Chronic Low Back Pain. Do I have to see this patient?

Chronic Low Back Pain. Do I have to see this patient? Wayne State University Update in Internal Medicine: Rahul Vaidya MD FRCSc Chief of Orthopedic Surgery Detroit Medical Center Professor of Orthopaedic Surgery Wayne State 1 University

Chronic Low Back Pain EMERGENCY ROOM 1.Sciatica (positive SLR) 2.Cauda Equina (Bowel & Bladder Incontinence) 3.CHRONIC LOW BACK PAIN 2

The Cary Grant Treatment is 1. Give them a shot 2. A px for Narcotics 3. Get them the hell out of your ER 3

Chronic Low Back Pain Chronic 3-6 months Lower back 4

History AGE 18-40 40-60 >60

Classification of low-back disorders according to the Quebec Task Force on Spinal Disorders 1. Pain in the back 2. Pain with radiation to lower limb proximally 3. Pain with radiation to lower limb distally 4. Pain with radiation to lower limb and neurological signs 7

Age what they do? History Brief hx and chronology constant intermittent progressive constant unrelenting R/O abdominal, vascular, GU, OB/GYN hip and knee osteoarthritis, trochanteric bursitis

neurologic symptoms numbness paresthesias weakness bowel or bladder difficulties

functional questions work whats worse sitting, standing, lying down how long can you: sit stand sleep how far can you walk

What have you tried? Medications PT Chiropractic treatment Acupuncture Shots Surgery

Physical exam neurologic exam SLR sensory, motor, reflexes tender points vascular exam*****

ODI 0% to 20%: minimal disability: The patient can cope with most living activities. Usually no treatment is indicated apart from advice on lifting sitting and exercise. 21%-40%: moderate disability: The patient experiences more pain and difficulty with sitting lifting and standing. Travel and social life are more difficult and they may be disabled from work. Personal care sexual activity and sleeping are not grossly affected and the patient can usually be managed by conservative means. 41%-60%: severe disability: Pain remains the main problem in this group but activities of daily living are affected. These patients require a detailed investigation. 61%-80%: crippled: Back pain impinges on all aspects of the patient's life. Positive intervention is required. 81%-100%: These patients are either bed-bound or exaggerating their symptoms.

Chronic Low Back Pain 643 consecutive patients who presented to my office with Chronic Low Back Pain and had a definitive work up including ODI, Xrays and an MRI 14

Lumbar degenerative disorders Age 15-40 40-60 Age over 60 Sciatica/HNP Degenerative disc Spondylolysis/ listhesis Spinal Stenosis Facet OA Compression fx R/O Tumor, trauma, infx

X-Rays 17

Aneurysmal bone cyst 15 y old girl, pain 30

MRI 32

Lumbar Radiculopathy Herniated disc Imaging MRI

Lumbar Radiculopathy Herniated disc Confirm the diagnosis protrusion extrusion sequestrated

Lumbar Radiculopathy Surgical indications Herniated disc impairment of bowel and bladder function gross motor weakness evidence for increasing impairment of nerve root conduction (progressive motor weakness) severe sciatic pain persisting or increasing despite 4-12 weeks of tx recurrent incapacitating episodes of sciatica

Treatment Lumbar Radiculopathy Herniated disc discectomy, micro discectomy laminotomy and disc excision laminectomy and disc excision endoscopic discectomy transforaminal standard Discectomy and fusion

Discogenic Pain /Degenerative Disc Disease

Painful Degenerative Disc Painful degeneration of the lumbar spine is a common problem In 1970, Henry Crock postulated that the most likely cause of chronic low back pain is internal disruption of the disc

Discogenic Pain Typically mechanical Intolerant to axial activities Sitting, standing Increases with activity Usually no neurologic signs May have radiation of pain Can become incapacitating

Discogenic Pain Pain generator Annular tear?

