1. Common spine problems and their treatment a peek behind the curtain
Andrew Moulton, MD

2. Goals
1) Terminology

3. Goals 2) Common conditions: 3) Treatment concepts
Acute neck pain/whiplash
Cervical radiculopathy
Cervical myelopathy
Thoracic disc herniations
Osteoporotic spine fractures
Acute low back pain
Lumbar stenosis
Lumbar radiculopathy/sciatica
3) Treatment concepts

4. Mechanical Back Pain
Focal aching nature increasing with activity and decreasing with rest
Pain increases as day progresses vs infection/neoplasm (unrelenting)
Degenerative conditions: increased pain in the morning due to muscle/joint stiffness from decreased motion during sleep cycle

5. Discogenic Pain Increased by: Axial load Flexion-extension
Exposure to vibration (ex: operating vibrating machinery/forklift)
Sitting in a car

6. Axial Back Pain Acute sources of pain Muscle strains
Ligamentous injury
Chronic sources of pain:
Disk (sinuvertebral nerve, nerve endings)
Facet joints (dorsal primary rami)
Dorsal root ganglia irritation

7. Neurogenic Claudication
Classic symptom of spinal stenosis
Progressive loss of walking ability and duration of standing ability
Pain in lower back, lower legs
Positive “shopping cart sign”
Lumbar radiculopathy

8. Acute Neck Pain
Soft tissue injury or inflammation: muscular or ligamentous strain
Limited motion, no radicular symptoms
Sclerotomal pattern (trapezial regions)
Non-operative care

9. Whiplash Rear-end collisions
Acute cervical strain with neck pain and stiffness
Pain worse following day
Other presentations: trapezial pain, headaches, dysesthesias, paresthesias, persistent stiffness
Plain XR’s/MRI persistent axial neck pain, true radiculopathy, other neurologic abnormalities

10. Cervical Spine: Radiculopathy
Compression of a single cervical root (cervical disk herniation/DDD)
Sensory dysfunction
Loss of DTR’s
Muscle atrophy
Flacid weakness or paralysis

11. Cervical Radiculopathy Bottom Line
>90% patients improve with non-operative care:
Time
Physical Therapy
NSAID’s
Steroid blocks
Weakness, numbness and reflex changes ARE NOT indications for surgery
Most neurologic deficits resolve with non-operative therapy.
Many patients are not aware that reflex, sensory and motor deficits can persist despite surgery.

12. Cervical Myelopathy One of the most commonly missed diagnosis
“Absolute” surgical indication
Etiology: cervical spinal stenosis (spondylotic vs congenital vs acute)

13. Cervical Myelopathy Presentation:
Unexplained extremity weakness, “heaviness”
Gait abnormality, loss of balance, falls – loss of proprioception
Loss of coordination
Dexterity loss, “clumsiness”
Neck pain, arm pain NOT common
Signs: Hoffman’s, hyper-reflexic DTR’s

14. Cervical Myelopathy Surgery:
Anterior diskectomy vs corpectomy and fusion
Posterior decompression
Laminectomy
Laminoplasty
Decompression and fusion
Surgical intervention usually associated with improved neurologic outcome

15. Cervical Spine Non-op Treatment
Goals: help control patient’s pain and limit disturbance of his/her everyday limit
Pain cycle: pain -> immobilization -> deconditionning/muscle atrophy/joint adhesions -> pain ….

16. Cervical Spine Non-op Treatment
Modalities:
- rest: >2 days associated with loss of strength, flexibility, and aerobic fitness
- soft c-collar: keep neck in some flexion (extension can be painful), wear at night (protect discs from overload due to poor posture) – ONLY for a few days
- passive modalities, ice, heat
- traction: no proven benefit except in acute herniated discs with arm pain (keep neck in some flexion

17. Cervical Spine Non-op Treatment
Isometric exercises – prevent muscular atrophy in patients with poor mobility HOWEVER it can lead to disc loading
Flexibility exercises – AVOID passive motion as patients may not be able to protect themselves from injury
Aerobic conditioning – more for chronically debilitated patient severely deconditioned – LOW IMPACT (exercise bike, treadmill walking, elliptical)

18. Cervical Spine Non-op Treatment
Resistive Exercises:
Early supervision
Start with warm-up (aerobic exercise)
Proper alignment of the head in relationship to the trunk w/ abdominal exercises
Special attention to shoulder girdle and neck musculature
Initially: low weights, high repetitions - endurance

19. Cervical Spine Non-op Treatment
For cervical disc disease patients emphasis on scapular stabilization muscles (trapezius, deltoid, latissimus dorsi, rhomboids)
Shrugs, dumbbell rows, upright rows, pull downs to the chin (not to the back of head – minimize forced flexion), front and lateral dumbbell raises

20. Cervical Manipulation
Contraindications:
Vertebral fracture/dislocation
Infection
Malignancy
Spondylolisthesis
Myelopathy
Vertebral hypermobility
Osteoporosis
Severe diabetes melitus
Anticoagulation therapy
Spinal nerve root compromise

21. Cervical Spine - Surgery
Posterior Cervical Decompression Fusion – risk of muscle atrophy, kyphotic deformity
0-4/6 weeks: control pain/ inflamation (ice, electrical stim, massage)
Active Modalities: cardiovascular, neck/upper back muscle stabilizers
Body mechanics: keep neck in stable positions
3-6 months (after fusion): no restrictions

22. Cervical Spine - Surgery
Anterior Cervical Discectomy and Fusion
0-4/6 weeks: body mechanics, restrict motion
3 months (after fusion): full unrestricted activities

