LBP - Low Back Pain Nabeel Kouka, MD, DO, MBA MD, Nabeel...

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Unformatted text preview: Low Back Pain Nabeel Kouka, MD, DO, MBA MD, Nabeel www.brain101.info Epidemiology Incidence of LBP: 60-90 % lifetime incidence 5 % annual incidence 90 % of cases of LBP resolve without treatment within 6-12 treatment within 6-12 weeks 40-50 % LBP cases resolve without treatment in 1 week 75 % of cases with nerve root involvement can resolve in 6 in months LBP and lumbar surgery are: 2nd and 3rd highest reasons for physician visits 2nd 5th leading cause for hospitalization 3rd leading cause for surgery www.brain101.info 1 Disability Age and LBP: Leading cause of disability of adults < 45 45 years old Third cause of disability in those > 45 45 years old Prevalence rate: Increased 140 % from 1991 to 2000 with 140 only125 % population growth Nearly 5 million people in the U.S. are on million disability for LBP www.brain101.info 2 Lifetime Return to Work Success of < 50 % if off work > 6 months Success 50 25 % success rate if off work > 1 year Nearly 0 % success if return to work has not occurred in 2 years www.brain101.info 3 Occupational Risk Factors Low job satisfaction Monotonous or repetitious work Educational level Adverse employer-employee relations Recent employment Frequent lifting Especially exceeding 25 pounds Utilization of poor body mechanics in technique www.brain101.info 4 Differential Diagnoses Lumbar Strain Disc Bulge / Protrusion / Extrusion producing Radiculopathy producing Radiculopathy Degenerative Disc Disease (DDD) Spinal Stenosis Spondyloarthropathy Spondylosis Spondylolisthesis Sacro-iliac Dysfunction Sacro-iliac Dysfunction www.brain101.info 5 Frequency of Back Pain Types 97% “mechanical” www.brain101.info 6 Frequencies of Causes of LBP Mechanical LBP Mechanical 97% 97% Non-Mechanical 1% Lumbar sprain = Lumbago =70% Lumbar Neoplasia = 0.7 % 0.7 Disk/facet degeneration = 10% Disk/facet Multiple Myeloma Myeloma Herniated disk = 4% Herniated Lymphoma/leukemia Lymphoma/leukemia Spinal cord tumors Spinal Spinal Stenosis = 3% 3% Osteopor. Compre. Frx = 4% Osteopor Compre 4% Retroperitoneal tumors Retroperitoneal Spondylolisthesis = 2% 2% Traumatic fractures = < 1% Traumatic Congenital < 1% Congenital Severe kyphosis Severe kyphosis Severe Scoliosis Severe Internal disk disruption Internal Primary vertebral tumors Primary INFECTION (0.01%) INFECTION Osteomyelitis Osteomyelitis Paraspinal abscess Paraspinal Herpes Zoster Herpes Spondyloarthropathy (0.3%) (0.3%) Ankylosing Spondylitis Ankylosing www.brain101.info 7 Biomechanics 80% Anterior 20% Posterior The 80-20 rule of Spine loading www.brain101.info 8 Diagnosis “Biggest challenge is to identify the pain generator” www.brain101.info 9 Diagnostic Tools 1. Laboratory: • Performed primarily to screen for other disease etiologies Infection Cancer Spondyloarthropathies No evidence to support value in first 7 weeks unless with red flags • Specifics: • WBC ESR or CRP HLA-B27 Tumor markers: Kidney Breast www.brain101.info Lung Thyroid Prostate 10 2. Radiographs: • Pre-existing Degenerative Joint Disease (Osteoarthritis) is most common diagnosis • Usually 3 views adequate with obliques only if equivocal findings • Indications: • History of trauma with continued pain • < 20 years or > 55 years with severe or persistent pain • Noted spinal deformity on exam • Signs / symptoms suggestive of spondyloarthropathy • Suspicion for infection or tumor www.brain101.info 11 www.brain101.info 12 a vertebral body d rt. pedicle, en face i interfacetal joint o rt. superior articular process r rt. inferior articular mass & facet Arrow absent pars = spondylolysis o1 rt. superior articular process & facet, subjacent vertebra d1 rt. pedicle, suprajacent vertebra p1 rt. subjacent intact pars www.brain101.info 13 3. Electromylogram (EMG): 3. (EMG): Measures muscle function Can demonstrate radiculopathy or peripheral nerve entrapment, but may not be positive in the extremities