1. UNDERSTANDING BACK PAIN
I. M. Doctor, M.D.
My Office
My City, State
Good [morning/afternoon]. I’m Dr. [Name], an orthopaedic surgeon at [office] and I’m here to today to talk to you about back pain, what causes it, and what you can do to keep your back strong and flexible.

2. for his significant contributions to the content of this presentation.
The information in this presentation was provided to the presenter by the American Academy of Orthopaedic Surgeons and may be modified.
Endorsement of this presentation by the AAOS is not implied or inferred.
Thank you to
A. Herbert Alexander, MD
for his significant contributions to the
content of this presentation.
The information in this presentation was provided to me by the American Academy of Orthopaedic Surgeons and may be modified. Endorsement of this presentation by the AAOS is not implied or inferred.

3. Understanding Back Pain
Orthopaedics and The Bone and Joint Decade
Types of back pain
Diagnosing the causes of back pain
Who is at risk for back pain?
We will begin our discussion today with a brief overview of orthopaedics and the Bone and Joint Decade before moving into back pain. We’ll look at the types of back pain, how your orthopaedic surgeon can diagnose the cause of your back pain, and who is at risk.

4. Understanding Back Pain
Seeking help
Therapies to help back pain sufferers
Medications
Surgery
Nonsurgical treatments
Complementary approaches
We will also discuss where to go for help, and therapies to help people with back pain such as medications, surgery, non-surgical treatments, and complementary approaches.

5. What is an orthopaedic surgeon?
MD who specializes in treatment and health maintenance of musculoskeletal system (bones, joints, ligaments, muscles, tendons, cartilage and spine)
An orthopaedic surgeon is a medical doctor with extensive training in keeping your bones, joints, ligaments, muscles, tendons, cartilage and spine in good working order. Together, all of these parts of our bodies make up our musculoskeletal system

6. What is an orthopaedic surgeon?
The expert in treating the musculoskeletal system
The expert in maintaining musculoskeletal health
The expert in understanding both operative and non-operative treatment options
Orthopaedic surgeons have the greatest knowledge of and experience with the wide range of conditions and treatment options available in musculoskeletal care, many of which do not involve surgery. However, if surgery is the best recommendation for recovery, the orthopaedic surgeon is the best trained to provide that surgical treatment.

7. Educating an Orthopaedic Surgeon
College
Medical School
Internship
Orthopaedic Residency
Fellowship (optional)
2 Years Practice
TOTAL
4 1 (1) 2 16 years!
As this chart shows, it typically takes 16 years or more of formal education and training to become an orthopaedic surgeon. Beyond that, special certification and life-long learning is essential, as orthopaedics is a field that is continually growing and evolving.

8. What do orthopaedic surgeons do?
Diagnose
Treat
Medication
Physical Therapy
Exercise
Brace
Surgery
Prevent
Orthopaedic surgeons use the most effective and efficient diagnostic tools and our experience in musculoskeletal treatment to determine the best course of treatment for our patients.

9. Your Orthopaedic Surgeon— Getting You Back In The Game
Back Pain
Your Orthopaedic Surgeon—
Getting You Back In The Game
Now let’s talk more about back pain symptoms, prevention and treatment.

10. Back Pain Structural Issues: Psychological Issues: Medical Issues:
Muscular
Arthritic
Disk
Psychological Issues:
Emotional stress
Medical Issues:
Infections
Inflammatory conditions
Back pain has physical, mental, and emotional factors. The wide variety of potential causes for back pain can present this pain and discomfort in several different ways, all of which affect your quality of life by limiting your activity or taking away the pleasure when pain accompanies the things you enjoy doing.

11. Symptoms Throbbing, aching, shooting, stabbing, dull or sharp pain
Pain down one or both legs with very little pain in the lower back
Numbness or weakness in the legs
A general back problem or a spinal condition can include many different symptoms: Throbbing, aching, shooting, stabbing, dull, or sharp pain; pain down one or both legs with very little pain in the lower back; numbness or weakness in the legs…

12. Symptoms
Pain down in the lower back & legs in certain positions such as standing or walking
Sleep problems, decreased energy, depression, and anxiety
Pain that stress and emotional issues causes or makes worse
Pain down in the lower back and legs in certain positions such as standing or walking; sleep problems, decreased energy, depression and anxiety; or pain that stress and emotional issues causes or makes worse.