23. Cervical Spine - Surgery
Laminoplasty – decompressive procedure without fusion
PT: more aggressive ROM, strenthening

24. Cervical Spine - Surgery
CONCEPTS:
With fusion patients: body mechanics, preserve ROM, muscle conditionning until fully fused then full unrestricted activities (3-6 months)
With non-fusion patients (decompression, laminoplasty): more aggressive ROM, active modalities once soft tissue healed then full unrestricted activities (4-6 weeks)

25. Thoracic Disc Herniation
Symptoms: axial pain (nerve fibers annulus fibrosus/PLL), radiculopathy (pain in chest wall, burning sensation, numbness), thoracic myelopathy
Worse with Valsalva maneuver
Imaging: XR, MRI, CT myelogram (if MRI contraindicated)

26. Thoracic Disc Herniation
Frequency: % of all disk herniations (incidental finding in 20% cases)
Most commonly at T10-L1

27. Thoracic Disc Herniation
Treatment:
Nonsurgical: no significant neurologic dysfunction or myelopathy
Bed rest, mobilization
Meds: oral corticosteroids, NSAID’s, opiates
Orthosis PT
Injection
Surgical - fusion

28. Thoracic Disc Herniation
Physical Therapy:
Maintain ROM/strengthening / body mechanics
Minimize increased disc pressure/axial loads:
Decrease full flexion
Minimize heavy lifting
Use pain as a limiting factor
Posterior Spinal Fusion:
Body mechanics, ROM, strengthening 6-8 weeks postop
Full physical activities once healing is evident at 3-6 months

29. Osteoporotic Compression Fractures
2/3 undetected and pain free
1/3 chronically painful
None ever spontaneously regain height or sagittal alignment

30. Osteoporotic Compression Fractures: Treatment
Vertebroplasty or Kyphoplasty
Both are very effective in treating pain, ~90%
Both have a very low complication rate, <1%
Kyphoplasty has the potential to restore anatomy

31. Impact of Osteoporotic Compression Fractures
Spinal deformity correlates with
Impaired gait, poor balance (Gold 1996, Sinaki 2004)
Disability, reduced quality of life (Leidig-Bruckner 1997)
Reduced lung function (Leech 1990, Culham 1994, Schlaich 1998)
Early satiety, gastric distress (Gold 1996)
Future facture risk (Kado 2003)
Excess mortality (Kado 1998, Kado 2004, Huang 2005)

32. Osteoporotic Compresion Fractures – Non-op Treatment
Non-operative:
Body mechanics – minimize kyphosis
Strengthening, cardiovascular
Postoperative (kyphoplasty) care:
FULL unrestricted activities – no fusion and only minimal soft tissue dissection
Emphasize extension exercises, ROM

33. Lumbar Spine Acute Low Back Pain
Second most frequent request for medical attention (after URI)
80% adult population: at least 1 episode
Most common cause - soft tissue structures:
Muscular strain, ligamentous sprain from overuse or acute injury
Acute stretching of posterior longitudinal ligament or anulus fibrosus (disk herniation)

34. Lumbar Spine: Low Back Pain
Muscle strain, ligament sprain
Discogenic pain, annular tears
Segmental instability
Facet joint arthropathy
Spondylolisthesis
Spinal stenosis

35. Acute Low Back Pain
Acute disk herniation: initial LBP (both sides, muscle spasm, pain referred to buttocks) followed by radicular symptoms after several days
Facet syndrome: inflammation or injury of isolated facet – localized ipsilateral pain
Aggravation of lumbar spondylosis: in patients with chronic LBP (minor injury)

36. Chronic Low Back Pain Degenerative conditions
Disk dehydration (“black disk disease”)
Disk height loss -> osteophyte formation, facet arthrosis and ligamentum flavum hypertrophy
Typically no leg symptoms (if no stenosis)
Typical patient: obese, limited muscle mass, poor anaerobic conditioning, smoke, medical comorbidities

37. Surgical Treatment of Back Pain
Fusion
Artificial Disc
Pain relief success rate: 65%

38. Lumbar Radiculopathy - Sciatica
Acute onset with disk herniation in 20-30’s - see prodrome of low back pain
Typically unilateral
Associated paresthesias
Possible associated weakness
Symptoms worse with increased intrathecal pressure (coughing, sneezing, and straining with BM), sitting (vs. walking)
Buttock pain: radiculopathy vs. facet joint pathology
Bilateral radiculopathy vs cauda equina

39. Spinal Stenosis Normal progression of aging
Most people do not develop symptoms
Most patients do not require surgery

40. Spinal Stenosis Presentation: neurogenic claudication
It is a disease of exertion
Physical exam is most often normal
Weakness and numbness is not typical

41. Spinal Stenosis: Classic Presentation
Buttock and leg pain when walking or standing
Starts proximally and moves distally
Relieved by sitting or bending over
Normal exam

42. Lumbar Stenosis Surgical options: Continue to evolve Laminectomy
Minimally invasive decompression
Interspinous Devices (X-Stop)

43. Lumbar Spine – Treatment Concepts
Non-operative patients:
Acute low back pain: initial emphasis on passive then switch to active modalities
Chronic low back pain: active modalities, ROM
Disc Herniation: minimize axial loading, body mechanics
Post-operative patients:
Non-fusion: active modalities
Fusion:
0-4/6 weeks: soft tissue work, body mechanics,
3-6 months: return to full activities

44. Thank You!