Assessment of the cervical spine in degenerative pathologies
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This document discusses the assessment and treatment of cervical spine degenerative pathologies and cervical myelopathy. It outlines how to examine the cervical spine by looking for deformities, feeling for masses or tenderness, moving to assess pain and stiffness, and testing neurology. Imaging options like x-rays, CT, and MRI are mentioned. The timing of surgery is discussed as well as the advantages and disadvantages of anterior versus posterior surgical approaches for conditions like radiculopathy, myelopathy, and cervical fusion versus disc replacement. Key factors in the choice of surgical approach include the number of levels involved and the cervical lordosis.
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Plain film x-rays are useful for initially evaluating spinal trauma and detecting abnormalities like fractures and disc space narrowing. CT scans are better for detecting spinal fractures and bone fragments in the spinal canal. MRI is the best imaging technique for evaluating the spinal cord, nerves, soft tissues, and detecting conditions like disc herniations, spinal tumors, and spinal cord injuries. It can also detect bone marrow abnormalities and is the most accurate test for multiple myeloma, metastases and infections affecting the spine.
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The document discusses spine radiography and provides guidelines for evaluating cervical and thoracolumbar spine x-rays. It emphasizes using a systematic approach to evaluate coverage, alignment, bones, spacing, soft tissues and image edges. Factors like normal anatomy, fracture patterns and the three-column injury model are reviewed. Clinical assessment is important as some fractures may be missed on x-rays alone. CT may be needed if injury is suspected or x-rays are unclear.
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Cervical spondylosis is a common cause of neck pain, radiculopathy, and myelopathy. It involves chronic degenerative changes in the cervical discs and vertebrae due to aging. Common symptoms include neck pain, headaches, and radiating arm pain. Diagnosis involves clinical exam showing signs of radiculopathy or myelopathy as well as imaging like x-rays, CT, and MRI to identify areas of nerve root or spinal cord compression. Treatment options include conservative measures or surgery to decompress the spinal cord if conservative treatment fails.
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The cervical spine consists of 7 vertebrae that give rise to 8 cervical nerves and two plexuses - the cervical and brachial plexuses. The document then provides details on the history, physical examination, and investigations for cervical, thoracic, and lumbar spine conditions. It lists the nerves associated with each region and describes red flags, movements tested, and special tests like Schober's test and straight leg raise test in the physical examination.
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The document discusses common lumbar spine conditions including disc herniation, spinal stenosis, and chronic low back pain. It describes the causes, symptoms, treatments including surgery, and outcomes. For disc herniation, surgery in the form of discectomy is recommended for severe or unremitting leg pain and can provide relief in 90% of cases. Spinal stenosis is treated initially with physiotherapy or epidural injections, with surgery as an option for severe, unresolved symptoms. Fusion surgery is not usually indicated for chronic low back pain alone but may be used for instability or certain structural deformities.
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Cervical radiculopathy is a peripheral nerve syndrome caused by mechanical injury or chemical irritation of the cervical nerve roots. It typically affects the C5-T1 nerve roots, accounting for 5-30% of radiculopathy cases. Common causes include spondylosis, cervical disc disease, disc herniation, and biochemically-induced inflammation. Symptoms include neck pain radiating into the arms and hands with weakness, numbness, or tingling. Diagnosis involves electrodiagnostic tests, imaging like MRI, and the Spurling maneuver. Initial treatment focuses on conservative options like medication and physical therapy, with surgery reserved for cases that fail non-operative management.
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This document discusses different types of back surgery for low back pain, including discectomy and spinal fusion. It provides details on discectomy for disc herniation, including causes, symptoms, prerequisites for surgery, expected outcomes, and the surgical procedure. For spinal fusion, it notes the procedure is generally only good for low back pain if there is a specific diagnosis, clearly defined pain source, suitable patient candidate without psychosocial factors, and an appropriate surgical technique is used to address the underlying pathology. Results are not as good for fusion compared to discectomy or for non-specific low back pain. The document also discusses factors that make a patient suitable or unsuitable for fusion surgery.
Case Presentation
Dave, a 38-year old factory worker, sees a doctor for worsening back pain that radiates down his left leg. Imaging reveals chronic pars defects, grade 1 spondylolisthesis, and disc degeneration. He is referred to specialists, prescribed medications, and advised to file a workers compensation claim to receive treatment including epidural injections and physical rehabilitation with the goal of a gradual return to work.
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Lumbar disc herniation and stenosis are common causes of low back pain that often improve without surgery. Post-surgery rehabilitation focuses on education, low-impact exercises, and a gradual return to normal activities. Key goals include reducing pain and improving function to allow patients to return to work and daily life. Appropriate exercises target the lumbar spine, hips, and core muscles while avoiding positions that increase pain. Outcomes are best with a multidisciplinary approach including exercise prescription managed by a physiotherapist or exercise physiologist.
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Dave is a 38-year old factory worker who presents with worsening back pain that has failed to improve with rest, over-the-counter medications, and a prescription for Endone. He wants advice on his diagnosis, pain management options, submitting a workers' compensation claim, and the possibility of surgery. A comprehensive assessment and multidisciplinary approach is needed to properly manage Dave's chronic back pain.
