2017 Women’s Health Conference...Epidemiology • Prevalence - 50% of all adults have low back...
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2017 Women’s Health Conference Body & Soul: Discovering a Healthy U California Lutheran University Thousand Oaks
2017 Women’s Health Conference...Epidemiology • Prevalence - 50% of all adults have low back pain every year • 15 – 20% seek medical attention • #1 cause of disability for
Parisa Sadoughi, MDPain ManagementUCLA Health Thousand Oaks
Treating Back Pain
Parisa Sadoughi, MD
Anatomy of the Spine
Presenter
Presentation Notes
I would like go orerwith looking on anatomty of spine , it is very easy to understand why b p is commom. Lumar spine needs to tolerate the wt of main portion of body it is also an area of body with a lot of mobility( bending) so we need use it the way to minimize any extra stress on spine during lifting bending excecising.. Any abnormal
Risk Factors• OCCUPATIONAL HAZARDS• SEDENTARY JOBS • increasing age: up to age 60, male = female after 60,women
> male due to osteoporosis.• size and shape of spinal canal• Smoking- cough • extended driving, due to low back strain • stress and other psychological factors • strenuous physical labor
Epidemiology
• Prevalence - 50% of all adults have low back pain every year
• 15 – 20% seek medical attention
• #1 cause of disability for Americans younger than 45 years of age
Presenter
Presentation Notes
Very common. Only 1/5 go to doctors. # 1 cause of disability in young adult.Framingham study showed obesity has a positive correlation with sudden death and angina. Associated hypertrophied ventricles. Depressed LV fxn even in young asymptomatic obese patients, improves after weight loss. Hypertension presumed from increased cardiac output. Increased cardiac output correlated to weight and proportional to increased O2 consumption. Change from sit to supine increase CO, PAWP, MPAP. Increased total blood volume, less on a volume/wt basis. Increased blood volume to feed adipose tissue
Natural History of Low Back Pain
• 70 % IMPROVE WITHIN 2 WEEKS
• 90 % IMPROVE WITHIN 6 WEEKS
• 3% DO NOT IMPROVE WITHIN 6-12 WEEKS
• 50 % of low back pain (LBP) cost is due to these patients
Presenter
Presentation Notes
Fortunitly benign or good result in 90% in 6 weeksonly 3% have issue after 3 month. This 3% is very costy. They become a chronic pain pt.. They are very hard to treat especially those they have psych issue and workers com or invovle in some type of legal issue. They are tolerance to any type of treatment
Who Treats The Pain
• Family physicians and internists• Physiatrists• Chiropractors • Neurologists• Pain specialists and anesthesiologists • Pain psychologists • Spine surgeons
Presenter
Presentation Notes
Treatment Goals:�Reduce pain to an acceptable level�Improve function�Improve coping strategies�Promote patient satisfaction�Patient education
Diagnosis Of Low Back Pain
• When did the pain begin? • What precipitated it; was there an injury, or did
it occur spontaneously? • Does it stay in the back, or does it travel down the leg, and it
so, where in the leg does it go? • What makes the pain better, and what makes it worse? • Is there any weakness associated with it? • Is there any loss of bowel or bladder control?
Presenter
Presentation Notes
when did the pain begin what precipitated it; was there an injury, or did it occur spontaneousluy? does it stay in the back, or does it travel down the leg, and it so, where in the leg does it go what makes the pain better, and what makes it worse is there any weakness associated with it is there any loss of bowel or bladder control
Physical Exam
• Tenderness to palpation over the lumbar spine• Bone and joint involvement
• Weakness in the lower extremities• Nerve Involvement
• Range of motion limitations• Muscle, nerve, and/or arthritis
Exams & Tests to Assess Low Back Pain
• Lumbar spine x-rays (films)• CT scans (computed axial tomography scans)• MRI scans (magnetic resonance imaging) • Myelograms • Post myelographic CT scans, • EMG/NCV (electromyogram/nerve conduction velocity) studie • Discograms• Bone density tests
Lumbosacral X-RayAP Lateral
Presenter
Presentation Notes
After taking a thorough history, and performing a detailed physical examination, radiological confirmation is important. After all, this is a picture which tells the physician whether or not there is something mechanically present which may explain the symptoms. An AP (anterior to posterior ) film of the lumbar spine is looking through the body, from front to back. This type of view can spot fractures, and is often useful for early detection of tumors involving the bone. lateral x ray of the lumbar spine is excellent for determining alignment of the spine. Compression fractures can detected easily. In addition, collapse of the disk spaces may indicate degenerative disk disease.
