Low Back Pain abc A review of anatomy and treatment options for low back pain.

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1. Raed M. Ali, M.D.
St. Jude Heritage Medical Group
Orthopaedic Surgery Department
April 11, 2005
Current Concepts in the Evaluation and
Management of Low Back Pain

2. Current Concepts in the Evaluation and
Management of Low Back Pain
OBJECTIVES
•Common Causes of Low Back Pain
•Evaluation of Low Back Pain
•Treatment Options for Low Back Pain

3. Why is this Important?
•80% of people will experience back pain
•35% with LBP develop sciatica
•14% of new patient visits to physicians are for LBP
•13 million physician visits each year are for LBP
•2.4 million in US with Chronic Disability due to LBP
•50% with LBP had been hospitalized
•22% with LBP had undergone surgery
National Center for Health Statistics.

4. Why is this Important?
•Most frequent cause of disability in <45 yo
•if out of work >6mo only 25% return to work
•if out >2 y probability of return is negligible
•Occupations with high risk
•Nurses
•Truck drivers
National Center for Health Statistics.

5. Causes of Low Back Pain…

6. Common Causes of Low Back Pain…
•Muscle Strains and Ligament Sprains
•Degenerative Disk Disease
•Herniated Disk
•Lumbar Stenosis
•Fractures

7. Lumbar Strains and Sprains
DEFINITIONS
•STRAIN = Partial or complete muscletear.
•SPRAIN = Partial or complete ligamenttear.

8. Lumbar Strains and Sprains
COMMON CAUSES
•Motor Vehicle Accidents (MVA) = “Whiplash”
•Poor body mechanics/posture at home or work
•Overuse injuries (frequent/repetitive activities)

9. Lumbar Strains and Sprains
Low Back Pain Vicious Cycle
Injury
Stiffness Stop
Moving
Low Back Pain
Hurts to Move
Weakness
Break the Cycle with:
-Physical Therapy
-Aerobic Exercises
-Proper Posture
Bedrest is proven
not to be as effective!!

10. Lumbar Strains and Sprains

11. Lumbar Strains and Sprains

12. Lumbar Strains and Sprains

13. Herniated Disk with
Nerve Compression
= “Sciatica”
•Pressure or
Traction on nerve
root Components
of the Sciatic
Nerve
•It produces pain/
numbness/
weakness in the leg

16. Clinical Presentation
1-RADICULAR SYMPTOMS
•Motor/Sensory change correspond to involved root
•“Painless Weakness”
2-LOW BACK PAIN
3-LOW BACK AND RADICULAR SYMPTOMS

17. RADICULAR PAIN
•caused by nerve root compression
•classically a sharp, lancing pain
•pain typically increased by any activity that
increases intraspinal and intradiscal pressures
•back pain may abate with onset of leg pain
(Sciatica)
•L5 and S1 nerve roots most commonly involved

18. MOTOR SYMPTOMS
•motor group weakness corresponds to nerve
root involvement
•motor symptoms present as isolated
phenomena
•relatively painless mono-or multi-radicular
paresis may suggest alternative pathology
•metabolic or infectious neuropathy
•space-occupying lesion of the cord
•stenosis

19. Cauda Equina Syndrome
•usually results from central disc herniation
classically involving all nerve roots below L1
•most consistent finding is urinary retention
•most common sensory deficit over buttocks,
post-superior thighs, and peroneal regions
(saddle anesthesia)
•anal sphincter tone diminished in 60-80%

20. Evaluationof Sciatica/LBP:
HISTORY
•Character of pain
•Location of pain
•Exacerbaitng phenomena
•Ameliorating phenomena
•Radiation of pain (radicular vs.....
referred)
•Time Relationships (e.g. night pain)
•Associated Phenomena

21. Degenerative Lumbar Disk Disease
•Disc Degeneration (resorption/narrowing)
•Segmental Instability (Abnormal Joint Motion)
•End Plates Inflammatory Changes
•Foraminal Volume Decrease (stenosis/radicul.)
•Baseline Stiffness
•Occasionally Discogenic Pain
•Chronic Low Back Pain

22. SPINAL STENOSIS
•Buttock pain radiating to lower extremities
•Pain on standing with relief by lying/sitting down
•Cramping and pain in calves with walking short
distances
•With continued walking paresthesia and numbness
•Walking uphill is easier than walking downhill
•Riding bike with ease
•Hyperextension produces pain

23. SPINAL STENOSIS
Potential Coexistent Problems
•Neurogenic Claudication
•Vascular claudication
•Degenerative Disc Disease
•Primary osteoarthritis of the hip

24. Evaluation of Low Back Pain

25. Evaluation of Low Back Pain:
Team Approach
•Initial Evaluation (Primary Care Doctors,
Chiropractic, Orthopedic Surgeons, Nurse Case
Managers )
•Initial Diagnosis and Treatment.
•Referral to specialist if necessary.

