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Prevention & Treatment Of Cervical & Lumbar Injury
- 1. Prevention & Treatmentof Cervical & Lumbar Injury for the Oculofacial SurgeonRenée Ostertag, DPT, MPT, COMTDenver, ColoradoASOPRS Spring Meeting, 2011- Amelia Island
- 2. ObjectivesIncreased awareness toaid in prevention of injury
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- 4. Physiology of aDisc
- 5. Cervical PhysiologyCervical Protrusionand RetractionCervical Flexion and Extension
- 6. Lumbar Disc PhysiologyLumbarFlexionLumbar Extension
- 7. Load to LumbarDisc
- 8. Load to LowerCervical DiscNeutral Head Position is 12 lbs.Forward Head Position is 36 lbs.
- 9. Pathophysiology Stage #1MicroscopictearsWeakens annulus
- 10. Pathophysiology Stage #2Disruptionof inner layers of annulusNo innervation of inner 1/3 of disc
- 11. Pathophysiology Stage #3TissueDamage has reached innervated tissue
- 12. Pathophysiology Stage #4Markeddisplacement of nerve rootSymptoms:Severe neck/UE painUE weakness and/or incoordinationLoss of sensation and reflexes+/- surgery
- 13. Operating Room SuggestionsAvoidsustained end range loadingPractice “Neutral Spine” posture
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- 17. More Practical SuggestionsSetyour ideal posture firstAdapt the patient and environment to youAvoid sustained end range positionsTake breaks from positions every 15-20 min.Avoid loupes/head lamps as ableHigh Powered Reading Glasses as alternative?Dictation Headpiece vs. holding phone to ear
- 18. Exercises 1. HeadRetractionCommon ErrorsTipping head backTensing up neck/shouldersThoraco-lumbar compensationVariationsAdd “overpressure”Stand at a wall Repeated or sustained
- 19. Exercises 2. PostureCorrectionSlouched Overcorrected Less 10%= IDEAL “Neutral Spine”
- 20. Exercises 3. BackExtension in StandingVariationsBend back over counter/chair
- 21. Exercises 2. BackExtension in ProneCommon ErrorsTensing back/buttocksLetting hips come offVariationsRepeated or sustainedSustain position by propping on elbowsRest on pillows
- 22. Guidelines for Self-CareGREENLIGHTNo current symptomsNeck and Back exercises 5-10 reps, ≥5x/dayCurrent symptoms: local neck, scapular or shoulder pain/stiffnessNeck and Back exercises 5-10 reps, 10x/daySymptoms reduce/eliminated during and/or immediately after exercise
- 23. Guidelines for Self-CareYELLOWLIGHTI/M neck/back symptoms that respond to position change or movementSymptoms produced or increased during exerciseno worse or better immediately afterNeck and/or Back exercises 5-10 reps, 10x/day
- 24. Guidelines for Self-CareREDLIGHT – seek medical attention!Constant neck/back symptomsI/M or Constant radicular painLoss of/change in extremity power, sensation, coordination Symptoms that are worse or peripheralized after exercise
- 25. Further ReadingRobin McKenzie“TreatYour Own Back”“Treat Your Own Neck”
Editor's Notes
- #2 Thank you for the opportunity to speak here today. I am honored for this privilege and hopeful that it will be of benefit to you. As Dr. Fante mentioned, everything is evidence-based, and if you would like any references or resources, please ask me for them after the presentation or feel free to email me- my information is in the handout. If you have any questions during the presentation, feel free to ask as we go along.
- #3 Aid in prevention for this potentially devastating occupational work hazard.
- #4 I’m going to start with an anatomy review. The disc looks and behaves basically the same throughout the spine- it acts as a cushioning shock absorber made up of water and collagen.
- #5 Non-degenerated discs move predictably in this fashion, degenerated discs move less predicatbly. Review of the dynamic disc model that suggests that the nucleus pulposus migrates in response to movement and positions. Twelve articles were located that demonstrated in vitro and in vivo that the nucleus migrated anteriorly during extension ad posteriorly during flexion. There was limited and contradictory data to support this model in the symptomatic and degenerated disc.
