Evaluation and Management of Select Spine …...10/2/2018 1 Evaluation and Management of Select Spine Conditions Michael E. Zychowicz, DNP, ANP, ONP, FAAN, FAANP Professor & Director,

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Evaluation and Management of Select

Spine Conditions

Michael E. Zychowicz, DNP, ANP, ONP, FAAN, FAANP

Professor & Director, MSN Program

Lead Faculty, Orthopedic NP Specialty

Director, Duke-Durham VA Nursing Academic Partnership

Duke University School of Nursing

• Second most frequent primary care complaint• 80–90% of adults - at least once in their life

• Leading cause for visits to: • Orthopedist, Neurosurgeon, Occupational

medicine

• Bad News• Leading cause of work disability• 4% of patients have symptoms > 6 months

• Good News• Symptoms are usually self limiting• 85% of patients improve within 1 month• Even without treatment

Back Pain

• Back pain is not always just back pain!!!!!!!

• Many differentials• Strain/ sprain, degenerative disc disease, arthritis

• Spondylolisthesis, fibromyalgia, spinal stenosis

• Cancer pain, infection, cauda equina, fracture

• Abdominal aortic aneurysm, disc herniation, spinal tumor

• Pyelonephritis, renal calculi, endometriosis

• Spinal TB, Paget’s disease, etc, etc, etc

Back Pain

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• Sprain/strain/ nonspecific low back pain• Usually low back pain +/- leg discomfort

• Decreased range of motion

• Possible guarding or muscle spasm

• Degenerative disease/ Arthritis• back pain +/- leg pain

• Decreased range of motion

• Pain with activities

• May or may not have neuro deficit

Common Causes of Back Pain

• Cancer• Prior Hx of CA• Unexplained weight loss +/- change in appetite• Night or rest pain• > 50y/o and <20y/o• Failure to improve with therapy

• Spinal infection• Fever• Hx of IV drug use• Recent bacterial infection• Immunocompromised state

• Steroid, organ transplant, diabetes, HIV

• Pain at rest

Back Pain: Red Flags

• Fracture• Use of corticosteroids• Age greater than 70• History of osteoporosis• Recent significant trauma

• Cauda equina syndrome• Urinary retention or incontinence• Saddle anesthesia• Anal sphincter tone decrease or fecal incontinence• Lower extremity weakness, numbness or progressive

neurologic deficit• Usually bilateral

• IMMEDIATE surgical consultation!!!

Back Pain: Red Flags

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• X-ray• Fractures, bony tumors, arthritis, disc

height• Consider if unimproved in 6-8 weeks or

trauma• Consider if suspicious for “red flag”

problems

• MRI• Very good for imaging soft tissues• Disc herniation, tumor, infection, cord or nerve

compression Consider if suspicious for myelopathy, infection, neoplasm

• Trauma – bone edema from fractures• Radicular sx w/ motor/ reflex deficit• Radicular sx unimproved in 6-8 weeks

Imaging

• CT Scan• Good for imaging cortical bone• fractures

• arthritis

• Bone Scan• Useful if plain x-rays are normal

and suspicious for:• Osteomyelitis, neoplasm, metastatic

disease, occult fracture

Imaging

• First visit

• Physical Exam• Consider referral if red flags present

• Treat low back pain/ radicular symptoms• Activity modification• No heavy lifting, pushing or pulling

• Progressive ROM and light aerobic exercise• Walking, stationary bike, gentle pool movement

• Medication management• NSAIDS – inflammation and pain

• Muscle relaxers – muscle spasm

• (Non) Narcotic analgesics – pain

Treatment Guideline: Modified from American Academy of Orthopedic Surgeons (2002) Adult Patients

with Low Back Pain/ Sciatica [Acute]

Back Pain Treatment

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• Treatment options cont.• Physical therapy/ home exercise• ROM, stretching, strengthening, heat/ cold, ultrasound, TENS,

traction, massage

• Adjuncts – conflicting evidence• Shoe inserts, back belts, lumbar corsets, biofeedback, chiropractor,

acupuncture

• Bed rest• 2 days at most

• Prolonged may lead to deconditioning



Back Pain Treatment

• Follow-up• 1-3 weeks as indicated by pain and injury• If unimproved or worsening symptoms• Continue or modify plan for up to 4-6 wks• Reassurance/ patience is helpful• Refer as needed

• If improved• Off meds/ Return to activities• Maintain stretching/ strengthening program



Back Pain Treatment

• At 4-6 weeks• If the patient is unimproved or worse• Repeat psychosocial and physical assessment

• Reconsider red flag differentials

• Obtain AP and Lateral lumbar spine x-ray

• Consider MRI and referral:

• neurologic deficit

• Modify meds/ treatment as needed

• If improved• Off meds/ Return to activities

• Maintain stretching/ strengthening program



Back Pain Treatment

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• Follow up at 8-12 weeks• If unresolved or worse• Repeat psychosocial and physical assessment

• Reconsider red-flag differentials

• Consider MRI

• Modify meds/ treatment as needed

• Consult ortho or neuro for further evaluation/treatment

• If resolved• Off medications/ Return to activities

• Maintain stretching/ strengthening program



Back Pain Treatment

Lumbar Radiculopathy

• AKA: Sciatica

• Neurogenic pain• Nerve root compression or chemical

irritation

• Mostly leg pain across dermatome• May have some back pain

• Causes• Disc herniation

• Spinal stenosis

• Primary or metastatic tumor


• A 38 y/o male comes to the office c/o constant left lateral thigh and calf pain. He had a sudden onset of pain yesterday after lifting a heavy object at home. The pain is worsening. He is having difficulty finding a comfortable position. NSAIDS have not helped the pain. No bowel or bladder dysfunction.

