Spinal disorders

From Advances in Neurology and Neurosurgery 2009, sponsored by Cedars-Sinai Medical Center, Los Angeles, CA

Educational Objectives

The goal of this program is to improve the management of spinal disorders. After hearing and assimilating this pro­gram, the clinician will be better able to:

1.   Identify forthcoming technologies for management of spinal pain.

2.   Counsel patients on expected rehabilitation course after spinal fusion and nonfusion surgeries.

3.   Recognize most common back pain diagnoses in distinct patient demographic groups.

4.   Review options for adjunctive therapy for treatment of spinal pain.

5.   Utilize appropriate pharmaceutical therapies for acute and chronic back pain.

Faculty Disclosure

In adherence to ACCME Standards for Commercial Support, Audio-Digest requires all faculty and members of the planning committee to disclose relevant financial relationships within the past 12 months that might create any personal conflicts of in­terest. Any identified conflicts were resolved to ensure that this educational activity promotes quality in health care and not a proprietary business or commercial interest. For this program, the following has been disclosed: Dr. Johnson serves as a consul­tant for and is a stockholder of: Alphatec Spine, Flexuspine, Pioneer Medical, and Spine Wave. Dr. Johnson also serves as a consultant for De Pay, and Johnson and Johnson. Drs. Johnson and Oshiro present information related to off-label or investiga­tional use of a therapy, product, or device. Dr. Baumgarten and the planning committee reported nothing to disclose.

Acknowledgements

Drs. Johnson, Baumgarten, and Oshiro spoke February 14, 2009, in Marina del Rey, CA, at Advances in Neurology and Neuro­surgery 2009, presented and sponsored by Cedars-Sinai Medical Center, Los Angeles, CA. The Audio-Digest Foundation thanks the speakers and the sponsor for their cooperation in the production of this program.

Motion Preservation: Artificial Disc, Nucleus Replacement

J. Patrick Johnson, MD, Director of Education, Cedars-Sinai Institute for Spinal Disorders, Neurological and Orthopedic Spine Fellowship Program, Co-Director, Spine Stem Cell Research, Cedars-Sinai Institute for Spi­nal Disorders, Cedars-Sinai Medical Center, Los Angeles, CA, Director, California Association of Neurologic Surgeons

Spinal motion: most loading of spinal column occurs anteriorly, then in posterior facet joints and ligamentous struc­tures; similar to tricycle with big wheel in front and two small wheels in back

Artificial disc mechanics: initial spinal surgeries inserted steel ball into disc space to preserve motion; however, fol­low-up studies showed ball imploded into endplate; Synthes ProDisc, Food and Drug Administration (FDA)-ap­proved in 2006, used most today; many types of artificial discs available; ball socket style gives some translational facet joint motion, but unclear how much motion allowed

Disc replacement surgery: complicated access; enter through anterior spine; initial operation technically feasible, but revision difficult and life threatening; very small window of exposure behind aorta and vena cava

Alternatives: fusion at L5-S1 and artificial disc; two-level fusion

Future of lumbar artificial discs: less invasive techniques utilizing extreme lateral approach

Cervical artificial discs: some shock absorbing capabilities and translational motion (Bryan Disc); issues after fu­sion include hypermobility at adjacent segments due to increased stress and strain; easier to reaccess for revision than lumbar spine

Available discs: many designs, but each “one design fits all”; unanswered questions remain about mechanics, sizes, and shapes of artificial discs

Discectomy mechanics: disc collapsed down and allowed to stiffen; nothing replaced; not all patients do well with treatment, and many go on to spinal fusion

Disc nucleus replacement: nucleus not source of pain, but restoring height of disc space and annulus restores some mechanical structure in functional manner; maintains flexibility and stability of disc

Injectable technologies: applicable in lumbar spine; cervical spine nucleus too small to benefit; restores and main­tains mechanics; mimics stiffness and water content of disc; consists of biopolymers that adhere to annulus and col­lagen fibers; complete in minutes, with no exothermic reaction; crosslinked with adhesive hydrogel made from silicon-elastin; mechanical and chemical bonding involved; completely synthetic, but similar to natural nucleus in many respects, eg, water content, pH; early clinical trials look favorable, but none done in United States as yet; pain and functional studies consistent with standard microdiscectomy; patients and outcomes similar

