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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
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.
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
Scoliosis – Trauma - Tumors
77 y/o female New onset pain 6/10 VAS Multiple medical issues
AAOS
Position statements on Osteoporotic fractures
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
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
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
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
2003
Cost an estimated $61.2 Billion/ year Due to HA LBP Arthritic pain Musculoskeletal pain Majority was due to lost productive time
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
Spondylolisthesis
Pars defect with a spondy
Multilevel degenerative disc
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
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
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
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
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
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
ZW
41 y/o male c/o severe L leg pain x 1 mo NSAIDS, MS Contin, Norco, Soma Refused ESI VAS 10/10
L5/S1
Tx
L5-S1 micro discectomy Resolution of all leg symptoms
Herniated Lumbar Disk
AKA : “Pinched nerve” “Sciatica” “Blown disk”
Herniated Lumbar Disk
Clinical PresentationSudden 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
Herniated Lumbar Disk
Clinical PresentationSudden 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
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
Herniated Lumbar Disk
Natural History:80% have significant
symptomatic improvement within 1 month
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!
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
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
Herniated Lumbar Disk
Clinical PresentationStraight leg raise test
Nerve root tension sign Positive test if extremity pain is reproduced between 35 to 70 degrees of elevation
Lumbar Herniated Disk
Midline HNP at L4-L5 L5, S1, S2, S3
nerves can be compressed
Lumbar Herniated Disk
Lateral HNP at L4-L5
Compresses L5 nerve root
Lumbar Herniated Disk
Natural History90% of patients have
gradual and progressive resolution of symptoms within 3 months of onset without surgical intervention.
Lumbar Herniated Disk
Treatment Medications Bedrest (1-4 days) Activity modification Physical therapy Steroid injection Surgery
Lumbar Herniated Disk
Surgical IndicationsProgressive neurologic deficitCauda equina syndromePersistent radiculopathy,
incapacitating pain After non-operative interventions have failed
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
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
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
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.
2720 patients screened for eligibility 1991 eligible
747 refused 1244 enrolled- 743 enroled in observational
cohort
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
Discogenic Back Pain
EtiologyInternal disk
disruption (acute annular tear)
Degenerative disk disease
Discogenic Back Pain
ImagingX-ray: loss of disk height,
osteophyte formation, spondylolisthesis
MRI:“high intensity zone”, “black disk disease”
Discography: concordant provocative pain and morphologic abnormalities
Intervertebral DiskFunctions
Energy absorption
Intervertebral DiskFunctions
Spinal flexibility
Intervertebral DiskFunctions
Appropriate load distribution
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
Discogenic Back Pain
TreatmentNSAID’sActive rehabilitationSurgery
Discogenic Back Pain
Surgical TreatmentAnterior interbody fusionPosterior interbody fusionPosterolateral fusionAP or 360º fusionDisk replacement
Interbody Fusions
PLIF-(Posterior)
TLIF- (Trans-foraminal)
XLIF/ DLIF- TRANSPSOAS APPROACH (extreme lateral)
ALIF-(Anterior)
Spinal stenosis
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
Lumbar Spinal Stenosis
Contributing Factors Hypertrophy of apophyseal joints Ligamentum flavum hypertrophy Degenerative Spondylolisthesis Scoliosis Synovial Cysts Degenerative Disc Disease Congenital narrowing of canal
Lumbar Spinal Stenosis
Differential Diagnosis Vascular claudication Osteoarthritis of hip or knee Lumbar disc protrusion Intraspinal tumor Unrecognized neurologic disease Arteriovenous malformation Peripheral neuropathy
Symptoms
EVALUATION VASCULAR NEUROGENIC
Walking distance Fixed Variable
Palliative factors Standing Bending/ sitting
Provocative factors Walking Walking/ standing
Walking up hill Painful Painless
Bicycle test Positive Negative
Pulses Absent Present
Skin Shiny/ loss of hair Normal
Weakness Rarely Occasionally
Back pain Occasionally Commonly
Back motion Normal Limited
Pain character Cramping distal to prox
Numbness aching prox to distal
Atrophy Uncommon Occasionally
Canal Shapes
Round Triangular Trefoiled
(15%) Trefoiled &
asymmetric
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
Pathogenesis of Spinal Stenosis
Degenerative Retrolisthesis Disc collapse
exceeds facet arthritic changes
Posterior overriding of the facet joints
Foraminal narrowing
Retrolisthesis
Disc Collapse
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
Treatment
Conservative External Support Pharmacologic Exercise / PT Injection
Surgical Decompression Decompression and
arthrodesis
Treatment
Surgical IndicationsNeurogenic claudication,
pain or motor dysfunction unresponsive to conservative treatment
Treatment
Surgical GoalsIncreased function,
decreased pain, and prevention of neurologic deficit progression
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
Treatment
Surgical Treatment Outcome
70-90% good to excellent
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
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)