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!