Upload
hoangnhi
View
220
Download
0
Embed Size (px)
Citation preview
Managing Spine Problems Managing Spine Problems iiin in
Primary CarePrimary Care
Gregory Holm, PhD, NP, FAANPGregory Holm, PhD, NP, FAANP
Steamboat Springs, ColoradoSteamboat Springs, Colorado
Professor: USF College of Medicine: Family & Sports MedicineProfessor: USF College of Medicine: Family & Sports Medicine
Commissioner: American Academy of Nurse Practitioners Certification Commissioner: American Academy of Nurse Practitioners Certification PPProgramProgram
Behavioral ObjectivesBehavioral ObjectivesBehavioral ObjectivesBehavioral Objectives
At the end of the sessionAt the end of the session At the end of the session, At the end of the session, the practitioner will be able to:the practitioner will be able to:
–– Perform an accurate physical assessment of Perform an accurate physical assessment of common spine issues found in the primary care common spine issues found in the primary care settingsettinggg
–– Successfully manage common spine issues found Successfully manage common spine issues found in the primary care settingin the primary care setting
–– Identify dangerous &/or malignant issuesIdentify dangerous &/or malignant issuesIdentify dangerous &/or malignant issues Identify dangerous &/or malignant issues concerning the spine presenting to the primary concerning the spine presenting to the primary care cliniccare clinic
DisclosureDisclosure
I have no current affiliation or financialI have no current affiliation or financial–– I have no current affiliation or financial I have no current affiliation or financial interest with any grantor or interest with any grantor or commercial interests that might have commercial interests that might have ggdirect interest in the subject matter of direct interest in the subject matter of the CE Program.the CE Program.
AgendaAgendagg Important InformationImportant Information
–– Review of Spine TermsReview of Spine Terms–– Anatomical ReviewAnatomical Review
ExaminationExamination Differential DiagnosisDifferential Diagnosis Differential DiagnosisDifferential Diagnosis TreatmentTreatment
–– Lumbar SpineLumbar Spine–– Lumbar SpineLumbar Spine–– Cervical SpineCervical Spine
Lumbar Spine PearlsLumbar Spine Pearls Cord stops @ LCord stops @ L--11
LL 2 less often2 less often–– LL--2 less often2 less often–– conus medularisconus medularis–– then Cauda Equinathen Cauda Equinat e Cauda qu at e Cauda qu a
Umbilicus LUmbilicus L--3/4 3/4 –– aortic bifurcationaortic bifurcation
into illiacsinto illiacs
Intervertebral disc Intervertebral disc –– annulus annulus –– nucleus pulposanucleus pulposa
90% f HNP’90% f HNP’–– 90% of HNP’s 90% of HNP’s L4L4--5 or L55 or L5--S1S1
Spinal ElementsSpinal ElementsSpinal ElementsSpinal ElementsSpinous processSpinous process
Transverse
Lamina
a s e seprocess
Pars articularis
Spinal foramenPedicle
Spinous Body
Neurology of the Lower Neurology of the Lower ExtremityExtremity
Disc Root Reflex Muscle Sensation_______L3-4 L4 Patellar Anterior Tibialis -Medial leg/foot
(foot inversion)
L4 5 L5 N E t h ll i L t l l &/L4-5 L5 None Extensor hallucis -Lateral leg &/or (dorsiflex big toe) -dorsum foot
