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Lage rugpijn:Indeling, definities, natuurlijk verloop
en kostenplaatje
Jan Van Zundert, MD, PhD.Ziekenhuis Oost-Limburg, Genk
Academisch Ziekenhuis, Maastricht
Wetenschappelijke Vereniging voor Verzekeringsgeneeskunde
27 April 2007
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BPS Survey 1999
• Medical imaging indicates, in most of the cases, the cause of low back pain.
• The most important therapeutic option for acute low back pain is bed rest.
• Surgery is the only possible treatment for herniated disc.
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The problem of low back pain
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The problem of low back pain
Waddell G.
“Low back pain: a twenthieth century healthcare enigma”
Spine 1996, 21
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Definitions
• Low back pain: pain occurring in an area between the lowest ribs and the iliac crest
• Acute : lasting less than r 1 week
• Sub acute: lasting between r 1 and r 6 weeks
• Chronic: lasting longer than r 3 months
• Cave: radicular pain/sciatica
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Low back pain
7 days 4 weeks 7 weeks 12 weeks
80%
26%17%
13% 8%
6 months
Based on Spitzer et al. 1987
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Evolution towards chronicity
• 90 % spontaneous resolution? • Literature review
– Pain after 12 months 62 % – 6 months after inclusion still incapable to work 16 % – Repeat incapacity to work 33 %– Reccurent episodes of low back pain 60 %– Prevalence in pts with first episode 56 %– Prevalence in pts without first episode 22 %
Hestbaek et al. Eur Spine J 2003
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Yellow flags
• Risk factors for chronicity
– Inappropriate attitudes and beliefs about back pain– Inappropriate behavior– Work-related problems
Airaksinen O et al. COST B 13 Eur Spine J 2006
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Classification of low back pain and sciatica
• “Specific” low back pain (5-10%)e.g.: tumor, infection, vertebral fractures, Bechterew
• “Non-specific” causes of low back pain (>90-95%)
Spitzer et al. Report on Quebec Task force on low back pain Spine 12 (1987) S1-S59
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Red flags
• Age of onset < 20 or > 55• Constant, progressive, non-mechanical pain (including
pain at night)• Thoracic pain• Post medical history of malignant tumor• Prolonged use of corticosteroids• Drug abuse, immunosuppression, HIV
Airaksinen O et al. COST B 13 Eur Spine J 2006
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Red flags
• Systematically unwell• Unexplained weight loss• Widespread neurological symptom (including cauda
equina syndrome)• Structural deformity• Fever
Airaksinen O et al. COST B 13 Eur Spine J 2006
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Classification of low back pain and sciatica
• “Specific” low back pain (5-10%)e.g.: tumor, infection, vertebral fractures, Bechterew
• “Non-specific” causes of low back pain (>90-95%)
“sub”diagnosis ?
Spitzer et al. Report on Quebec Task force on low back pain Spine 12 (1987) S1-S59
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“Sub”classification of “non-specific” low back pain and sciatica
• “Mechanical” low back pain:– Facet pain (10-20%?)– Discogenic pain (>40%?)– Sacro-iliac joint pain (?)
Schwarzer et al. Spine 1995
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“Sub”classification of “non-specific” low back pain and sciatica
• “Mechanical” low back pain:– Facet pain (10-20%?)– Discogenic pain (>40%?)– Sacro-iliac joint pain (?)
• Sciatica:– Radicular pain– Neuropathic pain (with objective signs of nerve damage)– Sympathetic maintained pain (?)
Schwarzer et al. Spine 1995
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Why are “sub” diagnoses important?
• No diagnosis• No specific (interventional) therapy• No result !!!
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How to diagnose?
No gold standard
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Courtesy of
University HospitalMaastricht
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Costs of low back pain
7 days 4 weeks 7 weeks 12 weeks
80%
26%17%
13% 8%
6 months
Costs
Based on Spitzer et al. 1987
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Cost/burden of illness
Direct medical costs
Costs for diagnosis and therapy
15 – 20 % of total cost
Indirect costs
Socio-economic costs
Van Tulder et al. Pain 1995
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Impact of the health care organisationon the costs of the management
• The Netherlands– Multidisciplinary management– Waiting lists for most
of the treatments
• Belgium– MPC’s only recently recognized– Limited waiting lists
Van Zundert J. (2001). Verhandeling Ziekenhuisbeleid en -management KULeuven.
