Managing Spine Problems Managing Spine Problems iiin in

Primary CarePrimary Care

Gregory Holm, PhD, NP, FAANPGregory Holm, PhD, NP, FAANP

Steamboat Springs, ColoradoSteamboat Springs, Colorado

Professor: USF College of Medicine: Family & Sports MedicineProfessor: USF College of Medicine: Family & Sports Medicine

Commissioner: American Academy of Nurse Practitioners Certification Commissioner: American Academy of Nurse Practitioners Certification PPProgramProgram

Behavioral ObjectivesBehavioral ObjectivesBehavioral ObjectivesBehavioral Objectives

At the end of the sessionAt the end of the session At the end of the session, At the end of the session, the practitioner will be able to:the practitioner will be able to:

–– Perform an accurate physical assessment of Perform an accurate physical assessment of common spine issues found in the primary care common spine issues found in the primary care settingsettinggg

–– Successfully manage common spine issues found Successfully manage common spine issues found in the primary care settingin the primary care setting

–– Identify dangerous &/or malignant issuesIdentify dangerous &/or malignant issuesIdentify dangerous &/or malignant issues Identify dangerous &/or malignant issues concerning the spine presenting to the primary concerning the spine presenting to the primary care cliniccare clinic

DisclosureDisclosure

I have no current affiliation or financialI have no current affiliation or financial–– I have no current affiliation or financial I have no current affiliation or financial interest with any grantor or interest with any grantor or commercial interests that might have commercial interests that might have ggdirect interest in the subject matter of direct interest in the subject matter of the CE Program.the CE Program.

AgendaAgendagg Important InformationImportant Information

–– Review of Spine TermsReview of Spine Terms–– Anatomical ReviewAnatomical Review

ExaminationExamination Differential DiagnosisDifferential Diagnosis Differential DiagnosisDifferential Diagnosis TreatmentTreatment

–– Lumbar SpineLumbar Spine–– Lumbar SpineLumbar Spine–– Cervical SpineCervical Spine

Terms to KnowTerms to Know

Lumbar Spine PearlsLumbar Spine Pearls Cord stops @ LCord stops @ L--11

LL 2 less often2 less often–– LL--2 less often2 less often–– conus medularisconus medularis–– then Cauda Equinathen Cauda Equinat e Cauda qu at e Cauda qu a

Umbilicus LUmbilicus L--3/4 3/4 –– aortic bifurcationaortic bifurcation

into illiacsinto illiacs

Intervertebral disc Intervertebral disc –– annulus annulus –– nucleus pulposanucleus pulposa

90% f HNP’90% f HNP’–– 90% of HNP’s 90% of HNP’s L4L4--5 or L55 or L5--S1S1

Spinal ElementsSpinal ElementsSpinal ElementsSpinal ElementsSpinous processSpinous process

Transverse

Lamina

a s e seprocess

Pars articularis

Spinal foramenPedicle

Spinous Body

Neurology of the Lower Neurology of the Lower ExtremityExtremity

Disc Root Reflex Muscle Sensation_______L3-4 L4 Patellar Anterior Tibialis -Medial leg/foot

(foot inversion)

L4 5 L5 N E t h ll i L t l l &/L4-5 L5 None Extensor hallucis -Lateral leg &/or (dorsiflex big toe) -dorsum foot

L5-S1 S1 Achilles Peroneus -Lateral foot(dorsiflex foot)( )

Adapted from Hoppenfeld p.254Adapted from Hoppenfeld p.254

Or simply:Or simply:p yp y Sensory Sensory Knee jerk Knee jerk

Dermatomes:Dermatomes:–– “3 to the knee”“3 to the knee”

“4 h i id lf”“4 h i id lf”

–– usually L4usually L4

–– “4 to the inside calf”“4 to the inside calf”–– “5 to the outside calf”“5 to the outside calf”

“S1 to the outer foot”“S1 to the outer foot”