L5-S1 S1 Achilles Peroneus -Lateral foot(dorsiflex foot)( )
Adapted from Hoppenfeld p.254Adapted from Hoppenfeld p.254
Or simply:Or simply:p yp y Sensory Sensory Knee jerk Knee jerk
Dermatomes:Dermatomes:–– “3 to the knee”“3 to the knee”
“4 h i id lf”“4 h i id lf”
–– usually L4usually L4
–– “4 to the inside calf”“4 to the inside calf”–– “5 to the outside calf”“5 to the outside calf”
“S1 to the outer foot”“S1 to the outer foot”
Ankle jerk Ankle jerk –– usually S1usually S1
–– S1 to the outer footS1 to the outer foot
Motor Deficit Motor Deficit (typical)(typical)
f t l t &/f t l t &/–– foot plantar &/or foot plantar &/or dorsiflexiondorsiflexion
–– L 5 / S1 nerve rootL 5 / S1 nerve root5 / S e e oo5 / S e e oo
LONG TRACT SIGNSLONG TRACT SIGNS(P th l i R fl )(P th l i R fl )(Pathologic Reflexes)(Pathologic Reflexes)
SUGGESTSUGGEST H ff ’H ff ’ SUGGESTSUGGESTUpper Motor Neuron Upper Motor Neuron
LesionLesion
Hoffman’sHoffman’sFor cervical spineFor cervical spine Indicates possibleIndicates possibleLesion Lesion
DTR’s DTR’s 3+ unilaterally; or 4+3+ unilaterally; or 4+
Indicates possible Indicates possible myelopathymyelopathy
Significance of Significance of 3 unilaterally; or 43 unilaterally; or 4Ankle clonusAnkle clonus
dorsiflexion of footdorsiflexion of foot
ggbilateral Hoffman’s is bilateral Hoffman’s is uncertainuncertain
Babinski’s Babinski’s
LONG TRACT SIGNSLONG TRACT SIGNS(P th l i R fl )(P th l i R fl )(Pathologic Reflexes)(Pathologic Reflexes)
SUGGESTSUGGEST H ff ’H ff ’ SUGGESTSUGGESTUpper Motor Neuron Upper Motor Neuron
LesionLesion
Hoffman’sHoffman’sFor cervical spineFor cervical spine Indicates possibleIndicates possibleLesion Lesion
DTR’s DTR’s 3+ unilaterally; or 4+3+ unilaterally; or 4+
Indicates possible Indicates possible myelopathymyelopathy
Significance of Significance of 3 unilaterally; or 43 unilaterally; or 4Ankle clonusAnkle clonus
dorsiflexion of footdorsiflexion of foot
ggbilateral Hoffman’s is bilateral Hoffman’s is uncertainuncertain
Babinski’s Babinski’s
General Clinical ExamGeneral Clinical Exam Inspection Inspection
posture gaitposture gait posture, gaitposture, gait café au lait /skin tagscafé au lait /skin tags fauns beard / lipomatafauns beard / lipomata TT--L ROML ROM
PalpatePalpate PalpatePalpate spasms, spinal process, musclesspasms, spinal process, muscles SI joints, sciatic notch, hipSI joints, sciatic notch, hip abdomen & distal pulsesabdomen & distal pulses
DTR’DTR’ DTR’sDTR’s:: pathologic reflexes pathologic reflexes
cord/upper motorcord/upper motor hyper reflex hyper reflex ypyp
cord/upper motorcord/upper motor hypo reflex hypo reflex
below conusbelow conus Sharp/Dull discriminationSharp/Dull discrimination Sharp/Dull discriminationSharp/Dull discrimination
also vibratory sensealso vibratory sense Extremity strengthExtremity strength
tandem walktandem walk h l d ti t lkih l d ti t lki heel and tiptoe walkingheel and tiptoe walking squat and risesquat and rise
Patrick’s ManeuverPatrick’s ManeuverPatrick s ManeuverPatrick s Maneuver Also known as:Also known as: Also known as: Also known as:
F.A.B.E.R. & La F.A.B.E.R. & La FebereFeberetesttest
