Pain is a symptom. Not a diagnosis!

1. Spine Center of MiamiSpine Center of Miami
The Spine Center of Miami
John C. Nordt, M.D.

2. Spine Center of MiamiSpine Center of Miami
Pain is a symptom…
Not a diagnosis!
2

3. Spine Center of MiamiSpine Center of Miami
Diagnosis is the reason for the
problem
3

4. Spine Center of MiamiSpine Center of Miami
Back pain
80% of population
Resolves in 3 months
4

5. Spine Center of MiamiSpine Center of Miami
Causes of back pain
Muscle
Ligament
Disc
Nerve
Bone
5
tumor
infection
fracture
instability

6. Spine Center of MiamiSpine Center of Miami
Pain generator
That which causes pain is more
clearly understood now…
6

7. Spine Center of MiamiSpine Center of Miami
Improved tests clarify source/origin
7

8. Spine Center of MiamiSpine Center of Miami
Over zealous physician can push
treatment plan without clear
diagnoses
8

9. Spine Center of MiamiSpine Center of Miami
History
Back pain?
Leg pain?
Combination? 50/50
9

10. Spine Center of MiamiSpine Center of Miami
Positional or postural
exacerbation
10

11. Spine Center of MiamiSpine Center of Miami
Careful & thoughtful history
• Back Pain?
• Leg Pain?
• Combination?

12. Spine Center of MiamiSpine Center of Miami
Alf Nachemson
Disc Pressure measurements
In the 1960’s at L-3-4
Sitting caused 2-3 x body weight
pressure

13. Spine Center of MiamiSpine Center of Miami
• Positional Exacerbation
Back Pain
Leg Pain

14. Spine Center of MiamiSpine Center of Miami
Sitting
Exacerbates
• Degenerative Disc
• Herniated Disc

15. Spine Center of MiamiSpine Center of Miami
Standing
Exacerbates
• Central Stenosis or
• Dynamic Foraminal Stenosis

16. Spine Center of MiamiSpine Center of Miami
Supine
Awaken from sleep with rolling over
Rotation is least stable in spine
with degenerative disc.

17. Spine Center of MiamiSpine Center of Miami
Diagnostic tests
• Selective Foraminal Root Injection
• Facet Injection
• Discography

18. Spine Center of MiamiSpine Center of Miami
Dynamic Examination LS Spine to assess:
• Canal stenosis
• Foraminal stenosis or
• Instability

19. Spine Center of MiamiSpine Center of Miami
Gold Standard
• Standing Flex/Extmyelogram

20. Spine Center of MiamiSpine Center of Miami
Magnetic Resonance Imaging
• Since 1988
• Significant source of information

21. Spine Center of MiamiSpine Center of Miami
Improved resolution of image
• Magnet Strength
• Software

22. Spine Center of MiamiSpine Center of Miami
Diagnosis?
• Degenerated Disc
• Foraminal Stenosis
• PARS Defect
• Central Stenosis
• Lateral Disc or Foraminal Disc
• Herniated Disc

23. Spine Center of MiamiSpine Center of Miami
• If your car won’t start-
• You don’t just change the battery

24. Spine Center of MiamiSpine Center of Miami
False positives with evaluative tests
Are eliminated with Clinical Correlation

25. Spine Center of MiamiSpine Center of Miami
• Abnormal MRI’s in Normal Subjects
Scott Boden, M.D., etal JBJS
March 1990

26. Spine Center of MiamiSpine Center of Miami
• 100 normal subjects 17-70 yrs.
• 37% + MRI that would require
surgery

27. Spine Center of MiamiSpine Center of Miami
Outline mutually agreed upon
expectation of surgery clearly
• Leg pain
• Back pain

28. Spine Center of MiamiSpine Center of Miami
• Incorrect or Incomplete Diagnosis
Discordant Symptom

29. Spine Center of MiamiSpine Center of Miami
Instability of the Degenerative Disc
• Pain with sitting-Relief Standing
• Pain awakens at night

30. Spine Center of MiamiSpine Center of Miami
• Inconclusive Radiologic Criteria
• Therefore need to assess within the
clinical context

31. Spine Center of MiamiSpine Center of Miami
Flex/Ext. MRI
• Pain Relief Supine
• Supine MRI
• Demonstrates?

32. Spine Center of MiamiSpine Center of Miami
Back Surgery wonderful tool to help

33. Spine Center of MiamiSpine Center of Miami
• Accurate Diagnosis
• Accurate Surgery

34. Spine Center of MiamiSpine Center of Miami
• Remember:
• A second surgery with clear
correctable problem will be
successful

35. Spine Center of MiamiSpine Center of Miami
Thank You
SPINE CENTER OF MIAMI