The Spine Center of Miami

John C. Nordt, M.D.

Spine Center of Miami

Pain is a symptom
Not a diagnosis!

Spine Center of Miami

Diagnosis is the reason for the

problem

Spine Center of Miami

Back pain
80% of population
Resolves in 3 months

Spine Center of Miami

Causes of back pain

Muscle
Ligament
Disc
Nerve
Bone

tumor
infection
fracture
instability

Spine Center of Miami

Pain generator
That which causes pain is more
clearly understood now

Spine Center of Miami

Improved tests clarify source/origin

Spine Center of Miami

Over zealous physician can push

treatment plan without clear
diagnoses

Spine Center of Miami

History
Back pain?
Leg pain?
Combination? 50/50
9

Spine Center of Miami

Positional or postural
exacerbation

10

Spine Center of Miami

Careful & thoughtful history

Back Pain?
Leg Pain?
Combination?

Spine Center of Miami

Alf Nachemson
Disc Pressure measurements
In the 1960s at L-3-4
Sitting caused 2-3 x body weight
pressure

Spine Center of Miami

 Positional Exacerbation
Back Pain
Leg Pain

Spine Center of Miami

Sitting
Exacerbates

Degenerative Disc

Herniated Disc

Spine Center of Miami

Standing
Exacerbates

Central Stenosis or

Dynamic Foraminal Stenosis

Spine Center of Miami

Supine
Awaken from sleep with rolling over
Rotation is least stable in spine
with degenerative disc.

Spine Center of Miami

Diagnostic tests

Selective Foraminal Root Injection

Facet Injection

Discography

Spine Center of Miami

Dynamic Examination LS Spine to assess:

Canal stenosis

Foraminal stenosis or

Instability

Spine Center of Miami

Gold Standard

Standing Flex/Extmyelogram

Spine Center of Miami

Magnetic Resonance Imaging

Since 1988

Significant source of information

Spine Center of Miami

Improved resolution of image

Magnet Strength
Software

Spine Center of Miami

Diagnosis?
Degenerated Disc
Foraminal Stenosis
PARS Defect
Central Stenosis
Lateral Disc or Foraminal Disc
Herniated Disc
Spine Center of Miami

 If your car wont start You dont just change the battery

Spine Center of Miami

False positives with evaluative tests

Are eliminated with Clinical Correlation

Spine Center of Miami

 Abnormal MRIs in Normal Subjects

Scott Boden, M.D., etal JBJS
March 1990

Spine Center of Miami

 100 normal subjects 17-70 yrs.

37% + MRI that would require
surgery

Spine Center of Miami

Outline mutually agreed upon

expectation of surgery clearly

Leg pain

Back pain

Spine Center of Miami

 Incorrect or Incomplete Diagnosis

Discordant Symptom

Spine Center of Miami

Instability of the Degenerative Disc

Pain with sitting-Relief Standing

Pain awakens at night

Spine Center of Miami

 Inconclusive Radiologic Criteria

Therefore need to assess within the
clinical context

Spine Center of Miami

Flex/Ext. MRI

Pain Relief Supine

Supine MRI

Demonstrates?

Spine Center of Miami

Back Surgery wonderful tool to help

Spine Center of Miami

Accurate Diagnosis
Accurate Surgery

Spine Center of Miami

Remember:
A second surgery with clear
correctable problem will be
successful

Spine Center of Miami

Thank You
SPINE CENTER OF MIAMI

Spine Center of Miami