Future directions: stem cells potentially useful for treating spinal cord and column; mesenchymal cells used for spi­nal fusion, and for regeneration of other tissues (eg, nucleus and annulus); preservation of motion of spinal column important focus in field of spinal surgery; “best disc you have is one you are born with” but mechanical discs still have place in treatment

Rehabilitation of the Postoperative Spine Patient

Jana Baumgarten, MD, Associate Medical Director, Department of Physical Medicine and Rehabilitation, Ce­dars-Sinai Medical Center, Los Angeles, CA

Discectomy patients: lumbar surgery rate in United States 40% higher than in any other country; most patients dis­satisfied because of pain, motor deficits, decreased functional status, or combination of these; only 70% return to work within 12 mo of surgery; patient satisfaction improved by meeting goals, decreasing pain, and improving function

Rehabilitation programs: programs that start immediately or within 4 to 6 wk of lumbar spine surgery most effec­tive; result in faster decrease in pain, rapid improvement in range of motion (ROM), and lower disability scores; high-intensity programs result in faster decreases in pain, and supervised programs more effective than home-based programs; inconsistent data at 12 to 24 mo; pain and function better initially but levels out by 24 mo; need good communication between team members

Rehabilitation goals: determine patient’s personal goal; goals to reduce pain, improve function and activities of daily living (ADLs), and improve mobility and endurance; surgery makes structural changes but does not correct poor posture and body mechanics, relieve myofascial pain, or remedy faulty motor patterns

Initial evaluation: identify surgery performed; review limitations, preoperative symptoms, and postoperative course; review medical comorbidities, past functional history, and patient goals

Physical examination: examine surgical site and drains; check strength and ROM; pain triggers or provocations; pain management therapy

Nonfusion Spinal Surgery

Evaluation: identify initial needs; determine whether inpatient rehabilitation or home-based therapy indicated; re­view surgeon’s postoperative restrictions on bending, lifting, twisting, lifting weight, posture, positioning, and bracing

Phase 1 rehabilitation: protective phase; £3 wk postoperatively; goals include protecting surgical site, maintaining nerve root mobility, decreasing pain and inflammation, and maximizing independence with mobility and ADLs; educate patient on body mechanics; minimize fear and anxiety; reassure patient about normal postsurgical pain; interventions  —  patient education on proper standing and sitting posture and mechanics; supportive sleeping posi­tions; avoid bending at waist; proper body mechanics with ADLs and lifting (although no lifting typically allowed during phase 1); review bracing and activity restrictions; modalities  —  electric stimulation and cold laser to pro­mote wound healing; ice; dural stretching helps prevent fibrosis and dural adhesions; spinal stabilization; stretching programs to include gastrocnemius, soleus, gluteal, and hamstring muscles; start walking program, either house­hold distances or short distance in community; spine stabilization program using abdominal and back extensor muscle recruitment; isometrics with small ROM (pain free positions for first 2 wk); good posture; mobility with neutral spine; stretching and ankle mobility; anterior thigh stretching while side-lying or prone; avoid twisting and bending; start upper extremity assisted active ROM; sitting and standing balance practice, with knee bends and slow sit-downs

Phase 2: functional recovery phase; 4 to 6 wk postoperatively; advance everything from phase 1; understand and maintain neutral spine; improve cardiovascular conditioning; improve trunk and lower extremity strength and flex­ibility; consider physical capacity tests or functional capacity evaluations; continue modalities, especially soft tis­sue mobilization for viable surgical scar; proper gluteal and paraspinal muscle function; spinal mobilization to restore spinal hypomobile segments; cardiovascular conditioning with treadmill walking and stationary bicycling; strength training

Phase 3: resistive training phase; 7 to 11 wk postoperative; proper body mechanics and independence in ADLs; in­creasing activity tolerance and returning to previous level of function; functional training exercises; return to leisure or sport-specific activities; work hardening programs; soft tissue and spinal mobilization; start discharge planning for independence in home exercise programs

Specific recommendations: and no bending, lifting >10 lb, twisting or driving before 6 wk postoperatively; body mechanics and low back support; ice; preferred sleeping positions; cardiovascular conditioning

