Low Back Pain and

Lumbar Disc Disease

John M. Blair, MD

Puget Sound Spine Institute

Low Back Pain

Incidence:60-90% Lifetime prevalence5% Annual incidence1:1 Female/Male ratio except after age 60

Sciatica:40% Lifetime prevalence10% of patients with low back pain

Low Back Pain Natural History

• 33% Pain free after one week• 75% Pain free after one month• >90% Pain free after three

months

Low Back Pain

Acute Low Back Pain:

•Pain in the low back which lasts less than 90 days

Chronic Low Back Pain:

•Pain in the low back which exceeds 6 months duration•3-5% of all back pain

Acute Low Back PainInitial Management

• Mechanical vs. Non-mechanical

• X-rays

• Exam

Acute Low Back PainManagement

• Bed rest (2-7 days)• Early mobilization• Anti-inflamatories, muscle relaxants and

narcotics • Ice• Bracing

Acute Low Back PainManagement

• Physical Therapy

• Spinal manipulation: May speed recovery but no long term efficacy.

• Massage Therapy: Feels good but unproven.

DRX 9000

DRX 9000

• There is no published literature in peer reviewed journals which supports or refutes the efficacy of this device.

• Traction has been shown to be effective in the treatment of some spinal conditions.

Chronic Low Back PainLong-term management and

treatment

• Determine source of symptoms

• Treatment

Low Back Pain

Determine source of symptoms:• Lumbar disk• Facet joint• Spinal nerves• Vertebral body• Soft tissues• Hip or sacroiliac joint

Low Back Pain Diagnostic Tests

• X-Rays• MRI• CAT scan +/- myelogram• Discogram• EMG• Bone scan• Injections

Low Back PainLong-Term Management

• Therapy/Conditioning

• Lifestyle changes

• Medication

• Injections

• Surgery

Low Back PainLong-Term Management

The goal of long-term management is to reduce stress and strain on the back by strengthening the muscles surrounding the spine and eliminating activities or habits which accelerate the degenerative process.

Low Back PainLong-Term Management

Low Back PainLong-Term Management

• Passive care directed at symptom relief does not address the underlying dysfunction.

Low Back PainLong-Term Management

EXERCISE !• Walk, Bike, Swim, Treadmill, Elliptical

trainer• Stretching• Avoid impact and twisting activities:

Running, Tennis, Golf

Low Back PainLong-Term Management

• Increased pain during the initial phases of rehabilitation is common and should not cause alarm.

Low Back PainLong-Term Management

• Quit smoking• Osteoporosis: Consult your doctor regarding

diet, hormonal replacement and bone building drugs.

TreatmentMedications

• Anti-Inflammatories: Motrin, Advil, Aleve, Aspirin, Tylenol

• Prescription NSAID’s: Lodine, Arthrotec, Mobic, Celebrex

• Narcotics• Anti-Depressants• Anti-Convulsants

TreatmentInjections

• Epidural

• Selective nerve root block (SNRB)

• Facet joint block

All injections should be done with x-ray guidance!

Lumbar Spine Surgery

Surgery of the low back is best directed toward relief of pain originating from a compressed or irritated nerve root(s).

Low Back PainSurgical Treatment of Sciatica

• Laminectomy• Discectomy• Sometimes fusion

is also performed.

Low Back PainSurgical Treatment of Sciatica

• Short procedure (1hr. Average)

• < 24 hour hospital stay

• Good-excellent results in most patients

Surgery for

Chronic Low Back PainTraditional• Lumbar fusionNew Options• IDET• Kyphoplasty/vertebroplasty• Artificial disc replacement (ADR)

Surgery for

Chronic Low Back PainTraditional:

• Fusion

Lumbar Fusion

• Posterior

• Anterior

Lumbar Fusion

Lumbar Fusion

• Combined

Surgical Treatment of Low Back Pain

New Options

• Intradiscal Electrothermal Annuloplasty (IDET)

• Artificial disc replacement (ADR)

• Vertebroplasty / Kyphoplasty

IDET

• A metal coil is inserted into a disc.

• The coil is heated and seals a painful tear.

• Outpatient procedure under IV sedation.

IDET

IDET

Indications:

• One or two painful discs with a tear.

• No prior surgery.

• Well preserved disc height.

Results:

• 60% Good to Excellent results

• Anterior abdominal incision.

• Disc is completely removed.

• Artificial disc is placed.

• Hospital stay of 1-2 days.

Artificial Disc Replacement

Artificial Disc Replacement

Criteria:• 1-2 degenerated disks• Good disk height• No facet arthritis• No prior surgery• No sciatica

70-80% good to excellent results in properly selected patients.

Artificial Disc Replacement

• Best results seem to correlate with less motion (I.e. fusion).

Kyphoplasty / Vertebroplasty

• Cement is injected into a broken vertebrae.

Kyphoplasty / Vertebroplasty

• Balloon is used to create cavity prior to injection of cement with kyphoplasty.

• Outpatient procedure often with immediate pain relief.

Resources

• Puget Sound Spine Institute

• WebMD

• North American Spine

Society

• American Academy of

Orthopedic Surgeons. www.aaos.org

Thank-you!