UPDATE ON LOWERBACK PAIN

Zee Khan M.D.Assistant Professor

Orthopaedic Spine SurgerySpineou@gmail.com

(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 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

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

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 Presentation

Straight 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 Indications

Progressive 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 Imaging

X-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

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

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)