Fusion Surgeries

Evaluation: determine approach and instrumentation used; review levels; determine which bracing or restrictions ap­ply; program based on medical history, pre and postoperative symptoms, and postoperative course; determine amount of pain or orthostasis, and ability to participate in therapies; baseline strength, flexibility and conditioning; as for nonfusion surgery, obtain good functional and medical history and physical examination; look at surgical site; review basic patient instructions for sitting and sleeping positions, lifting restrictions, and good posture; home exercise program with basic stabilization and abdominal exercises, and stretching

Phase 1: inpatient; maximize mobility and ADLs; pain control; understanding restrictions for bending, lifting, and twisting; teach patient how to put on and take off braces; teach social support how to help patient; isometric exer­cise program for quadriceps, hamstrings, gastrocnemius, and soleus muscles; stretching; start walking program

Phase 2: outpatient; reinforce proper posture and body mechanics; decrease pain and inflammation with cryotherapy and alternating rest periods; oral or topical medication; educate about expected postoperative course; bracing; teach self-management of flares and correct use of medications; icing; stabilization and reconditioning exercises; scar and soft tissue mobility; aerobic program (minimum 30 min; walking or aquatic exercise)

Phase 3: return to work or previous activities and level of function; advance exercise program to specific stretching, focusing on areas of tightness; spinal stabilization; strength training with low weight and high repetitions; cardio­vascular conditioning on treadmill or stationary bicycle; posture training

Spine Pain Diagnosis and Management

Resa Oshiro, MD, Department of Physical Medicine and Rehabilitation, Cedars-Sinai Medical Center, Los An­geles, CA

Spine pain intake: speaker does not  look at films before talking to patient; can diagnose 90% of problems with good history and physical examination; sit down with patients and determine how pain affects emotional health, and how they cope with pain

Review demographics: discogenic pain and disc herniation more common in younger patients; degenerative changes (eg, stenosis, degenerative arthropathy, facet pain, lateral disc herniation, compression fractures) more common in older patients; white and Asian patients more susceptible to osteoporosis and compression fractures; discogenic and rheumatologic problems (eg, ankylosing spondylitis and Reiter’s syndrome) more common in men; osteoporo­sis, compression fractures, fibromyalgia, and rheumatoid arthritis more common in women

History: short-term onset (weeks or months) more likely to resolve than something lasting years; chronic pain vs acute flare of long-term condition; mechanism of injury; recent changes in activity; gradual or sudden; potential for secondary gain (work situation, personal injury case, motor vehicle accident, or other litigation pending)

Location of pain: in back, consider annular tears, degenerative disc disease, facet pain, bony lesions, fractures, or muscle pain; if lower extremity pain, consider herniated disc, sciatica, stenosis, or peripheral nerve lesion with compression of lumbar plexus; has location of pain changed? is pain localized or diffuse; have patient mark areas of discomfort and quality of pain on pain diagram, then focus on most bothersome area

Origins of pain: focus on function; neck pain often accompanied by jaw pain or temporomandibular joint (TMJ) dys­function and headaches; arm pain possibly cervical stenosis or cervical radiculopathy, or carpal tunnel syndrome; back pain radiating into groin often from hip joint; left leg pain due to sciatica or stenosis; foot numbness could be from peripheral neuropathy

Imaging: changes seen on imaging often normal for age range; if asymptomatic, do not treat; manage with strength­ening or by addressing medical condition; do not treat imaging study

Aggravating and relieving factors: impulse pain worse with Valsalva, cough, or sneeze; tends to aggravate disc pain; if worsened by standing or walking and relieved by sitting, think stenosis, but first rule out vascular claudica­tion; stenosis patients prefer to walk uphill and lean forward on grocery cart; patients with vascular claudication prefer to walk downhill; determine walking distance; impact on quality of life and normal activities; hip pain wors­ens when legs crossed; pain only at night or at rest raises concern for infection or tumor

Treatments received: determine response to previous treatments, eg, medications, physical therapy; review exercises learned, exercises being done at home, and whether patient continuing exercises even when pain free; injections (therapeutic and diagnostic); surgery not guarantee of freedom from pain as spine matures; ask whether surgery helped and for how long

