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Stephen Bartol MD MBA FRCSCWindsor, ON / Detroit, MI
Disclosures
• Consultant: Johnson & Johnson, Stryker, LDR Stock Ownership: Sentio (acquired by Johnson & Johnson (2017)
• Patents: assigned to Johnson & Johnson and Ford Motor Co.
• Research: Medtronic, DePuy Synthes, BCBSM
• Boards/Committees: AAOS, NASS, MSSIC, Musculoskeletal Transplant Foundation
The Problem
>80% of us experience disabling back problems1
85% experience lifetime recurrance2
54% of these have
>5 yrs of pain1
2nd most common reason for seeing a doctor
1Rubin. Neurol. Clin 2007 25(2)2Best pract res Clin Rheumatol 2002 16(5)
Huge Problem for Women + Elderly
>30% of women in any given year
>35% of those over 65 in any given year
Arch Intern Med. 2009 Feb 9; 169(3): 251–258
The Rising Prevalence of Chronic Low Back Pain
An Expensive Problem
A Bigger Problem
• ~25% of opioid prescriptions are for back pain3
(despite almost universal recommendations against it!)
• Up to 40% of patients put on opioids for non-malignant MSK pain develop dependency behavior4
• 60-80% of all patients referred to spine surgeons exhibit narcotic dependency behaviour on INITIAL presentation5
3 Ann Intern Med. 2015 Feb 17;162(4):295-3004 Rhon et al. Perioperative Medicine (2018) 7:255 MSSIC database
What We’ll Talk About
• Common presentations
• Causative factors
• Current role of surgical vs. non-surgical treatment
• Basic prevention tips
Radicular Pain = ‘Nerve Pain’
• Pain that follows the path of a nerve
– Typically L4, L5 or S1
∴ below the knee
• Leg pain > back pain
• Aggravated by stretching or pinching the nerve
• Relieved by anything that releases pressure
Image from cms.gov
Causes
• Herniated disc (younger)
Normal
Herniated
Images from fda.gov and cms.gov
Causes
• Foraminal stenosis (>40y)
Images from fda.gov and cms.gov
Initial Treatment
• Medication + Motion
• Short term meds: this pain can be HORRIBLE! – Gabapentin
– NSAIDS
– Opioids are appropriate (short term)
– Muscle relaxants (for sleep, short term)
• Lack of evidence for:Long term opioids, muscle relaxants
Treatment - Activity
Walking (everybody)
The McKenzie Institute International®
McKenzie exercises for disc herniation
Treatment: expectations
• Most improve (even with no tx) within 4-6 wks
Indications for referral for intervention:
Absolute: Progressive neurological deficit
Severe pain > 6 wks
Relative: Disabling pain > 6 wks
Interventional Treatments
Steroid injections: 65% get temp reliefComplications rates are high.Do risks outweigh benefits?
N Epstein. Surg Neurol Int. 2013; 4(S2): 74-93.
Surgery: 95% get significant relief (leg pain)5% experience complications
SPORT trial: after 6 weeks of symptoms, surgery has superior outcomes to non-surgical management
JAMA 2006
Takeaway
Most get better but …
Surgery works really well when needed
Spinal Stenosis
Images cms.gov
Spinal Stenosis
• F>M, older patients
• Back pain, “weak” legs, “tired” legs
• + Shopping cart sign
Spinal Stenosis
Normal Canal
Treatment
• Medication doesn’t help
• Walking is good exercise but is limited by the disease
– Excellent way to monitor disease progression
• Exercise is important to maintain function:– Low impact exercise
e.g. Tai Chi, swimming, cycling
The Best Exercises for Stenosis
Strength + balance: buttocks, posterior thigh
→ Fight gravity
Only 2 Interventions Help
Epidural steroids (short term, but are risks too high?)6
Surgery: decompression (+/- fusion)
SPORT trial:7
“Patients with symptomatic spinal stenosis treated surgically compared to those treated non-operatively maintain substantially greater improvement in pain and function” at 4yr and 8yr
6 www.cdc.gov/hai/outbreaks/meningitis7 Spine (Phila Pa 1976). 2015 Jan 15;40(2):63-76
Takeaway
Surgery works(but it is sometimes a very big deal)
Need to optimize medical status pre-op
Refer BEFORE you see health deteriorate from lack of activity!
Mechanical Back Pain
• Back pain that changes with mechanical forces
• Typically: – Worse:
prolonged posture, heavy activity
activity that stresses the back
– Better:
changes in posture
& when lying down
Image: cms.gov
What is NOT Mechanical Back Pain?
