CONSERVATIVE CARE

Douglas Koontz, M.D.

Neurosurgery Specialists

What does conservative care entail?

• In neurosurgery, conservative treatment is treatment for neck or back pain with therapies other than surgery

• Often utilizes medication, physical therapy and/or injections

First Evaluation

• Physical exam of the patient

- many times, the patient comes to us after they have seen one or two other physicians such as primary care

• History taken of pain and all complaints

- ie: numbness, tingling, etc.

• Discussion of options with the patient

Medications

• Many times the patient can be treated with anti-inflammatory medication, steroids and muscle relaxers.

• Take into account patients complaints, history and medications they are already taking

Medications

• NSAID’s or anti-inflammatories reduce inflammation in and around the spinal area

• Steroids may be prescribed for a SHORT amount of time. This is often known as a Medrol Dose pack.

Medications

• Muscle relaxers can be prescribed when the patient is experiencing spasms.

• Common forms of muscles relaxers are: Flexeril, SOMA, Valium, Skelaxin and Robaxin

• Side effects can include drowsiness and dependence so these should be prescribed with caution

Medications

• Gabapentin

• Lyrica,

• Cymbalta

• All used to treat neuropathic pain

Physical Therapy

• This should be considered if back pain has lasted from between 2-6 weeks and the patient has experienced no relief

• Physical therapy evaluation is the first step

- The therapist can then develop a specific treatment plan for the patient including many different modalities

Physical Therapy

• Aquatic therapy

- low impact exercises for patients who are in severe pain or might have a disability that precludes them from participating in land based physical therapy

Physical Therapy

• TENS Unit

-involves high or low frequency stimulation

-placement of electrodes on or around the painful area

- trials are available to see if patient responds well to the TENS unit

Physical Therapy

• Land based, or traditional physical therapy involves exercises meant to reduce pain.

• This can involve strengthening certain muscle groups

• The therapist is also able to instruct the patient with home exercises to improve their outcome

Other Modalities

• Acupuncture

• Biofeedback

• Massage

• Manipulation

• Ultrasound

Diagnostic Testing

• Xray

-used to investigate if there is a fracture

• CT

-more in depth test to investigate any bone injuries

• MRI

-more common to order in neurosurgery

-used to diagnose soft tissue injury

Diagnostic Testing

• MRI cont.- this diagnostic test most often helps

neurosurgeons diagnose things like herniated disks

Diagnostic Testing

• Discogram

- This is used to locate the disk that is generating the pain

- Performed by a pain management doctor

- Usually involves the disk above and below the suspected “problem disk”

- Controversial

Diagnostic Testing

• CT Myelogram

- used to diagnose herniated disk, tumor, spinal stenosis and infection

- Many times this is used after an MRI is performed for a more detailed study

Diagnostic Testing

• EMG- Performed by a neurologist

- Used to record activity by the muscles

- An order is an EMG of the left/right upper extremities or the left/right lower extremities

- EXAMPLE: A patient with negative MRI but persistent leg numbess

Epidural Steroid Injections

• Performed by a pain management physician, usually in the hospital

• Outpatient procedure that should not interfere with patient’s daily activities

• Using x-ray guidance, a thin needle is inserted into the epidural space and a steroid (cortisone) is injected

Epidural Steroid Injections

• Can be ordered in a series

• Patient will come back to see his or her neurosurgeon approximately 2 weeks after the procedure to gauge whether it was a success

• Injections are considered safe and effective as treatment for pain

Injections: Continued

• Selective Nerve Root Block

• Trigger Point Injections

• Facet Injections

• Rhizotomy

Surgery

• Surgery is indicated if:

- Patient fails conservative treatment

- Their condition interferes with their ability to function

- The benefits of the procedure outweigh the risks

- In some cases, the symptoms may be so severe that conservative treatment is not an option and surgery must be performed immediately.

Questions?