Nonsurgical Mgmt of Spinal Conditions Notes PDF

**WASHINGTON UNIVERSITY SCHOOL OF MEDICINE** **PROGRAM IN PHYSICAL THERAPY** **John Metzler, MD** Conservative Management of Spinal Condition I. Low back pain A. Conservative Care 1. Vast majority of patients with LBP are not operative candidates 2. Trial o...

**WASHINGTON UNIVERSITY SCHOOL OF MEDICINE** **PROGRAM IN PHYSICAL THERAPY** **John Metzler, MD** Conservative Management of Spinal Condition 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 8. Degenerative changes in the lumbar spine 9. Disc - Vertebrae B. Myelogram 4. 5. 6. 7. 8. C. 9. **In children can occur spontaneously, in adults usually after procedure (anywhere in the body)** 10. **Severe pain limited ROM, may have fever** 11. Check WBC, inflammatory markers, blood cultures 12. Often unable to isolate an organism 13. 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 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 3. +/- Neck and/or arm pain 4. Gradual onset 5. Most pts have arm and leg symptoms- UE's may feel weak or clumsy 6. 13% have cervical & lumbar involvement with combo upper & lower motor neuron changes 7. Loss of balance, difficulty with gait, wide based gait 8. Urinary urgency 9. 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** 10. **No great surgical option** 11. **Trying to get them as "good as it gets" in preparation for surgery** 12. **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 13. Age 14. Medical, psychological problems 15. Concurrent medications 16. 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 17. 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 18. Episodic pain -- shorter half-life 19. Chronic, constant pain -- longer half-life 49. Side effects 20. Hepatic- 21. Renal- 22. GI- 23. 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) 24. Combined with acetaminophen 25. Most commonly used agents 55. Long acting agents (OxyContin, MS contin, Fentanyl patches) 26. Should be considered if long term usage is absolutely necessary 27. No maximal dosage 28. 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 29. No need to check blood levels 30. 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 31. 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 D. [Indications:] epidurals done for radiculopathy (nerve root), not isolated back pain E. **Facet Injections** 84. **Indicated for pain believed to be from facet joint: axial pain, no radiation, worse with standing** 85. **Injections are both diagnostic and therapeutic; therapeutic injections are adjunct therapy** 86. **90% performed at L4-L5-S1** V. Anatomy review F. True synovial joint: cartilage, synovial membrane, fibrous capsule, nociceptive & autonomic nerve fibers G. Innervation 87. Each joint innervated by the medial branches (MBs) of the primary dorsal rami (DR) from that level and the level above. 88. *L1-4 MB nerves run across the superior portion of the subjacent TP, under the MAL, and on to the lamina.* 89. ***The diagnosis of Zygapophysial joint pain remains one of exclusion.*** 32. ***Confi*rmation of diagnosis requires analgesic injection of the joint or its nerve supply** H. Medial Branch Blocks 90. primarily diagnostic 91. extended pain relief rare because nerves regenerate 92. blocks afferent nerve supply to facet joint 93. can be used when intraarticular injection not technically possible 94. prognosticate benefit of medial branch neurotomy I. Medial Branch Radiofrequency Neurotomy 95. destroy afferent supply to facet joints 96. nerve regeneration occurs 9-12 months VI. **[Compression fractures ]** J. Sacral fractures- non-traumatic, stress fracture 97. Population: 33. Military or distance runners 34. Post-menopausal osteoporotic women 35. Pregnant or post-partum K. Symptoms 98. Pain & tenderness over sacrum, pain may radiate to low back, hip, groin 99. Pain may be severe 100. Activities are limited 101. Increased sx associated with loading the sacral area 36. Weightbearing 37. Rotation L. Diagnosis with CT scan or bone scan M. Treatment 102. Treat osteoporosis 103. Limit weight bearing until pain decreased by use of crutches/walker; 104. gradual increase in activity 105. Address imbalances contributing to abnormal stresses on sacrum N. Vertebrae: Etiology 106. OA wedging vs osteoporotic fracture 107. Osteoporotic fx in T-spine: 38. Exaggerated reduction of the mid-height to posterior height ratio & reduction of the anterior to posterior height 39. T-spine incidence of anterior wedge fxs increases with severity of kyphosis 108. Types of Osteoporotic Fractures: Wedge, Concave (biconcave), Crush 109. Differential diagnosis 40. Infection 41. Tumor 42. Spondyloarthropathy 43. Diffuse Idiopathic Skeletal Hyperostosis O. Complications 110. Acute 44. Ilieus 45. Urinary retention 46. Cord compression 111. Long-term 47. Kyphosis 48. Insomnia 49. Depression 50. Generalized deconditioning P. Management Acute Vertebral Compression Fractures 112. Education in positions of comfort 113. Medications 114. Ice/cool 115. Bracing 116. Rest 117. Core strengthening 118. Anxiety/depression Q. Choices when conservative management is failing 119. Hospitalization for pain control 120. Vertebroplasty 51. Percutaneous infusion of polymethylmetacrelate (PMMA) 52. Analgesic affect by reinforcing vertebral 121. Kyphoplasty 53. Percutaneous infusion of PMMA into balloon within the compression fracture 54. Can restore some vertebral height 122. Surgical stabilization R. Vertebroplasty/Kyphoplasty Complications 123. Contraindicated if bony fragments extend into canal 124. Bleeding 125. Infections 126. Fracture 127. Injury to nerve root or spinal cord 128. Leakage of material into epidural space or surrounding tissues 129. Embolization into pulmonary vasculature S. Outcomes Vertebroplasty/Kyphoplasty 130. Reduce pain 131. Improve stability 132. ? Improve function 133. ? Reduce morbidity 134. ? Reduce costs 135. Vertebroplasty effective treatment for intractable pain due to osteoporotic vertebral compression fractures 136. Improvements in pain & function at 1 month were maintained at 1 yr T. Problem-solving with vertebral compression fractures 137. Radicular pain 138. Increased pain postprocedure 55. New compression fx 56. Collapse of untreated vertebrae 57. Rib fx 139. Is it the fracture or the deformity? U. Post-procedure management 140. Modalities 141. Taper medications 142. Bracing 143. Therapeutic exercise 144. Osteoporosis tx V. Return to exercise VII. **[Sacroiliac Joint Dysfunction]** W. **Sacroiliac Joint** X. Sacral motion in relation to the ilium or Ilial motion in relation to the sacrum Y. Pain with hip loading/rotation 145. (increased) Shear forces through the joint? Z. **Symptoms** 146. Often unilateral 147. Pain localization 148. Pain in the gluteal region 149. Posterior pelvis; can be through thigh, groin, occasionally all the way down leg. A. Provocative activities 150. Transitional activities 151. Increase in walking pace 152. Loading the limb B. Popping or clicking in posterior pelvis C. Diagnostic Testing 153. Xray 58. Changes do not indicate source of pain 154. CT 59. Can show early joint narrowing 60. Best to show bone abnormalities 155. Bone Scan 61. Identify fracture, tumor, infection 156. MRI 157. Fluoroscopic-guided SI Joint injection with local anesthetic is **considered the gold standard!** D. Physician's Treatment of SIJ Dysfunction 158. SI Injections- both diagnostic and therapeutic 159. Done under fluoroscope guidance 160. Surgical arthrodesis- last resort 161. *A*lternative treatments: acupuncture, biofeedback