Your SlideShare is downloading. ×
Neck and Back Pain: "Doctor, I'm hurting!
Upcoming SlideShare
Loading in...5
×

Thanks for flagging this SlideShare!

Oops! An error has occurred.

×

Introducing the official SlideShare app

Stunning, full-screen experience for iPhone and Android

Text the download link to your phone

Standard text messaging rates apply

Neck and Back Pain: "Doctor, I'm hurting!

1,660
views

Published on

Published in: Health & Medicine

0 Comments
0 Likes
Statistics
Notes
  • Be the first to comment

  • Be the first to like this

No Downloads
Views
Total Views
1,660
On Slideshare
0
From Embeds
0
Number of Embeds
0
Actions
Shares
0
Downloads
23
Comments
0
Likes
0
Embeds 0
No embeds

Report content
Flagged as inappropriate Flag as inappropriate
Flag as inappropriate

Select your reason for flagging this presentation as inappropriate.

Cancel
No notes for slide

Transcript

  • 1. Neck and Back Pain: “Doctor, I’m hurting! Can you help me?” Richard V. Chua, MD FACS Northwest NeuroSpecialists Tucson, AZ
  • 2. Northwest NeuroSpecialists 5860 N. La Cholla Blvd., Suite 100 (520) 742-7890
    • Neurosurgeons
      • Timothy K. Putty, MD
      • Thomas B. Scully, MD
      • Richard V. Chua, MD FACS
    • Neurologists
      • Jeanette Wendt, MD
      • David Weidman, MD
    • Physician Assistants
      • Roxann Lafferty, PA-C
      • Sonrisa Raths, PA-C
  • 3. “ The Reality of Life”
    • Low back pain is one of the most common reasons for visiting any physician
    • Most common reason for visiting a physical therapist
    • Most common complaint among persons accessing chiropractic care
    • More than 80% of the population will have at least one episode/yr requiring treatment
  • 4. “ Who will take care of me?”
    • Friends, family, and neighbors
      • especially your spouse
    • Primary care physician
    • Physical therapists
    • Chiropractors
    • Massage therapists
    • Acupuncturists
  • 5. “ Who will take care of me?”
    • Doctors of Osteopathy (D.O.)
    • Doctors of Medicine (M.D.)
      • Neurologists
      • Rheumatologists
      • Physical Medicine and Rehabilitation Specialists (PM&R), Physiatrists
      • Neurosurgeons
      • Orthopedic Surgeons (Spine)
      • Anesthesia Pain Specialists
  • 6. “ What kind of problems will I have?”
    • Overuse
      • “My husband thinks he’s still in his 20’s!”
    • Improper use
      • “My wife won’t let me hire a gardener!”
    • Injury-related
      • “I told my husband not to climb the ladder or he will fall, and he did!”
  • 7. “ What kind of problems will I have?”
    • Osteoarthritis
      • “My parents and grandparents had old ‘Arthur’, I guess I will get to know him too”
      • More about this one later
    • Infection of the spine
      • “I sure hope not, how did I get that?”
    • Cancer of the spine
      • “I better not have that!”
  • 8. “Which problem do I have?”
    • Overuse
    • Misuse
    • Injury-related
    • Osteoarthritis
    • Infection of the spine
    • Cancer of the spine
    • These represent the vast majority of the causes of low back and neck pain
    • These occur much less frequently
  • 9. “What’s in there?” Anatomy 101 - Neck and Back
    • Muscles
      • several layers
      • all have names
      • several attachments
      • all work together
    • Spine
      • discs (“cushion”)
      • major bones
      • minor bones
      • joints (“shingles”)
    • Nervous System
      • brain
      • spinal cord
      • major spinal nerves
      • minor spinal nerves
      • nerves within joints
    • Blood vessels
      • major
      • minor
  • 10. “What’s not in there…” Anatomy 102 - What else?
    • Lymph nodes
      • tumors
      • infection
    • Breathing tube/lungs
      • inflammation
      • infection
      • complicated allergies
    • Swallowing tube
      • GERD
      • ulcers
    • Intestinal tract
      • cancers
    • Gall bladder
      • stones
    • Genitourinary system
      • kidney stones
      • kidney disease
      • infection
  • 11. “What’s not there..there’s more”
    • Female system
      • cancers
      • cysts
    • Male system
      • prostate cancer
    • Circulatory system
      • aneurysm of aorta
      • blockages of major arteries to legs
    • Bones and Joints
      • not spine
      • shoulders and elbows
      • hips and knees
      • pelvis and sacroiliac
  • 12. “How do you figure it out?”