Ankle jerk Ankle jerk –– usually S1usually S1

–– S1 to the outer footS1 to the outer foot

Motor Deficit Motor Deficit (typical)(typical)

f t l t &/f t l t &/–– foot plantar &/or foot plantar &/or dorsiflexiondorsiflexion

–– L 5 / S1 nerve rootL 5 / S1 nerve root5 / S e e oo5 / S e e oo

LONG TRACT SIGNSLONG TRACT SIGNS(P th l i R fl )(P th l i R fl )(Pathologic Reflexes)(Pathologic Reflexes)

SUGGESTSUGGEST H ff ’H ff ’ SUGGESTSUGGESTUpper Motor Neuron Upper Motor Neuron

LesionLesion

Hoffman’sHoffman’sFor cervical spineFor cervical spine Indicates possibleIndicates possibleLesion Lesion

DTR’s DTR’s 3+ unilaterally; or 4+3+ unilaterally; or 4+

Indicates possible Indicates possible myelopathymyelopathy

Significance of Significance of 3 unilaterally; or 43 unilaterally; or 4Ankle clonusAnkle clonus

dorsiflexion of footdorsiflexion of foot

ggbilateral Hoffman’s is bilateral Hoffman’s is uncertainuncertain

Babinski’s Babinski’s

HOFFMAN’SHOFFMAN’S

LONG TRACT SIGNSLONG TRACT SIGNS(P th l i R fl )(P th l i R fl )(Pathologic Reflexes)(Pathologic Reflexes)

SUGGESTSUGGEST H ff ’H ff ’ SUGGESTSUGGESTUpper Motor Neuron Upper Motor Neuron

LesionLesion

Hoffman’sHoffman’sFor cervical spineFor cervical spine Indicates possibleIndicates possibleLesion Lesion

DTR’s DTR’s 3+ unilaterally; or 4+3+ unilaterally; or 4+

Indicates possible Indicates possible myelopathymyelopathy

Significance of Significance of 3 unilaterally; or 43 unilaterally; or 4Ankle clonusAnkle clonus

dorsiflexion of footdorsiflexion of foot

ggbilateral Hoffman’s is bilateral Hoffman’s is uncertainuncertain

Babinski’s Babinski’s

General Clinical ExamGeneral Clinical Exam Inspection Inspection

posture gaitposture gait posture, gaitposture, gait café au lait /skin tagscafé au lait /skin tags fauns beard / lipomatafauns beard / lipomata TT--L ROML ROM

PalpatePalpate PalpatePalpate spasms, spinal process, musclesspasms, spinal process, muscles SI joints, sciatic notch, hipSI joints, sciatic notch, hip abdomen & distal pulsesabdomen & distal pulses

DTR’DTR’ DTR’sDTR’s:: pathologic reflexes pathologic reflexes

cord/upper motorcord/upper motor hyper reflex hyper reflex ypyp

cord/upper motorcord/upper motor hypo reflex hypo reflex

below conusbelow conus Sharp/Dull discriminationSharp/Dull discrimination Sharp/Dull discriminationSharp/Dull discrimination

also vibratory sensealso vibratory sense Extremity strengthExtremity strength

tandem walktandem walk h l d ti t lkih l d ti t lki heel and tiptoe walkingheel and tiptoe walking squat and risesquat and rise

Patrick’s ManeuverPatrick’s ManeuverPatrick s ManeuverPatrick s Maneuver Also known as:Also known as: Also known as: Also known as:

F.A.B.E.R. & La F.A.B.E.R. & La FebereFeberetesttest

Flex knee & place ankleFlex knee & place ankle Flex knee & place ankle Flex knee & place ankle above contralateral above contralateral kneeknee

Apply downward forceApply downward force Apply downward force Apply downward force onto the flexed knee to onto the flexed knee to stress lower back, SI stress lower back, SI joint & hipjoint & hipj pj p

Pain points to source of Pain points to source of pathologypathology

Patrick’s ManeuverPatrick’s Maneuver

Patrick’s ManeuverPatrick’s ManeuverPatrick s ManeuverPatrick s Maneuver Also known as:Also known as: Also known as: Also known as:

F.A.B.E.R. & La F.A.B.E.R. & La FebereFeberetesttest

Flex knee & place ankleFlex knee & place ankle Flex knee & place ankle Flex knee & place ankle above contralateral above contralateral kneeknee

Apply downward forceApply downward force Apply downward force Apply downward force onto the flexed knee to onto the flexed knee to stress lower back, SI stress lower back, SI joint & hipjoint & hipj pj p

Pain points to source of Pain points to source of pathologypathology

Sciatic (Nerve) StretchSciatic (Nerve) Stretch• SLR

• Straight leg raise• Supine, passive

• Reproduces radicular pain (below kneepain (below knee paresthesias) if +

SLRSLR

Sciatic (Nerve) StretchSciatic (Nerve) Stretch• SLR

• Straight leg raise• Supine, passive

• Reproduces radicular pain (below kneepain (below knee paresthesias) if +

• LaSegue’s (aka Bragard’s) g ( g )• “original SLR”

• Same; but stop at first sign of pain … then lower until pain gone … then dorsiflex foot which stretches onlyfoot which stretches only the nerve (not hamstrings)

Sitting Leg ExtensionSitting Leg Extension

Also a sciatic stretchAlso a sciatic stretch•• Also a sciatic stretchAlso a sciatic stretch•• Aka: SLE , Flip signAka: SLE , Flip sign

•• OK for follow up OK for follow up examsexams

Sitting Leg ExtensionSitting Leg Extension

Sitting Leg ExtensionSitting Leg Extension

Also a sciatic stretchAlso a sciatic stretch•• Also a sciatic stretchAlso a sciatic stretch•• Aka: SLE , Flip signAka: SLE , Flip sign

•• OK for follow up OK for follow up examsexams

Femoral (Nerve) StretchFemoral (Nerve) Stretch• Opposite of the sciatic

stretches:SLE/SLR/L S• SLE/SLR/LaSegues

• Tests L- 3:Tests L 3:• femoral nerve• “reverse straight leg

i ”raise”

• Best done pronep• Produces L3

radicular symptoms • (down to the• (down to the

anterior knee)

Femoral (Nerve) StretchFemoral (Nerve) Stretch

Femoral (Nerve) StretchFemoral (Nerve) Stretch• Opposite of the sciatic

stretches:SLE/SLR/L S• SLE/SLR/LaSegues

• Tests L- 3:Tests L 3:• femoral nerve• “reverse straight leg

i ”raise”

• Best done pronep• Produces L3

radicular symptoms • (down to the• (down to the

anterior knee)

FIRST R/O THESE MALIGNANT PROBLEMS !FIRST R/O THESE MALIGNANT PROBLEMS !

InfectionInfectionInfectionInfection septicemiasepticemia

usually Staph or Strepusually Staph or Strep P tt S d liti (TB)P tt S d liti (TB) Potts Spondylitis (TB)Potts Spondylitis (TB)

NeoplasmNeoplasmworse while lying downworse while lying down worse while lying downworse while lying down

AneurysmAneurysm abdominal masses/bruitsabdominal masses/bruits abdominal masses/bruitsabdominal masses/bruits pulsespulses

Cauda Equina SyndromeCauda Equina SyndromeCauda Equina SyndromeCauda Equina Syndrome

What is Cauda Equina Syndrome?What is Cauda Equina Syndrome?

