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degenerative disc disease

Primary Care Approach to Degenerative Cervical Myelopathy

Teaser: 

1Ali Moghaddamjou, MD,2Jetan H. Badhiwala, MD,3Michael G. Fehlings. MD, Phd, FRCSC, FACS,

1Division of Neurosurgery, Department of Surgery, University of Toronto, Spinal Program, Toronto Western Hospital, University Health Network, Toronto, Ontario, Canada. 2Division of Neurosurgery, Department of Surgery, University of Toronto, Spinal Program, Toronto Western Hospital, University Health Network, Toronto, Ontario, Canada. 3Division of Neurosurgery, Department of Surgery, University of Toronto, Spinal Program, Toronto Western Hospital, University Health Network, Toronto, Ontario, Canada.

CLINICAL TOOLS

Abstract: Degenerative cervical myelopathy is an umbrella term describing all degenerative conditions that present with cervical myelopathy due to compression of the spinal cord. The role of primary care physicians (PCPs) in early identification is vital as delayed diagnosis can lead to irreversible neurological impairment. Patients often present with subtle neurological deficits associated with neck or upper extremity pain. Screening for upper motor neuron signs, gait disturbances, fine motor abnormalities and bowel bladder symptoms is critical. Currently, surgical decompression is the treatment of choice but with future advancements in non-operative treatments, PCPs are expected to play a larger role in treatment plans.
Key Words: degenerative cervical myelopathy, primary care, cervical spondylotic myelopathy, degenerative disc disease.

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PCPs play a vital role in the management of DCM as a delayed diagnosis can lead to irreversible neurological impairment.
A heightened level of awareness with a comprehensive history and a focused physical examination are essential.
With advancements in biomarkers and emerging neuroprotective and regenerative agents, we can expect an increased role in the primary care medical management of DCM patients soon.
The approach to DCM management is multidisciplinary and generally will involve PCPs, spinal surgeon, physiotherapist, pain specialist, and neurologist.
Patients with query bilateral carpal tunnel syndrome should be assessed for DCM.
Patients with moderate to severe DCM or unequivocal progression of mild DCM require surgical treatment while there exists clinical equipoise between structured non-operative therapies and surgical decompression for mild non-progressive cases of DCM.
Clinically monitor patients with mild DCM frequently and carefully for subtle signs of neurological progression
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Related Terms: Back Health, degenerative cervical myelopathy, primary care, cervical spondylotic myelopathy, degenerative disc disease
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Clinical Disorders of the Aging Spine

Clinical Disorders of the Aging Spine

Teaser: 
Edward P Abraham, MD, FRCSC,
Associate Professor of Surgery, Department of Orthopaedics, Dalhousie University Medical School, Saint John Campus, Saint John NB Canada Canada East Spine Centre, Horizon Health Network.
Hamilton Hall, MD, FRCSC,
Professor, Department of Surgery, University of Toronto, Executive Director, Canadian Spine Society, Toronto, ON.

CLINICAL TOOLS

Abstract: In spite of the slightly increased incidence of infections, malignancies and systemic illnesses affecting the older spine, about 90% of back pain in the elderly, as in younger patients, is mechanical. This article covers several of the common problems: neurogenic claudication, degenerative disc disease, degenerative spondylolisthesis, disc herniation, spinal deformity and osteoporotic compression fractures. Treatment is both non-operative and surgical and the decisions about which to choose and therefore when to refer depend as much on the age and functional capacity of the patient as upon the specific pathology.
Key Words: neurogenic claudication, degenerative disc disease, degenerative spondylolisthesis, disc herniation, spinal deformity, osteoporotic fractures, imaging.

The diagnosis of neurogenic claudication is made on the history of intermittent leg dominant pain brought on by activity, usually walking, and relieved by rest in flexion, usually by sitting down. The physical examination while the patient is at rest is often normal.
Mechanical back pain associated with disc degeneration is seldom an indication for surgery and can usually be adequately managed through a combination of education, activity modification, general fitness and exercises selectively tailored to improve the pain-producing positons and movements.
Disc herniation producing acute sciatica is uncommon in the older patient and the diagnosis should be made with caution. True radicular pain is constant and leg dominant. Referred, intermittent leg pain frequently accompanies back dominant pain and should not be treated as sciatica.
Enduring spine surgery is a major challenge for the elderly patient. The decision to operate must be made after comprehensive consultation, emphasizing the prolonged recovery and weighing the potential benefits against the inevitable risks, including the risk to life.
Osteoporotic vertebral body compression fractures frequently occur without a recognized history of trauma. The pain, often in the thoracic or upper lumbar area, appears suddenly, is aggravated by movement (particularly bending forward) and is reduced but not eliminated by lying down. The acute phase can last several weeks but usually subsides without specific treatment. Multiple compression fractures over time will produce a kyphotic spine.
Back pain in the elderly should be managed with a minimum of medication. Mechanical pain can usually be controlled with the appropriate mechanical measures and additional analgesia is not required. Recourse to pain medication as a first line of treatment is not recommended and when employed should be limited to non-narcotic formulations. With the possible exceptions of acute sciatica and recent vertebral compression fractures, opioids should not be used.
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Related Terms: Back Health, neurogenic claudication, degenerative disc disease, degenerative spondylolisthesis, disc herniation, spinal deformity, osteoporotic fractures, imaging
Disclaimer: 
This article was published as part of Managing the Health of Your Aging Patient: Therapies that Could Help Improve Quality of Life eCME resource. The development of Managing the Health of Your Aging Patient: Therapies that Could Help Improve Quality of Life eCME resource was supported by an educational grant from Medtronic Canada.