Back Pain Update. Timothy McHenry, M.D. Orthopaedic Spine Surgery Greenville Health System

Transcription

1 Back Pain Update Timothy McHenry, M.D. Orthopaedic Spine Surgery Greenville Health System

2 Why would an orthopaedic surgeon read the New England Journal of Medicine? Medical Journal Impact Factor (2015) NEJM Lancet JAMA Gastroenterology 16.7 Ann Neurol 9.98 Med J Australia 4.09 JBJS (Am) 5.28 J Neurosurg 3.74 Spine 2.30 Not enough pictures, though! Impactfactor.weebly.com

3 Randomized, prospective studies (level 1 evidence) Highest quality research in order to be published Medline Diabetes = 670 references Spine = 35 references Snap shot of surgical conditions

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5 Multicenter, randomized, double-blind, placebocontrolled trial 78 participants with back pain following fracture Fractures <12 months old 38 received vertebroplasty 40 underwent sham procedure Followed up to 6 months post-procedure Vertebroplasty did not result in a significant advantage in any measured outcome at any time point.

6 Osteoporotic Compression Fracture Typical Natural History Healing in 6 to 12 weeks Slight increase in compression during healing process is common Progressive increase in activity during healing process

7 Standard Treatment Recommendations Lumbar corset Pain medications Activity modification Reassurance Osteoporosis Program calcium + vitamin D BMD testing to establish severity of disease bisphosphonates calcitonin teriparatide fall prevention program

8 Vertebroplasty vs. Kyphoplasty Likely no difference in clinical outcomes between the two procedures

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10 Failure to heal?? Persistent pain (>12 weeks) Patient selection in Buchbinder study was increased signal on MRI STIR sequences (nonspecific for identifying reason for persistent pain) Non-healing fracture Kummel s Disease Severe kyphosis Deconditioning Decreasing likelihood that vertebroplasty will alleviate pain

11 Kummel s Disease Osteonecrosis of the vertebral body Fragmentation Air Non-healing

12 Severe Kyphosis Mechanical pain from sagittal imbalance

13 Deconditioning/Deterioration General Core 5 year survival after osteoporotic vertebral body fracture 72% for men 84% for women Mortality more a result of medical comorbidities than fracture itself

14 T7 kyphoplasty, s/p prior T4 and T12 kyphoplasties When might it still be reasonable to perform vertebroplasty? #1. Early, severe, debilitating pain <6 weeks mobility problems of recumbency VTE Pressure sores Pulmonary Admitted to hospital for pain control, etc. Buchbinder et al. study underpowered for this sub-group

15 When might it be reasonable to perform vertebroplasty? #2. Pathologic fracture from malignancy Continued active process Provisional stabilization for lytic lesions

16 Conclusion Vertebroplasty/kyphoplasty is not a panacea for osteoporotic compression fractures as it was initially marketed Some specific indications may remain but, in general, it should be sparingly used

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18 Randomized, double-blinded, multisite study of 400 patients Epidural injections of steroid plus short-acting anesthetic versus short-acting anesthetic alone Translaminar or transforaminal approach Primary outcome was Roland-Morris Disability Questionnaire (RMDQ)

19 Results Primary Outcomes Measure (RMDQ) MCID for RMDQ is approximately 5 points 1 1 Lauridsen et al, BMC Musculoskeletal Disorders, 2006

20 Results Secondary Outcome Measures No difference in RMDQ score between glucocorticoidlidocaine group and lidocaine-alone group at 6 weeks

21 Subgroup analysis showed no difference in outcomes in patients who received interlaminar versus transforaminal injections

22 Uncertainties of the Study Placebo effect? (no true sham procedure) Dilutional effect? Systemic steroid effect? Severity of the stenosis?

23 Lumbar ESI Theory of Action: anesthetic steroid Pain dilution Theory of three injections Historically only 1 in 3 in right place when performed without fluoroscopic guidance "Insanity: doing the same thing over and over again and expecting different results." Time

24 Grading Stenosis Poor interobserver reliability mild moderate severe

25 ESI Adverse Effects 17% for lidocaine only 29% for glucocorticoidlidocaine Cortisol suppression Excessive pain Headache Fever, infection or both Dizziness Numbness/Tingling Etc.

26 When do I use ESI in lumbar stenosis? Diagnosis Neurogenic versus vascular claudication Patients that are poor surgical risks Insurer mandated non-surgical care prior to approval for surgery

27 N Eng J Med 2008; 358:

28 Multicenter study 289 patients in randomized cohort 365 patients in observation cohort Surgical care: standard decompressive laminectomy Non-surgical care ( usual care ) PT Education Home exercises NSAIDs

29 Large amount of cross-over As-treated analysis: Significantly better outcomes with surgery compared with non-surgical care Differences remained significant at 2 and 4 years

30 Surgery Adverse Events

31 Lumbar Spinal Stenosis Untreated Natural History Symptoms relative stable Over 4 years: 70% unchanged 15% worsened (none severe) 15% improved Johnsson et al. Clin Orthop, 1992

32 Treatment selection (Selection, Selection, Selection) Neurogenic Symptoms Imaging Red-Herrings MRI or CT-myelogram are not screening studies for low back pain Significant functional limitations due to symptoms

33 Avoid spine surgery Irrational Fear? 11 Spine surgery phobia

34 Thank you