• To rule out compression fracture or other bony damage, especially if over 50 (plain films or CT)
• In patients with known osteoporosis or history of cancer
• If no red flags, no need for imaging or lab for first 4-6 weeks of conservative therapy for LBP as 90% recover within one month!
CT Scan, Myelogram, Discogram
Presenter
Presentation Notes
CT (computed axial tomography) scan shows "slices" through the lumbar spine. This type of image uses x rays, delivered in a circular manner circumferentially around the body. A sophisticated computer then adds the various rays, calculates densities of bones and soft tissue within the center of the rays, and produces a picture. The first CT scanner was made by EMI (which also produced Beatles records), and was extremely slow, and the pictures were relatively poor, by today's standards. Present day CT scans are fast, and quite sharp. CT is best for looking at bone, while soft tissue within the lumbar spine (such as nerves and herniated disks) are less optimally seen. A myelogram is a study in which a spinal tap is performed within the lumbar spine, and radioopaque (shows up on x-ray) dye is placed within the spinal fluid. X-rays are then taken, and CT scans are taken as well. The dye provides an outline of the nerves, and any abnormality, such as a herniated disk, can be seen as an indentation or defect in the normal filling of dye. In the myelogram on the left, the normal column of white dye is significantly narrowed by compression upon the nerves. MRI (magnetic resonance imaging) provides exquisite views of the nerves and other soft tissues around the lumber spine. While they don't provide as much detail about the bone as a CT scan does, they do offer the advantage of showing images in many different planes (axial, coronal, sagittal). Sometimes herniated disks which are subtle and difficult to see in one plane, are easily seen in another. These scans rely on magnetization of hydrogen atoms, and so far have not been found to have any long lasting adverse risks. Some patients have difficulty because the "bore" into which they must lie is relatively narrow, and "open" MRI scanners suit these patients better. Unfortunately there is some compromise of image quality in the open MRI scanners, and the closed machines of comparable technology still provide the best pictures. A discogram is a study in which radioopaque dye is injected into the disk space. This is both an anatomical study as well as a functional study. It looks at the anatomy of the disk space, and can show when dye leaks through rents in the annulus fibrosis. But just as or even more important, it is a functional test. When the physician injects dye into the disk space, the patient reports, on a scale from 1 to 10, how much pain has been produced. If the pressure injection of dye into the disk space reproduces the patients usual low back pain, then surgical fusion of the disk space may have some benefit in improving the pain. As far as the low back team knows, it is the only test in which we hope a patient has significant pain, because that means the disk is likely a cause of the pain, and surgical fusion may help. This is usually a method of last resort, after all else has failed.