Flex knee & place ankleFlex knee & place ankle Flex knee & place ankle Flex knee & place ankle above contralateral above contralateral kneeknee
Apply downward forceApply downward force Apply downward force Apply downward force onto the flexed knee to onto the flexed knee to stress lower back, SI stress lower back, SI joint & hipjoint & hipj pj p
Pain points to source of Pain points to source of pathologypathology
Patrick’s ManeuverPatrick’s ManeuverPatrick s ManeuverPatrick s Maneuver Also known as:Also known as: Also known as: Also known as:
F.A.B.E.R. & La F.A.B.E.R. & La FebereFeberetesttest
Flex knee & place ankleFlex knee & place ankle Flex knee & place ankle Flex knee & place ankle above contralateral above contralateral kneeknee
Apply downward forceApply downward force Apply downward force Apply downward force onto the flexed knee to onto the flexed knee to stress lower back, SI stress lower back, SI joint & hipjoint & hipj pj p
Pain points to source of Pain points to source of pathologypathology
Sciatic (Nerve) StretchSciatic (Nerve) Stretch• SLR
• Straight leg raise• Supine, passive
• Reproduces radicular pain (below kneepain (below knee paresthesias) if +
Sciatic (Nerve) StretchSciatic (Nerve) Stretch• SLR
• Straight leg raise• Supine, passive
• Reproduces radicular pain (below kneepain (below knee paresthesias) if +
• LaSegue’s (aka Bragard’s) g ( g )• “original SLR”
• Same; but stop at first sign of pain … then lower until pain gone … then dorsiflex foot which stretches onlyfoot which stretches only the nerve (not hamstrings)
Sitting Leg ExtensionSitting Leg Extension
Also a sciatic stretchAlso a sciatic stretch•• Also a sciatic stretchAlso a sciatic stretch•• Aka: SLE , Flip signAka: SLE , Flip sign
•• OK for follow up OK for follow up examsexams
Sitting Leg ExtensionSitting Leg Extension
Also a sciatic stretchAlso a sciatic stretch•• Also a sciatic stretchAlso a sciatic stretch•• Aka: SLE , Flip signAka: SLE , Flip sign
•• OK for follow up OK for follow up examsexams
Femoral (Nerve) StretchFemoral (Nerve) Stretch• Opposite of the sciatic
stretches:SLE/SLR/L S• SLE/SLR/LaSegues
• Tests L- 3:Tests L 3:• femoral nerve• “reverse straight leg
i ”raise”
• Best done pronep• Produces L3
radicular symptoms • (down to the• (down to the
anterior knee)
Femoral (Nerve) StretchFemoral (Nerve) Stretch• Opposite of the sciatic
stretches:SLE/SLR/L S• SLE/SLR/LaSegues
• Tests L- 3:Tests L 3:• femoral nerve• “reverse straight leg
i ”raise”
• Best done pronep• Produces L3
radicular symptoms • (down to the• (down to the
anterior knee)
FIRST R/O THESE MALIGNANT PROBLEMS !FIRST R/O THESE MALIGNANT PROBLEMS !
InfectionInfectionInfectionInfection septicemiasepticemia
usually Staph or Strepusually Staph or Strep P tt S d liti (TB)P tt S d liti (TB) Potts Spondylitis (TB)Potts Spondylitis (TB)
NeoplasmNeoplasmworse while lying downworse while lying down worse while lying downworse while lying down
AneurysmAneurysm abdominal masses/bruitsabdominal masses/bruits abdominal masses/bruitsabdominal masses/bruits pulsespulses
Cauda Equina SyndromeCauda Equina SyndromeCauda Equina SyndromeCauda Equina Syndrome
What is Cauda Equina Syndrome?What is Cauda Equina Syndrome?