26. Evaluation of Low Back Pain:
Team Approach
•>90% with Low Back Pain Respond to Initial
Conservative Treatment.
•Remaining 5-10% may develop more chronic
symptoms. (These result in >90% of medical
treatment expense of LBP).
•Aggressive early treatment and return to functional
activities and work is IMPERATIVE!!
•<25% of those off work for >6 months will ever
return to work!

27. Basic History
•Onset of Pain (DOI)
•Did the pain begin after an injury?
•Is there associated leg pain, weakness, or numbness?
•How severe are the symptoms? (Scale 0 –10)
•Medical and Surgical History. (Previous Back Surg.)
•Social History (Smoking, EtOH, etc)
•Psychosocial History (Depression, etc)

28. BASIC PHYSICAL EXAM
•Complete motor, sensory &
reflex exam
•Peripheral vascular exam
•Joint examination
•Abdominal Exam
•Rectal Exam when indicated

29. INSPECTION
•sciatic scoliosis, list
•loss of lumbar lordosis
•antalgic gait, stance with leg in flexed
position

30. Sciatic Scoliosis

31. Sciatic Scoliosis

32. PALPATION
Is There A Tender Spot?
Or is it a deeper pain unaffected by palpation?

33. TENSION SIGNS
Supine Straight Leg Raise Sign
Crossed Straight Leg Raise Sign

34. Some things are not what they appear…
•We occasionally see fictitious
claims for secondary gain!
•Patients may “Fake”the physical
exam, and occasionally they can
be pretty good at it.
•As the physician, it is important to
give our patients the benefit of the
doubt and rule out real pathology.

35. Radiographic Evaluation
•Plain Radiographs
•CT scan
•Myelogram
•CT –Myelography
•MRI –Most Sensitivity/Specificity for Lumbar Abnormalities
–Jarvik JG; Neuroimaging Clin N Am 2003 May
•Nuclear Medicine (Tc-Bone Scan)
•Discography
•Post Discogram CT

36. PLAIN X-RAY

37. Plain CT-Scan
3-D CT

38. M
Y
E
L
O
G
R
A
M

39. Myelogram -CT
Post-Myelogram CT
Myelogram

40. LUMBAR
SPINAL
STENOSIS:
Synovial
Cyst
Plain CT-Scan
Myelogram
MRI

41. MRI

42. Normal StenosisHerniated Disk

43. Abnormal magnetic-resonance scans of the lumbar spine in
asymptomatic subjects. A prospective investigation.
Boden et al. J Bone Joint Surg [Am] 1990;72:403-408
Under 60 years Over 60 years
•Herniated Disk22 % 36 %
•Spinal stenosis1% 21 %
•Bulging disc54 % 79 %
•Degenerated disc46 % 93 %
•Given the high prevalence of Low Back Pain and of anatomic
abnormalities, MRI findings of degenerative disks or
protrusions in people with low back pain may often be
coincidental.

44. Abnormal MRI Scans of the Cervical Spine in Asymptomatic
Subjects. A Prospective Investigation.
Boden et al. J Bone Joint Surg Am, Sep 1990, 72(8) p1178-84
Under 40 yearsOver 40 years
•Herniated Disk 10% 5%
•Foraminal Stenosis4% 20%
•Degenerative Disk25% 60%

45. Nuclear Medicine Imaging

46. Nuclear Medicine Imaging
•Nuclear medicine studies have a limited role in the acute
phase of lumbar spine injury
•After 24 hours, a bone scan demonstrates increased
uptake in the area of a fracture. ( A delay of as long as
72 hours may be necessary to identify some fractures.)

47. Discogram + Discogram-CT
DISCOGRAM
POST DISCOGRAM -CT

49. ELECTRODIAGNOSIS
•Confirmation of physical exam findings
•Anatomic localization
•Distinguish overlapping conditions
•Electromyograms (EMG)
•Nerve Conduction Velocity (NCV)
•Somatosensory Evoked Potential (SSEP)

50. Treatment of Low Back Pain

51. Non-Surgical Treatment
•Bedrest
•Bedrest and Normal Daily Activity Were Equivalent for Acute
Low Back Pain.
–Boden SD et al; JBJS (Am) May 2003
–Rozenburg S et al; Spine July 2002
•Brace Treatment –Not effective for Acute Low Back
Pain
–Jellema P et al; Spine Feb 2001
•Physical Therapy --Active Therapy +/-Modalities
effective for Acute Low Back Pain
–Multiple studies
•Exercise –Effective for Long term prevention of LBP
•There is a lower incidence of Low Back Pain among runners
(36%) than the general population (80%).
–Ali RM et al; NASS Poster Presentation 2000