13. General Treatment Examination by an orthopaedic surgeon
Period of activity modification
Perhaps medication to decrease pain and inflammation
Complete inactivity is not advised for more than a couple of days
In general, the goal of treatment for back pain is simple: To improve the pain symptoms, prevent further injury, and get you back into your life and the activities you enjoy. While specific circumstances will dictate treatment, following an examination, we generally recommend that those experiencing back pain modify their activity for a given period of time and may recommend medication to decrease pain and inflammation. However, complete inactivity such as bed rest is not advised for more than a couple of days.

14. General Treatment Rehabilitation Goals Increased muscle strength
Increased endurance
Increased flexibility
Improve aerobic fitness
Once the pain is eased, your physician may recommend some form of rehabilitative exercise program with the goals of increasing your muscle strength, endurance, flexibility, and aerobic fitness to improve your spinal health and limit future episodes of back pain.

15. Healthy Spine Function
Spinal Column
Cervical
Thoracic
Your back has three natural curves, forming an S shape. The cervical curve is made up of the first seven bones, or vertebrae, in your neck and back. The middle of your back is called the thoracic curve, while the lower back is the lumbosacral curve. Below the lumbar vertebrae are five more vertebrae which are fused together called the sacrum. The coccyx is the very bottom structure of the bony part of your spine. It is made of three to five small vertebrae attached to the bottom of your sacrum; the end of your coccyx is sometimes called your tailbone.
Ligaments are strong bands of fibrous tissue that knit your spine together. These ligaments contain pain fibers, and connect the functional units of your spine together. They help control the motion of your spine while providing flexibility.
The sacroiliac joints attach the sacrum to the iliac, or hip bones. The hip bones are also attached to the sacrum by a number of ligaments on either side.
Lumbar
Sacrum
Coccyx

16. Healthy Spine Function
Facet joint
Vertebra
Disc
Spinal canal
The vertebrae are one of the most important parts of your spine. This diagram shows two vertebrae with a disc in between.
Discs are your spine’s cushioning pads or shock absorbers. The disc allows the bony vertebrae to move back and forth, giving your spine great flexibility.
The spinal canal is the opening through which the spinal cord and spinal nerves pass.
The facet joint is a gliding joint between each vertebra. They help keep the vertebrae in alignment as your spine moves.
In between the facet joints are joint capsules made of a smooth lining called synovium. The synovium produces synovial fluid in the joint capsule, helping to lubricate the joint and allow smooth movement and providing nourishment to the joint.
Vertebra

17. Healthy Spine Function
The spinal cord is made up of nerves that extend from the brain into the spinal canal then out to the various parts of the body. Cerebral spinal fluid partly fills the spinal cord to help protect the spinal cord within the canal.

18. Healthy Spine Function
Trapezius
Latissimus
Erector
spinae
muscles
Many muscles are involved in making sure your spine functions properly, including those in the back and abdominal area. The erector spinae muscles are the ones you can feel on either side of your lower spine and are often the culprits when you experience muscle spasms in your back.
On the front of your body, the psoas and abdominal muscles play a critical role in your spine’s forward movement and provide support. It is very important to keep these muscles strong.
Abdominal wall muscles
Obliques
Psoas
Gluteals

19. Burden of Disease
Lower back pain is the one of the most commons common causes of missed work
Eight out of ten adults will experience back pain at some time
Back pain is a very common health problem—as many as 80% of working Americans will experience back pain at some time. Lower back pain is one of the most common reasons for missing work – outnumbered only by upper-respiratory infections and the common cold.

20. Burden of Disease
58 million ambulatory care visits for back and neck pain
82 million work days lost
In 2004, nearly 45 million ambulatory care visits were to be treated for back pain, and more than 13 million visits were for neck pain. Additionally, in 2005 nearly 20 million people reporting back or neck pain also reported losing an average of more than 12 days of work—this adds up to about 82 million work days lost, a big hit to the U.S. economy.

21. Getting You Back In the Game
Robert Dover
Olympic equestrian
Age: 44
Condition/Injury: Low Back Pain
Robert Dover is an Olympic equestrian. During his training for the Olympics, he began to experience pain in his lower back that made it hard for him to ride. His orthopaedic surgeon was able to help him get back in the game without surgery.
[Presenter: You can download a short video on this case study at the AAOS web site, to use in this presentation. If you do not wish to use the video, please delete this slide.]

