Transcript Oh My Aching Back

Oh My Aching Back
Deborah Van Dommelen, MD/MPH
Northwestern Mutual
The Northwestern Mutual Life Insurance Company – Milwaukee, WI
Epidemiology of Back Pain
• Second most prevalent neurologic condition
in the US (#1 for men)
• Second most common symptom that
prompts MD visit in the US
• Typical age of onset is 30-50, but affects
some people into later years
• 80% of US population will have “disabling”
back pain in their lifetime
YOU WILL SEE THIS A LOT
Diagnosis Frequency by Age
Age 45-64
Age >65
1.
2.
3.
4.
Hypertension
URI
Diabetes
LBP
1.
2.
3.
4.
5.
6.
7.
Hypertension
COPD
CAD
URI
Diabetes
Arthritis
LBP
Annual Costs of Low Back Pain
• $40 Billion in Direct Costs
• >$100 Billion in Indirect Coasts
– Rapid increase in technology for imaging and
procedures is a significant contributor
– Of those with back pain, 75% sought medical
evaluation and 25% had a related hospitalization
– LTC Claims coverage could be part of these costs
Causes of Low Back Pain (LBP)
Mechanical (97%)
Spinal Stenosis
Degenerative Disc
Visceral (2%)
Aortic Aneurysm
Kidney Disease
Cancer (1%), increases with age up to 7%
Mechanical LBP
• Herniated Disc
• Compression Fracture
• Spinal Stenosis
• Ankylosing Spondylitis
• Cauda Equina Syndrome
• Nonspecific LBP (85%)
Lumbar Disc Disease
Imaging- MRI of Lumber Spine
Compression Fracture
Osteoporosis
Spinal Stenosis
• More common in men
• More common in older
ages
• Postural versus
Ischemic
Differentiating Vascular and
Neurologic Symptoms
Neurologic
Vascular
Location
Thighs, Calves, Back,
Buttocks
Buttocks, Calves
Quality
Exacerbation
Relief
Burning, Cramping
Cramping
Standing, Back Extension
Physical Activity with Legs
Sitting, Bending Forward,
Squatting
Rest
Blood
Pressure/Pulses
Normal
Extremities with low BP’s and
decreased or absent pulses
Skin Changes
None
Pallor, Cyanosis, Nail
Dystrophy
Autonomic
Possible Bladder
Incontinence
Possible Impotence
Spinal Stenosis- Bone/Ligament
Spinal Stenosis- Disc
Ankylosing Spondylitis
Ankylosing Spondylitis
Factors Determining Morbidity Risk
• Duration of Symptoms (acute vs. chronic)
• Recurrence
• Level of Function
• Imaging and Other Testing (EMG, ABI, etc)
• Treatment
– Medications
– Procedures
– Therapies
Factors Determining Morbidity Risk
•Duration of Symptoms (pain)
Chronicity of Back Pain
• Acute (< 6 weeks)
– Lumbar Strain/Sprain
– Osteoporotic Fracture
– Traumatic
• Subacute/Chronic (6-12 weeks/>12 weeks)
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Degenerative Disc Disease
Degenerative Joint Disease
Fibromyalgia
Polymyalgia Rheumatica
Parkinsons
Lumbar Stenosis
Chronic LBP
• Prior studies reported 90% of back pain
resolved within 4 weeks
• Recent research indicates that 62% still
have back pain after 12 months
• Over age 70, severity and duration of pain
are strongest predictors of function and
disability.
Factors Determining Morbidity Risk
•Duration of Symptoms (pain)
•Recurrence
Recurrence
• Single Episode
• Recurrent Symptoms
– Asymptomatic Periods
– Recurrence rate in 60-80% within 2 years
• Persistent Symptoms
– Never resolves
– Stability
– Effect on current activities (does it correlate
with severity?)
Case Example #1
• 57yo female 5’ 6” 140# (22.5). Works FT. NT
• Horse injury 2 yrs ago with period of paralysis (spinal cord
bruising).
• Neurosurgeon- Immediate quadraparesis after fall on neck.
• Imaging- Vertebral fracture and cord edema. Mod stenosis
multiple levels of cervical spine.
• Comorbids- Osteopenia (fractured wrist due to fall off horse)
• Function- Back to work within 2 months. No sx’s while taking
Neurontin. Currently pain free with daily workouts.
• Meds- Neurontin (weaned off within 6 months)
Factors Determining Morbidity Risk
•Duration of Symptoms (pain)
•Recurrence
•Level of Function
Function
• Unfavorable- General aging effects on the
ability to compensate for pain (physiology)
– Fall risk
– Cognition
– Tolerance of pain meds
– Ability to participate in therapy
• Favorable- Underwrite the specifics of this
applicant
– Golfing daily
– Still working
The Back Pain Function Scale (BPFS)
(Stratford et al)
• Able to do usual work housework?
• What are usual hobbies recreational or
sporting activities?
• Is sleep disturbed by pain?
• Able to do the following for 1 hour: lifting,
standing, walking, sitting, and driving?
• Able to go up or down 2 flights of stairs?
• Any problems putting on socks or shoes?
• Working outside home? FT?
