Spine Surgery for the PCP (Athanassious, 7/15/26)

A recording of this presentation is available HERE.

Many thanks to Dr. Christian Athanassious, orthopedic spine surgeon, who gave a really great Grand Rounds Treatment of the Spine for the PCP. The recording is worth watching! For those who prefer the written word. . .

Key learning points:

-The cervical and lumbar spine contains mobile segments>> most likely to develop problems (in contrast to thoracic spine)

-Cervical DJD can often radiate to the scapula

-Be sure to give high enough doses of gabapentin (e.g. 300mg QHS) for acute back pain, helping pts sleep improves pain

-Myelopathy with acute change in function (e.g. ability to hold a cup, balance) needs urgent eval

-If patient has >6 months pain with stenosis on MRI, they are unlikely to get better and should be referred to spine surgeon

-Spinal precautions: no twisting, bending or lifting > 10 pounds (fusion x  6 weeks, then can increase weight to 25 pounds x 3 months, laminectomy x 6 weeks)

Neck Pain

-Radiculopathy: compression of cervical nerve roots: deep aching, electrical feeling, stabbing, numbness/tingling (must be differentiated from carpal tunnel syndrome)

-DJD means "less hydration in the disk level" (doesn't mean there is compression nerve or pain generator)-- most adults will have 1-2 levels of DJD on imaging, must always correlate with history and physical exam findings

-Most common cervical problem is C5/C6:  neuroforaminal narrowing will affect the C6 nerve root (weak biceps, wrist extension, deltoid weak)

-Second most common: C6/C7: numbness and tingling over forearm, 2nd and 3rd digit (radial), wrist flexion weakness, triceps weakness

-if a cervical problem > 6 months, should refer to spine surgery

-Myelopathy: can present as a step-like decline (from one day to next), more urgent than radiculopathy. Pain doesn't follow dermatomal distribution because whole spinal cord is being compressed

-while nerve roots can recover (even after 1-2 years of injury), spinal cord injury does not recover as well

-surgical emergency if acute change in function

-"I was walking with a cane independently, and now I feel like I am drunk, I cannot control my feet, I do not know where my arms/legs are in space">> needs cervical and thoracic MRI and spine surgery consultation, may need ED visit

-sudden change in handwriting, in ability to hold a cup

-bowel and bladder dysfunction are rare (need major compression)

Lumbar Pain

Less urgent low back pain: sciatica/back pain

More urgent: cauda equina

L1-L5/Sacrum (6 vertebrae)

Discs: annulus fibrosis (outer fibrous layer), nucleus pulposus (gelatinous)>> pain from annulus being torn, another part is nerve roots being compressed or the pulp putting pressure on the nerves  caustic to nerve root, can cause pain). Acute annular tear, release of NT and tear can cause acute pain>> PT, back precautions, NSAIDSs vs. oral steroids

Non-operative management of acute lumbar disc herniation

-NSAID
-Physical therapy

-gabapentin/lyrica: make sure to dose gabapentin high enough

-oral steroid

-referral to pain mgt for epidural steroid injection

-brace (for fracture, first line for fracture tx unless severe compression of nerve root, patient with a body habitus that doesn't allow, or emphysema dx cannot tolerate) >>vertebroplasty/kyphoplasty: spine surgeon, IR, pain mgt surgeon (okay to call spine surgery if we have questions about what to do)

Ddx lumbar Pain: arthritis, stenosis, DJD (if bad enough), facet disease

Back symptoms:

-axial back pain: doesn't radiate (stenosis, arthritis in facet, severe DJD leading to bone on bone)

-radicular: irritates the nerve root, radiates down legs or out to arms, or to scapula (if thoracic, can radiate mid back toward ribs)

-loss of balance (spinal cord compression)

-loss of dexterity (spinal cord compression)

-weakness (can happen with nerve root or spinal cord compression)

***

Neck surgery:

-Most common: Anterior cervical discectomy and fusion (ACDF), less common disc arthroplasty (if disease limited to 1-2 levels)

-Disc removed, spinal cord and facet decompressed>> spacer placed. If fusion, plate placed over the top (if just arthroplasty, no plate placed)