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This document discusses interventional pain procedures for chronic pain, including epidural injections, facet joint injections, medial branch blocks, and radiofrequency nerve ablation. It provides details on how each procedure is performed, when they are appropriate, and their potential benefits which include temporary pain relief and allowing patients to progress in rehabilitation. It also covers guidelines for opioid prescribing for chronic pain, including maximum recommended doses, conversion between opioid medications, requirements for authorities to prescribe, and factors to consider in opioid trials and maintenance therapy.
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Lumbar disc herniation and stenosis are common causes of low back pain that often improve without surgery. Post-surgery rehabilitation focuses on education, low-impact exercises, and a gradual return to normal activities. Key goals include reducing pain and improving function to allow patients to return to work and daily life. Appropriate exercises target areas like the lumbar spine, hips, and core to improve mobility and reduce recurrence, while avoiding movements that increase pain. Outcomes are best with a multidisciplinary approach including exercise prescription tailored to individual needs and abilities.
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The document describes an exercise program for lumbar stretching rehabilitation. It includes 18 different stretching exercises targeting the lower back and hips. The exercises involve movements such as rolling the knees from side to side, bringing the bent knee towards the chest, tightening stomach muscles to lift the bottom, rocking backwards on hands and knees, and rotating the leg outwards while pulling it towards the chest. Each exercise provides instructions on body position, movement, and number of repetitions.
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This exercise program outlines rehabilitation exercises over 3 weeks following a lumbar discectomy surgery. The goals by 6 weeks include exercising 2-3 times per day, increasing walking, and lifting up to 10kg. The document provides detailed instructions for 20 different core-focused exercises involving positions like lying on the back or side, kneeling, and standing. Each exercise describes muscle activation and movements to help recovery while avoiding movements that could cause pain.
Initial Discectomy
This document outlines an exercise program for patients who have undergone a lumbar discectomy. The goals within 3 weeks are to do 2-3 exercise sessions per day, walk for a total of 5km split into two sessions, and lift weights up to 5kg. The program focuses on core stabilization exercises using a ball and includes exercises to do lying down, kneeling, sitting, and standing to strengthen the back and abdomen. Proper form is emphasized by engaging the transversus abdominis muscle and maintaining a neutral spine alignment throughout. Exercises are to be done in sets of 10-15 repetitions and held for 3-10 seconds, progressing to weight added as tolerated.
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The document contains a pain diagram and questionnaire for a patient to report their back pain. The pain diagram has the patient mark areas of pain and tingling. Two pain scales have the patient rate their average back and leg pain in the past week from 0 to 10. The back pain questionnaire has 10 sections for the patient to select the statement that best describes how their back pain affects daily activities like personal care, lifting, walking, sitting, standing, sleeping, social and work life, and traveling.
Rehabilitation for back pain
This document provides guidance on rehabilitation for non-operative and operative back pain. It discusses assessing abnormalities and treating to correct them. For severe back pain, it recommends reducing pain and inflammation through comfort positions, movement, medications, modalities, and exercise away from aggravation. For sub-acute back pain, it recommends manual therapy, restoring range of motion and flexibility/strength training. Post-episode, it recommends modifying activities, correcting biomechanical abnormalities, and implementing a home exercise regime. Core stability and stabilization exercises are emphasized for retraining deep muscles to maintain functional stability. Post-operative rehabilitation focuses on early mobility, exercises in neutral spine, and functional control prior to discharge with a home program.
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- 1. ASSESSMENT OF THE CERVICAL SPINE IN DEGENERATIVE PATHOLOGIES Paul Licina
- 2. EXAMINATION
- 3. LOOK
- 7. FEEL
- 9. MOVE
- 12. NEURO
- 14. NEURO
- 17. SPECIAL
- 18. Spurling’s
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- 43. Timing of surgery Cervical myelopathy surgical aspects •surgery indicated if •established myelopathy with symptoms and signs •aim is to halt progression •hope is to reverse deficit •earlier intervention gives better results •even severe deficit may improve •early myelopathy with documented progression •? subtle symptoms with no signs and only early MRI changes
- 45. What is the treatment? Cervical myelopathy surgical aspects anterior discectomy and fusion anterior corpectomy and fusion posterior laminectomy posterior laminectomy and fusion posterior laminoplasty D E C O M P R E S SI O N
- 46. Anterior surgery Cervical myelopathy surgical aspects Advantages • approach pathology directly • can decompress central and foraminal stenosis • can effectively stabilise the segment in lordosis • approach is easy and well tolerated
- 47. Anterior surgery Cervical myelopathy surgical aspects Disadvantages • osteophytes difficult to deal with • multiple levels more difficult • risks of • dysphagia / oesophageal injury • recurrent laryngeal nerve injury • neurological injury • vascular injury • adjacent degeneration may occur
- 48. Posterior surgery Cervical myelopathy surgical aspects Advantages • multiple levels easily addressed • usually reserved for 3 or more levels • no risk to vital anterior structures • less risk of neurological injury • can avoid fusion
- 49. Posterior surgery Cervical myelopathy surgical aspects Disadvantages • less effective in kyphosis as relies on posterior cord ‘drift’ • can result in kyphosis (10-50%) • increased pain from approach • dura exposed with possible peridural scar
- 50. Choice of approach Cervical myelopathy surgical aspects ANTERIOR POSTERIOR one or two levels more than three levels kyphosis lordosis disc prolapse osteophytes