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Update on lower back pain

Update on lower back pain. Zee Khan M.D. Assistant Professor Orthopaedic Spine Surgery Spineou@gmail.com (405) 271 BONE (2663). OAPA 39 TH Annual CME Conference. OBJECTIVES.

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Update on lower back pain

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  1. Update on lowerback pain Zee Khan M.D. Assistant Professor Orthopaedic Spine Surgery Spineou@gmail.com (405) 271 BONE (2663) OAPA 39TH Annual CME Conference

  2. 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.

  3. 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

  4. Scoliosis – Trauma - Tumors

  5. 77 y/o female • New onset pain • 6/10 VAS • Multiple medical issues

  6. AAOS • Position statements on Osteoporotic fractures

  7. 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

  8. 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

  9. 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

  10. 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

  11. 2003 • Cost an estimated $61.2 Billion/ year • Due to HA • LBP • Arthritic pain • Musculoskeletal pain • Majority was due to lost productive time

  12. 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

  13. Spondylolisthesis

  14. Pars defect with a spondy

  15. Multilevel degenerative disc

  16. 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

  17. 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

  18. 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

  19. 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

  20. 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

  21. 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

  22. ZW • 41 y/o male c/o severe L leg pain x 1 mo • NSAIDS, MS Contin, Norco, Soma • Refused ESI • VAS 10/10

  23. L5/S1

  24. Tx • L5-S1 micro discectomy • Resolution of all leg symptoms

  25. Herniated Lumbar Disk • AKA : • “Pinched nerve” • “Sciatica” • “Blown disk”

  26. 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

  27. 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

  28. Herniated Lumbar Disk • How Common is “Sciatic” Pain? • 1.6% have pain persisting > 2 weeks • Average age of onset: • Between 30 and 50 years of age • Age < 30 tend to have strong hereditary predisposition

  29. Herniated Lumbar Disk • Natural History: • 80% have significant symptomatic improvement within 1 month

  30. 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!

  31. 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

  32. 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

  33. 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

  34. Lumbar Herniated Disk • Midline HNP at L4-L5 • L5, S1, S2, S3 nerves can be compressed

  35. Lumbar Herniated Disk • Lateral HNP at L4-L5 • Compresses L5 nerve root

  36. Lumbar Herniated Disk • Natural History • 90% of patients have gradual and progressive resolution of symptoms within 3 months of onset without surgical intervention.

  37. Lumbar Herniated Disk • Treatment • Medications • Bedrest (1-4 days) • Activity modification • Physical therapy • Steroid injection • Surgery

  38. Lumbar Herniated Disk • Surgical Indications • Progressive neurologic deficit • Cauda equina syndrome • Persistent radiculopathy, incapacitating pain • After non-operative interventions have failed

  39. 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

  40. 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

  41. Lumbar Herniated Disk • Surgical Outcome • Risk 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

  42. 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.

  43. 2720 patients screened for eligibility • 1991 eligible • 747 refused • 1244 enrolled- 743 enroled in observational cohort

  44. 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

  45. Discogenic Back Pain • Etiology • Internal disk disruption (acute annular tear) • Degenerative disk disease

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