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• Physical exam• May have thoracic shift

• (+) straight leg raise or femoral stretch test

• Evaluate weakness, reflexes, sensation

• Differentials• Disc herniation, stenosis

• Femoral cutaneous nerve entrapment

• Trochanteric bursitis and ITB syndrome

• Primary or metastatic tumor


• Diagnostics• X-ray

• Evaluate for structural pathology

• MRI• Evaluate for herniation, stenosis, tumor

• EMG• May help clarify clinical picture

• Treatment• Relative rest and reassurance• NSAIDS, pain meds, consider oral steroids• Consider Physical therapy or chiropractic• Possible epidural steroids• See treatment for herniation and stenosis

• Nucleus pushes partly or fully through annulus• Pressure on nerve root or ligament

• Radicular symptoms

• Possible back pain

• Usually from disc degeneration • Trauma or repetitive loading

• Most commonly at L4-5

• Men > Female

• Smoking increases risk

Lumbar Disc Herniation

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• A 46 y/o male presents to the office c/o sudden onset of severe right lateral leg pain, numbness and tingling with mild back pain. He was at work yesterday lifting a heavy object when he developed the pain. No difficulty ambulating. No bowel or bladder dysfunction.

• Physical exam• Weakness, loss of DTR, or decreased sensation

• Gait abnormality or drop foot

• Straight leg raise

• Femoral stretch test

• Cauda equina syndrome (Emergency)

• Saddle anesthesia or bowel/ bladder change

• Loss of rectal tone

• Differentials• Degenerative disc disease, spinal stenosis

• Back strain


• Imaging• X-ray and MRI• Symptoms lasting > 6 weeks

• Trauma or suspected pathology

• Weakness and/ or loss of reflexes

• Cauda equina syndrome

• Most improve without surgery• Proper lifting, Activities as tolerated

• NSAIDS, muscle relaxer, narcotics, oral steroids

• Physical therapy, chiropractic, acupuncture

• Epidural steroids or selected nerve root block


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• Surgery• Emergent with Cauda equina

• Consider if unimproved in 6-8 weeks

• Consider if weakness, loss of reflexes intractable pain

• Post op• Disc degeneration

• Recurrent HNP

• Epidural fibrosis and chronic pain

• Infection and discitis


• Degeneration of intervertebral disc• Frequently asymptomatic• Intermittent or chronic pain

• Aging, trauma, infection, heredity, smoking• Disc dehydrates and looses height• Ligaments not as tight

• Increased abnormal motion causing tears• Foraminal stenosis

• Facet degeneration• Spurring and inflammation

• Onset 30 – 60 years old• Men sooner than women

Lumbar Degenerative Disc Disease


• A 45 year old male presents to the office for low back pain. He has had intermittent low back pain for the past 5 years lasting 1 week at each episode. His 4/10 pain is now constant for the past 6 weeks. He reports no trauma or injury. The pain radiates to the buttocks and upper posterior thighs. No other pain, numbness or tingling into the lower extremities. No reported weakness of the legs. No difficulty ambulating. No bowel or bladder dysfunction. The pain is aggravated with bending and lifting activities. Also worse with transition from a seated to standing position. NSAIDS and chiropractic have not helped. He feels he is unable to perform his job as a mechanic at this time due to the pain.

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• Physical exam• Discomfort with ROM• Usually no neuromuscular deficit• Possible discomfort with palpation• Muscle spasm or trigger points• Consider complicating psych conditions

• Differentials• Non-spinal cause of back pain• Inflammatory or seronegative arthropathy• Secondary gain, work place issues• Drug seeking behavior• Fracture, Potts disease• Disc or vertebral infection• Primary or metastatic tumor


• Diagnostics• X-ray

• not improving, trauma, suspected pathology

• MRI• Not improving, suspected pathology

• Rule out differentials

• Treatment• NSAIDS, Pain medication

• Pills, patches and creams

• Pain management specialist

• Physical therapy and home exercises• Weight reduction as needed

• Activity as tolerated• Chiropractic or acupuncture may help

• Address radicular component• Possible steroids injections

• Associated trigger points or facet pain

• Surgical fusion last resort


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• Narrowing of the canal and/or foramina• Cauda Equina, roots and vascular compression

• Worse with extension• Neural root ischemia and neurogenic

claudication

• Improved with flexion• Opens canal and foramen

• Relieves nerve pressure

• Contributing causes:• Degenerative disc, facet joint arthropathy

• Spondylolisthesis, fractures, tumor

• Ligamentum flavum hypertrophy, synovial cysts

Spinal Stenosis

Spinal Stenosis

• A 68 y/o male presents with pain, numbness and weakness in the lower extremities while walking a short distance. This has been gradually worsening over the past 2 years. He has occasional back pain. He notices the pain is improved with sitting and leaning forward or leaning over a shopping cart while grocery shopping. No bowel or bladder dysfunction.

