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Thomas Cha: Role of Specialists in Accountable Care Organizations

Grand Rounds Video of Dr Tom Cha at Mass General Hospital, Boston, MARole of Specialists in Accountable Care Organizations:An Example of Spinal Stenosis
Thomas Cha, MD
Department of Orthopaedic Surgery
Massachusetts General Hospital,
Boston, MA
Grand Rounds presented on March 28, 2013 at the O’Keeffe Auditorium, Massachusetts General Hospital, Boston, MA
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Evaluating the Cervical Spine

Mitch Harris, MD, is Chief of the Orthopedic Trauma Service, at Brigham and Women’s Hospital, and Associate Professor of Orthopaedic Surgery at Harvard Medical School.
Here, Dr Harris shares a very useful algorithm for evaluating patients with trauma to the cervical spine.


Imagine getting called to the Emergency Department to evaluate a painful and swollen knee after a skiing accident. The plain x-rays are read as normal, with no evidence of acute fracture and demonstrate evidence of degenerative arthritis of the knee. If the patient is experiencing too much pain to allow for an adequate exam, a knee brace will be provided and the patient re-evaluated in the office in 7-10 days. If there is significant ligamentous injury, the brace will suffice for temporary stability and a follow-up MRI might be required to fully define the extent of the injury.

Now consider another presentation. This time the mechanism of injury is a fall from standing in an elderly woman and the area of concern is her cervical spine. The patient has a black eye, no history of loss of consciousness and complains of neck pain while in the collar. There are no other associated injuries. Plain x-rays of her cervical spine are read as normal, with no evidence of acute fracture and demonstrate evidence of degenerative arthritis of the neck. The questions now are: what should the next tests be, and can the patient be safely discharged in a collar for a follow-up appointment in 1-2 weeks?

Normal appearing Left and Right facets of the cervical spine from MD Computerized Tomography (MDCT) scan.
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What should I do for back pain?

Question:

Since shoveling snow two weeks ago, I have constant low back pain. What should I do for the pain?

Response:

Low back pain is one of the most common reasons for patients seeking medical advice. Most patients can find relief by using simple remedies at home.

Rest: During the initial phase, bed rest may relieve the pain, but should be limited to one or two days.

Medication: Over the counter medications such as ibuprofen (Motrin, etc) or naproxyn (Aleve, etc.) reduce the inflammation and relieve pain.

Talk to your primary care physician if the pain persists despite these measures. They may initially recommend –
Physical Therapy: A physical therapist often uses various techniques to decrease inflammation and will walk you through an exercise regimen to improve muscle strength and mobility. Patients can continue to perform these exercises as part of a home-based program to maintain these benefits over time.

Improvements in Posture: A simple tip to remember for the next time you are shoveling or lifting a heavy package is to use proper lifting techniques emphasizing the thigh and leg muscles, and not the back.

FDA Panel Approves Artificial Cervical Intervertebral Disc

A key Advisory Panel of the Food and Drug Administration (FDA) has recommend approval for an artificial cervical intervertebral disc device. The panel’s recommendations were based on results of limited clinical trials and the FDA is likely to approve the device for use in patients.

While artificial discs have been used in UK and Europe for many years, this will be the first artificial cervical disc approved for use in patients in the US. Artificial discs by other manufacturers are also at various stages of clinical trials and are in the process of seeking FDA approval.

Healthy spinal discs are soft but tough shock absorbers that separate each vertebral body making up the spine. Discs allow the spine to bend and twist. As we age, discs begin to dry out and lose their ability to absorb shocks, resulting in their bulging. This can put pressure on the spinal cord and nerves, leading to neck or arm pain.

In current surgical practice, the degenerated disc is removed and adjacent vertebrae are fused together with a metal plate, aiming to lessen the pain. But it also prevents natural movement of the spine, putting additional stresses on the adjacent (healthy) non-fused discs, quickening their breakdown and possibly leading to additional surgery.

The new artificial discs will be placed between the two vertebral bodies after the affected disc has been removed. Ideally, the artificial disc acts much like a human disk, providing flexible motion while acting as a shock absorber in the spine.

As part of the approval, the FDA panel has also insisted that the manufacturer Medtronic Sofamor Danek, Minneapolis, MN, conduct additional clinical studies to determine the long term durability of this device. This process will provide an early warning of complications and unexpected problems in a larger patient population.

“Surgeons here at the Orthopaedic Spine Center at MGH will be involved in the use and study of artificial cervical discs in the months to come,” reports Dr Kirkham Wood MD, Chief of the Orthopaedic Spine Service at MGH, and Assistant Professor of Orthopaedic Surgery at Harvard Medical School.