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Nonsurgical Management of Acute and Chronic Back Pain. Rocco Simmerano, MD Morris County Orthopaedic Group February 3, 2009. Outline. Epidemiology Etiology/Basic Science Diagnosis Treatment options Treatment failures/referrals. What is “back pain”?.

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Nonsurgical management of acute and chronic back pain

Nonsurgical Management of Acute and Chronic Back Pain

Rocco Simmerano, MD

Morris County Orthopaedic Group

February 3, 2009


Outline
Outline

  • Epidemiology

  • Etiology/Basic Science

  • Diagnosis

  • Treatment options

  • Treatment failures/referrals


What is back pain
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.


Epidemiology
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


Epidemiology1
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


Risk factors
Risk Factors

  • Age (35-55)

  • Gender ?

  • Physical activity

  • Not associated with

    • Obesity

    • Postural deformities

    • Unequal leg lengths


On the job
On the Job

  • Heavy lifting

  • Static posture

  • Bending and twisting

  • Vibration

  • Most predictive?

    • Psychosocial factors (monotony, job dissatisfaction, etc.)


Smoking and back pain
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


Anatomy
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



Etiology
Etiology

Degeneration

Facet arthropathy

Segmental instability

spinal stenosis foraminal stenosis

BACK PAIN

NERVE PAIN


Degenerative disease
Degenerative Disease

  • Loss of water content

  • Annulus tears


Degenerative disease1

Loss of water content

Annulus tears

Increased stresses on the facet joints

Degenerative Disease


Degenerative disease2
Degenerative Disease

  • Loss of water content

  • Annulus tears

  • Increased stresses on the facet joints

  • Loss of disc space

  • Herniation


Mechanical vs neurogenic pain

Wear and tear

Begins as back pain

Later stages associated with nerve problems

Not associated with weakness, numbness

Mechanical vs. Neurogenic Pain


Mechanical vs neurogenic pain1

Spinal nerve irritation

Radicular

Pain, numbness, weakness

Mechanical vs. Neurogenic Pain


History
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


Red flags
Red Flags

  • Fractures

  • Tumor

    • Known lesions

    • Night pain, weight loss

  • Infection

  • Cauda Equina

    • Urinary or bowel symptoms, severe progressive motor or sensory loss


Nonorganic pain
Nonorganic Pain

  • Fails to follow anatomic distributions

  • Always in pain

  • Intolerance to treatments

  • Exam

    • Superficial pain

    • Pain with axial loading

    • Distraction

    • Inconsistent motor exam


Exam

  • Lumbar ROM

    • Pain on flexion, extension, both

  • Palpation for spasm

  • Straight leg raising

  • Neurologic Exam

  • Waddell’s tests


Imaging
Imaging

  • A/P and lateral radiographs

  • CT scanning

  • MRI scanning

  • Discography



Who gets an mri
Who Gets an MRI?

  • Failed conservative treatment

  • Acute neurologic findings



Electromyography
Electromyography

  • Radicular pain


Diagnosis by age
Diagnosis by Age

  • 20-40

    • Muscular (will also see spondylolisthesis)

  • 30-50

    • Disc Herniation

  • >50

    • OA

  • >60

    • Spinal stenosis


Treatment
Treatment

  • Patient education is key

  • Evidence-based guidelines are lacking

  • Combination treatment

  • Goals

    • Educate

    • Relieve pain

    • Improve function

    • Limit side effects

    • Prevent chronicity


Treatment1
Treatment

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


Treatment2
Treatment

  • Bed Rest vs. Activity Modification

  • Medications

    • NSAIDs

    • Tylenol

    • Tramadol

    • Topicals

    • Opioid analgesia

    • Steroids

    • Muscle relaxers

    • Antidepressants


Heat or ice

Muscle relaxer

Increases exercise tolerance

Better in the sub-acute period

Decreases inflammation

Modulates pain

Heat or Ice?


Physical therapy
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


TENS

  • Transcutaneous electrical nerve stimulation

    • Endorphin modulated

    • Altered CNS transmission of pain

  • NEJM 1990, controlled study, no different than placebo


Traction
Traction

  • Enlarges foramen

  • Vacuum effect

  • PLL traction

  • Relaxation of spasm

  • Decreases intradiscal pressures up to 30%

  • Prospective studies show no long term benefit


Chiropractic care
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


Trigger point injections
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


Braces
Braces

  • Indicated with fracture, instability

  • No evidence to support long term use

  • Weakening of postural muscles

  • Do not really immobilize


Treatment failures
Treatment Failures

  • Failure to respond to conservative measures (6 weeks)

  • Progression to involve radiculopathy

  • Rapidly progressive neurologic symptoms

  • Chronic pain (> 12 weeks)


Options
Options

  • Orthopaedic/Neurosurgery

  • Pain Management/Anesthesia


Injection therapy
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


Non musculoskeltal causes
Non-musculoskeltal Causes

  • Renal

    • Lateral pain

  • Cardiovascular

    • Abdominal exam

  • Neoplastic


Summary
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



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