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Comparison of the interventionsBelgium –The Nederlands (1999)
1.6 / 11 / 33 / 1
1 / 2.84 / 14 / 1
5.5 / 12.6 / 1
118.970.331.160.40
0.0050.0020.240.12
188.300.113.500.140.02
0.0081.290.32
Prescription medicationTENSEpidural steroid injectionsRFEpidural neuromodulationIntrathecal medicationSurgery without arthrodesisSurgery with arthrodesis
Ratio Be/NlNr/ 1,000 Inhabitants Nl
Nr / 1,000 inhabitants Be
Van Zundert J. (2001). Verhandeling Ziekenhuisbeleid en -management KULeuven.
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Results
Big discrepancy in the frequency of use of the different treatment modalities
Minimal invasive interventional techniques significantly less in België
Surgery and neuromodualation significantly more in Belgium
Calculated extra cost for the management of low back pain in Belgium ¼ 36,2 million
No proof for better clinical outcome and/or better quality of life in Belgium
Cost efficacy evaluation of the management of low back pain
Van Zundert J. (2001). Verhandeling Ziekenhuisbeleid en -management KULeuven.
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Cost effectiveness evaluation of the management of chronic low back pain
• Treatment of low back pain in Belgium Ä Problems in termsof cost effectiveness
• MONOdisciplinary MULTIdisciplinary• Screening by specialty Step-wise approach
Integrated screening process
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Cost effectiveness evaluation of the management of chronic low back pain
• Treatment of low back pain in Belgium Ä Problems in termsof cost effectiveness
• MONOdisciplinary MULTIdisciplinary• Screening by specialty Step-wise approach
Integrated screening process
• Higher use of more expensive treatmentmodalities
Higher use:
- of less expensive, minimalinvasive interventionaltreatment modalities
- cognitive behavorial rehabprograms
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UCL : Dept physical medicine and rehabilitation
ZOL : Multidisciplinary pain center
ULg : Dept occupational medicine
in cooperation with SSMG, Cebam, Intego, Intermedicale, FAT, Soc Mut
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KCE Study Chronic Low Back Pain
• Part I: Evaluation and treatment: EBM guideline
• Part II: How are chronic LBP patients assessed andtreated in Belgium?
• Part III: Chronic LBP and occupational health in Belgium
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The extend of the problem in Belgium
• National health survey (2004)Prevalence man 10 % women 11 %
• Intego (2004)Incidence ~ 51 per 1000 practice population
– (each GP with a practice of 1000 patients sees 1 newcase/week)
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The extend of the problem in Belgium
• National health survey (2004)Prevalence man 10 % women 11 %
• Intego (2004)Incidence ~ 51 per 1000 practice population
– (each GP with a practice of 1000 patients sees 1 newcase/week)
• MKG/RCM (2004)~ 95 000 hospital stays for chronic low back pain~ 40 000 classic hospitalization; 45 000 one day
hospitalization
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Management of low back pain in BelgiumKey points for 2004
• Frequent use of medical imaging– ~ 700 000 medical imaging – cost ¼ 36.9 million 1
– LBP patient mean of 7 medical imaging within max 1 year of the first RX of the lumbar spine 2
1 RIZIV Nomenclature d-base2 Study Soc. Mut.
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Management of low back pain in BelgiumKey points for 2004
• Frequent use of back surgery …– 22 940 hospital stays for surgery (5 394 for fusion)1
• … and Failed Back Surgery Syndrome– 392 neurostimulators and 1 120 electrodes 2
1 MCD – d-base2 RIZIV Nomenclature d-base
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Adapted fromGunzburg and Szpalski
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Summary of cost estimation anno 2004
164 712 379
3 746 590Only cost for implantation and material noconsultation
SCS
81 541 728Only cost during hosp stay- heavilyunderestimated
Surgery
81 286133 433
Cost for cons. in one day clinic no info onambulatory procedures and cost of medication
Epidural steroidsPercut. RF
11 518 77136 971 2054 652 396
19 312 6256 754 355
Largely underestimatedOnly for spec pop repeat imag.Prescription drugs onlyInfo on spec pop after med imIdem
History takingMedical imagingPharmacologicalPhysiohterapyRehabilitation
Cost in ¼CommentIntervention
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• Direct medical cost ~ 164 million Euros
• Global burden of LBP ~ 1.6 billion Euros
Summary of cost estimation anno 2004
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Recommendations
• In Belgium need for more systematic data collectionconcerning: diagnosis en treatment of low back pain and the impact of the disease on the work situation
• Need for implementation of the national guideline regardingdiagnosis and management of non-specific chronic low back pain
• Need for multidisciplinary management of low back pain– Complete pain control is unrealistic– Pain reduction where possible– Help the patient accept rest pain: coping– Encourage maximum functionality: rehabilitation
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Recommendations
• Redefinition of the role and responsibilities of occupational physicians/health services and medicaladvisors in preventing chronicity
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www.kenniscentrum.fgov.be
KCE reports vol. 48A
Chronische Lage Rugpijn
