Conservative Management of Spinal Conditions PDF

**WASHINGTON UNIVERSITY SCHOOL OF MEDICINE** **PROGRAM IN PHYSICAL THERAPY** **John Metzler, MD** Conservative Management of Spinal Conditions *Highlights are fyi* I. Low back pain A. Conservative Care 1. Vast majority of patients with LBP are not operative candidat...

**WASHINGTON UNIVERSITY SCHOOL OF MEDICINE** **PROGRAM IN PHYSICAL THERAPY** **John Metzler, MD** Conservative Management of Spinal Conditions *Highlights are fyi* I. Low back pain A. Conservative Care 1. Vast majority of patients with LBP are not operative candidates 2. Trial of conservative management for almost all of those who are surgical candidates 3. Most prefer a non-surgical over a surgical option 4. Black box of conservative care 1. Specific diagnosis not often given - Nonspecific diagnosis=nonspecific treatment 2. Multiple treatment options available - Very little data behind any of the treatments 5. Importance of basics a. H & P should guide management - When and what to image - Relevance of finding - Diagnosis is a process b. Patients' agenda, goals, concerns, beliefs 5. Imaging- varying sensitivity/specificity c. Imaging results do not equal symptoms d. Normal study may lead to lack of appropriate care B. Differential diagnosis of low back and lower extremity pain 5. Spinal 3. Lumbar radiculopathy 4. Facet joint arthritis 5. Neurogenic claudication due to lumbar spinal stenosis 6. Fracture 7. Tumor 8. Infection 6. Non spinal 9. Intrarticular hip pain 10. Piriformis syndrome 11. Peripheral neuropathy 12. Vascular claudication G. General red flags 1. Night pain 2. Relentless constant pain, not related to movement or position 3. Constitutional symptoms: weight loss/appetite changes/fevers 4. H/O systemic disease or systemic symptoms a. myocardial infarction b. cancer c. aneurysm H. **Neurologic red flags** 5. **Bowel/bladder dysfunction (*retain urine so develop overflow incontinence)*** d. **Cauda equina syndrome = true surgical emergency** - **Sacral roots do not recover from injury as well as other nerves, must be addressed immediately- pt needs to go straight to ER** 6. **Progressive lower extremity weakness** 7. **Sexual dysfunction** I. Radiographic red flags 8. Compression fractures 9. Change in pedicle appearance (look at AP xray) 10. New onset spinal malalignment 11. Change in disc height with vertebral body end plate erosions (infection) J. **Lumbar disc herniation** 12. Most commonly affects young adults 13. May or may not have leg pain 14. Herniation vs bulge vs degeneration II. Selected Examples or Diagnoses A. Discal Pathology 1. Often diagnosed with MRI 2. **Schmorl's nodes** 1. Vertical herniation -superior/inferior protrusion of disc-- herniates through the endplate 2. Upper lumbar and lower thoracic segments most common 3. Often occur in adolescents after injury but occas older pts assoc with injury 4. Potentially quite painful & takes months to calm down 5. Treatment is usually conservative: bracing for comfort, activity restriction 3. **Disc Herniations** 6. Location/direction of herniation determines symptoms - Parasagittal most common 7. Foraminal disc herniation- - May have leg symptoms without back pain - Can be missed by MRI- Need the appropriate cut 8. Degenerative changes in the lumbar spine 9. Disc - Vertebrae B. Myelogram 4. 5. 6. 7. 8. C. *Discogram* 9. *Not used very frequently anymore* 10. *Contrast into disc- usually at least 3 levels* 11. *Unpleasant for the patient* 12. *Subjective -- comparison* 13. *May be recommended only if considering surgery* D. Edema in the spinal cord- seen on MRI 14. With myelopathic signs -- *refer to surgeon immediately* 15. You will likely not be making interpretations on these things so it is a nice to know. E. Discitis 16. **In children can occur spontaneously, in adults usually after procedure (anywhere in the body)** 17. **Severe pain limited ROM, may have fever** 18. Check WBC, inflammatory markers, blood cultures 19. Often unable to isolate an organism 20. Treatment rest, antibiotics if + culture, high WBC or high fever. III. Cervical Degenerative Disc Disease A. Neck pain B. Radicular dx's 1. Pain, Weakness, Numbness C. Myelopathy 2. Clinical 3. Imaging D. Natural Course of cervical degeneration 4. Noninflammatory disc degeneration 1. Starts with mild