Does it really exist as a diagnosis? People like this show up in my clinic Nothing else seems to work for them Who are they? Reviewed our 5 year old data base which is collected prospectively VAS PAIN DIAGRAMS OSWESTRY SCORES

Discogenic Pain our patients 128 consecutive cases Demographics Age range 17-53 median 42 Eliminate the outliers 30-48 Male 56% female 44% These are all working age people

Discogenic Pain Usually patients present with chronic history of back pain >1.5 yrs (range 13-72 months) >85% are referred and have tried all modalities including PT, chiropractic care, pain clinic injections

Discogenic pain The patients are fed up Their wives and husbands are fed up 87% on narcotics most of them feel they have been injured at work or by an accident so have someone else to blame Insurance 100% workmans comp/litigation 72%

Discogenic pain Psychologic problems/ depression Familial dysfunction Which comes first the pain or the psychology

87% are off work 18% are already on disability Type of work Laborer / factory worker 54% Policeman, Fireman, 2% mail person usually sorter not delivery 3% Truck driver fork lift 7% Nurses1% Teacher 1% Waitress 5% House wife 7% Clerical 8% Professional lawyer doctor, 0% Engineer 1% Professional athlete 0% Discogenic pain

Discogenic pain Neurologic exam Usually normal Except mild altered sensation EMG NCS normal Waddell signs

Waddell Signs Waddell, et al. (1980) described five categories of signs: Tenderness tests: superficial and diffuse tenderness and/or nonanatomic tenderness Simulation tests: these are based on movements which produce pain, without actually causing that movement, such as axial loading and pain on simulated rotation Distraction tests: positive tests are rechecked when the patient's attention is distracted, such as a straight leg raise test Regional disturbances: regional weakness or sensory changes which deviate from accepted neuroanatomy Overreaction: subjective signs regarding the patient's demeanor and reaction to testing 55

VAS back and leg pain Discogenic Pain

Oswestry disability index >50 most individuals

Pain Diagrams Discogenic Pain

Xrays Discogenic Pain

Discogenic Pain CT Myelogram MRI s

Discogenic Pain Modic changes appear to be a relatively specific but insensitive sign of a painful lumbar disc in patients with discogenic low back pain. Vertebral end-plate (Modic) changes on lumbar spine MRI: correlation with pain reproduction at lumbar discography. Braithwaite I, White J, Saifuddin A, Renton P, Taylor BA.

Discogenic Pain High Intensity Zone MRI s Gadolinium enhanced

Once you have the diagnosis What do we do? IDET, Nucleoplasty Spine fusion Posterolateral Interbody PLIFF TLIF ALIF FRONT BACK Disc replacement Dynamic Stabilization

Lumbar degenerative disorders Age 15-40 40-60 Age over 60 Sciatica/HNP Spondylolysis/ listhesis Spinal Stenosis Facet OA Compression fx R/O Tumor, trauma, infx

Spondylolysis Def: defect in the pars interarticularis most common cause of LBP in children+ adolescents caused by a fatigue fracture from repetitive hyperextension stresses (gymnasts, football lineman) may be hereditary

Spondylolysis Imaging plain lateral x-rays demonstrate 80% of cases another 15% localized on lateral xrays

Spondylolysis Imaging CT Bone scan SPECT scan

Spondylolysis Treatment Children bracing or casting for acute lesions usually aimed at symptomatic relief rather than fracture healing activity restriction flexion excercises bracing nonunion common and may have a normal scan

Spondylolisthesis Def: forward slippage of one vertebra over another 6 types

Spondylolisthesis Slip Severity I 0-25% II 25-50% III 50-75% IV 75-100% V >100% Slip angle

Spondylolisthesis Treatment children low grade slip grade I if asymptomatic no restrictions grade II asymptomatic restricted from football gymnastics surgery if progression of the slip intractable pain and failed non op therapy

Spondylolisthesis Treatment children high grade slip III or IV surgery recomended

Spondylysis listhesis Adult isthmic spondylolisthesis Symptoms vary chronic low back pain (instability) radicular pain usually L5 in a L5S1 slip may have neurologic findings discogenic pain from the level above

Spondylysis listhesis Adult isthmic spondylolisthesis tx non op conservative treatment rest, corsets, nsaids, PT pars block, epidural.