Losing use of leg (s)Losing use of leg (s) Bowel or bladder symptoms Bowel or bladder symptoms

mostly urinary retentionmostly urinary retention

Saddle numbness &/orSaddle numbness &/or Saddle numbness &/or Saddle numbness &/or tinglingtingling

Decreased anal sphincter Decreased anal sphincter tone tone

Hypo reflexiaHypo reflexia

True emergency:True emergency: referral to Ortho or Neuro spinereferral to Ortho or Neuro spine referral to Ortho or Neuro spine referral to Ortho or Neuro spine

surgeon (ED)surgeon (ED)

Red FlagsRed FlagsR t t Recent trauma

History of osteoporosis Abdominal pain radiates p

straight through to back Fever IV drug use IV drug use Unexplained weight loss History of cancer y Pain worse at night

– pain not relieved in the supine positionp

– awakens patient from sleep w/o movement

Bowel/bladder dysfunction Saddle area paresthesia Weakness

TREATMENTTREATMENT1.1. Ice:Ice: 20 minutes (Rule of 3)20 minutes (Rule of 3)1.1. Ice: Ice: 20 minutes (Rule of 3)20 minutes (Rule of 3)

q hour x 3q hour x 3 then 3x/day x 3 daysthen 3x/day x 3 days then moist heatthen moist heat

2.2. COMMON NSAID ClassesCOMMON NSAID Classes SalicylatesSalicylates

–– ASA, ASA, SalsalateSalsalate

Arachadonic Acid Cascade

ProprionicProprionic acidsacids–– IBP, Naproxen, IBP, Naproxen, KetoprofenKetoprofen

AlkanonesAlkanones–– NabumetoneNabumetone (Relafen)(Relafen)NabumetoneNabumetone (Relafen)(Relafen)

HeteroarylHeteroaryl acetic acidsacetic acids–– DiclofenacDiclofenac, , KetorolacKetorolac

IndoleIndole/Indene Acetic acids/Indene Acetic acidsI d th iI d th i S li dS li d

http://www.creatingtechnology.org/biomed/aspirin.htm–– IndomethacinIndomethacin, , SulindacSulindac

OxicamsOxicams (Cox 2 > Cox 1)(Cox 2 > Cox 1)–– PiroxicamPiroxicam, , MeloxicamMeloxicam

PyranocarboxylicPyranocarboxylic acids acids (Cox 2 > Cox 1)(Cox 2 > Cox 1)y yy y–– EtodolacEtodolac

COX 2 selectiveCOX 2 selective–– celecoxibcelecoxib

Muscle RelaxersMuscle RelaxersCC A tiA ti titi1.1. Common Common AntiAnti--spasmoticsspasmotics

SedatingSedating–– cyclobenzaprinecyclobenzaprine ((FlexirilFlexiril))

i d li d l (S )(S ) IIIIII–– carisoprodalcarisoprodal (Soma) (Soma) cIIIcIII

•• 11stst pass = pass = meprobamatemeprobamate ((EquanilEquanil: : tranquiliziertranquilizier))–– tizanidinetizanidine ((ZanaflexZanaflex))

orphenadrineorphenadrine ((NorflexNorflex))–– orphenadrineorphenadrine ((NorflexNorflex))–– chlorzoxazonechlorzoxazone ((ParafonParafon Forte)Forte)

NonNon--sedating sedating –– MetaxaloneMetaxalone ((SkelaxinSkelaxin))MetaxaloneMetaxalone ((SkelaxinSkelaxin))–– MethocarbamolMethocarbamol ((RobaxinRobaxin))

2.2. AntiAnti--spastics spastics (sometimes used)(sometimes used)Sh ld b d f C P M S tSh ld b d f C P M S t–– Should be reserved for C.P. ; M.S. etcShould be reserved for C.P. ; M.S. etc

BaclofenBaclofen ((LioresalLioresal)) DantroleneDantrolene ((DantriumDantrium)) BenzodiazepineBenzodiazepine

•• diazepam (Valium)diazepam (Valium) cIVcIV

•• anxiolyticanxiolytic, anti, anti--seizureseizure

GlucocorticoidsGlucocorticoidsGLUCOCORTICOID ORAL PULSE

• Predisone 50 mg daily x 3 daysM th l d i l (D P k)• Methylprednisolone (Dose Pak)

• taper no longer standard of care

IONTOPHORESIS

• Dexamethasone 4 mg/ml injectable

INJECTION

• Combine Steroids:• Fast onset-short acting

e.g. dexamethasoneg• Slow onset-long acting

e.g. depomedrol, triamcinalone• Anesthetic:

• Fast onset-short acting ge.g. xylocaine

• Slow onset-long acting e.g. bupivacaine

GENERIC TRADE Potency Onset

Cortisol n/a 1 FastCortisol n/a 1 Fast

Dexamethasone Decadron 4 Fast

Methylprednisolone Depomedrol 4 moderateMethylprednisolone DepomedrolD80

4 moderate

Triamcinolone acetonide

AristocortKenalog

5 moderate

K40

Betamethasone Celestone 25 slow

Further Plan of CareFurther Plan of Care Sufficient analgesiaSufficient analgesia

AcetaminophenAcetaminophen TramadolTramadol KetorolacKetorolac OpiatesOpiates

Physical TherapyPhysical TherapyPhysical TherapyPhysical Therapy Rest Rest

–– then home exercisesthen home exercises IMAGING:IMAGING:

–– XX--ray < 18 and > 50ray < 18 and > 50–– MRI: HNP Cancer AAAMRI: HNP Cancer AAAMRI: HNP, Cancer, AAAMRI: HNP, Cancer, AAA

Labs?Labs?–– ESRESR

A happy patient is a trusting patient–– CBCCBC–– CMPCMP

A happy patient is a trusting patient

CERVICAL SPINECERVICAL SPINECERVICAL SPINECERVICAL SPINE

5 C f P i5 C f P i 5 Causes of Pain5 Causes of Pain

1.1. DiscogenicDiscogenic2.2. RadiculogenicRadiculogenic3.3. MyelogenicMyelogenic4.4. SpondylogenicSpondylogenic5.5. CombinationCombination

EXAMINATIONEXAMINATION A tA t Assess motorAssess motor Active range of motion Active range of motion “Pinching between my “Pinching between my g yg y

shoulder blades”shoulder blades”•• cervical disccervical disc•• hand on head for reliefhand on head for reliefhand on head for reliefhand on head for relief

Arm/hand Arm/hand paresthesiaparesthesia may be only may be only

manifestationmanifestationmanifestationmanifestation Occipital headachesOccipital headaches

DJD @ C3 / C4 DJD @ C3 / C4 muscle spasmmuscle spasm muscle spasmmuscle spasm migraine?migraine?

R/O fracture R/O fracture i ll / h d i ji ll / h d i j•• especially w/ head injuryespecially w/ head injury

***INNERVATION***

•• C 5: C 5: •• Deltoid & Deltoid & BicepsBiceps musclemuscle•• BicepsBiceps DTRDTRBiceps Biceps DTRDTR

•• C6:C6:•• Biceps & Biceps & wrist extensorwrist extensor muscles muscles •• BrachioradialisBrachioradialis DTRDTR

•• C7: C7: •• TricepsTriceps & wrist flexor muscles& wrist flexor muscles•• TricepsTriceps & wrist flexor muscles, & wrist flexor muscles, •• Triceps Triceps DTRDTR

Provocative Cervical TestsProvocative Cervical Tests•• Spurling’sSpurling’s

•• suspect HNPsuspect HNPlik SLR b t flik SLR b t f•• like SLR, but for like SLR, but for neck issuesneck issues

Spurling’sSpurling’s

Provocative Cervical TestsProvocative Cervical Tests•• Spurling’sSpurling’s

•• suspect HNPsuspect HNPlik SLR b t flik SLR b t f•• like SLR, but for like SLR, but for neck issuesneck issues

•• Distraction & Distraction & CompressionCompression

•• Suspect HNPSuspect HNP

Swallowing TestSwallowing Test•• Swallowing TestSwallowing Test•• osteophyte, osteophyte,

hematoma, hematoma, infection, tumor, infection, tumor, HNPHNP

Llhermitte’sLlhermitte’s• Look up - Look down

• “Touch your chin to your y ychest”

• Positive if causes electric shocks down spine

(maybe even into legs)S t HNP t C S i• Suggests HNP at C - Spine• Like SLR for neck