22. Diagnosis Herniated disc/sciatica Sprain/Strain
Stress-related back pain
Because back pain often has physical, psychological, and emotional components and can have such a wide variety of causes, it is notoriously challenging to diagnose. There are a variety of potential diagnoses for back pain, such as herniated disc and sciatica, sprain or strain, or stress-related back pain.
This diagram shows a lumbar disc herniation. “A” is the exiting nerve root, “B” is main part of the disc, and as you can see, “C” is the herniated portion of the disc.

23. Diagnosis Arthritis of spine Symptomatic disc degeneration
Facet Syndrome
Spondylolisthesis & Spondylolysis
This graphic shows degenerative disc disease. Note discs appear dark because they are dessicated. This section (L5-S1) is also collapsed.
However, it is important to know that a desiccated disk doesn’t have to cause pain.

24. Diagnosis Spinal fractures Lumbar spinal stenosis
Chronic back pain syndrome
Spinal fractures, lumbar spinal stenosis, and chronic back pain syndrome, which is diagnosed when other causes have all been ruled out, are also possible diagnoses for back pain.

25. Actual Clinical Case Example:
Conchita Espinosa Chediak
Age: 41
Condition/Injury: Large herniated lumbar disc, severe back pain, and foot drop
Here’s another case study. Conchita Espinosa Chediak herniated a lumbar disc while bending forward and lifting. She had the sudden onset of low back pain followed by weakness in her right ankle, inability to raise her foot, and numbness in the foot.

26. Large Disc Herniation
This MRI shows that she had a large disc herniation that resulted in cauda equina syndrome. This condition can have very serious symptoms, including loss of urinary function and numbness in the buttocks and legs. Therefore, the patient was rushed into surgery, where the disc was removed through a two-inch incision using a microscope. The patient went home the same day of surgery and had a complete recovery from her symptoms.

27. Are You At Risk? Job requires frequent bending and lifting
Twisting body when lifting & carrying an object
Lifting and carrying in a hurry
There are several factors that put an individual at a higher risk of experiencing back pain:
Jobs requiring frequent bending or lifting,
Twisting your body when you are lifting or carrying an object, and
Lifting and carrying when you are in a hurry

28. Are You At Risk? Overweight Do not exercise regularly
Do not engage in recreational physical activity
Smoker
In addition:
Being overweight will increase your risk.
In addition, those who do not exercise regularly and are not involved in recreational physical activity have a higher chance of suffering from back pain.
Finally, researchers consistently find a connection between smoking and back pain, although it is unclear precisely what the nature of that connection is.

29. Tighten stomach muscles
Plan ahead, don’t hurry
Tighten stomach muscles
Move in close when placing object on high shelf
Bend knees
Improper lifting is a leading cause of back pain. Back pain caused by lifting can be prevented with proper technique and regular exercise. Simple things like always bending your knees and lifting with your legs, avoiding lifting over your head, planning ahead to avoid hurrying, spreading your feet shoulder distance apart, and getting help if something is too heavy for you to lift alone can make a tremendous difference in keeping your back healthy and pain free.
Don’t twist
Lift with leg muscles
Spread feet shoulder distance apart 29

30. Seeking Help Primary Care Physicians Orthopaedic Surgeons
Your primary care physician is often the first person you will consult with medical issues or concerns, including back pain. They may or may not be comfortable and confident in treating some forms of back pain, like those that appear to be stress induced. By asking some key questions, you and your doctor can decide if he or she is the best person to treat you, or whether a specialist might be appropriate.
Orthopaedic surgeons have many years of training and experience in musculoskeletal care. We can often get to the root of your problem fairly quickly and develop a treatment plan that will help get you back into the game. Our vast experiences in treating back pain helps us efficiently and effectively use only those diagnostic tools and tests which are truly needed to understand the source of your pain and treat it, whatever course that treatment needs to take to get your health back.
Spine surgeons are subspecialists who have undergone even more training in the area of spinal disorders and back pain. In some cases, you and your doctor may decide that a physician who spends all of his or her time working on the spine is your best choice.
Spine Surgeons

31. Seeking Help Before Your Appointment Prepare to describe your symptoms
Gather medical history
Make list of medications
Write down concerns and questions and bring them
Before you see your physician, it’s a good idea to assemble your records and make written lists of medications you are taking, your medical history—including things you may not think are related to your back problem—and your concerns and questions about your condition.
Many patients also decide to bring a friend or family member along. It’s common to be nervous when you are seeing your doctor for a health problem, so it can be beneficial to have another person to help you understand and remember what went on during your visit.