Spondylysis listhesis Adult isthmic spondylolisthesis Surgery

Degenerative slip 77

Lumbar degenerative disorders Age 15-40 40-60 Age over 60 Sciatica/HNP Spinal Spondylolysis/ listhesis R/O Tumor, trauma, infx Stenosis Facet OA Compression fx

Lumbar Spinal Stenosis

Lumbar Spinal Stenosis Most of the patients > 60 yo have some form of this problem Usually have no pain sitting Have trouble standing or walking Pain weakness or numbness into the buttocks or legs Can get quite severe to constant pain with cauda equina symptoms

Lumbar Spinal Stenosis Heterogenous disorder results in narrowing of the spinal canal + lateral recess 50 s 70 s 2-10 % of the population Structural predisposition (cong short pedicles) Sx disease assoc with OA of Lumbar Spine Males=females Deg spondylolisthesis Females : Males 4 : 1

Lumbar Spinal Stenosis Neurogenic Claudication Cause? Ischemia of lumbosacral roots metabolic demand from exercise + vascular compromise of the nerve pressure of the surrounding structures. Venous congestion with upright posture Sensory fibers more sensative than motor Pain numbness but no weakness

Lumbar Spinal Stenosis Central Stenosis Neurogenic claudication

Lumbar Spinal Stenosis Presentation Neurogenic Claudication Unilateral or bilateral discomfort Pain, paresthesias, weakness Buttock Hip Thigh Or Leg Precipitated by standing or walking Relieved by changing posture to Sitting, squating, bending forward Cauda Equina Syndrome

Lumbar Spinal Stenosis Presentation Triple flexed posture athropoid posture when walking Flexion like sitting to distract the facets and ligamentum flavum. Use the shopping cart when doing groceries

Lumbar Spinal Stenosis Differentiate Vascular claudication Trochanteric Bursitis Osteoarthritis

Lumbar Spinal Stenosis Exam Gait SLR Sensory Motor Reflex Neuro exam normal 18-50% pts (Mild L4,5,S1 weakness altered sensation and diminished reflexes)

Lumbar Spinal Stenosis Diagnostic Evaluation Plain Xrays Spondylolisthesis Facet OA Decreased AP diameter of Canal Oblique films may show pars defect Degenerative scoliosis

Lumbar Spinal Stenosis Diagnostic Evaluation MRI T2WI Poor for bone, good for soft tissue Really good for the foramen

Lumbar Spinal Stenosis Diagnostic Evaluation Myelogram

Flexion MYELOGRAM Extension L4 L4 L5 L5 S1 S1

Lumbar Spinal Stenosis KEY POINTS Most Common at L4-L5 level then L3-L4, L2-3 then L5-S1 L2 L3 L4 L5 S1 3 2 1 4

Lumbar Spinal Stenosis Diagnostic Tests EMG/NCS Particularily useful if you are wondering about peripheral neuropathy in NIDDM Bicycle Test Vascular Studies ABI 1 is normal.59 intermittent claudication.26 with rest pain

Lumbar Spinal Stenosis Treatment Initial treatment Medication NSAIDS (beware) Narcotics short course only Steroids Physiotherapy Therapeutic exercise program Epidural steroids Unclear although used extensively

Lumbar Spinal Stenosis Treatment Progression Johnsson et al (1990) 32 pts tx conservatively 4yrs 70% no change in sx 15% worsened 15% improved 38% worsened on EMG Remember other co-morbidities

Lumbar Spinal Stenosis Surgical Treatment Progressive neurological deficit Failure of conservative treatment If sx are severe or unacceptable to the patient If risk of surgery is reasonable Most patients have sx for greater than 1year

Lumbar Spinal Stenosis Surgical Treatment Goals Pain relief Reversal of neurologic deficit Halting progression of neuro deficit Increase in daily function

Conclusion Good outcomes come with good diagnosis matched with correct treatment Pts have many comorbidities surgery is still an art People can still live in a wheel chair

Chronic Low Back Pain and degenerative disease Facetogenic pain

Compression Fracture 105

MRI Infection vs mets vs osteoporotic Fx 108