segmental instability 2. See in 10% by age 25 and 95% by age 65 3. *Cadaver study estimated cervical stenosis (\70 yrs* (Lee MJ, *JBJS* 2007) 5. Often asymptomatic until 40 E. Axial neck pain 6. Commonly related to disc F. Cervical radiculopathy 7. Under age 55, related to disc 8. Over age 55 related to spinal canal or foraminal stenosis G. **Cervical myelopathy** 9. **Usually\> 60 yo, long-track signs are the hallmark** 10. Large disc herniation could create bilateral UE symptoms, but most common bilateral UE sx due to myelopathy 11. Presentation of cervical myelopathy 7. +/- Neck and/or arm pain 8. Gradual onset 9. Most pts have arm and leg symptoms- UE's may feel weak or clumsy 10. 13% have cervical & lumbar involvement with combo upper & lower motor neuron changes 11. Loss of balance, difficulty with gait, wide based gait 12. Urinary urgency 13. Long track signs: Hyperreflexia, Babinski, Hoffman's, clonus H. **Indications Surgical Referral From the Medically Managing Perspective** 12. **Progressive neurological decline** 13. **Motor weakness** 14. **Progressive paresthesias** I. **Failure of conservative treatment** 15. **Functional decline** 16. **Patient directed** J. **Things that make me refer quickly** 17. **Myelopathic findings** 18. **Bowel and/or bowel incontinence** 19. **Spinal cord signal change on MRI** K. **Indications for Conservative Management** 20. **None of the refer out criteria** 21. **The patient's choice** 14. **No great surgical option** 15. **Trying to get them as "good as it gets" in preparation for surgery** 16. **The default choice** L. **What Type of Conservative Care?** 22. **Trying to keep the patient away from surgery** 23. **Trying to get them as "good as it gets" in preparation for surgery** 24. **Patient refuses, is medically unable, or has been turned down by the surgeon** 25. **The default choice** M. **Questions to Ask That Direct Care** 26. Functional decline 27. Balance/Gait 28. Bowel and bladder 29. Weakness 30. Sensory deficits 31. Sleep 32. Psychosocial well being: N. **[Nonoperative Treatment for Patients with Spinal Pain Problems]** 33. Education 34. PT 35. Activity modification 36. Bracing 37. Injections 38. Medications III. **Medications** O. General issues P. Most patients need medication at some point 39. Part of an overall treatment plan 40. All medications have risks 41. Multiple risk factors to consider 17. Age 18. Medical, psychological problems 19. Concurrent medications 20. Severity, nature of pain Q. NSAIDS 42. Usage is common in both acute and chronic conditions b/c not sedative or addictive 43. Analgesic effect occurs at lower doses before any effect on inflammatory cascade 44. Analgesic effect occurs in conditions not associated with inflammation 45. Mechanism of action is essentially the same for all NSAIDS 21. Block cyclooxygenase (COX) enzyme 46. For any patient, variable response to any given agent 47. Usually try several different NSAIDS before giving up 48. Different dosing regimens depending on half life 22. Episodic pain -- shorter half-life 23. Chronic, constant pain -- longer half-life 49. Side effects 24. Hepatic- 25. Renal- 26. GI- 27. Cardiovascular R. Opioids/narcotics 50. Bind to opoid receptors 51. Important role in cancer pain and severe acute pain 52. Ideally for short term only; the role in chronic non-malignant pain is controversial (b/c dependence or tolerance) 53. Decreased pain and improved function are clear sign of efficacy 54. Short acting agents (hydrocodone, codeine) 28. Combined with acetaminophen 29. Most commonly used agents 55. Long acting agents (OxyContin, MS contin, Fentanyl patches) 30. Should be considered if long term usage is absolutely necessary 31. No maximal dosage 32. Can lessen "next dose" anxiety S. Muscle relaxants (Flexeril, Soma) 56. Do not selectively relax muscles 57. Generalized effect due to [CNS effect] 58. Can be helpful at bed time 59. [Short] term use with [acute pain] 60. Poor long term agent T. Anticonvulsants 61. Drug of choice for chronic neuropathic pain 62. Finding correct dosage takes time/effort 63. Lyrica (pregabalin) or Neurontin (gabapentin) most commonly used agents 33. No need to check blood levels 34. Few drug interactions U. Antidepressants 64. Useful for chronic pain esp. neuropathic pain 65. Direct effect on