Losing use of leg (s)Losing use of leg (s) Bowel or bladder symptoms Bowel or bladder symptoms
mostly urinary retentionmostly urinary retention
Saddle numbness &/orSaddle numbness &/or Saddle numbness &/or Saddle numbness &/or tinglingtingling
Decreased anal sphincter Decreased anal sphincter tone tone
Hypo reflexiaHypo reflexia
True emergency:True emergency: referral to Ortho or Neuro spinereferral to Ortho or Neuro spine referral to Ortho or Neuro spine referral to Ortho or Neuro spine
surgeon (ED)surgeon (ED)
Red FlagsRed FlagsR t t Recent trauma
History of osteoporosis Abdominal pain radiates p
straight through to back Fever IV drug use IV drug use Unexplained weight loss History of cancer y Pain worse at night
– pain not relieved in the supine positionp
– awakens patient from sleep w/o movement
Bowel/bladder dysfunction Saddle area paresthesia Weakness
TREATMENTTREATMENT1.1. Ice:Ice: 20 minutes (Rule of 3)20 minutes (Rule of 3)1.1. Ice: Ice: 20 minutes (Rule of 3)20 minutes (Rule of 3)
q hour x 3q hour x 3 then 3x/day x 3 daysthen 3x/day x 3 days then moist heatthen moist heat
2.2. COMMON NSAID ClassesCOMMON NSAID Classes SalicylatesSalicylates
–– ASA, ASA, SalsalateSalsalate
Arachadonic Acid Cascade
ProprionicProprionic acidsacids–– IBP, Naproxen, IBP, Naproxen, KetoprofenKetoprofen
AlkanonesAlkanones–– NabumetoneNabumetone (Relafen)(Relafen)NabumetoneNabumetone (Relafen)(Relafen)
HeteroarylHeteroaryl acetic acidsacetic acids–– DiclofenacDiclofenac, , KetorolacKetorolac
IndoleIndole/Indene Acetic acids/Indene Acetic acidsI d th iI d th i S li dS li d
http://www.creatingtechnology.org/biomed/aspirin.htm–– IndomethacinIndomethacin, , SulindacSulindac
OxicamsOxicams (Cox 2 > Cox 1)(Cox 2 > Cox 1)–– PiroxicamPiroxicam, , MeloxicamMeloxicam
PyranocarboxylicPyranocarboxylic acids acids (Cox 2 > Cox 1)(Cox 2 > Cox 1)y yy y–– EtodolacEtodolac
COX 2 selectiveCOX 2 selective–– celecoxibcelecoxib
Muscle RelaxersMuscle RelaxersCC A tiA ti titi1.1. Common Common AntiAnti--spasmoticsspasmotics
SedatingSedating–– cyclobenzaprinecyclobenzaprine ((FlexirilFlexiril))
i d li d l (S )(S ) IIIIII–– carisoprodalcarisoprodal (Soma) (Soma) cIIIcIII
•• 11stst pass = pass = meprobamatemeprobamate ((EquanilEquanil: : tranquiliziertranquilizier))–– tizanidinetizanidine ((ZanaflexZanaflex))
orphenadrineorphenadrine ((NorflexNorflex))–– orphenadrineorphenadrine ((NorflexNorflex))–– chlorzoxazonechlorzoxazone ((ParafonParafon Forte)Forte)
NonNon--sedating sedating –– MetaxaloneMetaxalone ((SkelaxinSkelaxin))MetaxaloneMetaxalone ((SkelaxinSkelaxin))–– MethocarbamolMethocarbamol ((RobaxinRobaxin))
2.2. AntiAnti--spastics spastics (sometimes used)(sometimes used)Sh ld b d f C P M S tSh ld b d f C P M S t–– Should be reserved for C.P. ; M.S. etcShould be reserved for C.P. ; M.S. etc
BaclofenBaclofen ((LioresalLioresal)) DantroleneDantrolene ((DantriumDantrium)) BenzodiazepineBenzodiazepine
•• diazepam (Valium)diazepam (Valium) cIVcIV
•• anxiolyticanxiolytic, anti, anti--seizureseizure
GlucocorticoidsGlucocorticoidsGLUCOCORTICOID ORAL PULSE
• Predisone 50 mg daily x 3 daysM th l d i l (D P k)• Methylprednisolone (Dose Pak)
• taper no longer standard of care
IONTOPHORESIS
• Dexamethasone 4 mg/ml injectable
INJECTION
• Combine Steroids:• Fast onset-short acting
e.g. dexamethasoneg• Slow onset-long acting
e.g. depomedrol, triamcinalone• Anesthetic:
