% will have serious systemic pathology • Thus many different interventions appear to be effective for acute back pain

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Acute - Management • • • • • • •

Short term activity modification Resume normal activity ASAP Walking, swimming especially helpful NSAIDs Tramadol may be comparable to codeine Chiropractic, acupuncture, massage, heat Opioids/narcotics: avoid, limit

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And now . . . . . . the 5% Who Need Further Intervention

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But first, a friendly reminder:

Oregon Health Plan and Medicaid require spinal fusion candidates to be smoke-free for 6 months prior to surgery. 8

Physiatrist—Rehabilitation Medicine

• A possible alternative or bridge to seeing a neurosurgeon • Highly competent at evaluating neck and back problems, and treating non-operative cases

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Pathology Conditions causing neck and back pain • Scoliosis/kyphosis

• Neoplasms • Infections

• Degenerative disease • Spondylosis

• Osteoarthritis • Inflammation 10

Pathology • Normal aging process •

↓ fluid content in nucleus pulposus – less efficient shock absorbers

• Degeneration of the posterior ligament

• Hypertrophy of facet joint and ligamentum flavum

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Degenerative Spine

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Etiology

• Trauma • Poor mechanics • Valsalva • Overuse/repetition • Genetics • Age 13

Manifestations: Back • Aching pain low back, buttocks • Sciatica: sharp, radiating pain down entire leg • Pain ↑ with valsalva

• ↑ pain with prolonged sitting

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Manifestations: Neck • Usually older adults • Lower cervical area • Herniation may be lateral or central • Cervical disc protrusion can cause root and cord compression

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Helpful Tests That You Can Do • • • • • • •

Sensation Reflexes Balance, Romberg Gait Heel/toe Cranial loading Specific physiological tests, below:

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Lasegue’s Sign, a.k.a. Straight Leg Lift

While patient is supine, lift patient’s straight leg.

Positive Lasegue’s = pain or spasm in posterior thigh or back.

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Trendelenberg’s Sign

Patient stands on affected leg.

Positive: pelvis droops on the unaffected side.

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Hoffman’s Sign Hold patient’s wrist. Firmly flip the middle fingernail.

Positive Hoffman’s sign elicits reflexive contraction of the thumb and index finger. 19

Spurling’s Sign Patient extends the neck and rotates and laterally bends the head toward the symptomatic side. Compress the top of the patient's head. Positive when the maneuver elicits radicular arm pain. 20

Wadell’s Signs

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Diagnostic Work-up • MRI – gold standard for neural and soft tissue problems • CT scan – standard for bone imaging • Nerve conduction studies • Lab work – sedimentation rate/ESR, CBC, urinalysis • Bone scan – if tumor or infection suspected • Lumbar spine films – fracture, alignment • Scoliosis series films 22

One More Friendly Reminder

Oregon Health Plan and Medicaid require spinal fusion candidates to be smoke-free for 6 months prior to surgery. 23

Complex Spinal Deformity Conference – – – – – – – –

Surgeon Anesthesiologist Neuroradiologist OR Nurse Floor Nurse Physical Therapist Nutritionist Other Specialists

All meet monthly to discuss our most complex spinal deformity cases

PPMC is the only community hospital doing this in the NW 24

Complex Spinal Deformity Conference Example #1 • 78 y/o f, BMI 27, c/o LBP and scoliosis • LBP worse on left side; occasional numbness in L great toe; no radicular pain down leg • Exacerbated by using kickboard while swimming; standing or walking 15+ min; sleeping; mopping; vacuuming • Ameliorated by sitting • Comorbidities include osteoporosis; RAD w/ persistent cough; hypertension; ankle swelling; unhealed iliac fracture; paroxysmal supraventricular tachycardia/PSVT; hypothyroid • PMH: cervical pain ESI resolved, breast CA, hyperglycemia, anemia, gout

Complex Spinal Deformity Conference Example #1

• DEXA scan T-score 10/7/2014: -2.8 10/30/2009: -1.9

• 61° scoliotic curve along lumbar spine • Compensatory thoracic curve • Left lateral listhesis of L2 on L3 and L3 on L4

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Complex Spinal Deformity Conference Example #2 • 30 y/o m, BMI 23, originally presented to pulmonologist c/o dyspnia • FVC 1.83; 52% • Pulmonologist referred patient to Dr. Yost because pulmonary function compromised by 140+° kyphoscoliosis in upper thoracic spine • early myelopathy, as well • Latent TB w/o evidence of active TB

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Complex Spinal Deformity Conference Example #2

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Surgical Interventions • Discectomy – removal of nuclear disc material • Hemilaminectomy – part of lamina and posterior arch removed • Laminectomy – lamina removed • Foraminotomy – intervertebral foramen is enlarged to reduce pressure on nerve root; usually performed in the cervical area • Spinal fusion – immobilize and stabilize vertebral column • Fusion with bone chips/graft or plates and screws 29

Complications • Hematoma – severe incisional pain, decreased motor function, urinary retention

• Nerve root injury – foot drop, extremity weakness

• CSF leak – abnormal connection between the subarachnoid space and incision, dressing damp, possible infection/meningitis 30

Postoperative Management • Vital signs • Neurological assessment: weakness, numbness, pain could indicate nerve root compression • Monitor urinary function for retention or overflow • Monitor GI function – possible ileus • Pain assessment and management • Fluid and electrolyte balance • Blood loss replacement • Prevention of deep vein thrombosis – Thigh-high thrombosis embolic deterrent, TED – Sequential compression devices, SCDs 31

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Deyo, RA, et al. Descriptive epidemiology of low-back pain and its related medical care in the United States. Spine (Phila Pa 1976) 1987; 12:264. Hart LG, Deya RA, Cherkin DC. Physician office visits for low back pain. Frequency, clinical evaluation and treatment patterns from a US national survey. Spine (Phila Pa 1976) 1995; 20:11. Katz JN. Lumbar disc disorder and low-back pain: socioeconomic factors and consequences. J Bone Joint Surg Am 2006; 88 Supl 2:21. Battié, Michele C. et al., The Twin Spine Study: Contributions to a changing view of disc degeneration. The Spine Journal 2008; 9:1, 47-59 32