OHSU Spine Center
Low Back Pain: Myth vs. Reality
OHSU Spine Center
OHSU Spine Center
• Orthopaedic Spine
Surgeons
OHSU Spine Center
• Orthopaedic Spine
Surgeons
• Neurosurgeons
OHSU Spine Center
• Orthopaedic Spine
Surgeons
• Neurosurgeons
• Physical Medicine &
Rehabilitation
Specialists
OHSU Spine Center
• Orthopaedic Spine
Surgeons
• Neurosurgeons
• Physical Medicine &
Rehabilitation
Specialists
• Pain Man...
OHSU Spine Center
• Orthopaedic Spine
Surgeons
• Neurosurgeons
• Physical Medicine &
Rehabilitation
Specialists
• Pain Man...
OHSU Spine Center
• Orthopaedic Spine
Surgeons
• Neurosurgeons
• Physical Medicine &
Rehabilitation
Specialists
• Pain Man...
OHSU Spine Center
• Orthopaedic Spine
Surgeons
• Neurosurgeons
• Physical Medicine &
Rehabilitation Specialists
• Pain Man...
Identifying the Source of Low Back Pain
Diagnostic Tools:
– History
– Physical Exam
– Diagnostic Studies
• Imaging
• Labs
...
Myth vs. Reality?
Back pain …
• Affects everybody at some point
Myth vs. Reality?
Back pain …affects everybody
– Individual lifetime
occurrence rate
– 60-90%
– Yearly prevalence
rate
– 1...
Myth vs. Reality?
Back pain …affects everybody and gets better!
– Individual lifetime
occurrence rate
– 60-90%
– Yearly pr...
Myth vs. Reality?
Back pain …
• Affects everybody at some point
• Is result of poor design of the spine
Myth vs. Reality?
Back pain …is result of poor design of the spine
Myth vs. Reality?
Back pain …
• Affects everybody at some point
• Is result of poor design of the spine
• Is caused by dis...
Myth vs. Reality?
Back pain …is caused by disk degeneration
• 98 asymptomatic L-
Spine MRIs
– 52% bulges, 27%
protrusions,...
Myth vs. Reality?
Back pain …
• Affects everybody at some point
• Is result of poor design of the spine
• Is caused by dis...
Myth vs. Reality?
Back pain …requires activity limitations
• Earlier resumption of
work and activities
did not have an
eff...
Myth vs. Reality?
Back pain …
• Affects everybody at some point
• Is result of poor design of the spine
• Is caused by dis...
Myth vs. Reality?
Back pain …implies damage to the spine
Myth vs. Reality?
Back pain …
• Affects everybody at some point
• Is result of poor design of the spine
• Is caused by dis...
• Bedrest trials
– 0 vs 4 days (n=125)
– 2 vs 7 days (n=203)
• Shorter bedrest
– 45% fewer lost
workdays
– 42% fewer days ...
WHAT ABOUT MY ACTIVITIES?
Golfing? Running? Yardwork? Backpacking? Skiing? Firewood?
Hunting? Fishing? Camping? Driving? H...
Myth vs. Reality?
Exercise/Activity…
• Is bad for your back
Myth vs. Reality?
Exercise/Activity…is bad for your back
– Exercise:
• Focused on identifying and improving impairments
in...
Myth vs. Reality?
Exercise/Activity…
• Is bad for your back
• Is associated with spine degeneration
Myth vs. Reality?
Exercise/Activity…is associated with spine
degeneration
• 67 asymptomatic L-
Spine MRIs
– 20-39 y.o.:
• ...
Myth vs. Reality?
Exercise/Activity…
• Is bad for your back
• Is associated with spine degeneration
• Should be avoided wi...
Myth vs. Reality?
Exercise/Activity…should be avoided
with back problems
• “Proper Mechanics”
– “… learn to sit, stand,
li...
NO PAIN ----- NO GAIN
and the role of common sense
Myth vs. Reality?
Exercise/Activity…
• Myths
(traditional advice)
– avoid activity, be
passive
– spine easily damaged
– of...
Exercise and Back Pain…
• Degenerative changes are inevitable
Exercise and Back Pain…
degenerative changes are inevitable
• Degenerative
changes increase
with age
• Back pain levels
of...
Exercise and Back Pain…
• Degenerative changes are inevitable
• Muscle are shock absorbers
Exercise and Back Pain…
muscle are shock absorbers
• Restore
– Strength
– Flexibility
– Endurance
Exercise and Back Pain…
muscle are shock absorbers
• Restore
– Strength
– Flexibility
– Endurance
Exercise and Back Pain…
muscle are shock absorbers
• Restore
– Strength
– Flexibility
– Endurance
Exercise and Back Pain…
• Degenerative changes are inevitable
• Muscle are shock absorbers
• Muscles are modifiable and me...
Exercise and Back Pain…
muscles are modifiable and measurable
Reality!
Exercise and back pain…
• Back pain is common
• Degenerative changes don’t correlate well
to pain
• Any activity ...
TREATMENT OPTIONS
Therapy Medications Injections Surgery
Myth vs. Reality?
Spinal Surgery…
• Spine surgery won’t help me because I
know too many people who still have pain
after s...