Physical examination: assess associated neurologic symptoms; determine whether pain distribution along derma­tome or myotome, or regional; quality of pain (numbness, tingling, or burning); weakness may present as pain, so ask about tripping or knee buckling or difficulty going up or down stairs; patient off balance with  positive Tre­delenburg sign may have pinched L5 nerve; ask about bowel and bladder dysfunction and sexual dysfunction (in men ³70 yr of age consider benign prostatic hyperplasia); in younger patients, ask about difficulty urinating or in­continence; patients with cervical or thoracic cord compression complain of balance issues, loss of dexterity, trou­ble using computer, or difficulty cutting food

Functional history: occupation; desk jobs or extensive sitting difficult for discs; pain associated with stress? ask about sports that involve torsion or extension (facet pain)

Poor prognostic indicators: depression, smoking, substance abuse, sedentary lifestyle, and poor compliance

Imaging studies: history first; in study, 30% of patients with positive magnetic resonance imaging (MRI) findings do not have back pain; when participants followed 7 yr, positive findings not predictive of developing back pain

Medications for pain: anti-inflammatory drugs  —  Cochrane review found role in acute pain, but benefits do not out­weigh risks in chronic pain; try 3 or 4 drugs for 10- to 14-day trial periods; consider adding proton pump inhibitor if risk factors present; muscle relaxants  —  sedating, so typically given at night; use for acute pain; antidepressants  —  useful for chronic pain; half of patients with low back pain who screen negative for depression improve on antidepressants; tricyclic antidepressants best, but monitor side effects, especially in elderly; anticonvulsants  —  used off label for neuropathic pain; monitor side effect profile and sedation; corticosteroids  —  used for severe flares; opioids  —  use established for cancer and acute pain, but use in chronic and noncancer pain controversial; off-label alternatives available

Other treatments (Cochrane reviews): behavioral treatment; guided exercise programs; massage; acupuncture for chronic pain; electromagnetic therapy; heat for chronic injury; cold for acute injury; transcutaneous electrical nerve stimulation found effective in one review, equivalent to placebo in another; trigger point injections;  inconclusive or not reviewed  —  include Pilates, traction, chiropractic manipulation, and bracing; orthotic inserts; interventional pain management; Botulinum exotoxin A (Botox); prolotherapy; biofeedback

Suggested Reading

Anderson P et al: Predictors of outcome after anterior cervical discectomy and fusion: a multivariate analysis. Spine 34:161, 2009; Bron J et al: Repair, regenerative and supportive therapies of the annulus fibrosus: achievements and chal­lenges. Eur Spine J 18:301, 2009; Coric D Mummaneni P: Nucleus replacement technologies. J Neurosurg Spine 8:115, 2008; Heuer F et al: Biomechanical evaluation of conventional anulus fibrosus closure methods required for nucleus re­placement. J Neurosurg Spine 9:307, 2008; Kapural L et al: Intervertebral disc biacuplasty for the treatment of lumbar discogenic pain: results of a six-month follow-up. Pain Med 9:60, 2008; Lavelle W et al: Interventional techniques for back pain. Clin Geriatr Med 24:345, 2008; Lee S et al: Anterior minimally invasive approaches for the cervical spine. Or­thop Clin North Am 38:327, 2007; Levin K: Nonsurgical interventions for spine pain. Neurol Clin 25:495, 2007; Malfair D, Beall D: Imaging the degenerative diseases of the lumbar spine. Magn Reson Imaging Clin N Am 15:221, 2007; Mat­sumoto M et al: Nocturnal leg cramps: a common complaint in patients with lumbar spinal canal stenosis. Spine 34:189, 2009; Muijs S et al: Percutaneous vertebroplasty for the treatment of osteoporotic vertebral compression fractures: evalu­ation after 36 months. J Bone Joint Surg Br 91:379, 2009; Obray RW et al: MR imaging and osseous spinal intervention and intervertebral disk intervention. Magn Reson Imaging Clin N Am 15:257, 2007; Rubin D: Epidemiology and risk fac­tors for spine pain. Neurol Clin 25:353, 2007; Vernengo J et al: Evaluation of novel injectable hydrogels for nucleus pulposus replacement. J Biomed Mater Res B Appl Biomater 84:64, 2008; Zhao B et al: Clinical effects of acupuncture after surgical operation in patients with prolapse of the lumbar intervertebral disc. J Tradit Chin Med 28:250, 2008.