for the first 3-6 weeks and paraspinals for the first 2 weeks Would not be appropriate in clinically obvious radiculopathy 4. Bone Scan: Very sensitive but nonspecific Useful for: • Malignancy screening • Detection for early infection • Detection for early or occult fracture www.brain101.info 14 www.brain101.info 15 5. Myelogram: Procedure of injecting contrast material into the spinal canal with imaging via plain radiographs versus CT In past, considered the gold standard for evaluation of the spinal canal and determining the cause of pressure on the spinal cord or spinal nerves. With potential complications, as well as advent of MRI and CT, is less utilized: • More common: Headache, nausea / vomiting • Less common: Seizure, pain, neurological change, anaphylaxis Myelogram alone is rarely indicated. Hitselberger study 1968 Journal of Neurosurgery: • 24 % of asymptomatic subjects with defects www.brain101.info 16 1 Spinal cord 2 Contrast in subarachnoid space 3 Intervertebral disc 4 Nerve rootlets of cauda equina www.brain101.info 17 www.brain101.info 18 6. CT with Myelogram: Can demonstrate much better anatomical detail than Myelogram alone Utilized for: • Demonstrating anatomical detail in multilevel disease in pre-operative state • Determining nerve root compression etiology of disc versus osteophyte • Surgical screening tool if equivocal MRI or CT www.brain101.info 19 A CT-myelogram sagittal 2D reconstructed image shows the expanding intraspinal low-density mass (arrow) surrounding by myelogram contrast. A CT-myelogram coronal 2D reconstructed image shows the intraspinal lipoma (arrows). Note the displaced nerve roots to the left of the conus. A Tarlov cyst (nerve root sleeve cyst or diverticulum) of left S3 is incidentally noted (arrowhead). www.brain101.info 20 7. CT: Best for bony changes of spinal or foraminal stenosis Also best for bony detail to determine: • Fracture • Degenerative Joint Disease (DJD) • Malignancy SW Wiesel study 1984 Spine: • 36 % of asymptomatic subjects had “HNP” at L4-L5 and L5-S1 levels www.brain101.info 21 8. Discography (Diagnostic disc injection) Less utilized as initial diagnostic tool due to high incidence of false positives as well as advent of MRI Utilizations: • Diagnose internal disc derangement with normal MRI / Myelogram • Determine symptomatic level in multi-level disease Criteria for response: • Volume of contrast material accepted by the disc, with normals of 0.5 to 1.5 cc • Resistance of disc to injection • Production of pain - MOST SIGNIFICANT MOST Usually followed by CT to evaluate internal architecture, but also may utilize MRI As outcome predictor (Coulhoun study 1988 JBJS): • 89 % of those with pain response received benefit from surgery • 52 % of those with structural change received surgical benefit www.brain101.info 22 Discography Clinical pain provocation test Test is positive only if: The disc is abnormal in appearance AND Patient’s clinical pain is provoked during injection www.brain101.info 23 www.brain101.info 24 9. MRI • Best diagnostic tool for: Soft tissue abnormalities: • Infection • Bone marrow changes • Spinal canal and neural foraminal contents Emergent screening: • • • • Cauda equina syndrome Spinal cored injury Vascular occlusion Radiculopathy Benign vs. malignant compression fractures Osteomyelitis evaluation Evaluation with prior spinal surgery www.brain101.info 25 www.brain101.info 26 Has essentially replaced CT and Myelograms for initial evaluations Boden study 1990 JBJS: 20 % of asymptomatic population < 60 years with “HNP” • 36 % of asymptomatic population of 60 years • Jensen study 1995 NEJM: 52 % of asymptomatic patients with disc bulge at one or more levels • 27 % of asymptomatic patients with disc protrusion • 1 % of asymptomatic patients with disc extrusion • www.brain101.info 27 MRI with Gadolinium contrast: Gadolinium is contrast material allowing enhancement of intrathecal nerve roots Utilization: • Assessment of post-operative spine - most most frequent use • Identifying tumors / infection within / surrounding spinal cord • Diagnosis of radiculitis Post-operatively can take 2-6 months for reduction of mass effect on posterior disc and anterior epidural soft tissues which can resemble preoperative studies Only indications in immediate post-operative period: • Hemorrhage • Disc infection www.brain101.info 28 10. Psychological tools: Utilized in case scenarios where psychological or emotional overlay of pain is suspected • Symptom magnification • Grossly abnormal pain drawing • Non-responsive to conservative interventions but with essentially normal diagnostic studies Includes: • Pain Assessment Report, which combines: • McGill Pain Questionnaire • Mooney Pain Drawing Test • MMPI • Middlesex Hospital Questionnaire • Cornell Medical Index • Eysenck Personality Inventory www.brain101.info 29 Disc Degeneration: Findings? Narrowing Osteophyts Endplate sclerosis www.brain101.info 30 Degeneration & Tears www.brain101.info 31 Disc Normal Bony Endplate Bulge Canal Disc Classification Protrusion www.brain101.info Extrusion 32 Bulging www.brain101.info 33 Protrusion www.brain101.info 34 Protrusion www.brain101.info 35 Extrusion www.brain101.info 36 Extrusion www.brain101.info 37 Extrusion www.brain101.info 38 Classification of Nerve Roots Normal Contacted Displaced Compressed www.brain101.info 39 Normal Nerve Roots Normal Contacted Nerve Root Contacted Contacted Nerve Root Contacted Displaced Nerve Root Displaced Compressed Nerve Root Compressed Displaced & Compressed Displaced Nerve Root Displaced and Compressed Displaced Nerve Root Treatment “Every thing doctors do is to help patients to avoid surgery” www.brain101.info 47 Treatment Pharmacological NSAIDS Muscle relaxents: • Re-establish sleep patterns • More useful in myofascial/muscular pain Membrane stabilizers • TCA / Neurontin • Re-establish sleep pain • Reduce radicular dysesthesias Narcotics: rarely indicated • Morphine, Oxy/hydrocodone, Oxymorphone, Hydromorphone, Fentanyl, Methadone Steroids: more useful for radiculitis Non-narcotic analgesics: Ultram (Tramadol) www.brain101.info 48 Physical Therapy Modalities • • • • • • • Electrical Stimulation/TENS Postural Education / Body Mechanics Massage / Mobilization / Myofascial Release Stretching / Body Work Exercise / Strengthening Traction Pre-conditioning / Work-conditioning Injections (Neural blockade) • • • • Epidural blocks Facet blocks Trigger point SI joint www.brain101.info 49 Osteopathic Manipulation Manipulation & Mobilization Central & unilat PAs, Transverse Specific Passive Physiological Rxs Several tqs performed during 1 Rx session 9 Rxs over 3 wks www.brain101.info 50 Review of 27 SMT trials for acute NSLBP SMT produces better outcomes than placebo, no Rx, & massage. SMT vs placebo: -18mm (-24 to -13) SMT vs no Rx: -17mm (-26 to -8) [Pain reduction, 100mm VAS, <4/52] SMT & ‘usual physiotherapy’, & ‘usual medical care’ appear to produce similar outcomes. SMT vs medical care: -4mm (-14 to 6) [Pain reduction, 100mm VAS, <4/52] www.brain101.info 51 Psychological therapy Behavioral treatments (chronic LBP) Biofeedback Alternative Therapy Acupuncture Multidisciplinary approaches www.brain101.info 52 Interventional Therapy Sympathetic Diagnostic Therapeutic Neurolytic Steroid injections Implantation technology Intrathecal pumps Neuromodulation Spinal cord stimulation Peripheral nerve stimulation www.brain101.info 53 Surgery Laminectomy Hemilaminectomy Discectomy Fusion – Instrumented – Non-instrumented fusion Minimally Invasive Spine Surgery (MISS) – Kyphoplasty – Percutaneous Disc Decompression (PDD) Percutaneous Disc www.brain101.info 54 Spine Arthroplasty Spine Arthroplasty (Fusion w/Disc Prosthesis) Fusion w/Disc Prosthesis) Indications Chronic low back pain +/- leg pain Persisting > 6 months Associated with degenerative disc changes Leg pain Radicular Pseudoradicular Foraminal stenosis Secondary to disc space height loss – may be relieved indirectly by disc height restoration www.brain101.info 55 