When To Order Radiological Evaluation• Consider MRI if no improvement after 4-6 weeks
conservative treatment
• MRI for suspicion of Cauda Equina Syndrome
MRI
Presenter
Presentation Notes
MRI (magnetic resonance imaging) provides exquisite views of the nerves and other soft tissues around the lumber spine. While they don't provide as much detail about the bone as a CT scan does, they do offer the advantage of showing images in many different planes (axial, coronal, sagittal). Sometimes herniated disks which are subtle and difficult to see in one plane, are easily seen in another. These scans rely on magnetization of hydrogen atoms, and so far have not been found to have any long lasting adverse risks. Some patients have difficulty because the "bore" into which they must lie is relatively narrow, and "open" MRI scanners suit these patients better. Unfortunately there is some compromise of image quality in the open MRI scanners, and the closed machines of comparable technology still provide the best pictures
Causes Of Pain in Lower Back & Extremities • Sprained/strained ligaments, tendons, muscles• Herniated discs • Spinal Stenosis • Degenerative disc disease• Spondyolisis, Spondylolisthesis • Facets joints arthritis• Sacroiliac joint• Osteoporosis• Ankylosing Spondylitis• Arthritis (osteoarthritis and rheumatoid arthritis)
Presenter
Presentation Notes
Low back pain and lower extremity pain often get lumped into one category, but the causes, and therefore the treatments, can be quite different. Lower extremity pain, when it radiates from the low back, is usually the result of pressure on a nerve. The pain is often in the distribution which the nerve supplies. Low back pain, on the other hand, is often related to the mechanics of the spine. Muscle strain, arthritis, trauma, osteoporosis, and fracture are often causes. Often, disease processes which cause lower extremity pain can also cause low back pain, and vice versa. Psychological and emotional factors can play a role as well. When one has a tough day, their back might hurt, but later that day, while having fun with friends, the same person can completely forget about the pain. Low back pain can also be multifactorial, involving several causes. Here we will outline some of the general categories into which low back and lower extremity pain are often classified sprained/strained ligaments, tendons, and muscles.� ligaments connect bone to bone. tendons connect muscle to bone. All of these elements can become bruised as a result of sports injuries or heavy lifting. Although these injuries are usually self limited, and heal with time, repeated trauma can cause chronic pain.�degenerative disc disease� after we turn 20, each of us suffers a slow degeneration of the discs of the spine. Normally, the disk is a shock absorber situated between two vertebral bodies. It consists of a soft jelly in the center, called the nucleus pulposis, and it is held together by a firm band called the annulus fibrosis. When the disc dries up, it shrinks, and can result in mechanical pain. In addition, as the disc height collapses, the exiting nerves can become compressed, leading to lower extremity pain. Generally, this condition poses no danger, but can be very annoying to patients.�
Low back pain and lower extremity pain often get lumped into one category, but the causes, and therefore the treatments, can be quite different. Lower extremity pain, when it radiates from the low back, is usually the result of pressure on a nerve. The pain is often in the distribution which the nerve supplies. Low back pain, on the other hand, is often related to the mechanics of the spine. Muscle strain, arthritis, trauma, osteoporosis, and fracture are often causes. Often, disease processes which cause lower extremity pain can also cause low back pain, and vice versa. Psychological and emotional factors can play a role as well. When one has a tough day, their back might hurt, but later that day, while having fun with friends, the same person can completely forget about the pain. Low back pain can also be multifactorial, involving several causes. Here we will outline some of the general categories into which low back and lower extremity pain are often classified sprained/strained ligaments, tendons, and muscles.� ligaments connect bone to bone. tendons connect muscle to bone. All of these elements can become bruised as a result of sports injuries or heavy lifting. Although these injuries are usually self limited, and heal with time, repeated trauma can cause chronic pain.�degenerative disc disease� after we turn 20, each of us suffers a slow degeneration of the discs of the spine. Normally, the disk is a shock absorber situated between two vertebral bodies. It consists of a soft jelly in the center, called the nucleus pulposis, and it is held together by a firm band called the annulus fibrosis. When the disc dries up, it shrinks, and can result in mechanical pain. In addition, as the disc height collapses, the exiting nerves can become compressed, leading to lower extremity pain. Generally, this condition poses no danger, but can be very annoying to patients.�
Acute Low Back Pain• Less than 3 months onset
• Non-Radiating vs. Radiating Low back pain
• Initial Treatment is usually the same • EXCEPT Loss of bowel/urine/numbness in genital area
