Back Pain 2 nd most common cause for office visit 60-80% of population will have lower back pain at some time in their lives Each year, 15-20% will have back pain Most common cause of disability for persons < 45 years 1% of US population is disabled Costs to society: $20-50 billion/year

2 nd most common cause for office visit

60-80% of population will have lower back pain at some time in their lives

Each year, 15-20% will have back pain

Most common cause of disability for persons < 45 years

1% of US population is disabled

Costs to society: $20-50 billion/year

Oh My Aching Back Treatment Options for Back Pain Steven Stoltz, M.D. Assistant Clinical Professor of Medicine UCSF-Fresno

Outline Part 1: Introduction Review of anatomy Part 2: Acute low back pain Part 3: Chronic low back pain Prevention Questions ??

Part 1:

Introduction

Review of anatomy

Part 2:

Acute low back pain

Part 3:

Chronic low back pain

Prevention

Questions ??

Low Back Pain “ One would have thought by now that the problem of diagnosis and treatment would have been solved, but the issue remains mysterious and clouded with uncertainty.” Rosomoff HL, Rosomoff RS. Low back pain: Evaluation and management in the primary care setting. Med Clin North Am 1999;83:643-62.

“ One would have thought by now that the problem of diagnosis and treatment would have been solved, but the issue remains mysterious and clouded with uncertainty.”

Rosomoff HL, Rosomoff RS. Low back pain: Evaluation and management in the primary care setting. Med Clin North Am 1999;83:643-62.

- Anatomy Lesson #1

- Anatomy Lesson #2

Introduction to Ed Ed has had lower back pain for the past 24 hours that he feels is related to yard work that he did over the weekend. He missed work today, Monday. He wants to know what can be done for his back pain?

Ed has had lower back pain for the past 24 hours that he feels is related to yard work that he did over the weekend. He missed work today, Monday.

He wants to know what can be done for his back pain?

What should Ed expect from his health care professional? Be able to recognize the difference between routine lower back pain and dangerous forms of lower back pain. Provide information, advice, and a plan of action.

Be able to recognize the difference between routine lower back pain and dangerous forms of lower back pain.

Provide information, advice, and a plan of action.

% of Back Pain due to Herniated Disk? 4% 14% 40% None of the above

4%

14%

40%

None of the above

Causes of Low Back Pain Lumbar “strain” or “sprain” – 70% Degenerative changes – 10% Herniated disk – 4% Osteoporosis compression fractures – 4% Spinal stenosis – 3% Spondylolisthesis – 2%

Lumbar “strain” or “sprain” – 70%

Degenerative changes – 10%

Herniated disk – 4%

Osteoporosis compression fractures – 4%

Spinal stenosis – 3%

Spondylolisthesis – 2%

Causes of Low Back Pain… Spondylolysis, diskogenic low back pain or other instability – 2% Traumatic fracture - <1% Congenital disease - <1% Cancer – 0.7% Inflammatory arthritis – 0.3% Infections – 0.01%

Spondylolysis, diskogenic low back pain or other instability – 2%

Traumatic fracture - <1%

Congenital disease - <1%

Cancer – 0.7%

Inflammatory arthritis – 0.3%

Infections – 0.01%

Red Flags History of cancer Unexplained weight loss Intravenous drug use Prolonged use of corticosteroids Older age Major Trauma Osteoporosis Fever Back pain at rest or at night Bowel or bladder dysfunction

History of cancer

Unexplained weight loss

Intravenous drug use

Prolonged use of corticosteroids

Older age

Major Trauma

Osteoporosis

Fever

Back pain at rest or at night

Bowel or bladder dysfunction

Medications Anti-inflammatory medications (NSAID’s): Beneficial; no differences; watch side-effects Tylenol: Narcotic Pain Relievers: No more effective than NSAID’s Many side effects Muscle Relaxants (ie. Flexeril ® ): Can decrease pain and improve mobility 70% with drowsiness/dizziness

Anti-inflammatory medications (NSAID’s):

Beneficial; no differences; watch side-effects

Tylenol:

Narcotic Pain Relievers:

No more effective than NSAID’s

Many side effects

Muscle Relaxants (ie. Flexeril ® ):

Can decrease pain and improve mobility

70% with drowsiness/dizziness

Chiropractic/Osteopathic Davenport, Iowa in 1895 by David Palmer; ‘done by hand’ (Greek) Spinal manipulation Conflicting evidence on the effects of spinal manipulation ~75-90% improvement anyway within 4 weeks Greater patient satisfaction

Davenport, Iowa in 1895 by David Palmer; ‘done by hand’ (Greek)

Spinal manipulation

Conflicting evidence on the effects of spinal manipulation

~75-90% improvement anyway within 4 weeks

Greater patient satisfaction

Exercise & Bed Rest Advice to stay active: ‘ There is no evidence that advice to stay active is harmful for either acute low back pain or sciatica.’ Hurt does not equal harm One or two days of bed rest if necessary Light activity, avoiding heavy lifting, bending or twisting (ie. walking) No data on any particular exercises

Advice to stay active:

‘ There is no evidence that advice to stay active is harmful for either acute low back pain or sciatica.’

