neck and back pain: "doctor, i'm hurting!

Neck and Back Pain:Neck and Back Pain:“Doctor, I’m hurting! “Doctor, I’m hurting! Can you help me?”Can you help me?”

Richard V. Chua, MD FACSRichard V. Chua, MD FACS

Northwest NeuroSpecialistsNorthwest NeuroSpecialists

Tucson, AZTucson, AZ

Northwest NeuroSpecialistsNorthwest NeuroSpecialists5860 N. La Cholla Blvd., Suite 1005860 N. La Cholla Blvd., Suite 100

(520) 742-7890(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

““The Reality of Life”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

““Who will take care of me?”Who will take care of me?”

• Friends, family, and neighbors– especially your spouse

• Primary care physician

• Physical therapists

• Chiropractors

• Massage therapists

• Acupuncturists

““Who will take care of me?”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

““What kind of problems will I have?”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!”

““What kind of problems will I have?”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!”

““Which problem do I have?”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

““What’s in there?”What’s in there?”Anatomy 101 - Neck and BackAnatomy 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

““What’s not in there…”What’s not in there…”Anatomy 102 - What else?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

““What’s not there..there’s more”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

““How do you figure it out?”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?

““How do you figure it out?”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?

““Help me figure it out!”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

““Help me figure it out”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

““Aren’t you going to order an MRI?”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”

““Now are you going to order my MRI?”Now are you going to order my MRI?”Not quite yet...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

““How about my MRI now?”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

““More tests…?”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”

““Even more tests…”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

““Doctor, what do I have?”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”

““Who is Old Arthur, What is..?”Who is Old Arthur, What is..?”OsteoarthritisOsteoarthritis

• 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

““Old Arthur…and…pain?”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

““Old Arthur” in the SpineOld Arthur” in the Spine• Discs

– Herniated disc– Degenerative disc disease– Annular tear

• Spinal Canal– Central stenosis– Foraminal stenosis

• Alignment– Spondylolisthesis

““Make Arthur go away, please”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

““Arthur, go away!”Arthur, go away!”

• Exercise – walking, bicycling, swimming, water-based

exercise– stretching and strengthening

• yoga• Pilate's• exercise ball

““Arthur, go away”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

““Make him go away faster”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

““Make it go away faster”Make it go away faster”

• Medications– Muscle relaxers

• Soma, Flexeril, Valium, Zanaflex

– Nerve modulators• Neurontin, Lyrica

– Antidepressants• Prozac, Paxil, Zoloft

• Nutritional supplements– Glucosamine/chondrointin

““Faster, faster…”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

““What about surgery?”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

““How does surgery do that?”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

““What surgery do I need?”What surgery do I need?”ABC’s of Doing Spine SurgeryABC’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

MicrodiscectomyMicrodiscectomy

LaminectomyLaminectomy

Stabilization and FusionStabilization and Fusion

Stabilization and FusionStabilization and Fusion

Stabilization and FusionStabilization and Fusion

““How successful is surgery?”How successful is surgery?”We’re not perfect, but..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

Benefits of SurgeryBenefits 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)

““Why should I have surgery?”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

““How do I decide what to do?”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

““Where can I learn more about..?”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

Internet SourcesInternet Sources

• Spineuniverse.com

• Back.com

• Neck.com

• Neurosurgery.org

• AANS.org

• NeurosurgeryToday.org

• Neurosurgeon.org

Neck and Back Pain:Neck and Back Pain:“Doctor, I’m not hurting anymore!”“Doctor, I’m not hurting anymore!”

Richard V. Chua, MD FACSRichard V. Chua, MD FACS

Northwest NeuroSpecialistsNorthwest NeuroSpecialists

Tucson, AZTucson, AZ

THANK YOU