Low Back Pain and Lumbar Disc Disease

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Low Back Pain and Lumbar Disc Disease

• John M. Blair, MD
• Puget Sound Spine Institute

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Low Back Pain

• Incidence
• 60-90 Lifetime prevalence
• 5 Annual incidence
• 11 Female/Male ratio except after age 60
• Sciatica
• 40 Lifetime prevalence
• 10 of patients with low back pain

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Low Back Pain Natural History

• 33 Pain free after one week
• 75 Pain free after one month
• gt90 Pain free after three months

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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

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Acute Low Back PainInitial Management

• Mechanical vs. Non-mechanical
• X-rays
• Exam

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Acute Low Back PainManagement

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

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Acute Low Back PainManagement

• Physical Therapy
• Spinal manipulation May speed recovery but no
  long term efficacy.
• Massage Therapy Feels good but unproven.

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DRX 9000
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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.

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Chronic Low Back PainLong-term management and
treatment

• Determine source of symptoms
• Treatment

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Low Back Pain

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

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Low Back Pain Diagnostic Tests

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

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Low Back PainLong-Term Management

• Therapy/Conditioning
• Lifestyle changes
• Medication
• Injections
• Surgery

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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.

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Low Back PainLong-Term Management
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Low Back PainLong-Term Management

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

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Low Back PainLong-Term Management

• EXERCISE !
• Walk, Bike, Swim, Treadmill, Elliptical trainer
• Stretching
• Avoid impact and twisting activities Running,
  Tennis, Golf

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Low Back PainLong-Term Management

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

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Low Back PainLong-Term Management

• Quit smoking
• Osteoporosis Consult your doctor regarding
  diet, hormonal replacement and bone building
  drugs.

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TreatmentMedications

• Anti-Inflammatories Motrin, Advil, Aleve,
  Aspirin, Tylenol
• Prescription NSAIDs Lodine, Arthrotec, Mobic,
  Celebrex
• Narcotics
• Anti-Depressants
• Anti-Convulsants

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TreatmentInjections

• Epidural
• Selective nerve root block (SNRB)
• Facet joint block

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All injections should be done with x-ray guidance!
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Lumbar Spine Surgery

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

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Low Back PainSurgical Treatment of Sciatica

• Laminectomy
• Discectomy
• Sometimes fusion is also performed.

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Low Back PainSurgical Treatment of Sciatica

• Short procedure (1hr. Average)
• lt 24 hour hospital stay
• Good-excellent results in most patients

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Surgery for Chronic Low Back Pain

• Traditional
• Lumbar fusion
• New Options
• IDET
• Kyphoplasty/vertebroplasty
• Artificial disc replacement (ADR)

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Surgery for Chronic Low Back Pain

• Traditional
• Fusion

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Lumbar Fusion

• Posterior

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Lumbar Fusion

• Anterior

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Lumbar Fusion

• Combined

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Surgical Treatment of Low Back PainNew Options

• Intradiscal Electrothermal Annuloplasty (IDET)
• Artificial disc replacement (ADR)
• Vertebroplasty / Kyphoplasty

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IDET

• A metal coil is inserted into a disc.
• The coil is heated and seals a painful tear.
• Outpatient procedure under IV sedation.

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IDET
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IDET

• Indications
• One or two painful discs with a tear.
• No prior surgery.
• Well preserved disc height.
• Results
• 60 Good to Excellent results

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Artificial Disc Replacement

• Anterior abdominal incision.
• Disc is completely removed.
• Artificial disc is placed.
• Hospital stay of 1-2 days.

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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.

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Artificial Disc Replacement

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

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Kyphoplasty / Vertebroplasty

• Cement is injected into a broken vertebrae.

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Kyphoplasty / Vertebroplasty

• Balloon is used to create cavity prior to
  injection of cement with kyphoplasty.
• Outpatient procedure often with immediate pain
  relief.

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Resources

• Puget Sound Spine Institute
• WebMD
• North American Spine
• Society
• American Academy of
• Orthopedic Surgeons. www.aaos.org

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Thank-you!