Kyphoplasty It is used to treat painful progressive vertebral body collapse/fracture due to osteoporosis or the metastasis to the vertebral body. Accomplished by inserting a balloon into the center of the vertebral body (See Figure 1). Then the balloon is inflated (See Figure 2). This pushes the bone back towards its normal height and shape. It also helps create a cavity. Then the cavity is filled with the bone cement. www.brain101.info 56 www.brain101.info 57 Percutaneous Disc Decompression (PDD) Percutaneous Disc Benefits: Outpatient procedure Minimal to no epidural scarring No general anesthesia Spine stability preservation Decreased cost Low rate of complications: Infection Peripheral nerve injury www.brain101.info 58 Types of PDD Chemonucleolysis (w/Papain) Intradiscal Electrothermy (IDET®) or Spine CATH Laser Disc Decompression (LASE®) Intradiscal Coblation® Therapy (Nucleoplasty®) Mechanical Nuclear Removal (DeKompressor®). Endoscopic MISS Endoscopic MISS www.brain101.info 59 Endoscopic MISS Endoscopic MISS The Goal of Endoscopic MISS The MISS “Less is Better, But Less is More” Spinal Motion Preservation Non-fusion Technology Dynamic Stabilization Spinal Arthroplasty www.brain101.info 60 Indications for Endoscopic MISS Indications MISS Patients with uncomplicated herniated discs/degenerative spine disease accompanied by the following: Pain of back, neck, trunk, and limbs with neurological deficit Pain that has not responded to conventional treatments,including physical therapy, medication, exercise, rest for at least eight twelve weeks A positive CT scan, MRI scan, myelogram, and positive discogram for disc herniation Positive virtual 3D endoscopic findings, and EMG findings are helpful www.brain101.info 61 Contraindications for Endoscopic MISS Contraindications MISS Evidence of pathologies such as fracturedislocation, large spinal tumors, pregnancy, or active infections Clinical findings that suggest pathology other than degenerative discogenic disease (e.g. multiple sclerosis, vascular anomalies, degenerative myelopathy) Evidence of neurologic or vascular pathologies mimicking a herniated disc Evidence of acute or progressive spinal cord disease Cauda equina syndrome Painless motor deficit www.brain101.info 62 Possible Rx for chronic LBP European Guidelines 2004 Conservative treatments: Cognitive behavioural therapy, supervised exercise therapy, brief educational interventions, multidisciplinary (biopsycho-social) treatment, back schools, manipulation/mobilisation, heat/cold, traction, laser, ultrasound, short wave, interferential, massage, corsets, TENS. Pharmacological treatments: NSAIDs, weak opioids, noradrenergic or noradrenergicserotoninergic antidepressants, muscle relaxants, capsicum plasters, Gabapentin. Invasive treatments: Acupuncture, epidural corticosteroids, intra-articular (facet) steroid injections,local facet nerve blocks, trigger point injections, botulinum toxin, radiofrequency facet denervation, intradiscal radiofrequency lesioning, intradiscal electrothermal therapy, radiofrequency lesioning of the dorsal root ganglion, spinal cord stimulation, intradiscal injections, prolotherapy, percutaneous electrical nerve stimulation (PENS), neuroreflexotherapy, surgery. www.brain101.info 63 Recommended Treatments European Guidelines 2004 Conservative treatments: Cognitive behavioural therapy, supervised exercise therapy, brief educational interventions, multidisciplinary (bio-psycho-social) treatment, back schools, manipulation/mobilisation, heat/cold, traction, laser, ultrasound, short wave, interferential, massage, corsets, TENS. Pharmacological treatments: NSAIDs, weak opioids, NSAIDs weak opioids noradrenergic or noradrenergicserotoninergic antidepressants, noradrenergic antidepressants, muscle relaxants, capsicum plasters, Gabapentin. muscle Gabapentin Invasive treatments: Acupuncture, epidural corticosteroids, intraintraarticular (facet) steroid injections,local facet nerve blocks, trigger articular (facet) point injections, botulinum