On a scale of 1-10, how bad is your pain?Answer: “15”
Where does it hurt?Answer: “Everywhere”
What makes your pain worse?Answer: “Everything”
What makes it better?Answer: “Nothing”
= non-specific LBP
Mechanical Back Pain
• Underlying problem may be:
– Structural defect
– Chronic wear and tear or DDD (degenerative disc disease)
Chronic Wear & Tear: DDD
DDD▪ Decrease water
content in discs▪ Collapse of disc
space▪ Osteophytes▪ Facet
osteoarthritis
Mechanical failure of the spine
NormalDDD
Why did my discs wear out, Doc?
Answer:
1. Because of the genes you were born with
and…
2. Because of everything you’ve done in your life
How do I stop it, Doc?
• Make the back stronger & healthier
– Exercise
– Weight control
– A healthy diet
– & QUIT SMOKING!
Treatment of DDDWARNING: published studies poorly differentiate mechanical LBP v. non-specific LBP
Strong evidence against8:Narcotics, bed rest
Lack of good evidence8 for:Physiotherapy, chiropractic, manipulation, massage, TENS, laser, accupuncture, other “modalities”, gabapentin, pregabalin
Moderate evidence8 for:combining massage with PT or Chiroheat
NSAIDs do help (Enthoven, JAMA 2017) “small but significant improvement”
8Eur Spine J. 2018 Nov,27(11): 2791-2803
The Key to Treatment is Exercise(and avoidance of aggravating mechanical factors)
• Moderate evidence8 for:
– Low impact exercise programs
e.g. walking, yoga, Tai Chi, pool exercise
– Resistance training
emphasize core muscles
Pier Digital Library8Eur Spine J. 2018 Nov,27(11): 2791-2803
Surgery?
Rarely, for degenerative disc disease
(but that may change in the future …)
Absolutely for structural problems
e.g. spondylolisthesis
Indication: failure of prolonged non-op Tx
What About Non-specific Pain?
Try to make a definitive diagnosis most have an underlying physical diagnosis, with symptom magnification
Treat the “other” problem as well as the underlying physical back problem
Much more difficult to rule out serious underlying pathology
Treatment of Non-specific Pain
Most guidelines fail to recognize the difference between non-specific pain and true mechanical pain
they are not the same, but both may be present
Follow treatment guidelines for mechanical pain but when present also address:
depression, anxiety
psycho-social & socio-economic issues
Use a ‘mind-body’ approach
What About Cancer?
Pain is usually non-specific (no consistent pattern)
may also have radicular pain or mechanical pain
Pain wakes you up out of a dead sleep
Usually worse at rest!
What About Cancer?
• Investigate pain that doesn’t resolve with treatment (guidelines range 4 – 102 wks; most suggest 4-6)
• Investigate pain with RED FLAGS– Hx of malignancy or HIV
– Unexplained weight loss
– Unexplained fever
– Significant trauma
– Significant risk of osteoporosis and (even minor) trauma
– Prolonged use of steroids
• Investigate neurological deficits and radicular symptoms that do not improve in 4 weeks
Case 1
• 84 yo F
• Severe radicular symptoms + claudication
• Cardiac Hx
• DM
• Obesity
• Hypertension
Degenerative scoliosis with foraminal stenosis
Case 1: First Line of Treatment
Choose:
1. NSAIDs + acetaminophen
2. Gabapentin + acetaminophen
3. Low dose narcotic + cyclobenzaprine
4. Physiotherapy
5. Epidural Steroid injection
When Do I Order MRI?
Choose:
1. Immediately (because the waiting list is 6 months)
2. Never (because the waiting list is 6 months)
3. After 4-6 weeks
4. When she develops neurological deficit
5. When her health deteriorates
Procedure
• Lateral with MMG + posterior plates
• Outpatient procedure
• 1” lateral + 1.5” posterior incision
• 15cc blood loss
Case 2
• 48 yo F
• Severe LBP
• Obesity, BMI=35
When do you refer for surgery?
Choose:
1. After 12 weeks of PT
2. When the pain clinic says she is ready
3. Following failure of ESI’s
4. After 6 months of non-op Tx
5. After 2 years of disability
Procedure
• Lateral + posterior pedicle screws
• 1” incision lateral
• Percutaneous screws posterior
• Outpatient procedure
• Blood loss 5cc
Thank You!
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