update on lower back pain
DESCRIPTION
Update on lower back pain. Zee Khan M.D. Assistant Professor Orthopaedic Spine Surgery [email protected] (405) 271 BONE (2663). OAPA 39 TH Annual CME Conference. OBJECTIVES. - PowerPoint PPT PresentationTRANSCRIPT
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UPDATE ON LOWERBACK PAIN
Zee Khan M.D.Assistant Professor
Orthopaedic Spine [email protected]
(405) 271 BONE (2663)
OAPA 39TH Annual CME Conference
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OBJECTIVES IDENTIFY the new diagnostic modalities and
the rationale for selection of those that are appropriate for each patient.
ASSESS commonly over-looked diagnostic evidence in primary care.
DEFEND the rationale for the selection of different therapies based upon currently available, evidence-based information and individual patient consideration.
CLASSIFY the use of new medications; recommended uses, unique characteristics, side effects, interactions, dosage, and costs as well as other considerations.
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Topics covered today Anatomy of lumbar
spine Different types of
pain originating from the back HNP Stenosis DDD
Common myths Treatment options Non-operative Tx Operative Tx Goals of surgery
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Scoliosis – Trauma - Tumors
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77 y/o female New onset pain 6/10 VAS Multiple medical issues
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AAOS Position statements on Osteoporotic
fractures
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Osteoporotic fracturesmoderate
1. We suggest patients who present with an osteoporotic spinal compression fracture on imaging with correlating clinical signs and Moderate symptoms suggesting an acute injury (0–5 days after identifiable event or onset of symptoms) and who are neurologically intact
Treat with calcitonin for 4 weeks
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Osteoporotic fracturesWeak
Kyphoplasty is an option for patients who present with an osteoporotic spinal compression fracture on imaging with correlating clinical Weak signs and symptoms and who are neurologically intact
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Osteoporotic fracturesStrong
We recommend against vertebroplasty for patients who present with an osteoporotic spinal compression fracture on imaging with Strong correlating clinical signs and symptoms and who are neurologically intact
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LOW BACK PAIN IMPACT 60-85% of people will have LBP sometime in
their lives. 90% LBP resolves in 6 weeks 30% are referred to Ortho 3% admitted 0.5% operated
The total cost of management of back pain is $26.4 billion –direct cost
Indirect cost ~90 billion dollars
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2003 Cost an estimated $61.2 Billion/ year Due to HA LBP Arthritic pain Musculoskeletal pain Majority was due to lost productive time
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Lower Back Pain’s Economic Impact
# 1 reason for individuals under the age of 45 to limit their activity
2nd highest complaint seen in physician’s offices
5th most common requirement for hospitalization
3rd leading cause for surgery
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Spondylolisthesis
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Pars defect with a spondy
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Multilevel degenerative disc
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Lumbosacral Back Pain
Causes of Back Pain: Acute Injury
Strain Fracture
Chronic Injury Disc Disease
Discogenic Pain Disc Herniation
Facet Arthrosis
– Spondylolisthesis– Spinal Stenosis– Tumor
–Primary–Metastatic
– Infection– Sacroiliac joint
strain/inflammation
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Lumbosacral Back Pain Origin of Low back
pain : Annulus fibrosis Facet joint capsule Vertebral periosteum Ligamentum flavum Posterior spinal
musculature Thoracolumbar fascia Irritation of neural
structures (Spinal root, DRG)
SI joint
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Lumbosacral Back Pain Risk factors for low back pain:
Constitutional factors: age, physical fitness (abdominal muscle strength, flexor/extensor balance, muscular insufficiency)
Postural/structural: severe scoliosis, fractures, multilevel degenerative disc disease, spondylolisthesis
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Lumbosacral Back Pain Risk factors for LBP:
Lifestyle factors: smoking, anxiety, depression, stress
Recreational activities: golf, tennis, gymnastics, football, jogging
Occupational factors: bending, stooping, twisting, heavy lifting, prolonged sitting, vibration exposure, work dissatisfaction
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Lumbosacral Back Pain
Natural History: 70% recover within 3 days to 3 weeks >90% recover within 2 months with