neuromodulation (not simply treating masked depression) 66. Must be titrated 67. Side effects can be used to patient's advantage 35. Sedation -- amitriptyline, doxepin V. Glucocorticoids (prednisone, methylprednisone) 68. Short term usage 69. Control severe acute pain (or exacerbation) 70. Not a cure but may enable patient to begin therapy 71. Numerous severe side effects with long term usage 72. Minimal risk with short term (1-2 week) usage IV. **Injections** W. Types of Injections: trigger point, epidurals, facet joint, medial branch blocks X. Fluoroscopically Guided Diagnostic and/or Therapeutic Injections 73. re-evaluate after each injection 74. therapeutic injections should be **[adjunct] [treatment]** Y. Trigger point 75. **Injections -- often injection with anesthetic not steroid; it is thought that main effect is due to needle** 76. **Dry needling** Z. **Injections both [Diagnostic] & [Therapeutic]** 77. Anesthetic induces a reversible conduction block A. Corticosteroids 78. interfere with inflammatory mediators 79. act as membrane stabilizers 80. suppress ectopic neuronal discharges B. **Physiology of Nerve Root Pain** 81. vibration/proprioception: large, myelinated A alpha fibers, paresthesias 82. fast pain fibers & temperature: small, myelinated A-delta fibers, sharp dermatomal pain 83. slow pain fibers: unmyelinated C fibers, deep aching sclerotomal pain C. Efficacy Of Epidural Steroid Injections 84. *ESI used for "lumbago" since the 1930s but the use of fluoroscope guidance became popular in the late 1980s* 85. *Debates regarding efficacy continue: Most studies use surgery as endpoint & few studies report functional improvements with validated outcome tools* 86. Management 36. only one injection may be indicated 37. adjust site of injection based on results of prior injection 38. 2 weeks required to assess therapeutic benefit - **Really good FYI because patients will ask!** 87. Types of Epidurals 39. (know that there are different types; risk of spinal h/a if dura is punctured) D. [Indications:] epidurals done for radiculopathy (nerve root), not isolated back pain E. **This section is a good overview of the procedures. You will not be directing people on the types of injections they will receive.** F. Transforaminal -- done under fluoroscope 88. Dura is not punctured so spinal h/a is not a side effect 89. Medication placed at specific level 90. Insures medication reaching anterior epidural space G. Translaminar -- classic epidural; most often done under fluoroscope 91. Usually obtain bilateral flow 92. May not flow completely anteriorly 93. Greater risk of puncturing the dura mater 94. effect can be obtained over more than 1 level but since it is not specific to 1 nerve root it is not diagnostic H. Caudal 95. little risk of puncturing the dura 96. high volume of contrast shown to advance to thoraco-lumbar junction 97. commonly accepted to reach L4 level 98. *without fluoro, 30% not in epidural space* 99. this method used because of degenerative changes or hardware blocks other entry points I. **Facet Injections** 100. **Indicated for pain believed to be from facet joint: axial pain, no radiation, worse with standing** 101. **Injections are both diagnostic and therapeutic; therapeutic injections are adjunct therapy** 102. **90% performed at L4-L5-S1** V. Anatomy review J. True synovial joint: cartilage, synovial membrane, fibrous capsule, nociceptive & autonomic nerve fibers K. Innervation 103. Each joint innervated by the medial branches (MBs) of the primary dorsal rami (DR) from that level and the level above. 104. *L1-4 MB nerves run across the superior portion of the subjacent TP, under the MAL, and on to the lamina.* 105. ***The diagnosis of Zygapophysial joint pain remains one of exclusion.