Transcript Lumbar Discogenic Pain Treatment Options

Lumbar Discogenic Pain
Treatment Options
J. Scott Bainbridge, MD
www.DenverBackPainSpecialists.com
Denver Spine Institute Winter Meeting
February 24-27, 2011
Disclosures
International Spine Intervention Society
Research Committee Chairman
 Research Director for Nimbus Concepts
 Ownership interest in ASC
 No specific medical devices will be
endorsed or discussed
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Low Back Pain (Discogenic) Case
Study
AS – 21yo F
1 ½ years of disruptive axial LBP
ODI 26, hold on masters program and only
working part time (as host) due to pain
 Pain scores: 3-8/10
 Pain with: bend/lift/sneeze/sit
 PT (manual, exercise)
 ESI x 2, non-dx facet blocks
 TENS
 Medications (Prozac, Elavil, Soma,Valium,
Zomig)
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LBP Diagnostic Tools
Medial Branch Blocks (Zygapophysial
Joint)
 Sacroiliac Joint Blocks
 Discography (Provocative, Functional
Anesthetic)
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Diagnosis of Disc Pain – Criterion Standard is
Provocation Discography
Yin/Bogduk; Bonica’s Management of Pain, 4th Edition
Unequivocal L5-S1 Discogenic Pain
L3-4: Normal, P0/P0
L4-5: Normal, P0/P0
Disc Level: L5-S1
Pain Response: P2/P2/R1.
Opening Pressure: 6.
Pressure to Pain: 18. Pain response 8/10 axial
low back pain, which was concordant.
 Disc Architecture: Posterior annular tear, grade
III.
 Comment: Concordant pain response rated 8/10,
at 12 PSI above opening pressure with associated
grade III posterior annular tear.
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www.spinalrestoration.com
Conservative Therapies for LBP
Various approaches with various grades of
evidence
 Chou (American Pain Society, Health
Technology Assessment Program,
Spectrum Research, Inc.)
(2008,2009,2010)
 The Spine Journal 8(1) (2008) -dedicated
issue
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Chou, Systematic Reviews, and
Policy
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Chou, R. (2009). "Same trials, different conclusions: sorting out discrepancies
between reviews on interventional procedures of the spine." Spine J 9(8): 679689.
Chou, R. (2010). "Pharmacological management of low back pain." Drugs
70(4): 387-402.
Chou, R., S. J. Atlas, et al. (2009). "Nonsurgical interventional therapies for low
back pain: a review of the evidence for an American Pain Society clinical
practice guideline." Spine (Phila Pa 1976) 34(10): 1078-1093.
Chou, R., J. Baisden, et al. (2009). "Surgery for low back pain: a review of the
evidence for an American Pain Society Clinical Practice Guideline." Spine
(Phila Pa 1976) 34(10): 1094-1109.
Chou, R., J. D. Loeser, et al. (2009). "Interventional therapies, surgery, and
interdisciplinary rehabilitation for low back pain: an evidence-based clinical
practice guideline from the American Pain Society." Spine (Phila Pa 1976)
34(10): 1066-1077.
Chou, R., A. Qaseem, et al. (2007). "Diagnosis and treatment of low back pain:
a joint clinical practice guideline from the American College of Physicians and
the American Pain Society." Ann Intern Med 147(7): 478-491.
Spectrum Research, Inc. > Health Technology Assessment Program
http://www.hta.hca.wa.gov
Conservative therapies for LBP –
Education, Watchful Waiting, Activity
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Pradhan Spine J 2008
Conservative therapies for LBP –
Physical Therapy Approaches
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Standaert Spine J 2008
◦ Stabilization – moderate evidence, not sig
different from manual therapy or general
exercise
May Spine J 2008
McKenzie – good evidence of efficacy
Conservative Therapies for LBP – NSAIDS, Muscle
Relaxants, Opiods, Others
Malanga Spine J 2008
 Chou 2007, 2009
 Individualize and consider combination
therapies
 Consider risks
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DATA SYNTHESIS: We found good evidence
that NSAIDs, acetaminophen, skeletal muscle
relaxants (for acute low back pain), and
tricyclic antidepressants (for chronic low back
pain) are effective for pain relief. The magnitude
of benefit was moderate (effect size of 0.5 to
0.8, improvement of 10 to 20 points on a 100point visual analogue pain scale, or relative risk
of 1.25 to 2.00 for the proportion of patients
experiencing clinically significant pain relief),
except in the case of tricyclic antidepressants
(for which the benefit was small to moderate).
We also found fair evidence that opioids,
tramadol, benzodiazepines, and gabapentin (for
radiculopathy) are effective for pain relief. We
found good evidence that systemic
corticosteroids are ineffective. Adverse events,
such as sedation, varied by medication,
although reliable data on serious and long-term
harms are sparse. Most trials were short term
(< or =4 weeks). Few data address efficacy of
dual-medication therapy compared with
monotherapy, or beneficial effects on functional
outcomes.