-Disc arthroplasty: not indicated for >2 disc levels, facet disease often a problem. Usually indicated only in young patient with little facet disease, short hx of axial neck pain, acute issue 2/2 fall or accident (disc replacement). Many will eventually need a fusion

Normal ACDF recovery: 

    -some degree of difficulty swallowing (no need for swallow study), have to chew longer, cut smaller. Pay attention when swallowing. Can last weeks to 1-2 months, almost always resolves

    -pain in front of neck

    -mild swelling in front of neck>> make sure breathing okay, can speak, eat and drink. Can consider TXA post-op to prevent seeping

    -mid-scapula pain: spacers cause stretch on facets and capsule and can cause posterior neck that radiates to scapula

    -strength doesn't come back right away, can continue to see recovery up too 2 years post-op

    -neck braces after fusion (1 level 4 weeks, 2 levels 8 weeks, 3 level 12 weeks in brace)

Abnormal ACDF recovery:

    -C5 radiculopathy (difficulty lifting shoulder) common after severe spinal stenosis due to posterior drift, not permanent, give brace so arm not hanging, will resolve over time

    -redness/infection of surgical site (if no fever, can rx cephalexin; if fever, may need admission for IV abx, MRI to ensure infection is superficial)

    -any NEW dense weakness>> get MRI

    -Horner syndrome: symptomatic treatment, lubricating drops for eyes

surgical decompression (microdiscectomy)

Low Back Surgery

    -microdiscectomy most common

    -laminectomy (full removal) vs. laminotomy

    -#1 indication for spinal fusion is mobile spondylolisthesis (pt flexes and extends and has >3mm motion between flexion/extension). If spinal stenosis and symptoms correlate, not improving 3-6 months, intolerable of pain

    -Why fuse?

        -DJD with stenosis

    -Adjacent level disease

        -degenerative scoliosis

Access lumbar spine from the 1) front (anterior retroperitoneal approach): incision in midline of stomach, go around peritoneum, fuse in retroperitoneal. 2) lateral anterior retroperitoneal approach, 3)  posterior fusion

ALIF: anterior lumbar interbody fusion. Very stable, access via vascular surgery (higher risk of bleeding), powerful way to treat patients IF treating L5/S1 (cannot be accessed frmo the side). Downsides: post-op bleeding, post-op infection (superficial vs. deep (abnormal labs, fever/vital sign instability), DVT/PE (increased due to vessel manipulation), sympathetic chain compromise 

PLIF: posterior lumbar interbody fusion. Less effective, more problematic. Have to take down a lot of paraspinal musculature, removal of bone and ligament from posterior canal. Cannot correct deformity as well as ALIF. 

EXLIF: minimally invasive procedure, eXtreme lateral interbody fusion. Much smaller incision (compared to PLIF). Can use large cage. large graft to increase stability. L5-S1 cannot be accessed due to the anatomy (pelvis in the way). Can get anterior thigh numbness/hip flexion weakness (psoas mm)

What requires urgent spine surgery attention?

-Myelopathy: quick change in function, send to ED, call spine surgeon

-Severe radiculopathy with weakness

-If symptoms > 6 months, doesn't need ED eval but should refer to spine surgery (especially if MRI finds stenosis)

-Cauda equina: severe excruciating back pain, weakness on exam, numbness ins addle, bowel/bladder incontinence. Usually caused by acute event (should be treated within 48 hours, bowel and bladder function may not return)

Evaluation and Treatment of Shoulder Pain (Pourtaheri, 2/16/2022)

Many thanks to Dr. Neema Pourtaheri of Santa Rosa Orthopedics for his presentation, Evaluation and Treatment of Shoulder Pain 

A recording of his presentation is available HERE.

