Transcript Lumbosacral Back Pain

Zee Khan M.D.
Assistant Professor
Orthopaedic Spine Surgery
[email protected]
(405) 271 BONE (2663)
OAPA 39TH Annual CME Conference
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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, evidencebased 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.
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Anatomy of lumbar
spine
Different types of
pain originating from
the back
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HNP
Stenosis
DDD
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Common myths
Treatment options
Non-operative Tx
Operative Tx
Goals of surgery
77 y/o female
 New onset pain
 6/10 VAS
 Multiple medical
issues
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Position statements on Osteoporotic fractures
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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
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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
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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
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60-85% of people will have LBP sometime in their
lives.
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90% LBP resolves in 6 weeks
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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
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Cost an estimated $61.2 Billion/ year
Due to HA
LBP
Arthritic pain
Musculoskeletal pain
Majority was due to lost productive time
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# 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
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Causes of Back Pain:
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Acute Injury
 Strain
 Fracture
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Chronic Injury
Disc Disease
 Discogenic Pain
 Disc Herniation
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Facet Arthrosis
– Spondylolisthesis
– Spinal Stenosis
– Tumor
– Primary
– Metastatic
– Infection
– Sacroiliac joint
strain/inflammation
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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
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Risk factors for low back pain:
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Constitutional factors:
age, physical fitness
(abdominal muscle strength,
flexor/extensor balance,
muscular insufficiency)
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Postural/structural:
severe scoliosis, fractures,
multilevel degenerative disc
disease, spondylolisthesis
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Risk factors for LBP:
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Lifestyle factors:
smoking, anxiety, depression, stress
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Recreational activities:
golf, tennis, gymnastics, football, jogging
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Occupational factors:
bending, stooping, twisting, heavy
lifting, prolonged sitting, vibration
exposure, work dissatisfaction
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Natural History:
70% recover within 3 days to 3 weeks
 >90% recover within 2 months with
conservative measures
 4% progress to chronic disability
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Quebec Task Force of Spinal Disorders 1987
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X-ray indications in low lack pain
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age > 50 or < 20
neurologic deficit
h/o trauma
Red Flags:
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Bladder/ bowel
Weight loss
Malaise
Fever/ chills
Weakness
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41 y/o male c/o severe L leg pain x 1 mo
NSAIDS, MS Contin, Norco, Soma
Refused ESI
VAS 10/10
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L5-S1 micro discectomy
Resolution of all leg symptoms
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AKA :
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“Pinched nerve”
“Sciatica”
“Blown disk”
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Clinical Presentation
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Sudden onset of back pain
 May coincide with tearing of
highly innervated outer
annular fibers
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Radicular pain
 Back pain may decrease after
herniation, with depressurization of
disk space and relief of annular tension
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Clinical Presentation
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Sudden onset of back pain
 May coincide with tearing of
highly innervated outer
annular fibers
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Radicular pain
 Back pain may decrease after
herniation, with depressurization of
disk space and relief of annular tension
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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
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Natural History:
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80% have significant symptomatic
improvement within 1 month
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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!
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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
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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
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Clinical Presentation
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Straight leg raise test
 Nerve root tension sign
 Positive test if extremity pain is
reproduced between 35 to 70 degrees
of elevation
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Midline HNP at
L4-L5
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L5, S1, S2, S3
nerves can be
compressed
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Lateral HNP at
L4-L5
Compresses L5
nerve root
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Natural History
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90% of patients have gradual
and progressive resolution of
symptoms within 3 months of
onset without surgical
intervention.
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Treatment
Medications
 Bedrest (1-4 days)
 Activity modification
 Physical therapy
 Steroid injection
 Surgery
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Surgical Indications
Progressive neurologic deficit
 Cauda equina syndrome
 Persistent radiculopathy,
incapacitating pain
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 After non-operative interventions
have failed
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Cauda Equina Syndrome
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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
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Surgical Procedure
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“Gold Standard” is limited open
lumbar laminotomy and
diskectomy with magnification by
surgical loupes or operating
microscope
>90% successful for relief of sciatica
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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
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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.
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2720 patients screened for eligibility
1991 eligible
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747 refused
1244 enrolled- 743 enroled in observational cohort
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Results:
Intent to treat analysis:
For each measure and each point at 3, 12, 24
months
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Results favored surgery
As treated analysis:
Significant advantage of surgery over nonoperative measures
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Etiology
Internal disk
disruption (acute
annular tear)
 Degenerative
disk disease
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Imaging
X-ray: loss of disk height, osteophyte
formation, spondylolisthesis
 MRI: “high intensity zone”, “black
disk disease”
 Discography: concordant
provocative pain and morphologic
abnormalities
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Energy absorption
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Spinal flexibility
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Appropriate load distribution
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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
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Treatment
NSAID’s
 Active rehabilitation
 Surgery
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Surgical Treatment
Anterior interbody fusion
 Posterior interbody fusion
 Posterolateral fusion
 AP or 360º fusion
 Disk replacement
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PLIF-(Posterior)
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TLIF- (Trans-foraminal)
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XLIF/ DLIFTRANSPSOAS APPROACH (extreme lateral)
ALIF-(Anterior)
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76 y/o Female, h/o LBP and LP
Works full time
Duration of symptoms 7 yrs
Failed:
NSAIDS
 ESI
 Facet injections
 PT/ Aquatherapy
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Contributing Factors
Hypertrophy of apophyseal joints
 Ligamentum flavum hypertrophy
 Degenerative Spondylolisthesis
 Scoliosis
 Synovial Cysts
 Degenerative Disc Disease
 Congenital narrowing of canal
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Differential Diagnosis
Vascular claudication
 Osteoarthritis of hip or knee
 Lumbar disc protrusion
 Intraspinal tumor
 Unrecognized neurologic disease
 Arteriovenous malformation
 Peripheral neuropathy
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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
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Round
Triangular
Trefoiled
(15%)
Trefoiled &
asymmetric
Spinous Process
Degenerative
Facet Joint
Cauda Equina
DRG
Vertebral Body
Hypertrophied Ligament
Degenerative
Disc
Transverse
Process
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Degenerative
Retrolisthesis
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Retrolisthesis
Disc collapse exceeds
facet arthritic
changes
Posterior overriding
of the facet joints
Foraminal narrowing
Disc Collapse
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Degenerative
Anterolisthesis
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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
Facet
Degeneration
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Conservative
External Support
 Pharmacologic
 Exercise / PT
 Injection
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Surgical
Decompression
 Decompression and arthrodesis
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Surgical Indications
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Neurogenic claudication, pain or
motor dysfunction unresponsive
to conservative treatment
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Surgical Goals
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Increased function, decreased
pain, and prevention of
neurologic deficit progression
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Surgical Treatment
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“Gold Standard”
 Wide decompressive laminectomy
 Excision of hypertrophied
ligamentum flavum
 Removal of osteophytes for lateral
recess and foraminal
decompression
 +/- Diskectomy
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+/- Spinal fusion
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Surgical Treatment Outcome
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70-90% good to excellent
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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
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Address all the patients issues
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Depression, de-conditioned status, life stresses,
pharmacological dependence, secondary gain,
Weight issues
Give the patient realistic goals
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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)