Case Example #2
• 60yo male 6’ 1” 210 (BMI 28). Works FT.
• Intermittent back pain for more than 10 years.
• Imaging- x-ray from 8 years ago showing mild scoliosis.
• Tx includes: chiro, PT, and NSAID’s for flares. No surgeries or
injections. No narcotics due to nausea.
• Recurrence averages 2-3 times a year. Usually due to lifting
activities related to home improvement projects. Takes 3-7
days before back to normal activities.
• Most recent exacerbation 2 months ago after laying sod on
1/2 acre lot. Now reported to be sx free (completed 4 weeks
of chiro).
• Since then had a GXT as part of application for life insurance
(13 minutes, 14 METS)
Factors Determining Morbidity Risk
• Duration of Symptoms (pain)
• Time to Recovery (function)
• Recurrence
• Level of Function
• Imaging and Other Testing (EMG, ABI, etc)
Testing
• Imaging
– X-Rays (radiation exposure)
– CT Scan
– MRI
• Nerve Conduction Studies (EMG)
• Ankle Brachial Indices (ABI)
• Bone Mineral Density (BMD)
Why so much Imaging??
• Between 1994 and 2005, Lumbar MRI’s
increased by 400% in the Medicare population
• Use of imaging directly affected patient
satisfaction scores for providers
• Scanners are more available
• Medicare reimbursement much higher for MRI
than traditional films
• Defensive medicine (more cancer in older
population)
Imaging of the Spine
• Probability of identifying specific cause of
back pain on radiographs < 1%.
• Age contributes to false-positive findings on
radiographic studies
– 50% of asymptomatic people over age 40 will
have an abnormal CT or MRI
– Gets worse with age
*Do NOT read too much into imaging*
Asymptomatic at Age 60
• Herniated Disc
36%
• Spinal Stenosis
21%
• Degenerative/Bulging Disc
90%
Does Imaging Mean Anything?
• Does the location of symptoms match the
abnormality on CT/MRI?
• Is the severity of symptoms consistent with
the degree of abnormality on the CT/MRI?
Case Example #3
• 57yo male 5’ 9” 195# (BMI 29)
• No prescription meds. PRN OTC NSAID.
• End stage DDD. Imaging from 2006 shows
loss if disc space at L4-5 with impingement
of L5 nerve root. Disc extrusion affecting L3
and L4 nerves.
• Neck pain in 2009 treated with chiro, then 2
prednisone bursts, followed by an epidural
Case #3 continued
• Works 50 hours a week as an executive and
volunteers in his free time.
• Prior disc surgeries in 1980’s. No issues
since then. No current symptoms.
• Appears agile on exam with no gait
abnormalities. Able to rise out of chair
without assist.
Treatment
• Chiropractic Adjustments
• Adaptive Devices
• Epidural Injections
• Nerve Stimulation (TENS)
• High Risk Medications
• Surgery
Beers Criteria
• Potentially “inappropriate” medications for
older adults (65+).
– Higher risk for toxicity
– Higher risk for side-effects
– Generally ineffective
• For full list of medications, refer to this site:
http://archinte.amaassn.org/cgi/content/full/163/22/2716
Beers Criteria (LBP related)
• Any benzodiazepine (alprazolam, lorazepam,
etc)
• Muscle relaxants (Soma, Paraflex, Skelaxin,
Flexeril, etc)
• Anti-inflammatory (Toradol, Indocin, Naprosyn,
Daypro, etc)
• Narcotics (Demerol)
• Miscellaneous (Elavil)
• NO MORE Darvocet
So what medications are left for pain
management?
• Tylenol
• Narcotics
– Oral vs. parenteral/patch/cocktail
– Potency
– Scheduled vs. intermittent use
• Neurotin/Lyrica
Surgical Outcomes
• Discectomy improvement demonstrated at
1 year, but not at 4 years or 10 years.
• 70% will develop recurrent back pain years
later
• Risk of disc herniation is 10X higher in this
population
What is underlying anatomic abnormality that
allowed the initial lesion?
Case Example #4
• 55yo female 5’ 7” 210# (BMI 33). Works FT.
NT.
• PMH- Osteopenia, hypothyroid, lumbar fusion
(15yrs ago).
• Recent visit- Left LE numbness associated with
chronic LBP and radiculopathy (occasional
weakness). Has cane and walker at home but
does not use them.
• Treatment- Prior back surgery failed (remote).
Radiofrequency ablation little improvement.
ESI last month.
Case Example #4 Continued
• Comorbids- Osteopenia treated with fosamax,
but stopped due to GI sx’s. No follow-up BMD.
• Meds- tried neurotin and lyrica (too sedating).
GI upset with NSAID’s. So given narcotics and
steroid bursts for exacerbations.
• Imaging- Mod degenerative changes lumbar
and cervical spine (osteophytes and disc space
narrowing). Noted hardware for prior fusion
causes artifact)
Take Home Pearls……………………
• Is this really Mechanical back pain?
• Is my decision overly influenced by
Imaging?
• Does Treatment match the symptoms?
• Are there any Co-morbid conditions to be
considered?
• What is their Function?
Questions to follow……….