toxin, radiofrequency facet denervation, point denervation iintradiscal radiofrequency lesioning, intradiscal electrothermal ntradiscal lesioning intradiscal therapy, radiofrequency lesioning of the dorsal root ganglion, spinal therapy, of cord stimulation, intradiscal injections, prolotherapy, percutaneous cord prolotherapy percutaneous electrical nerve stimulation (PENS), neuroreflexotherapy, surgery. electrical neuroreflexotherapy www.brain101.info 64 Recommended under some situation European Guidelines 2004 Conservative treatments: Cognitive behavioural therapy, supervised therapy, exercise therapy, brief educational interventions, multidisciplinary (biopsycho-social) treatment, back schools, manipulation/mobilisation, heat/cold, traction, laser, ultrasound, short wave, interferential, massage, corsets, TENS. Pharmacological treatments: NSAIDs, weak opioids, noradrenergic or noradrenergicserotoninergic antidepressants, muscle relaxants, capsicum plasters, Gabapentin. Gabapentin Invasive treatments: Acupuncture, epidural corticosteroids, intra-articular intra-articular (facet) steroid injections,local facet nerve blocks, trigger point injections, botulinum toxin, radiofrequency facet denervation, intradiscal botulinum denervation intradiscal radiofrequency lesioning, intradiscal electrothermal therapy, radiofrequency radiofrequency lesioning therapy, llesioning of the dorsal root ganglion, spinal cord stimulation, intradiscal esioning intradiscal iinjections, prolotherapy, percutaneous electrical nerve stimulation (PENS), njections, prolotherapy neuroreflexotherapy, surgery. www.brain101.info 65 Not Recommended European Guidelines 2004 Conservative treatments: Cognitive behavioural therapy, supervised therapy, exercise therapy, brief educational interventions, multidisciplinary (biopsycho-social) treatment, back schools, manipulation/mobilisation, psycho-social) manipulation/mobilisation heat/cold, traction, laser, ultrasound, short wave, interferential, massage, corsets, TENS. Pharmacological treatments: NSAIDs, weak opioids, noradrenergic or NSAIDs weak opioids noradrenergicserotoninergic antidepressants, muscle relaxants, capsicum noradrenergicserotoninergic antidepressants, plasters, Gabapentin. Invasive treatments: Acupuncture, epidural corticosteroids, intra-articular (facet) steroid injections,local facet nerve blocks, trigger point injections, botulinum toxin, radiofrequency facet denervation, intradiscal radiofrequency lesioning, intradiscal electrothermal therapy, radiofrequency lesioning of the dorsal root ganglion, spinal cord stimulation, intradiscal injections, prolotherapy, percutaneous electrical nerve stimulation (PENS), electrical neuroreflexotherapy, surgery. www.brain101.info 66 Results: Acute LBP Effective: Advice to Stay Active, Advice NSAIDs & Muscle Relaxants NSAIDs Muscle Not effective: Bed Rest & Specific Bed Exercises No consistent evidence for for Acupuncture & Lumbar Supports www.brain101.info 67 Results: Chronic LBP LBP Effective: Exercise Therapy, Osteopathic Exercise Manipulations, Behavioural Therapy & Multidisciplinary pain treatment programs Likely to be effective: Back Schools & Back Massage Not effective: TENS TENS No consistent evidence for: Acupuncture; Acupuncture; Facet, Epidural & Local Injections; Lumbar Supports www.brain101.info 68 Results: Disc Prolapse Surgery Disc No difference between Micro- & Standard Discectomy Standard Discectomy Chemonucleolysis produced better Chemonucleolysis produced clinical outcomes than Percutaneous clinical Percutaneous Discectomy & Placebo Discectomy Placebo Surgical Discectomy produced better Surgical produced clinical outcomes than Chemonucleolysis with Chymopapain Chemonucleolysis Chymopapain www.brain101.info 69 ...
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This note was uploaded on 12/24/2011 for the course STEP 1 taught by Professor Dr.aslam during the Fall '11 term at Montgomery College.

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