Nonsurgical Management of Acute and Chronic Back Pain

1. Nonsurgical Management of Acute and Chronic Back Pain Rocco Simmerano, MD Morris County Orthopaedic Group February 3, 2009

3. Outline • Epidemiology • Etiology/Basic Science • Diagnosis • Treatment options • Treatment failures/referrals

4. What is “back pain”? • From the American Academy of Orthopaedic Surgeons: It is a loosely defined diagnosisthat may refer to multiple patterns of pain with complex issues surrounding its diagnosis and treatment. There is a paucity of evidence from the literature regarding its cause, management and prognosis. The difficulty of managing patients with low back pain stems from the fact that there often is very little association between physical findings and the patient’s pain and disability.

5. Epidemiology • Back pain is the second most common reason adults over 40 visit their physicians • Annual incidence 5%/year • Prevalence of 60-90% • Leading cause of disability in those under age 45 • Direct medical costs over 40 billion/year • Indirect costs over 90 billion/year

6. Epidemiology • Low back pain is a self-limited disease • Up to 80% will improve in the first 2 weeks • 90% by 2 months • Observation vs. active treatment • New England Journal study85% of back pain cases will not have a physical or diagnostic explanation • Role of psychosocial issues

7. Risk Factors • Age (35-55) • Gender ? • Physical activity • Not associated with • Obesity • Postural deformities • Unequal leg lengths

8. On the Job • Heavy lifting • Static posture • Bending and twisting • Vibration • Most predictive? • Psychosocial factors (monotony, job dissatisfaction, etc.)

9. Smoking and Back Pain • Smokers have 3-4 times risk of cervical or lumbar herniations • Nicotine • Decreased oxygen levels • Higher treatment failures • Good opportunity to discuss cessation

10. Anatomy L1 • 5 or 6 lumbar vertebrae • Lordosis • Cauda equina • Intervertebral disk • Nucleus pulposis • Annulus fibrosis • Facet joints • Neural foramen L2 L3 L4 L5 S1

11. Anatomy

12. Etiology Degeneration Facet arthropathy Segmental instability spinal stenosis foraminal stenosis BACK PAIN NERVE PAIN

14. Degenerative Disease • Loss of water content • Annulus tears

15. Loss of water content Annulus tears Increased stresses on the facet joints Degenerative Disease

16. Degenerative Disease • Loss of water content • Annulus tears • Increased stresses on the facet joints • Loss of disc space • Herniation

17. Wear and tear Begins as back pain Later stages associated with nerve problems Not associated with weakness, numbness Mechanical vs. Neurogenic Pain

18. Spinal nerve irritation Radicular Pain, numbness, weakness Mechanical vs. Neurogenic Pain

19. History • Onset • Acute vs. insidious • Acute vs. chronic (12 weeks) • Relation to activity • Symptoms • Pain in back, buttocks or thighs (vs. radiating) • Stiffness • Weakness, numbness

20. Red Flags • Fractures • Tumor • Known lesions • Night pain, weight loss • Infection • Cauda Equina • Urinary or bowel symptoms, severe progressive motor or sensory loss

21. Nonorganic Pain • Fails to follow anatomic distributions • Always in pain • Intolerance to treatments • Exam • Superficial pain • Pain with axial loading • Distraction • Inconsistent motor exam

22. Exam • Lumbar ROM • Pain on flexion, extension, both • Palpation for spasm • Straight leg raising • Neurologic Exam • Waddell’s tests

23. Imaging • A/P and lateral radiographs • CT scanning • MRI scanning • Discography

24. Discography

25. Who Gets an MRI? • Failed conservative treatment • Acute neurologic findings

26. Disc Herniation

27. Electromyography • Radicular pain

28. Diagnosis by Age • 20-40 • Muscular (will also see spondylolisthesis) • 30-50 • Disc Herniation • >50 • OA • >60 • Spinal stenosis

29. Treatment • Patient education is key • Evidence-based guidelines are lacking • Combination treatment • Goals • Educate • Relieve pain • Improve function • Limit side effects • Prevent chronicity

30. Treatment • Regardless of what I do, you are likely to get better!

31. Treatment • Bed Rest vs. Activity Modification • Medications • NSAIDs • Tylenol • Tramadol • Topicals • Opioid analgesia • Steroids • Muscle relaxers • Antidepressants

33. Muscle relaxer Increases exercise tolerance Better in the sub-acute period Decreases inflammation Modulates pain Heat or Ice?

34. Physical Therapy • Stretching, strengthening and education • Superior to chiropractic care for chronic low back pain • Flexion-based, extension based, progressive resistence and dynamic stabilization • No clear benefit to one type • May depend on the patient’s pain • Massage

36. TENS • Transcutaneous electrical nerve stimulation • Endorphin modulated • Altered CNS transmission of pain • NEJM 1990, controlled study, no different than placebo

37. Traction • Enlarges foramen • Vacuum effect • PLL traction • Relaxation of spasm • Decreases intradiscal pressures up to 30% • Prospective studies show no long term benefit

38. Chiropractic Care • Most common “alternative medicine” • Up to 30% of back pain sufferers • 2002 UCLA randomized trial • Equivalent to PT for acute pain • Spine 1998 • Chiropractic care better for acute, PT better for chronic • Meta-analysis 2003 • Manipulation under anesthesia

39. Trigger Point Injections • Myofascial back pain • Responds better to stretching, local modalities • Used when other treatments fail • Anesthetic +/- steroid • Limit the number of injections • Prolotherapysclerosing agent • No scientific evidence

40. Braces • Indicated with fracture, instability • No evidence to support long term use • Weakening of postural muscles • Do not really immobilize

41. Treatment Failures • Failure to respond to conservative measures (6 weeks) • Progression to involve radiculopathy • Rapidly progressive neurologic symptoms • Chronic pain (> 12 weeks)

42. Options • Orthopaedic/Neurosurgery • Pain Management/Anesthesia

43. Injection Therapy • Anesthesia plus anti-inflammatory effect • Epidural injection • Good for nerve root irritation • Unclear in mechanical back pain • Effective for facet joint arthropathy, sacroiliac disease • Radiofrequency dorsal rhizotomy

44. Non-musculoskeltal Causes • Renal • Lateral pain • Cardiovascular • Abdominal exam • Neoplastic

45. Summary • Back pain is self-limited • Supportive care and education are key • Acute pain • NSAIDs • Muscle relaxer • Short-term rest • Early institution of physical therapy • Chronic painfind the pain generator

46. Thank You!