*** 40. ***Confi*rmation of diagnosis requires analgesic injection of the joint or its nerve supply** L. Medial Branch Blocks 106. primarily diagnostic 107. extended pain relief rare because nerves regenerate 108. blocks afferent nerve supply to facet joint 109. can be used when intraarticular injection not technically possible 110. prognosticate benefit of medial branch neurotomy M. Medial Branch Radiofrequency Neurotomy 111. destroy afferent supply to facet joints 112. nerve regeneration occurs 9-12 months VI. **[Compression fractures ]** N. Sacral fractures- non-traumatic, stress fracture 113. Population: 41. Military or distance runners 42. Post-menopausal osteoporotic women 43. Pregnant or post-partum O. Symptoms 114. Pain & tenderness over sacrum, pain may radiate to low back, hip, groin 115. Pain may be severe 116. Activities are limited 117. Increased sx associated with loading the sacral area 44. Weightbearing 45. Rotation P. Diagnosis with CT scan or bone scan Q. Treatment 118. Treat osteoporosis 119. Limit weight bearing until pain decreased by use of crutches/walker; 120. gradual increase in activity 121. Address imbalances contributing to abnormal stresses on sacrum R. Vertebrae: Etiology 122. OA wedging vs osteoporotic fracture 123. Osteoporotic fx in T-spine: 46. Exaggerated reduction of the mid-height to posterior height ratio & reduction of the anterior to posterior height 47. T-spine incidence of anterior wedge fxs increases with severity of kyphosis 124. Types of Osteoporotic Fractures: Wedge, Concave (biconcave), Crush 125. Differential diagnosis 48. Infection 49. Tumor 50. Spondyloarthropathy 51. Diffuse Idiopathic Skeletal Hyperostosis S. Complications 126. Acute 52. Ilieus 53. Urinary retention 54. Cord compression 127. Long-term 55. Kyphosis 56. Insomnia 57. Depression 58. Generalized deconditioning T. Management Acute Vertebral Compression Fractures 128. Education in positions of comfort 129. Medications 130. Ice/cool 131. Bracing 132. Rest 133. Core strengthening 134. Anxiety/depression U. Choices when conservative management is failing 135. Hospitalization for pain control 136. Vertebroplasty 59. Percutaneous infusion of polymethylmetacrelate (PMMA) 60. Analgesic affect by reinforcing vertebral 137. Kyphoplasty 61. Percutaneous infusion of PMMA into balloon within the compression fracture 62. Can restore some vertebral height 138. Surgical stabilization V. Vertebroplasty/Kyphoplasty Complications 139. Contraindicated if bony fragments extend into canal 140. Bleeding 141. Infections 142. Fracture 143. Injury to nerve root or spinal cord 144. Leakage of material into epidural space or surrounding tissues 145. Embolization into pulmonary vasculature W. Outcomes Vertebroplasty/Kyphoplasty 146. Reduce pain 147. Improve stability 148. ? Improve function 149. ? Reduce morbidity 150. ? Reduce costs 151. Vertebroplasty effective treatment for intractable pain due to osteoporotic vertebral compression fractures 152. Improvements in pain & function at 1 month were maintained at 1 yr X. Problem-solving with vertebral compression fractures 153. Radicular pain 154. Increased pain postprocedure 63. New compression fx 64. Collapse of untreated vertebrae 65. Rib fx 155. Is it the fracture or the deformity? Y. Post-procedure management 156. Modalities 157. Taper medications 158. Bracing 159. Therapeutic exercise 160. Osteoporosis tx Z. Return to exercise VII. **[Sacroiliac Joint Dysfunction]** A. **Sacroiliac Joint** B. Sacral motion in relation to the ilium or Ilial motion in relation to the sacrum C. Pain with hip loading/rotation 161. (increased) Shear forces through the joint? D. A better name ***lumbo-pelvic-hip*** problem 162. ***Q. Does it cause pain? A. Yes*** 163. ***Innervation of SIJ*** 66. ***Anterior joint/ligaments: branches off L2-S2 roots*** 67. ***Posterior joint/ligaments: branches of dorsal primary rami L4-S3*** 68. ***Receptors for pain, temp, mechanoreceptors, autonomic*** E. **Symptoms** 164. Often unilateral 165. Pain localization 166. Pain in the gluteal region 167. Posterior pelvis; can be through thigh, groin, occasionally all the way down leg. F. Provocative activities 168. Transitional activities 169. Increase in walking pace 170. Loading the limb G. Popping or clicking in posterior pelvis H. Diagnostic Testing 171. Xray 69. Changes do not indicate source of pain 70. Best view 30° angle to AP 172. CT 71. Can show early joint narrowing 72. Best to show bone abnormalities 173. Bone Scan 73. Identify fracture, tumor, infection 174. MRI 175. Fluoroscopic-guided SI Joint injection with local anesthetic is **considered the gold standard!** I. Physician's Treatment of SIJ Dysfunction 176. SI Injections- both diagnostic and therapeutic 177. Done under fluoroscope guidance 178. Surgical arthrodesis- last resort 179. *A*lternative treatments: acupuncture, biofeedback