    • Complete history of the symptoms
      • Where? Specifically where? Point to where?
      • How long has it been going on?
      • How did it start? Abruptly? Gradually?
      • What were you doing when it started?
      • What had you been doing just before it started?
      • How bad does it hurt? Scale of 1-10?
  • 13. “How do you figure it out?”
    • Any associated symptoms?
        • Arm or leg pain
        • Numbness/tingling
        • Weakness of muscles, arms, or legs
        • Changes in bladder/bowel/sexual function
        • Weight loss or weight gain
        • Worse/better with any specific activity
      • Have you had it before?
        • Was it treated? Treated how?
    • What treatments have you tried?
  • 14. “Help me figure it out!”
    • Review of pertinent medical history, previous operations, allergies/intolerance to medications, family medical history, social history
    • Thorough physical examination
      • Musculoskeletal system
        • bones
        • joints
        • muscles
  • 15. “Help me figure it out”
      • Vascular system
        • arteries
        • veins
      • Nervous system including spine
        • range of motion
        • muscle strength/power
        • sensation - touch, pin prick, vibration, temperature, position
        • reflexes
        • gait/walking - normal, tandem, heel, toe
        • balance
  • 16. “ Aren’t you going to order an MRI?”
    • Often unnecessary to order any tests initially
      • acute neck or low back pain without injury
        • less than 6 weeks duration
      • chronic pain previously evaluated
      • acute worsening of chronic problem
      • stable neurological examination
      • low suspicion for the “bad things”
  • 17. “ Now are you going to order my MRI?” Not quite yet...
    • Treat patients presumptively over few weeks for overuse, misuse, injury, “old Arthur”
    • If after treatment, symptoms continue - consider tests
    • If during treatment, new symptoms appear - consider tests
    • If during treatment, neurological exam changes - consider tests
  • 18. “How about my MRI now?”
    • Plain x-rays
      • front view, side view, diagonal views
      • bending forward, bending backward
    • MRI
      • “gold standard”
      • prefer closed MRI over open MRI
        • better pictures, stronger magnet
        • claustrophobia usually not a problem
        • patient size less of a problem
  • 19. “More tests…?”
    • CT scan
      • with or without myelogram
      • may require a spinal tap
    • Muscle/Nerve test (EMG/NCV)
      • “ ouch, this one sometimes hurts”
    • Bone scan
    • Bone density scan
      • osteopenia
      • osteoporosis
    • Discogram
      • “ this one really hurts”
  • 20. “Even more tests…”
    • Injection treatments
      • positive, beneficial response provides useful diagnostic information
      • negative, lack of beneficial response also provides useful diagnostic information
    • Repeat visits (perhaps most important)
      • confirm previous information
      • assess response to treatment and tests
      • provide series of exams
  • 21. “Doctor, what do I have?”
    • Neck and/or back STRAIN
      • Overuse, misuse, injury-related
      • YES, it can and does happen
      • YES, it can cause severe pain and disability
      • YES, it can last for more than a few days
      • No, it’s not the fancy, highly technical, or sexy diagnosis
    • Many things related to “Old Arthur”
  • 22. “Who is Old Arthur, What is..?” Osteoarthritis
    • Who - EVERYONE
    • What - normal aging process of the spine
    • What - thickening of the ligaments, bone, and joints of the spine
    • What - weakness of the ligaments, bone, and joints of the spine
    • Why - no one really knows for sure
    • Where - low back and neck
    • When - progressively occurs with time
  • 23. “Old Arthur…and…pain?”
    • Overall weakness of the spine requires more work and stress on the muscles and ligaments
    • Pressure on the spinal nerves
    • Irritation/inflammation of the spinal nerves
    • Instability of the ligaments and joints
  • 24. “Old Arthur” in the Spine
    • Discs
      • Herniated disc
      • Degenerative disc disease
      • Annular tear
    • Spinal Canal
      • Central stenosis
      • Foraminal stenosis
    • Alignment
      • Spondylolisthesis
  • 25. “Make Arthur go away, please”
    • Most important treatment for neck and back pain is PREVENTION