Chou 2007
Conservative therapies for LBP –
Adjuvant Medications
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Chang, Gonzalez, Akuthota Spine J 2008
Conservative Therapies for LBP –
Nutritional Supplements
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Gagnier Spine J 2008
Conservative therapies for LBP –
CAM
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Ammendolia Spine J 2008
◦ Acupuncture effective short term – good for
combination with other therapies
Bronfort Spine J 2008
Manipulation – mixed evidence – viable option
with similar outcomes to exercise, other
American Recovery and Reinvestment Act
of 2009
American Recovery and Reinvestment Act
Conservative therapies for LBP
Low cost, or
 High co-pays, or
 Costs shifted to patients (OTC, CAM)
 Consumer driven health care (limited
niche)?
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Interdisciplinary Rehabilitation
Chou (Spine 2009) APS Guidelines
 Physical rehab/exercise with
cognitive/behavioral emphasis
 Strong recommendation
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Interventional Therapies for LBP –
Epidural Steroid Inj., SIJ, Facet Blocks
Washington State sponsored Health
Technology Assessment (APS Guidelines
heavily referenced)
 3/18/11 hearing at Washington State
Legislature
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Chou – Spine 2009
1. AJNR Am J Neuroradiol. 2010 Jul 8. Therapeutic Trial of Fluoroscopic Interlaminar
Epidural Steroid Injection forAxial Low Back Pain: Effectiveness and Outcome Predictors.
Lee JW, Shin HI, Park SY, Lee GY, Kang HS.Departments of Radiology and Rehabilitation
Medicine, Seoul National University Bundang Hospital, Gyeongi-Do, Korea.
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BACKGROUND AND PURPOSE: An ESI for managing LBP is one of the most
commonly performed interventions. The purpose of this observational study was to
assess the effect of a therapeutic trial of a fluoroscopic interlaminar ESI for axial
LBP and to analyze the outcome predictors.
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MATERIALS AND METHODS: All patients who received an interlaminar ESI for
axial LBP at our facility in 2007 and 2008 were included. Initial short-term follow-up
was done at <1 month after ESI. ESI was considered effective if patients had a
reduction of >50% in their pain scores. In July 2009, telephone interviews were
conducted by using formatted questions including the NASS patient-satisfaction
index. The symptom-free interval was computed by the Kaplan-Meier method.
Outcome predictors such as age, sex, duration of LBP, and MR imaging findings were
statistically analyzed by the Mann-Whitney U and the Fisher exact tests.
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RESULTS: Eighty-one patients (male/female = 16:65; mean age, 49.9 years; range, 1777 years) were included in the study. The interlaminar ESI was effective in 63 of the
81 patients (77.8%) at initial short-term follow-up. For the 63 patients in whom ESI
was effective, the median symptom-free interval was 154 days (95% CI, 96-212 days).
Among 68 patients for whom telephone interviews were possible, 44 patients
(64.7%) replied positively to the NASS patient satisfaction index (NASS patientsatisfaction index, 1 or 2). There were no significant outcome predictors.
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CONCLUSIONS: The therapeutic trial of a fluoroscopic interlaminar ESI was
Courtesy RE Wright
effective for axial LBP without significant outcome predictors.
Nucleoplasty
Derby, Baker, Lee 2008 Spine J
 No strong evidence of support
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Intradiscal Therapies for Low Back
Pain – Yin, Bogduk; Bonica’s Management of Pain, 4 Edition
th
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Regenerative Therapies
◦ Investigational
◦ Not covered by payers
Intradiscal Therapies for Low Back
Pain – Yin, Bogduk; Bonica’s Management of Pain, 4 Edition
th
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Denervation
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Ramus communicans lesions
Intranuclear radiofrequency
Sinuvertebral nerve lesions
Intradiscal electrothermal therapy (IDET)
Intradiscal Therapies for Low Back
Pain –
Thermal Therapies (IDET)
 Derby, Baker, et al. 2008 Review:
 6 IDET studies: 38-94% (ave. 71%) with >
50% relief of pain for 6-24 months
 Andersson 2006 Review –
positive/comparable to fusion
 Chou 2009 – not supported
 Payor Coverage:
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◦ UHC, Anthem, Medicare – no coverage
Intradiscal Therapies for Low Back
Pain – Yin, Bogduk; Bonica’s Management of Pain, 4 Edition
th
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Chemical Therapies
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Intradiscal steroids - Chou
Etanercept
Methylene blue – positive RCT (Peng 2010)
Ozone
Proliferants - Derby
The use of methylene blue for
the treatment of discogenic LBP
J. Scott Bainbridge, MD
Mechanisms of Action
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Inhibition of guanylate cyclase and nitric
oxide synthase
◦ MB blocks degradative effects of NO
(Yin/Bogduk)
Weak neurolytic effects
Surgical Options for LBP
Options: various
fusion/fixation/movement sparing options
 Increasing utilization (Deyo 2005)
 Payer Coverage: variable without
instability
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◦ Case presented > MB failed, fusion denied
HTA – Washington State
 North Carolina
 Milliman Care Guidelines
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Chou (Spine 2009) APS Guidelines
Milliman Care Guidelines
www.careguidelines.com
 Originated as Milliman & Robertson
 Milliman is among the world's largest independent
actuarial and consulting firms, with revenues of
$676 million in 2010. Founded in Seattle in 1947,
we currently have 54 offices in key locations
worldwide. Our staff of 2,500 people includes
more than 1,300 qualified consultants and
actuaries. We are owned and managed by
approximately 350 principals—senior consultants
whose selection is based on their technical,
professional and business achievements.
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References (partial list):