Hurt does not equal harm

One or two days of bed rest if necessary

Light activity, avoiding heavy lifting, bending or twisting (ie. walking)

No data on any particular exercises

Massage & Physical Therapy Might be beneficial More quality research is needed Different types of massage

Might be beneficial

More quality research is needed

Different types of massage

Acupuncture Very little quality research and data Seems to indicate that acupuncture is not effective for the treatment of back pain

Very little quality research and data

Seems to indicate that acupuncture is not effective for the treatment of back pain

Other Modalities Back Brace/Corset/Lumbar Support: Traction: Injections: Inconclusive evidence TENS: Hot/ Cold : Ultrasound:

Back Brace/Corset/Lumbar Support:

Traction:

Injections: Inconclusive evidence

TENS:

Hot/ Cold :

Ultrasound:

Ed, again… Now, Ed has not had improvement in his lower back pain and 6 weeks have gone by since the initial painful event. What types of therapies might be beneficial for Ed now?

Now, Ed has not had improvement in his lower back pain and 6 weeks have gone by since the initial painful event.

What types of therapies might be beneficial for Ed now?

Role of X-rays (Radiology) Usually unnecessary and not helpful Plain X-ray: Age>50 years No improvement after 6 weeks Other worrisome findings MRI: After 6 weeks if have sciatica

Usually unnecessary and not helpful

Plain X-ray:

Age>50 years

No improvement after 6 weeks

Other worrisome findings

MRI:

After 6 weeks if have sciatica

New England Journal of Medicine (February 2001)

Medications Similar to acute pain…. Antidepressant medications can improve pain relief

Similar to acute pain….

Antidepressant medications can improve pain relief

Exercises Improves pain and function Many programs available, but difficult to make any scientific recommendations for one type versus another

Improves pain and function

Many programs available, but difficult to make any scientific recommendations for one type versus another

Injections Epidural injections: Insufficient and conflicting evidence Facet joint injections: No improvement Local/Trigger point injections: Possibly some benefit

Epidural injections:

Insufficient and conflicting evidence

Facet joint injections:

No improvement

Local/Trigger point injections:

Possibly some benefit

Surgery Diskectomy improves pain in short term but not long term (ie. 10 years) Microdiskectomy similar to standard diskectomy Automated percutaneous diskectomy and laser diskectomy both less effective ? Arthroscopic diskectomy

Diskectomy improves pain in short term but not long term (ie. 10 years)

Microdiskectomy similar to standard diskectomy

Automated percutaneous diskectomy and laser diskectomy both less effective

? Arthroscopic diskectomy

Other Modalities Back Schools: - possibly effective Multidisciplinary Therapy: - probably yes TENS: - no Spinal manipulation: - conflicting data Massage: - probably yes IDET:

Back Schools: - possibly effective

Multidisciplinary Therapy: - probably yes

TENS: - no

Spinal manipulation: - conflicting data

Massage: - probably yes

IDET:

Intradiscal Electrothermal Therapy

IDET No convincing evidence that shows the short or long-term clinical efficacy of this procedure. Safe with few adverse effects ? Long-term effects Wall Street Journal (Feb. 11, 2003)

No convincing evidence that shows the short or long-term clinical efficacy of this procedure.

Safe with few adverse effects

? Long-term effects

Wall Street Journal (Feb. 11, 2003)

Prevention Exercise: Aerobic, back/leg strengthening Back braces and education about proper lifting techniques are ineffective ? weight loss and smoking cessation

Exercise:

Aerobic, back/leg strengthening

Back braces and education about proper lifting techniques are ineffective

? weight loss and smoking cessation

Web Resources www.mayo.edu www.cochraneconsumer.com (“Helping people make well-informed decisions about health care.”) www.library.ucsf. edu

www.mayo.edu

www.cochraneconsumer.com (“Helping people make well-informed decisions about health care.”)

www.library.ucsf. edu