- #8 There is a multitude of evidence demonstrating those who sit in slumped postures have significantly less trunk muscle activity.First ever study using upright magnetic resonance imaging of effect of functional positions on movement of the nucleus pulposus (NP) in 11 volunteers. In sitting there was significantly less lordosis than prone lying and standing, and significantly more posterior migration of the NP than other positions. FINGER ANALOGY
- #9 Forward Head Position = posterior migration of nucleus pulposus.More forward head posture has been associated with higher rates of neck pain and disability.Chronic placement of the head anterior to the body's center of gravity can be a component in the development of neurovascular and musculoskeletal dysfunction.
- #10 http://www.chirogeek.com/001_tutorial_birth_of_hnp.htmThe nucleus pulposus, because of the tremendous axial load upon it, It migrates in response to movements and positions. in 95% of healthy subjects the nucleus pulposus was displaced away from the direction of lateral flexion. In vivo flexion tends to cause posterior displacement of the nucleus pulposus and extension anterior displacement using MRI.
- #11 Asymptomatic
- #12 This is a grade III annular tear, hasn’t disrupted posterior annulus.Innervated tissue reached, but because one isn’t consciously aware of the posterior aspect of their C5/6 disc wall, they’ll feel symptoms of ….LEARNED FROM OPTHALMIC LECTURE: make pathophysiology relevant to them……*** Here is where (check this and if not here, find out where) we start having symptoms like a stiffness in the neck, tightness in the shoulder, or you “just woke up with it”.Another culprit is that individuals tend to blame an activity (gardening, shovelling snow etc) or sport that they do when they get hurt, but it may be that the problem was there all along, and that activity was simply the straw that broke the camel’s back to bring it to your conscious awareness.
- #13 Further migration of the nucleus into the anterior epidural spaceRupture of posterior longitudinal ligamentMarked displacement of transversing nerve rootOften indicates surgery*** After this slide, put in referred pain and find references for how disc can refer into the upper thoracic spine, and LE to foot!!!!
- #14 Change your environment to fit you. I encourage you to be creative because you’re much more familiar with this environment than I- turn the patients head, trendellenberg the table, I’m sure there are many possibilities. The key is to know the posture/position that YOU need to be in, and adjust accordingly as often as you can.Lumbar supports have been shown to reduce back pain in sitting, current practice dictates a stool… but there are stools available with lumbar support. If you want/need more info on this please see me after. The more hours you spend in lumbar flexion, the more likely you are to have an episode of acute non-specific LBP
- #15 Dropping one knee encourages more lumbar extension. a lordotic position, interspersed with regular movement, is the optimal sitting posture and assists in preventing back pain
- #16 what I’d like to suggest is to vary your position as there is research showing that workers with the least amount of medical visits due to spinal pain fluctuate their positions throughout the day- Varying the position has lower risk of injury…. Cite study of least injury with those who are always in different positions
- #17 Due to the nature of your work and current equipment for visualization, you’ll have to be in awkard positions… make sure you give your spine a break and get out of the posture when you can take a moment. Certainly if you feel pain, give the tissues a break… remember pain is protective and it’s trying to tell you that the pressure is on!
- #19 In a group of patients with neck and radicular pain a posture of sustained flexion caused a significant increase in peripheral pain and root compression as measured by H reflex amplitude. Repeated retractions caused a significant decrease in peripheral pain and decrease of nerve root compression.
- #20 Sitting uninterrupted with greater flexion leads to increased rates of neck and back pain
- #21 Easier to do during day
- #22 Obviously easier to do at home before/after surgery days, particularly long cases whilst sitting slouchedMore effective than standing
- #23 Symptoms gradually reduce with continued performance of exercises
- #25 Please raise your hand if you have any current symptoms- I/M pain, stiffness… please keep your hand up if you’re interested in addressing this issue.Lots of information jammed on here, and I apologize for that.. Please feel free to approach me here or send me an email if you have specific questions for your situationBelow the acromion process or fold of the buttock.PAIN IS PROTECTIVE and SERVES TO PROTECT AS A WARNING AGAINST TISSUE DAMAGE