• Physical exam• Neurovascular examination

• Motor exam

• Straight leg raise

• Phalen test to reproduce symptoms

• Differentiate from vascular problem

• Differentials• Disc herniation

• Tumor or space occupying lesion

• Peripheral vascular disease

Spinal Stenosis

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• Imaging• X-rays

• Evaluate for disk space narrowing and instability

• Osteophyte formation, ligament calcification

• Myelogram, CT scan, MRI• Evaluate the soft tissue, bone, canal and foramen

• Nonsurgical treatment• Possible epidural steroids

• Stretching and strengthening exercises

• Surgical Treatment• Decompression and possible fusion

Spinal Stenosis

Primary osteoporosis

Secondary osteoporosis• Drug-induced (corticosteroids, tobacco, etc)• Endocrine (hyperparathyroidism, diabetes)• Miscellaneous (renal failure, COPD,

rheumatoid, hepatic disease or transplant)

Osteolytic lesions• Multiple Myeloma• Bone metastases• Paget’s disease

• Trauma• Usually vertical compression

Lumbar compression fractures


• A 88 y/o osteoporotic female presents with a sudden onset of mid-back pain. No trauma. She has no complaints of shortness of breath. No pain, numbness or tingling into the extremities. She has had prior back pain the she has not been evaluated for. It seemed to dissipate over time. She has noticed a definite loss of height and her clothes are not fitting the way they used to.

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• Physical exam• Pain on palpating the spinous

process

• Kyphosis

• Loss of height

• Negative straight leg raise

• Normal neuro exam

• Protuberant abdomen



• Imaging– X-ray to visualize fracture

– MRI or Bone scan• Evaluate for occult fracture

• Determine acute vs old

• Evaluate for pathology

• Treatment

– Usually 3 months length

– Medical management of osteoporosis

– Muscle relaxers +/- pain meds

– Jewett brace, LSO or TLSO

• Surgical treatment• Not responding to conservative tx• Neurologic deficit or intractable back pain• Progressive loss of vertebral height

• Open Surgical Treatment• Only if neurologic deficit

• Instrumented fusion

• Vertebroplasty• Freezes fracture without reduction

• Kyphoplasty• Stabilize and reduces the Fracture


Bone cement in a

reduced vertebral fracture

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Cervical Degenerative Disc Disease (DDD)

• Neck pain with motion

• Limited motion

• Grinding or popping sensation

• Muscle spasm and headaches

• May have symptomatic stenosis• Spurs or osteophyte disc complex

Bone Spur

Normal disc

space

Decreased disc space

Cervical DDD

• Symptoms may last or come and go

• NSAIDS, Tricyclics or other pain meds

• Pillow or neck roll

• PT, chiropractic may help

• Topical arthritis creams

• Lidoderm patches

• Surgical fusion is last option

Axial neck pain, cervical radiculopathy, or non-complicated whiplash

• Initial Treatment • (No red flags suspected)

• Medication• NSAIDS/Tylenol/Muscle Relaxers/ Opioids

• May consider Medrol dose pack for radiculopathy

• Consider PT/ chiro/ acupuncture• Many conflicting studies

• Varied effectiveness of modalities

• Relative rest• Return to activities as early as possible

Clinical Guideline: Douglas & Bope (2004) Journal of the American Board of Family Medicine

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• Follow-up visit• Consider F/U in 1-2 weeks

• Repeat exam

• Dependent on pain, return to work, clinical concern, etc

• Consider PT/chiro, acupuncture if unimproved

• Adjust meds as needed

• Encourage patient

• Consider neuro/ortho referral • if loss of reflex or motor strength



• Follow-up visit• 4-6 weeks

• Repeat exam• Adjust meds as needed • Encourage patient• Consider PT/chiro, acupuncture if unimproved• X-ray neck if pain unimproved• If radicular symptoms persist

• Consider MRI• Consider antidepressant or anticonvulsant

• Consider ortho/ neuro referral


Whiplash with Neuro Symptoms

• Physical exam

• Pain meds• NSAIDS, (non) opioid meds, muscle relaxers

• X-ray neck• Immobilize neck and refer if fracture

• No fracture – treat same as radiculopathy


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Suspected infection, neoplasm, myelopathy

• Physical examination

• X-ray and MRI of C-spine

• Labs (CBC, CRP, ESR)

• Ortho/neuro referral


Summary

Documents

Evaluation and Management of Select Spine …...10/2/2018 1 Evaluation and Management of Select Spine Conditions Michael E. Zychowicz, DNP, ANP, ONP, FAAN, FAANP Professor & Director,