low back pain 3-4-03

8/12/2019 Low Back Pain 3-4-03

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3/4/03 Steven Stoltz, M.D.

Back Pain 2nd most common cause for office visit

60-80% of population will have lower back

pain at some time in their lives

Each year, 15-20% will have back pain

Most common cause of disability for

persons < 45 years

1% of US population is disabled

Costs to society: $20-50 billion/year

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8/12/2019 Low Back Pain 3-4-03



Outline Part 1:

– Introduction

– Review of anatomy

Part 2: – Acute low back pain

Part 3:

– Chronic low back pain – Prevention

Questions ??

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Low Back Pain

“One would have thought by now that the

problem of diagnosis and treatment would

have been solved, but the issue remainsmysterious and clouded with uncertainty.”

– Rosomoff HL, Rosomoff RS. Low back pain: Evaluation

and management in the primary care setting. Med Clin

North Am 1999;83:643-62.

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- AnatomyLesson #1

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- AnatomyLesson #2

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Introduction to Ed

Ed has had lower back pain for the past 24

hours that he feels is related to yard work

that he did over the weekend. He missedwork today, Monday.

He wants to know what can be done for his

back pain?

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What should Ed expect from

his health care professional?1. Be able to recognize the difference

between routine lower back pain and

dangerous forms of lower back pain.2. Provide information, advice, and a plan of

action.

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% of Back Pain due to

Herniated Disk?1. 4%

2. 14%

3. 40%

4. None of the above

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Causes of Low Back Pain

Lumbar “strain” or “sprain” – 70%

Degenerative changes – 10%

Herniated disk – 4%

Osteoporosis compression fractures – 4%

Spinal stenosis – 3% Spondylolisthesis – 2%

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Causes of Low Back Pain…

Spondylolysis, diskogenic low back pain or

other instability – 2%

Traumatic fracture - <1%

Congenital disease - <1%

Cancer – 0.7%

Inflammatory arthritis – 0.3%

Infections – 0.01%

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Red Flags

History of cancer

Unexplained weight

loss Intravenous drug use

Prolonged use of

corticosteroids Older age

Major Trauma

Osteoporosis

Fever

Back pain at rest or at

night

Bowel or bladderdysfunction

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Medications

Anti-inflammatory medications (NSAID‟s): – Beneficial; no differences; watch side-effects

Tylenol:

Narcotic Pain Relievers: – No more effective than NSAID‟s

– Many side effects

Muscle Relaxants (ie. Flexeril®

): – Can decrease pain and improve mobility

– 70% with drowsiness/dizziness

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Chiropractic/Osteopathic

Davenport, Iowa in 1895 by David Palmer;

„done by hand‟ (Greek)

Spinal manipulation

Conflicting evidence on the effects of spinal

manipulation

– ~75-90% improvement anyway within 4 weeks

Greater patient satisfaction

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Exercise & Bed Rest Advice to stay active:

– „There is no evidence that advice to stay activeis harmful for either acute low back pain or

sciatica.‟ – Hurt does not equal harm

One or two days of bed rest if necessary

Light activity, avoiding heavy lifting, bending or twisting (ie. walking)

No data on any particular exercises

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Acupuncture

Very little quality research and data

Seems to indicate that acupuncture is not

effective for the treatment of back pain

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Other Modalities

Back Brace/Corset/Lumbar Support:

Traction:

Injections: Inconclusive evidence

TENS:

Hot/Cold: Ultrasound:

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Ed, again…

Now, Ed has not had improvement in his

lower back pain and 6 weeks have gone by

since the initial painful event. What types of therapies might be beneficial

for Ed now?

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Role of X-rays (Radiology)

Usually unnecessary and not helpful

Plain X-ray:

– Age>50 years

– No improvement after 6 weeks

– Other worrisome findings

MRI:

– After 6 weeks if have sciatica

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New England Journal of Medicine (February 2001)

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Medications

Similar to acute pain….

Antidepressant medications can improve

pain relief

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Exercises

Improves pain and function

Many programs available, but difficult to

make any scientific recommendations forone type versus another

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Injections

Epidural injections:

– Insufficient and conflicting evidence

Facet joint injections:

– No improvement

Local/Trigger point injections:

– Possibly some benefit

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Surgery

Diskectomy improves pain in short term but

not long term (ie. 10 years)

Microdiskectomy similar to standarddiskectomy

Automated percutaneous diskectomy and

laser diskectomy both less effective

? Arthroscopic diskectomy

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Other Modalities

Back Schools: - possibly effective

Multidisciplinary Therapy: - probably yes

TENS: - no

Spinal manipulation: - conflicting data

Massage: - probably yes

IDET:

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Intradiscal Electrothermal Therapy

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IDET

No convincing evidence that shows the

short or long-term clinical efficacy of this

procedure. Safe with few adverse effects

? Long-term effects

Wall Street Journal (Feb. 11, 2003)

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low back pain 3-4-03

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