Myth of Spine Surgery
Jung U. Yoo, M.D.
Upright Balance
Provide Motion
Shock Absorption
House Neural Elements
Myths
• Minimally invasive surgery is better
• Those who have surgery have more pain
after the surgery than before
• Lates...
Arthroscopic or laser surgery?
Exposure
• Minimally invasive may require longer
surgery
• Surgeon may have limited view
• Small incision does not mean sm...
Laser Discectomy
Thermal Disc Coagulation
Protein Denaturation
THOSE WHO HAVE SURGERY HAV
Those who have surgery have more pain
after the surgery than before.
Why things fail
• Wrong diagnosis
• Wrong patient
• Wrong surgery
• Life is a percentage
• Conditions that we have to fix
• Conditions that we can fix
• Conditions that we cannot fix
Broken
Cancer
Herniated Disc
Spinal Stenosis
Deteriorated
I I want the latest technology.TECHNOLO
Wrong Surgery
Increased Stability
Artificial Disc
salvage
Thank you
OHSU Spine Center
OHSU Spine Center
OHSU Spine Center
OHSU Spine Center
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OHSU Spine Center

  1. 1. OHSU Spine Center Low Back Pain: Myth vs. Reality
  2. 2. OHSU Spine Center
  3. 3. OHSU Spine Center • Orthopaedic Spine Surgeons
  4. 4. OHSU Spine Center • Orthopaedic Spine Surgeons • Neurosurgeons
  5. 5. OHSU Spine Center • Orthopaedic Spine Surgeons • Neurosurgeons • Physical Medicine & Rehabilitation Specialists
  6. 6. OHSU Spine Center • Orthopaedic Spine Surgeons • Neurosurgeons • Physical Medicine & Rehabilitation Specialists • Pain Management Specialists
  7. 7. OHSU Spine Center • Orthopaedic Spine Surgeons • Neurosurgeons • Physical Medicine & Rehabilitation Specialists • Pain Management Specialists • Spine Physical Therapists
  8. 8. OHSU Spine Center • Orthopaedic Spine Surgeons • Neurosurgeons • Physical Medicine & Rehabilitation Specialists • Pain Management Specialists • Spine Physical Therapists • Spine Center Gym
  9. 9. OHSU Spine Center • Orthopaedic Spine Surgeons • Neurosurgeons • Physical Medicine & Rehabilitation Specialists • Pain Management Specialists • Spine Physical Therapists • Spine Center Gym • Spine Center
  10. 10. Identifying the Source of Low Back Pain Diagnostic Tools: – History – Physical Exam – Diagnostic Studies • Imaging • Labs • Electrodiagnostic Studies – Spinal Injections Diagnoses: • Radiculopathy • Spinal Stenosis • Non-Specific Benign LBP • Disc Degeneration • Myofascial Pain • Piriformis Syndrome • Sacroiliac Pain • Malalignment
  11. 11. Myth vs. Reality? Back pain … • Affects everybody at some point
  12. 12. Myth vs. Reality? Back pain …affects everybody – Individual lifetime occurrence rate – 60-90% – Yearly prevalence rate – 15-20%
  13. 13. Myth vs. Reality? Back pain …affects everybody and gets better! – Individual lifetime occurrence rate – 60-90% – Yearly prevalence rate – 15-20% – 50% better at 1 week – 90% better at 6-12 weeks – Dillane, Brit Med J, 1966 – Waddell, Spine, 1987 – Berquist, 1977
  14. 14. Myth vs. Reality? Back pain … • Affects everybody at some point • Is result of poor design of the spine
  15. 15. Myth vs. Reality? Back pain …is result of poor design of the spine
  16. 16. Myth vs. Reality? Back pain … • Affects everybody at some point • Is result of poor design of the spine • Is caused by disk degeneration
  17. 17. Myth vs. Reality? Back pain …is caused by disk degeneration • 98 asymptomatic L- Spine MRIs – 52% bulges, 27% protrusions, 1% extrusion – 14% ALT, 8% facet – 38% with multilevel abnormalities » Jensen, NEJM 1994
  18. 18. Myth vs. Reality? Back pain … • Affects everybody at some point • Is result of poor design of the spine • Is caused by disk degeneration • Requires activity limitations
  19. 19. Myth vs. Reality? Back pain …requires activity limitations • Earlier resumption of work and activities did not have an effect on pain and was associated with improved function – Gilbert, Deyo, Malmivaara
  20. 20. Myth vs. Reality? Back pain … • Affects everybody at some point • Is result of poor design of the spine • Is caused by disk degeneration • Requires activity limitations • Implies damage to the spine
  21. 21. Myth vs. Reality? Back pain …implies damage to the spine
  22. 22. Myth vs. Reality? Back pain … • Affects everybody at some point • Is result of poor design of the spine • Is caused by disk degeneration • Requires activity limitations • Implies damage to the spine • Is better with rest
  23. 23. • Bedrest trials – 0 vs 4 days (n=125) – 2 vs 7 days (n=203) • Shorter bedrest – 45% fewer lost workdays – 42% fewer days of decreased activity – No difference in pain » Deyo, 1986 » Gilbert, 1985 Myth vs. Reality? Back pain …is better with rest
  24. 24. WHAT ABOUT MY ACTIVITIES? Golfing? Running? Yardwork? Backpacking? Skiing? Firewood? Hunting? Fishing? Camping? Driving? Horseback Riding? Marathons? Lifting? Bending? Weight Training? Biking? Bowling? Working? Basketball? Softball? Grandkids? Kids? Hiking? Climbing? Woodworking? Painting? Kayaking? Mountain Biking?