• Fast onset-short acting ge.g. xylocaine
• Slow onset-long acting e.g. bupivacaine
GENERIC TRADE Potency Onset
Cortisol n/a 1 FastCortisol n/a 1 Fast
Dexamethasone Decadron 4 Fast
Methylprednisolone Depomedrol 4 moderateMethylprednisolone DepomedrolD80
4 moderate
Triamcinolone acetonide
AristocortKenalog
5 moderate
K40
Betamethasone Celestone 25 slow
Further Plan of CareFurther Plan of Care Sufficient analgesiaSufficient analgesia
AcetaminophenAcetaminophen TramadolTramadol KetorolacKetorolac OpiatesOpiates
Physical TherapyPhysical TherapyPhysical TherapyPhysical Therapy Rest Rest
–– then home exercisesthen home exercises IMAGING:IMAGING:
–– XX--ray < 18 and > 50ray < 18 and > 50–– MRI: HNP Cancer AAAMRI: HNP Cancer AAAMRI: HNP, Cancer, AAAMRI: HNP, Cancer, AAA
Labs?Labs?–– ESRESR
A happy patient is a trusting patient–– CBCCBC–– CMPCMP
A happy patient is a trusting patient
CERVICAL SPINECERVICAL SPINECERVICAL SPINECERVICAL SPINE
5 C f P i5 C f P i 5 Causes of Pain5 Causes of Pain
1.1. DiscogenicDiscogenic2.2. RadiculogenicRadiculogenic3.3. MyelogenicMyelogenic4.4. SpondylogenicSpondylogenic5.5. CombinationCombination
EXAMINATIONEXAMINATION A tA t Assess motorAssess motor Active range of motion Active range of motion “Pinching between my “Pinching between my g yg y
shoulder blades”shoulder blades”•• cervical disccervical disc•• hand on head for reliefhand on head for reliefhand on head for reliefhand on head for relief
Arm/hand Arm/hand paresthesiaparesthesia may be only may be only
manifestationmanifestationmanifestationmanifestation Occipital headachesOccipital headaches
DJD @ C3 / C4 DJD @ C3 / C4 muscle spasmmuscle spasm muscle spasmmuscle spasm migraine?migraine?
R/O fracture R/O fracture i ll / h d i ji ll / h d i j•• especially w/ head injuryespecially w/ head injury
***INNERVATION***
•• C 5: C 5: •• Deltoid & Deltoid & BicepsBiceps musclemuscle•• BicepsBiceps DTRDTRBiceps Biceps DTRDTR
•• C6:C6:•• Biceps & Biceps & wrist extensorwrist extensor muscles muscles •• BrachioradialisBrachioradialis DTRDTR
•• C7: C7: •• TricepsTriceps & wrist flexor muscles& wrist flexor muscles•• TricepsTriceps & wrist flexor muscles, & wrist flexor muscles, •• Triceps Triceps DTRDTR
Provocative Cervical TestsProvocative Cervical Tests•• Spurling’sSpurling’s
•• suspect HNPsuspect HNPlik SLR b t flik SLR b t f•• like SLR, but for like SLR, but for neck issuesneck issues
Provocative Cervical TestsProvocative Cervical Tests•• Spurling’sSpurling’s
•• suspect HNPsuspect HNPlik SLR b t flik SLR b t f•• like SLR, but for like SLR, but for neck issuesneck issues
•• Distraction & Distraction & CompressionCompression
•• Suspect HNPSuspect HNP
Swallowing TestSwallowing Test•• Swallowing TestSwallowing Test•• osteophyte, osteophyte,
hematoma, hematoma, infection, tumor, infection, tumor, HNPHNP
Llhermitte’sLlhermitte’s• Look up - Look down
• “Touch your chin to your y ychest”
• Positive if causes electric shocks down spine
(maybe even into legs)S t HNP t C S i• Suggests HNP at C - Spine• Like SLR for neck
Mi ht l l t• Might also apply vertex compression simultaneously to s u a eous y oincrease sensitivity of test
Adson’s ManeuverAdson’s ManeuverAdson s ManeuverAdson s Maneuver Suggests:Suggests:ggggThoracic Outlet SyndromeThoracic Outlet Syndrome
Look towards examinerLook towards examiner–– also look awayalso look away