conservative measures 4% progress to chronic disability
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Radiographs Quebec Task Force of Spinal Disorders
1987 X-ray indications in low lack pain
age > 50 or < 20 neurologic deficit h/o trauma Red Flags:
Bladder/ bowel Weight loss Malaise Fever/ chills Weakness
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ZW 41 y/o male c/o severe L leg pain x 1 mo NSAIDS, MS Contin, Norco, Soma Refused ESI VAS 10/10
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L5/S1
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Tx L5-S1 micro discectomy Resolution of all leg symptoms
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Herniated Lumbar Disk
AKA : “Pinched nerve” “Sciatica” “Blown disk”
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Herniated Lumbar Disk Clinical Presentation
Sudden onset of back pain May coincide with tearing of
highly innervated outer annular fibers
Radicular pain Back pain may decrease after
herniation, with depressurization of disk space and relief of annular tension
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Herniated Lumbar Disk Clinical Presentation
Sudden onset of back pain May coincide with tearing of
highly innervated outer annular fibers
Radicular pain Back pain may decrease after
herniation, with depressurization of disk space and relief of annular tension
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Herniated Lumbar Disk
How Common is “Sciatic” Pain?1.6% have pain persisting > 2
weeksAverage age of onset:
Between 30 and 50 years of age Age < 30 tend to have strong hereditary predisposition
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Herniated Lumbar Disk
Natural History:80% have significant
symptomatic improvement within 1 month
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Herniated Lumbar Disk When to refer: Not better in 1 month to 6 weeks- refer! Uncontrolled pain- refer! Changes in bowl or bladder function-
refer! Weakness, difficulty walking, tripping-
refer! Fracture- refer!
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Herniated Lumbar Disk Clinical Presentation:
Most herniations occur at L4-5 and L5-S1
Pain typically radiates through the affected dermatome L5 can present as lateral hip
pain S1 may present as isolated
buttock or posterolateral hamstring pain
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Anatomy“Lumbar Dermatomes”
Key Sensory Points: T12 Inguinal ligament L1 Anterior groin L2 Mid-anterior thigh L3 Medial femoral
condyle L4 Medial malleolus L5 Dorsum of foot at
3rd MTP joint
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Herniated Lumbar Disk Clinical Presentation
Straight leg raise test Nerve root tension sign Positive test if extremity pain is reproduced between 35 to 70 degrees of elevation
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Lumbar Herniated Disk
Midline HNP at L4-L5 L5, S1, S2, S3
nerves can be compressed
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Lumbar Herniated Disk Lateral HNP at
L4-L5 Compresses L5
nerve root
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Lumbar Herniated Disk
Natural History90% of patients have
gradual and progressive resolution of symptoms within 3 months of onset without surgical intervention.
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Lumbar Herniated Disk
Treatment Medications Bedrest (1-4 days) Activity modification Physical therapy Steroid injection Surgery
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Lumbar Herniated Disk Surgical Indications
Progressive neurologic deficitCauda equina syndromePersistent radiculopathy,
incapacitating pain After non-operative interventions have failed
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Lumbar Herniated Disk Cauda Equina Syndrome
Caused by compression of the nerve roots of the cauda equina by a space occupying lesion (large central disc herniation or tumor)
bowel or bladder dysfunction bilateral sciatica saddle anesthesia variable loss of motor and sensory
function in the lower extremities. Urgent evaluation, imaging and surgical
intervention is indicated
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Lumbar Herniated Disk
Surgical Procedure“Gold Standard” is limited open
lumbar laminotomy and diskectomy with magnification by surgical loupes or operating microscope
>90% successful for relief of sciatica
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Lumbar Herniated Disk
Surgical OutcomeRisk of reherniation: 5-20%Spinal fusion should be
considered for recurrent HNP x 3 with excessive back pain and sciatica
Pts need to be aware this surgery is NOT for LBP
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Prospective observational cohort study Patients with imaging-confirmed lumbar
intervertebral disk herniation 13 spine clinics 11 US states Declined randomization between March
2000 and March 2003.