Mi ht l l t• Might also apply vertex compression simultaneously to s u a eous y oincrease sensitivity of test

Llhermitte’sLlhermitte’s

Adson’s ManeuverAdson’s ManeuverAdson s ManeuverAdson s Maneuver Suggests:Suggests:ggggThoracic Outlet SyndromeThoracic Outlet Syndrome

Look towards examinerLook towards examiner–– also look awayalso look away

Head up & look over Head up & look over Head up & look over Head up & look over shouldershoulder

Take a deep breath & Take a deep breath & hold it:hold it:–– Positive: pulse Positive: pulse

diminishes in qualitydiminishes in qualityq yq y

Adson’sAdson’s

Allen’s TestingAllen’s Testing Circulation of handCirculation of hand Pump blood out;Pump blood out;Pump blood out; Pump blood out;

occlude arterial flowocclude arterial flow–– Release 1 @ a timeRelease 1 @ a time–– Normal: pink in <7 Normal: pink in <7

seconds & equallyseconds & equally

Allen’s TestingAllen’s Testing

TREATMENT FOR NECK PROBLEMSTREATMENT FOR NECK PROBLEMS E ti ll fE ti ll f Essentially same as for Essentially same as for

lumbar spinelumbar spine

HNP on MRI may need HNP on MRI may need semisemi--rigid cervical collarrigid cervical collar can’t take whiplashcan’t take whiplash can t take whiplashcan t take whiplash NONO soft collarssoft collars

May use tractionMay use traction May use tractionMay use traction 20# over the door 20# over the door t.i.dt.i.d.. Home Traction CollarHome Traction Collar

Myelopathy in general Myelopathy in general practice is treated as true practice is treated as true ppemergencyemergency•• burning in palmsburning in palms•• Hoffman’s reflexHoffman’s reflex

SUMMARYSUMMARY D l i lD l i l Dorsal spine rarely Dorsal spine rarely

involved involved well anchored by shoulderwell anchored by shoulder except fall on heels: Texcept fall on heels: T--1212

Full exam on each new Full exam on each new patientpatient

Good history is vitalGood history is vital R/O R/O

neoplasm osteomyelitisneoplasm osteomyelitis neoplasm, osteomyelitis, neoplasm, osteomyelitis, aneurysm, cauda equina aneurysm, cauda equina

Suspect nonSuspect non--spinal spinal etiologyetiologyetiologyetiology

Mobilize earlyMobilize early Conservative therapyConservative therapypypy Refer failures, neuro Refer failures, neuro

deficitsdeficitsThis is killing my back! This is killing my back!

Thank you!Thank you!Thank you!Thank you!

Questions???Questions???Questions???Questions???

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Cambridge Johnson, T.R., & Steinbach, L.S., 2004. Essentials of Musculoskeletal Imaging. AAOS. , , , , f g g

Rosemont, Ill. Baxter, RE. 2003. Pocket guide to musculoskeletal assessment. 2nd Edition. WB Saunders,

Philadelphia Griffin, L.Y. 2005. Essentials of Musculoskeletal Care. 3rd Edition. American Academy G , . . . sse tials of usculos eletal Ca e d d o . e c c de y

of Orthopoedic Surgeons. Rosemont Illinois BS Williams & SP Cohen, 2010. Greater Trochanteric Pain Syndrome: A Review of

Anatomy, Diagnosis and Treatment, Anesthesia & Analgesia (IARS). Kingsette - Taylor et al., Oct 1999. Tendinosis and tears of the gluteus media & minimusKingsette Taylor et al., Oct 1999. Tendinosis and tears of the gluteus media & minimus

muscles as a cause of hip pain: MR imaging findings. AJR 173, 1123-26 www.dynamicmedical.comwww.dynamicmedical.com www.xray2000.co.ukwww.xray2000.co.uk www uhrad comwww uhrad com www.uhrad.comwww.uhrad.com http://aisr1.lib.tju.edu/ha/anirefshttp://aisr1.lib.tju.edu/ha/anirefs