1. CONSERVATIVE CARE Douglas Koontz, M.D. Neurosurgery Specialists

2. What does conservative care entail? In neurosurgery, conservative treatment is treatment for neck or back pain with therapies other than surgery Often utilizes medication, physical therapy and/or injections

3. First Evaluation Physical exam of the patient - many times, the patient comes to us after they have seen one or two other physicians such as primary care History taken of pain and all complaints - ie: numbness, tingling, etc. Discussion of options with the patient

4. Medications Many times the patient can be treated with anti-inflammatory medication, steroids and muscle relaxers. Take into account patients complaints, history and medications they are already taking

5. Medications NSAID’s or anti-inflammatories reduce inflammation in and around the spinal area Steroids may be prescribed for a SHORT amount of time. This is often known as a Medrol Dose pack.

6. Medications Muscle relaxers can be prescribed when the patient is experiencing spasms. Common forms of muscles relaxers are: Flexeril, SOMA, Valium, Skelaxin and Robaxin Side effects can include drowsiness and dependence so these should be prescribed with caution

7. Medications Gabapentin Lyrica, Cymbalta All used to treat neuropathic pain

8. Physical Therapy This should be considered if back pain has lasted from between 2-6 weeks and the patient has experienced no relief Physical therapy evaluation is the first step - The therapist can then develop a specific treatment plan for the patient including many different modalities

9. Physical Therapy Aquatic therapy - low impact exercises for patients who are in severe pain or might have a disability that precludes them from participating in land based physical therapy

10. Physical Therapy TENS Unit -involves high or low frequency stimulation -placement of electrodes on or around the painful area - trials are available to see if patient responds well to the TENS unit

11. Physical Therapy Land based, or traditional physical therapy involves exercises meant to reduce pain. This can involve strengthening certain muscle groups The therapist is also able to instruct the patient with home exercises to improve their outcome

12. Other Modalities Acupuncture Biofeedback Massage Manipulation Ultrasound

13. Diagnostic Testing Xray -used to investigate if there is a fracture CT -more in depth test to investigate any bone injuries MRI -more common to order in neurosurgery -used to diagnose soft tissue injury

14. Diagnostic Testing MRI cont. - this diagnostic test most often helps neurosurgeons diagnose things like herniated disks

15. Diagnostic Testing Discogram - This is used to locate the disk that is generating the pain - Performed by a pain management doctor - Usually involves the disk above and below the suspected “problem disk” - Controversial

16. Diagnostic Testing CT Myelogram - used to diagnose herniated disk, tumor, spinal stenosis and infection - Many times this is used after an MRI is performed for a more detailed study

17. Diagnostic Testing EMG - Performed by a neurologist - Used to record activity by the muscles - An order is an EMG of the left/right upper extremities or the left/right lower extremities - EXAMPLE: A patient with negative MRI but persistent leg numbess

18. Epidural Steroid Injections Performed by a pain management physician, usually in the hospital Outpatient procedure that should not interfere with patient’s daily activities Using x-ray guidance, a thin needle is inserted into the epidural space and a steroid (cortisone) is injected

19. Epidural Steroid Injections Can be ordered in a series Patient will come back to see his or her neurosurgeon approximately 2 weeks after the procedure to gauge whether it was a success Injections are considered safe and effective as treatment for pain

20. Injections: Continued Selective Nerve Root Block Trigger Point Injections Facet Injections Rhizotomy

21. Surgery Surgery is indicated if: - Patient fails conservative treatment - Their condition interferes with their ability to function - The benefits of the procedure outweigh the risks - In some cases, the symptoms may be so severe that conservative treatment is not an option and surgery must be performed immediately.

22. Questions?