32. Seeking Help During Your Appointment
1. What should I expect from my treatment?
2. What effect will my treatment have on my daily activities?
3. What can I do to prevent further disability?
We find that it is usually helpful when patients or their companions take notes. It’s very important to ask questions about anything you don’t understand. Three key questions are:
What should I expect from my treatment?
What effect will my treatment have on my daily activities? And
What can I do to prevent further disability?
It’s usually helpful to ask your physician for any handouts or brochures that may help you and your family understand your condition and treatment. Your physician may refer you to the American Academy of Orthopaedic Surgeons’ patient education web site (orthoinfo.org) or other resource for more information.

33. Active Therapies Exercise is key Aerobic conditioning program
Special back exercises
Non-operative treatment for back pain can be divided into non-invasive and invasive types. Non-invasive treatments can be further broken down to active and passive therapies.
Non-invasive active treatments usually include general exercise, conditioning programs, and special back exercises. Exercise is one of the most important treatments that we are likely to recommend to help your back pain. Your physician or physical therapist will recommend exercises that are best for you, and provide you with instruction to make sure you do them properly.

34. Active Therapies: Exercise
None of us can avoid the normal effects of aging, but regular exercise is one of the best defenses we have against back pain, as well as a host of other health concerns.
Exercise lubricates spinal discs and helps overcome low back pain. In addition, strong back muscles improve posture and help support the bones and tendons in the back and torso.
Total body fitness should be a key component of your back pain rehabilitation program because overall physical health will also help your back. For example, strong abdominal muscles, gluteal muscles, and leg muscles can help support your back and prevent injury.

35. Active Therapies: Stretching
Combining exercise and aerobic conditioning with simple, non-impact stretching and strengthening is advantageous when striving to reduce and eliminate back pain. 35

36. Active Therapies Pain Programs
Involve multiple healthcare professionals
Different treatments at different times
Goal is to decrease pain, increase functioning
Patient must be highly motivated
Your orthopaedic surgeon may suggest trying a pain program if usual treatments aren’t helping and your pain is rather debilitating. Pain programs are characterized by four key components:
First, they are multidisciplinary, often involving a number of healthcare professionals working together under your orthopaedic surgeon’s direction.
Second, they are structured so that you receive various treatments at a specific time for a specific reason.
Third, the goal is to decrease your pain, increase your functioning and improve your quality of life.
And fourth, they are motivation driven—you must be highly motivated and involved for them to work.

37. Passive Therapies Ultrasound and massage Water therapy
Transcutaneous Electrical Nerve Stimulation (TENS)
Your orthopaedic surgeon may recommend non-invasive, passive treatment to relieve your back pain. Passive treatment is something that a physical therapist or other professional does to you. While there are a variety of passive treatments available, they share a common result—the pain relief achieved is largely temporary.
Common passive treatments include ultrasound and massage, water therapy, and Transcutaneous Electrical Nerve Stimulation, in which low-voltage electrical current provides some pain relief.

38. Passive Therapies Traction Corsets and braces
Traction, corsets, and braces are other passive treatments. They may provide temporary relief, but in the long term, they can weaken the back muscles, so they should not be worn for more than a week or two.

39. Medication 8 Important Questions to Ask Your Orthopaedic Surgeon
Why are you recommending this medication?
How will this medication help me to feel better?
What are the benefits and when will we know if it works?
You and your orthopaedic surgeon need to decide which medications, if any, are appropriate for you and your treatment of back pain. In conjunction with an overall treatment plan, medications can help decrease your pain, reduce inflammation, and relieve muscle spasms. When considering medications, there are eight important questions to ask your physician:
1. Why are you recommending this medication?
2. How will this medication help me to feel better?
3. What benefits should I expect, and how long before I know whether the medication is achieving the goal?