Head up & look over Head up & look over Head up & look over Head up & look over shouldershoulder
Take a deep breath & Take a deep breath & hold it:hold it:–– Positive: pulse Positive: pulse
diminishes in qualitydiminishes in qualityq yq y
Allen’s TestingAllen’s Testing Circulation of handCirculation of hand Pump blood out;Pump blood out;Pump blood out; Pump blood out;
occlude arterial flowocclude arterial flow–– Release 1 @ a timeRelease 1 @ a time–– Normal: pink in <7 Normal: pink in <7
seconds & equallyseconds & equally
TREATMENT FOR NECK PROBLEMSTREATMENT FOR NECK PROBLEMS E ti ll fE ti ll f Essentially same as for Essentially same as for
lumbar spinelumbar spine
HNP on MRI may need HNP on MRI may need semisemi--rigid cervical collarrigid cervical collar can’t take whiplashcan’t take whiplash can t take whiplashcan t take whiplash NONO soft collarssoft collars
May use tractionMay use traction May use tractionMay use traction 20# over the door 20# over the door t.i.dt.i.d.. Home Traction CollarHome Traction Collar
Myelopathy in general Myelopathy in general practice is treated as true practice is treated as true ppemergencyemergency•• burning in palmsburning in palms•• Hoffman’s reflexHoffman’s reflex
SUMMARYSUMMARY D l i lD l i l Dorsal spine rarely Dorsal spine rarely
involved involved well anchored by shoulderwell anchored by shoulder except fall on heels: Texcept fall on heels: T--1212
Full exam on each new Full exam on each new patientpatient
Good history is vitalGood history is vital R/O R/O
neoplasm osteomyelitisneoplasm osteomyelitis neoplasm, osteomyelitis, neoplasm, osteomyelitis, aneurysm, cauda equina aneurysm, cauda equina
Suspect nonSuspect non--spinal spinal etiologyetiologyetiologyetiology
Mobilize earlyMobilize early Conservative therapyConservative therapypypy Refer failures, neuro Refer failures, neuro
deficitsdeficitsThis is killing my back! This is killing my back!
BibliographyBibliography Mercier, L.R., 1995. Practical Orthopedics. Mosby-Year Book, St. Louis Hoppenfeld, S., 1976. Physical exam of the spine & extremities. Appleton & Lange.
Norwalk, CT Anderson, B.C., 1999. Office Orthopedics for Primary Care. W B Saunders, Philadelphia Moller, T., Reif, E, & Stark, P., 1993. Pocket Atlas of Radiographic Anatomy. Thieme , , , , , , f g p y
Flexbooks, NY Squire, L.F., Novelline, R.A., 1988. Fundamentals of Radiology. 4th Ed. Harvard Press.
Cambridge Johnson, T.R., & Steinbach, L.S., 2004. Essentials of Musculoskeletal Imaging. AAOS. , , , , f g g
Rosemont, Ill. Baxter, RE. 2003. Pocket guide to musculoskeletal assessment. 2nd Edition. WB Saunders,
Philadelphia Griffin, L.Y. 2005. Essentials of Musculoskeletal Care. 3rd Edition. American Academy G , . . . sse tials of usculos eletal Ca e d d o . e c c de y
of Orthopoedic Surgeons. Rosemont Illinois BS Williams & SP Cohen, 2010. Greater Trochanteric Pain Syndrome: A Review of
Anatomy, Diagnosis and Treatment, Anesthesia & Analgesia (IARS). Kingsette - Taylor et al., Oct 1999. Tendinosis and tears of the gluteus media & minimusKingsette Taylor et al., Oct 1999. Tendinosis and tears of the gluteus media & minimus
muscles as a cause of hip pain: MR imaging findings. AJR 173, 1123-26 www.dynamicmedical.comwww.dynamicmedical.com www.xray2000.co.ukwww.xray2000.co.uk www uhrad comwww uhrad com www.uhrad.comwww.uhrad.com http://aisr1.lib.tju.edu/ha/anirefshttp://aisr1.lib.tju.edu/ha/anirefs