  25. 25. Myth vs. Reality? Exercise/Activity… • Is bad for your back
  26. 26. Myth vs. Reality? Exercise/Activity…is bad for your back – Exercise: • Focused on identifying and improving impairments in flexibility and strength. – Results: • People with chronic LBP can substantially improve back flexibility and strength through exercise. This frequently translates into improved ability to function and less daily pain. » Mayer et al. JAMA 1987; Hazard et al. Spine 1989; Estlander et al. Scan J Rehab Med 1991; Manniche et al. Pain 1991; Rainville et al. Spine 1992; Nelson et al. Orthopedics 1995;
  27. 27. Myth vs. Reality? Exercise/Activity… • Is bad for your back • Is associated with spine degeneration
  28. 28. Myth vs. Reality? Exercise/Activity…is associated with spine degeneration • 67 asymptomatic L- Spine MRIs – 20-39 y.o.: • 35% Disc degeneration – <60 y.o.: • 20% Disc herniation – >60 y.o.: • 36% Disc herniation • 21% stenosis » Boden, JBJS 1990
  29. 29. Myth vs. Reality? Exercise/Activity… • Is bad for your back • Is associated with spine degeneration • Should be avoided with back problems
  30. 30. Myth vs. Reality? Exercise/Activity…should be avoided with back problems • “Proper Mechanics” – “… learn to sit, stand, lie, and do ADLs with LB in proper position” – Grant, 1975 • Increased LBP risk? – “… difficult recovery in patients using the wrong muscles to bend, lift” – Marras, Spine 2001
  31. 31. NO PAIN ----- NO GAIN and the role of common sense
  32. 32. Myth vs. Reality? Exercise/Activity… • Myths (traditional advice) – avoid activity, be passive – spine easily damaged – often damage is permanent – focus on pain • Reality – no serious disease – spine is strong, rarely damaged – pain does not mean harm – activity is important to recovery – focus on function Burton, Waddell et al; Spine 1999
  33. 33. Exercise and Back Pain… • Degenerative changes are inevitable
  34. 34. Exercise and Back Pain… degenerative changes are inevitable • Degenerative changes increase with age • Back pain levels off with age • McNab 1977
  35. 35. Exercise and Back Pain… • Degenerative changes are inevitable • Muscle are shock absorbers
  36. 36. Exercise and Back Pain… muscle are shock absorbers • Restore – Strength – Flexibility – Endurance
  37. 37. Exercise and Back Pain… muscle are shock absorbers • Restore – Strength – Flexibility – Endurance
  38. 38. Exercise and Back Pain… muscle are shock absorbers • Restore – Strength – Flexibility – Endurance
  39. 39. Exercise and Back Pain… • Degenerative changes are inevitable • Muscle are shock absorbers • Muscles are modifiable and measurable
  40. 40. Exercise and Back Pain… muscles are modifiable and measurable
  41. 41. Reality! Exercise and back pain… • Back pain is common • Degenerative changes don’t correlate well to pain • Any activity is better than no activity for the back
  42. 42. TREATMENT OPTIONS Therapy Medications Injections Surgery
  43. 43. Myth vs. Reality? Spinal Surgery… • Spine surgery won’t help me because I know too many people who still have pain after surgery
  44. 44. Myth of Spine Surgery Jung U. Yoo, M.D.
  45. 45. Upright Balance
  46. 46. Provide Motion
  47. 47. Shock Absorption
  48. 48. House Neural Elements
  49. 49. Myths • Minimally invasive surgery is better • Those who have surgery have more pain after the surgery than before • Latest technology is better • Doctors will make me better
  50. 50. Arthroscopic or laser surgery?
  51. 51. Exposure • Minimally invasive may require longer surgery • Surgeon may have limited view • Small incision does not mean small surgery • There are many type of minimally invasive surgery
  52. 52. Laser Discectomy
  53. 53. Thermal Disc Coagulation
  54. 54. Protein Denaturation
  55. 55. THOSE WHO HAVE SURGERY HAV Those who have surgery have more pain after the surgery than before.
  56. 56. Why things fail • Wrong diagnosis • Wrong patient • Wrong surgery • Life is a percentage
  57. 57. • Conditions that we have to fix • Conditions that we can fix • Conditions that we cannot fix
  58. 58. Broken
  59. 59. Cancer
  60. 60. Herniated Disc
  61. 61. Spinal Stenosis
  62. 62. Deteriorated
  63. 63. I I want the latest technology.TECHNOLO
  64. 64. Wrong Surgery
  65. 65. Increased Stability
  66. 66. Artificial Disc
  67. 67. salvage
  68. 68. Thank you

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