1. 1 Spinal disorders (or how do I deal with these back pain patients)

2. 2 Neck and Back Pain 85% with no specific diagnosis Look for red flags bed rest beyond 4 days not advised 80-90% improve within six to eight weeks with or without treatment, 80% of patients with sciatica eventually recover

3. 3 History and Physical History, history, history – the patient will tell you what is wrong almost ALWAYS! Neurological exam – Motor – Reflex – Sensory – Other

4. 4 Red Flags Cancer or infection spinal fracture- trauma, prolonged steroids, age greater that 70yrs cauda equina syndrome- acute onset of retention or incontinence, saddle anesthesia, weakness, fecal incontinence or loss of sphincter tone

5. 5 Motor Exam 5/5 Normal 4(+-)/5 Some resistance 3/5 Overcome gravity 2/5 Able to move but not overcome gravity 1/5 muscle flicker 0/5 No movement

6. 6 Motor Exam C5--Deltoids C6--Biceps C7--Triceps C8/T1--Grip

7. 7 Motor Exam L1/L2--Hip flexors L3/L4 --Leg extensors L5--Dorsiflexion S1--Plantarflexion

8. 8 Reflexes Biceps--C6 Triceps--C7 Knee Jerk--L3/L4 Ankle Jerk--S1

9. 9 Other Spurlings Maneuver Hoffman’s Sign Straight Leg Raise or Crossed SLR

10. 10 Radiculopathy vs. Myelopathy Radiculopathy -nerve root pressure – back or neck pain radiating to extremity – motor, sensory, reflex >>>>> decreased

11. 11 Radiculopathy vs. Myelopathy Myelopathy -- spinal cord pressure – history of gait disturbance, numbness, weakness, Lhermitte’s phenomenon – URINARY URGENCY or INCONTINENCE – motor and sensory >>>>>decreased – REFLEXES INCREASED

12. 12 Neck and Back Pain w/wo Radiculopathy (No Red Flags) (No myelopathy) History and physical No radiographs necessary for first month unless weakness present Treat with NSAIDS, Flexeril, Limited Use of narcotics (no refills)

13. How can you treat? Rest is not the same as limited duty or “don’t do anything” – Don’t aggravate! PT – health maint., stretch, therapies Chiropractics - Manipulate, therapies Acupuncture – Auricular, scalp, pplus, protocols (systemic) Pain clinic – ESI, Facet blocks, spinal stim 13

14. 14 Persistent Pain Neurosurgery-Okinawa Dogma – SM/Dep/VIP with persistent Low Back Pain without radicular pain has pars defect until proven otherwise – WRONG

15. 15 Persistent Pain Work-up Plain X-rays- AP, Lat, Obliques, Flex/Ext – In civilian community, 3 views may be enough MRI

16. 16 Persistent Pain If normal xray and mri – conservative pain management – PT – Limdu – If no improvement after 6-12 mos, refer to MED BOARD If normal xray and mri – Neurosurgery has nothing to offer

17. 17 Other problems Myelopathy, Weakness, Pars defect – Refer to Neurosurgery If persistent pain with failed conservative treatment and HNP, Stenosis, or fracture on x-ray / mri – Refer to (Tele)Neurosurgery

18. 18 Neurosurgery Clinic For weakness, myelopathy, pars defect- surgery recommended (considered) For persistent pain-- options offered – PT, Pain clinic, Chiro, Acupuncture, – Surgery – Med Board

19. 19 Neurosurgery Clinic Use the clinic staff when possible Always available Clinical Practice Guidelines\Low Back Pain

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