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Acute LBP Treatment
• Relative rest for a few days• More than 2 days of bed rest increases chance of muscle
weakness/de-conditioning• Ice/Heat• NSAIDS +/-Analgesics +/-Muscle relaxants• May benefit from steroid pack• Chiropractor• Acupuncture
Presenter
Presentation Notes
Framingham study showed obesity has a positive correlation with sudden death and angina. Associated hypertrophied ventricles. Depressed LV fxn even in young asymptomatic obese patients, improves after weight loss. Hypertension presumed from increased cardiac output. Increased cardiac output correlated to weight and proportional to increased O2 consumption. Change from sit to supine increase CO, PAWP, MPAP. Increased total blood volume, less on a volume/wt basis. Increased blood volume to feed adipose tissue
Non-Radiating Low Back Pain Causes
• BACK STRAIN-Muscles
• Osteoarthritis of spine
• Cancer
• Fracture
• Osteoporosis
• Spondylolisthesis
• Spondylysis
• Ankylosing spondylitis
Presenter
Presentation Notes
Framingham study showed obesity has a positive correlation with sudden death and angina. Associated hypertrophied ventricles. Depressed LV fxn even in young asymptomatic obese patients, improves after weight loss. Hypertension presumed from increased cardiac output. Increased cardiac output correlated to weight and proportional to increased O2 consumption. Change from sit to supine increase CO, PAWP, MPAP. Increased total blood volume, less on a volume/wt basis. Increased blood volume to feed adipose tissue
pain/tingling into the buttocks or lower extremity• Treated with injections of local anesthetic (and perhaps steroid)• Spray & stretch with home program• Deep cross tissue massage
Radiating Low Back Pain
•Disc Herniation
•Nerve Impingement
•Spinal Stenosis
•Sacroiliac joint dysfunction
•Myofascial Pain
•Cancer
•Infection
Presenter
Presentation Notes
Framingham study showed obesity has a positive correlation with sudden death and angina. Associated hypertrophied ventricles. Depressed LV fxn even in young asymptomatic obese patients, improves after weight loss. Hypertension presumed from increased cardiac output. Increased cardiac output correlated to weight and proportional to increased O2 consumption. Change from sit to supine increase CO, PAWP, MPAP. Increased total blood volume, less on a volume/wt basis. Increased blood volume to feed adipose tissue
Spinal Canal Stenosis• Greater than 50 years of age (usually in 60’s or 70’s)• LBP and leg pain with walking• Neurologic Claudication• Can be unilateral or bilateral • Increased pain with down hill walking and better with
walking uphill• + “shopping cart” sign
Lumbar Radiculopathy -“Sciatica”
• 1-2% of LBP patients have a compressed or inflamed lumbosacral nerve root
• Most common levels are L4-5 and L5-S1 (90% involve these two levels)
• Mechanism-annular degeneration leads to fissuring or tearing of the annulus which leads to disk rupture
Radicular Symptoms• Increased pain with:
-forward flexion-sitting, driving in car- cough, sneeze and bowel movement
• Indications• Relief of pain from nerve root irritation• Diagnosis of root level involved (SNRB)
• Medrol dose pack may be tried, if not contraindicated (infection, diabetes)
Radiculopathy - Treatment• SURGERY-5-10 % with disc herniation undergo surgery
(~280,000 per year in the US)
Facet Diseases• Pain may be localized to low back or radiate into
buttocks and posterior thigh• Unusual for this pain to go below the knee• Worse with extension and with prolonged standing• Can be dull toothache pain or sharp stabbing pain
Facet Diseases• Treatment
• Lumbar stabilization program• Facet mobilizations• Intra-articular injections under fluoroscopy• Medical branch blocks/ denervation under fluoro (diagnosis and treatment)
Sacroiliac Dysfunction• Pain is located in the low back and radiates into the
buttocks and posterior thighs• Special tests not very reliable• Patients will point to SI as source of pain• Can have associated piriformis spasm with “sciatica”• Common in pregnancy
Sacroiliac Dysfunction• Treatment
• NSAID’s• Heat/ice• Correct leg length discrepancy• SI mobilization• SI belt• Intra-articular injection under fluoroscopy
Framingham study showed obesity has a positive correlation with sudden death and angina. Associated hypertrophied ventricles. Depressed LV fxn even in young asymptomatic obese patients, improves after weight loss. Hypertension presumed from increased cardiac output. Increased cardiac output correlated to weight and proportional to increased O2 consumption. Change from sit to supine increase CO, PAWP, MPAP. Increased total blood volume, less on a volume/wt basis. Increased blood volume to feed adipose tissue
• Spinal Infections-fever with or without chills-worsening back pain, especially at night-increased risk if:
• 3% with acute LBP may have a potentially life-threatening condition-fever/chills-unexplained weight loss-persistent night pain-teenagers-greater than 50 years old-previous history of cancer (may require early imaging)
RED FLAG
• Possible Epidural Abscess (MRI)-fever-progressive neurological deficits-localized tenderness over abscessed bone
RED FLAG
• AAA-sudden searing intensifying pain from back to lower extremities-abdominal ultrasound-consider vascular consult
