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


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

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