52. Physical Therapy
•Active Therapy/Postural Training
•Home Exercise
•Aerobic Exercises are
encouraged
–Swimming, Walking, Jogging, Elliptical Trainer…
•Modalities -heat, cold, massage,
traction, electrical stimulation,and
ultrasound

53. Non-Surgical Treatment
•Anti-Inflammatory Agents
•Oral Steroids
•Analgesics(Narcotic and Non-
Narcotic)
•Muscle Relaxants (For Acute
Period)
•Antidepressants

54. Non-Surgical Treatment
•Injections
•Trigger Point
•Epidural
•(Selective and Midline)
•Facet
•Intradiskal
•Acupuncture
•Chiropractic
Selective Nerve Root Epidural
Midline Lumbar Epidurals

55. SURGICAL TREATMENT
•IDET
•KYPHOPLASTY
•DECOMPRESSION (Laminotomy/Laminectomy)
•DISK REPLACEMENT
•FUSION

56. IDET
Minimally Invasive Treatment for Painful Degenerative Disk
Indications:Discogram Positive Painful Mild to Moderate Degen. Disk

57. Kyphoplasty
Minimally Invasive Treatment of Osteoporotic/Painful
Vertebral Compression Fractures

58. Herniated Disk
SURGICAL TREATMENT
Indications
1.Absolute
a. Cauda Equina Syndrome
b. Progressive Neurologic Deficit
2.Relative
a. Intolerable pain
b. Severe pain that compromises function
c. Static Neurologic Deficit

59. TIMING FOR SURGERY
•No loss of quality of surgical results
if delayed up to 3 months
•Definite deterioration of surgical
results if delayed > 1 yr.

60. Herniated Disk
SURGICAL TREATMENT OPTIONS
•Standard diskectomy
•Limited Diskectomy
•Microsurgical Diskectomy
•Micro Endoscopic Diskectomy
•Minimally Invasive Microdiskectomy
•Percutaneous Techniques:
-Chymopapain
-Percutaneous Diskectomy
-Automated Percutaneous Diskectomy
-Laser
-Arthroscopic Diskectomy

61. Standard Diskectomy
•Open Incision
•Laminotomy
•Removal of Disk Fragment
•Incision of Annulus Fibrosus
•Removal of Central and Lateral portions
of the Nucleus

62. Standard Diskectomy

63. Microdiskectomy
•Williams, 1978
•Operating Microscope
•Minimal laminotomy/
foraminotomy
•Preserve healthy, non-
herniated disc material

64. Micro Endoscopic Diskectomy

65. Micro Endoscopic Diskectomy

66. Advocates of Microdiskectomy
•Less scarring
•Less muscle denervation
•Shorter Hospital stay (Outpatient)
•Earlier return to work

67. Herniated Disk
Surgical Treatment General Results
•90-97% Success Rate
•<5% Recurrence Rate
•<1% Dural Tear
•<1% Infection

68. SPINAL STENOSIS
SURGICAL TREATMENT
Indications for Surgery:
•Increasing pain resistant to conservative measures
•Progressively limited walking distances or standing
endurance
•Major neurologic deficits
•Progressive neurologic compromise
•Bowel or Bladder dysfunction

69. LAMINECTOMY

70. LAMINECTOMY

71. Pre-Decompression
Post-Decompression
LUMBAR STENOSIS

72. Degenerative Disc Disease
SURGICAL TREATMENT
•Chronic
Mechanical
Low Back pain
with or without
leg pain
SURGICAL INDICATIONS

73. Total Disk Replacement
XRAY
MRI Diskogram
Total Disk
Indications:
-> 6 months Low Back Pain
-Unresponsive to Cons. Tx
-Positive Diskogram
-One Level Disease (L4-5/L5-S1)
-No Instability/Stenosis/Facet Dz.
Charite

74. SPINAL FUSION
•Posterolateral Fusion
•Posterior Lumbar Interbody
Fusion (PLIF)
•Anterior Lumbar Interbody
Fusion (ALIF)
-Open
-Laparoscopically
•Global Fusion (360 degrees)

75. Indications For Fusion
•Obvious signs of instability
–Spondylolisthesis, Iatrogenic instability, Missing Posterior Facets
–(Grob et al. J.B.J.S. 77-A:1036 July 1995)
•Painful Degenerative Disk
–Controversial

77. Surgery on >65
•Satisfaction similar to younger patients
•Co-Morbidity does not affect results
•Outcome results stable over time
•No increase in cost / effectiveness ratio
with follow-up