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!