      • avoid putting yourself at risk for overuse, misuse, injury
      • use good body mechanics
        • lifting, bending, twisting, climbing
      • eat balanced diet
      • exercise appropriately
    • TREAT SYMPTOMS - REDUCE PAIN
  • 26. “Arthur, go away!”
    • Exercise
      • walking, bicycling, swimming, water-based exercise
      • stretching and strengthening
        • yoga
        • Pilate's
        • exercise ball
  • 27. “Arthur, go away”
    • Massage therapy
    • Chiropractic manipulation
    • Physical therapy
      • assist you with exercise
      • perform treatments on you with modalities
        • soft and deep tissue, iontophoresis, moist heat, joint stabilization, ultrasound, e-stim
  • 28. “Make him go away faster”
    • Medications
      • NSAIDS: ibuprofen (Motrin), naproxen (Aleve), Celebrex, Mobic, Relafen, Arthrotec
      • Acetaminophen (Tylenol, ES Tylenol, Tylenol Arthritis)
      • OTC: arthritis and sports cremes
      • Pain relievers: codeine, hydrocodone (Vicodin/Lortab), oxycodone (Percocet)
      • Steroids
  • 29. “Make it go away faster”
    • Medications
      • Muscle relaxers
        • Soma, Flexeril, Valium, Zanaflex
      • Nerve modulators
        • Neurontin, Lyrica
      • Antidepressants
        • Prozac, Paxil, Zoloft
    • Nutritional supplements
      • Glucosamine/chondrointin
  • 30. “Faster, faster…”
    • Injection therapies
      • trigger point into muscles and ligaments
      • epidural steroid into spinal canal
      • nerve block around specific nerve
      • facet/joint block into painful joint
      • sacroiliac joint
  • 31. “What about surgery?”
    • Goals of surgery
      • reduce, relieve, or eliminate pain
      • improve neurological function including sensory and motor
      • maintain or improve level of activity
      • improve quality of life
      • DO NO HARM
  • 32. “How does surgery do that?”
    • Relieves pressure on spinal cord and spinal nerves
    • Realigns the spine to reduce joint pain and compressed nerves
    • Stabilizes the spine with instrumentation including plates, screws, rods
    • Fuses bones together to eliminate pain from excessive movement
  • 33. “What surgery do I need?” ABC’s of Doing Spine Surgery
    • Microdiscectomy - removal of herniated portion of disc
    • Laminectomy - removal of bone and ligament
    • Combination of above
    • Stabilization and fusion
      • use of instrumentation and bone graft
    • Combination of above
  • 34. Microdiscectomy
  • 35. Laminectomy
  • 36. Stabilization and Fusion
  • 37. Stabilization and Fusion
  • 38. Stabilization and Fusion
  • 39. “How successful is surgery?” We’re not perfect, but..
    • Greater than 85% of patients undergoing spine surgery have significant, dramatic, or complete relief of their pain
      • arm/leg improves sooner and more completely than neck/back
    • More than 75% patients have improvement in their function
    • More than 90% of working patients return to work
  • 40. Benefits of Surgery
    • Over 95% of patients report they would have it again
    • Over 95% of patients would recommend the treatment to others
    • Successful fusion occurs in over 80% of patients (based on follow-up xrays)
  • 41. “Why should I have surgery?”
    • Failed conservative, non-surgical treatments for a period of 6 months
    • Progressive neurological deficit
    • Intractable pain
    • May be the best treatment depending on the circumstances
    • May be the only definitive treatment
    • Matter of convenience
  • 42. “How do I decide what to do?”
    • Have an open conversation with your surgeon about the rationale for surgery, indications, benefits, risks, and complications, success rate, recovery, etc
    • Asked lots of questions
    • Discuss with your primary physician
    • Do some research about your problem and treatment options
  • 43. “ Where can I learn more about..?”
    • Your physician
    • Your surgeon
    • Library
    • Try not to compare notes with family, friends, neighbors - it is difficult to do
    • Internet
  • 44. Internet Sources
    • Spineuniverse.com
    • Back.com
    • Neck.com
    • Neurosurgery.org
    • AANS.org
    • NeurosurgeryToday.org
    • Neurosurgeon.org
  • 45. Neck and Back Pain: “Doctor, I’m not hurting anymore!” Richard V. Chua, MD FACS Northwest NeuroSpecialists Tucson, AZ
  • 46. THANK YOU