3/4/03Steven Stoltz, M.D. Back Pain 2 nd most common cause for office visit 60-80% of population will have lower back pain at some time in their lives.

3/4/03 Steven Stoltz, M.D.

Back PainBack Pain2nd most common cause for office visit60-80% of population will have lower back

pain at some time in their livesEach year, 15-20% will have back painMost common cause of disability for

persons < 45 years1% of US population is disabledCosts to society: $20-50 billion/year

Oh My Aching BackOh My Aching BackTreatment Options for Back Treatment Options for Back

PainPain

Steven Stoltz, M.D.

Assistant Clinical Professor of Medicine

UCSF-Fresno


OutlineOutlinePart 1:

– Introduction– Review of anatomy

Part 2:– Acute low back pain

Part 3:– Chronic low back pain– Prevention

Questions ??


Low Back PainLow Back Pain

“One would have thought by now that the problem of diagnosis and treatment would have been solved, but the issue remains mysterious and clouded with uncertainty.”

– Rosomoff HL, Rosomoff RS. Low back pain: Evaluation and management in the primary care setting. Med Clin North Am 1999;83:643-62.


- AnatomyLesson #1


- AnatomyLesson #2


Introduction to EdIntroduction to Ed

Ed has had lower back pain for the past 24 hours that he feels is related to yard work that he did over the weekend. He missed work today, Monday.

He wants to know what can be done for his back pain?


What should Ed expect from What should Ed expect from his health care professional?his health care professional?

1. Be able to recognize the difference between routine lower back pain and dangerous forms of lower back pain.

2. Provide information, advice, and a plan of action.


% of Back Pain due to % of Back Pain due to Herniated Disk?Herniated Disk?

1. 4%

2. 14%

3. 40%

4. None of the above


Causes of Low Back PainCauses of Low Back Pain

Lumbar “strain” or “sprain” – 70%Degenerative changes – 10%Herniated disk – 4%Osteoporosis compression fractures – 4%Spinal stenosis – 3%Spondylolisthesis – 2%


Causes of Low Back Pain…Causes of Low Back Pain…

Spondylolysis, diskogenic low back pain or other instability – 2%

Traumatic fracture - <1%Congenital disease - <1%Cancer – 0.7%Inflammatory arthritis – 0.3%Infections – 0.01%


Red FlagsRed Flags

History of cancer Unexplained weight

loss Intravenous drug use Prolonged use of

corticosteroids Older age

Major Trauma Osteoporosis Fever Back pain at rest or at

night Bowel or bladder

dysfunction


MedicationsMedicationsAnti-inflammatory medications (NSAID’s):

– Beneficial; no differences; watch side-effects

Tylenol:Narcotic Pain Relievers:

– No more effective than NSAID’s– Many side effects

Muscle Relaxants (ie. Flexeril®):– Can decrease pain and improve mobility– 70% with drowsiness/dizziness


Chiropractic/OsteopathicChiropractic/Osteopathic

Davenport, Iowa in 1895 by David Palmer; ‘done by hand’ (Greek)

Spinal manipulationConflicting evidence on the effects of spinal

manipulation– ~75-90% improvement anyway within 4 weeks

Greater patient satisfaction


Exercise & Bed RestExercise & Bed RestAdvice to stay active:

– ‘There is no evidence that advice to stay active is harmful for either acute low back pain or sciatica.’

– Hurt does not equal harmOne or two days of bed rest if necessaryLight activity, avoiding heavy lifting,

bending or twisting (ie. walking)No data on any particular exercises


Massage & Physical TherapyMassage & Physical Therapy

Might be beneficialMore quality research is neededDifferent types of massage


AcupunctureAcupuncture

Very little quality research and dataSeems to indicate that acupuncture is not

effective for the treatment of back pain


Other ModalitiesOther Modalities

Back Brace/Corset/Lumbar Support:Traction:Injections: Inconclusive evidenceTENS:Hot/Cold:Ultrasound:


Ed, again…Ed, again…

Now, Ed has not had improvement in his lower back pain and 6 weeks have gone by since the initial painful event.

What types of therapies might be beneficial for Ed now?


Role of X-rays (Radiology)Role of X-rays (Radiology)

Usually unnecessary and not helpfulPlain X-ray:

– Age>50 years– No improvement after 6 weeks– Other worrisome findings

MRI:– After 6 weeks if have sciatica


New England Journal of Medicine (February 2001)


MedicationsMedications

Similar to acute pain….Antidepressant medications can improve

pain relief


ExercisesExercises

Improves pain and functionMany programs available, but difficult to

make any scientific recommendations for one type versus another


InjectionsInjections

Epidural injections:– Insufficient and conflicting evidence

Facet joint injections:– No improvement

Local/Trigger point injections:– Possibly some benefit


SurgerySurgery

Diskectomy improves pain in short term but not long term (ie. 10 years)

Microdiskectomy similar to standard diskectomy

Automated percutaneous diskectomy and laser diskectomy both less effective

? Arthroscopic diskectomy


Other ModalitiesOther Modalities

Back Schools: - possibly effectiveMultidisciplinary Therapy: - probably yesTENS: - noSpinal manipulation: - conflicting dataMassage: - probably yesIDET:


Intradiscal Electrothermal TherapyIntradiscal Electrothermal Therapy


IDETIDET

No convincing evidence that shows the short or long-term clinical efficacy of this procedure.

Safe with few adverse effects? Long-term effectsWall Street Journal (Feb. 11, 2003)


PreventionPrevention

Exercise:– Aerobic, back/leg strengthening

Back braces and education about proper lifting techniques are ineffective

? weight loss and smoking cessation


Web ResourcesWeb Resources

www.mayo.eduwww.cochraneconsumer.com (“Helping

people make well-informed decisions about health care.”)

www.library.ucsf.edu

3/4/03Steven Stoltz, M.D. Back Pain 2 nd most common cause for office visit 60-80% of population will have lower back pain at some time in their lives.

Documents

pain steven stoltz

pain relief slide

acute pain

benefit slide

sciatica slide

billionyear slide

pain spondylolysis

arthroscopic diskectomy