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2720 patients screened for eligibility 1991 eligible
747 refused 1244 enrolled- 743 enroled in observational
cohort
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Results: Intent to treat analysis: For each measure and each point at 3,
12, 24 months Results favored surgery
As treated analysis: Significant advantage of surgery over
non-operative measures
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Discogenic Back Pain
EtiologyInternal disk
disruption (acute annular tear)
Degenerative disk disease
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Discogenic Back Pain Imaging
X-ray: loss of disk height, osteophyte formation, spondylolisthesis
MRI:“high intensity zone”, “black disk disease”
Discography: concordant provocative pain and morphologic abnormalities
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Intervertebral DiskFunctions
Energy absorption
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Intervertebral DiskFunctions
Spinal flexibility
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Intervertebral DiskFunctions
Appropriate load distribution
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MODIC CHANGES Type 1: Low T1 & high T2. Endplate
disruption with ingrowth of fibrovascular tissue- can imply segmental instability and pain
Type 2: High T1 & normal/high T2. Fatty replacement of subchondral bone
Type 3: Hypointense on T1 & T2. Sclerotic advanced degenerative changes with less segmental motion
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Discogenic Back Pain
TreatmentNSAID’sActive rehabilitationSurgery
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Discogenic Back Pain
Surgical TreatmentAnterior interbody fusionPosterior interbody fusionPosterolateral fusionAP or 360º fusionDisk replacement
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Interbody Fusions PLIF-(Posterior)
TLIF- (Trans-foraminal)
XLIF/ DLIF- TRANSPSOAS APPROACH (extreme lateral)
ALIF-(Anterior)
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Spinal stenosis
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WP 76 y/o Female, h/o LBP and LP Works full time Duration of symptoms 7 yrs Failed:
NSAIDS ESI Facet injections PT/ Aquatherapy
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Lumbar Spinal Stenosis
Contributing Factors Hypertrophy of apophyseal joints Ligamentum flavum hypertrophy Degenerative Spondylolisthesis Scoliosis Synovial Cysts Degenerative Disc Disease Congenital narrowing of canal
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Lumbar Spinal Stenosis
Differential Diagnosis Vascular claudication Osteoarthritis of hip or knee Lumbar disc protrusion Intraspinal tumor Unrecognized neurologic disease Arteriovenous malformation Peripheral neuropathy
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SymptomsEVALUATION VASCULAR NEUROGENICWalking distance Fixed VariablePalliative factors Standing Bending/ sittingProvocative factors Walking Walking/ standingWalking up hill Painful PainlessBicycle test Positive NegativePulses Absent PresentSkin Shiny/ loss of hair NormalWeakness Rarely OccasionallyBack pain Occasionally CommonlyBack motion Normal LimitedPain character Cramping distal to
proxNumbness aching prox to distal
Atrophy Uncommon Occasionally
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Canal Shapes
Round Triangular Trefoiled
(15%) Trefoiled &
asymmetric
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Spinous Process
Transverse Process
DRG
Cauda Equina
Vertebral Body
DegenerativeFacet Joint
DegenerativeDisc
Spinous Process
Transverse Process
DRG
Cauda Equina
Vertebral Body
Pathogenesis of Stenosis
Hypertrophied Ligament
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Pathogenesis of Spinal Stenosis
Degenerative Retrolisthesis Disc collapse
exceeds facet arthritic changes
Posterior overriding of the facet joints
Foraminal narrowing
Retrolisthesis
Disc Collapse
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Pathogenesis of Spinal Stenosis
Degenerative Anterolisthesis Concurrent disc
and facet changes Facet joint erosion
and hypertrophy Redistribution of
forces Commonly occurs
at L4-5 (iliolumbar lig)
Foraminal narrowing
Anterolisthesis
Disc Collapse
FacetDegeneration
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Treatment Conservative
External Support Pharmacologic Exercise / PT Injection
Surgical Decompression Decompression and
arthrodesis
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Treatment
Surgical IndicationsNeurogenic claudication,
pain or motor dysfunction unresponsive to conservative treatment
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Treatment
Surgical GoalsIncreased function,
decreased pain, and prevention of neurologic deficit progression
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Treatment Surgical Treatment
“Gold Standard” Wide decompressive
laminectomy Excision of hypertrophied
ligamentum flavum Removal of osteophytes for
lateral recess and foraminal decompression
+/- Diskectomy +/- Spinal fusion
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Treatment
Surgical Treatment Outcome
70-90% good to excellent
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Fusion vs “usual” nonoperative care
63% surgical vs. 29% conservative rated results “better or much better”*
Greater improvement in pain and disability*
Back to work rate 36% for surgical versus 13% for conservative*
* p< 0.05 Fritzell et al Spine 2001; 26:2521-2534 Fritzell et al Spine 2002;27:1131-41
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Goals Address all the patients issues
Depression, de-conditioned status, life stresses, pharmacological dependence, secondary gain, Weight issues
Give the patient realistic goals Nothing will bring the pain to a VAS of 0 Realistic goal to get the pain to a tolerable
level 0-4 VAS, Validate their experience and the difficulty of
having constant pain Reinforce the need to get off of narcotics
(They are not the answer)