Shoulder pain is a very frequent complaint in primary care, can be broken down into several common categories

1) Rotator cuff and Proximal Biceps Tears (partial vs. full thickness, acute/traumatic vs. chronic/degenerative)

• the rotator cuff is responsible for shoulder rotation, stabilization, and arm elevation
• the rotator cuff holds the head of the humerus in the small shallow glenoid
• rotator cuff muscles: supraspinatous, infraspinatous, teres minor, subscapularis
• rotator cuff tear very common, 2 million people in US/year
• important history in your diagnosis of rotator cuff injury: usually in dominant arm, age >40 years, pain worse at night, interferes with sleep, weakness with rotation and lifting, unable to do daily tasks (e.g. combing hair, putting on shirt)
• Exam
• drop arm sign (supraspinatus)
• bear hug test (subscapularis)
• external rotation lag sign (infraspinatus)
• horn blower sign (teres minor)
• acute traumatic usually occurs in setting of fall, trauma, significant amount of force (particularly in young patients)
• chronic is degenerative, gradual onset, repetitive stress injury, occurs often in dominant arm, often as a result of bone spurs rubbing
• >40% of people >65 have chronic rotator cuff tear
• rotator cuff tears DO progress with time
• full thickness tendon tears progress more rapidly
• larger tears progress more quickly as well
• Non-surgical management: activity modification, NSAID, cortisone?? (controversial, Dr. Pourtaheri doesn't recommend steroid injection for rotator cuff injury), PT helps with strength and pain, doesn't fix the tear, work on strengthening other tendons
• All acute traumatic tears in people <60 should be fixed
• "old tendons are not fixable" (no atrophy on MRI)
• Shoulder arthroscopy: small incisions w/camera, nerve block for pain
• Rotator cuff repair in correct candidates have 95% success rate (in terms of pain, function), improved shoulder strength and prevent tears from progressing
• Post op course: 6 weeks in sling, 3 month limited lifting, PT

Many rotator cuff tears have an associated biceps tendon tear (should be repaired at the same time)

2) Impingement/Bursitis

• inflammation of the bursa, usually due to overuse (overhead activity), sometimes trauma
• pain exacerbated with activity, relieved with rest/NSAIDs, immobility
• no-op treatment: activity modification, steroid injection, ice, ultrasound, PT
• arthroscopic surgery for bursitis is generally arthroscopic bursectomy w/arthroplasty on the undersurface of the acromion 
• rehab is faster than rotator cuff: sling x 2 weeks, PT within 2 weeks of surgery

3) Shoulder Labrum Tear

• Labrum is fibro-cartilaginous ring that attaches to the glenoid, anchor point for gleno-humeral ligaments 
• labrum is essential for shoulder stability in people <40
• in people <40 tears are usually associated with trauma or dislocation event
• in people >40, most labrum tears are physiologic and don't need treatment or surgery
• PT is best non-operative management   
• Sometimes surgery is indicated for people who are young and failed PT

4) Shoulder arthritis

• >60 year old patient arthritis is a common cause of shoulder pain
• articular cartilage thins out with time, exposed bone
• X-ray: collapsed joint space, large bone spurs, thickening of subchondral
• Non operative management: NSAID, PT, steroid/cortisone injection (yes, indicated)
• PT to stretch the shoulder joint capsule (see exercises below)
• Operative tx: shoulder arthroscopy (to release joint capsule, usually in mild to mod arthritis)) and shoulder replacement
• Shoulder replacement 90% pain relief indicated for moderate-severe arthritis of gleno-humerus
• there have been significant advances in shoulder replacement techniques and technology over the last 10 years
• same day (outpatient surgery)
• 4-6 weeks immobilized in sling, PT within a week, full recovery 6 months-1 year
• two types of shoulder replacement: anatomic (intact rotator cuff) vs. reverse shoulder replacement (non anatomic)-- shoulder arthritis w/large rotator cuff tears
• in reverse, ball goes on socket side of shoulder, socket on ball side of shoulder

Final pearls:

• History and physical exam are key for assessment and diagnosis of shoulder pain
• X-rays are still always a good idea as an initial evaluation (arthritis, calcific tendonitis, acromial bone spurs, for large rotator cuff tears for decision-making for surgery)
• MRI definitively diagnose rotator cuff tears
• Role for ultrasound? In patients who cannot get MRI (e.g. pacemaker), can use for shoulder injections (ultrasound guided)
• Absolute indications for MRI in shoulder pain
• fall/acute injury with sudden onset weakness in the arm likely has an acute rotator cuff tear(to evaluate for rotator cuff tear, which should be repaired within a couple months of injury for best outcome, time sensitivite)
• if concern for biceps tendon "Popeye" arm (full thickness tear of biceps tendon)