40. Medication 4. How do I take this medication?
5. What are the side effects? What to do if I have side effects? Are they temporary?
6. Is it okay to use generic?
4. How do I take this medication?
5. What side effects should I be aware of? What should I do if these occur? Will they go away if I decide to stay on the medicine?
6. Is it okay to use the generic version of this medication?

41. Medication
7. Can I take this medication with others I’m currently taking?
8. How do I stop taking it safely?
7. Can I take this medication in addition to the other medications I am on?
8. How do I stop taking this medication safely?

42. Medication Analgesics Anti-inflammatories Muscle relaxants Sedatives
Anti-anxiety agents
Antidepressants
If medication is a good choice for you, your orthopaedic surgeon is likely to prescribe analgesics, anti-inflammatories, and/or muscle relaxants as part of your treatment for your back pain. Your orthopaedic surgeon may also prescribe sedatives, anti-anxiety agents or antidepressants, but these medications are less commonly used to treat back pain than those I just mentioned.

43. Invasive Conservative Treatments
Trigger point injections
Facet injection
Spinal epidural steroid injections
Selective nerve root blocks
What to show here?
If your orthopaedicc surgeon actually pierces your skin as part of the treatment, you are choosing invasive conservative treatments. These usually consist of injections. They are usually utilized when back pain problems are not responsive to non-invasive treatments.

44. Surgery May Be Your Choice When…
Leg pain rather than back pain
Non-operative treatments are ineffective
Symptoms match test findings
Symptoms prevent daily living activities
In some cases, spine surgery may be your best bet for treatment of back conditions and the pain they cause. With the many advances in spine surgery, success rates are tremendously high, often better than 90%. Deciding whether or not to have surgery is a big decision. Because spine surgery is usually elective, you have time to consult with your physicians and make an informed choice about your health. There are several common circumstances in which back surgery is likely to be a good treatment choice for you:
When you have leg pain rather than back pain, surgery may be a good choice to treat a disc herniation.
If you have not responded to conservative treatments, you and your doctors may decide that surgery is an option that will give you the relief you seek from back pain and the accompanying disability.
When the reason for your back pain is clearly established through testing and your symptoms match your test findings, spine surgery can be very successful.
If your symptoms continue to worsen and/or their severity prevents you from activities of daily living, surgery may be an option that could improve your quality of life.

45. Surgery Finding a Surgeon
Surgery is a big decision, and as such, you may choose to do a bit of research before deciding on an orthopaedic surgeon.
Finding a Surgeon

46. Asking Questions About Surgery
Why?
Alternatives?
Benefits and for how long?
In some cases of back pain or injury surgery may be warranted.
If you physican recommends surgery, there are some other questions you’ll want to ask:
Why is this procedure being recommended? Are there alternatives?
What are the benefits of this procedure in terms of pain relief and improvement of function and mobility? How long will the benefits last?

47. Asking Questions About Surgery
Risks?
What is procedure called?
How is it done?
Results?
What are the risks involved?
What is the procedure called? How is it done?
What percentage of patients improve following the procedure?

48. Asking Questions About Surgery
Duration of recovery?
Assistance at home and how long?
Disability after surgery?
Physical therapy?
Return to normal activity?
Part of understanding the course of action your physician recommends is being aware of what your recovery will be. Some questions to ask are:
How long will the recovery take? Will I need assistance at home afterwards? For how long?
Will I have any disability following surgery? Will I need physical therapy? When can I safely return to normal activity?

49. Back Pain Therapies Medication Surgery Complementary Approaches
Back pain is a serious and often complicated health issue for many people. As orthopaedic surgeons, our purpose is to use the wealth of treatment options available to us to do all we can to treat your back pain and its cause and get you fully back into your life. You don’t have to suffer from back pain; we can help.

50. American Academy of Orthopaedic Surgeons
Resources
American Academy of Orthopaedic Surgeons
6300 N. River Road
Rosemont, IL 60018
To locate a qualified orthopaedic surgeon, visit The American Academy of Orthopaedic Surgeons’ website at and click on “Find an Orthopaedic Surgeon”.

51. What are your questions and concerns?
Back Pain
What are your questions and concerns?
Do you have any other questions or concerns that we have not addressed today?

52. Back Pain Thank you for participating today
Remember, your orthopaedic surgeon can help get you back in the game
Thank you for participating today. Remember, your orthopaedic surgeon can help you get back in the game.