Low Back Pain and Lumbar Disc Disease John M. Blair, MD Puget Sound Spine Institute

Low Back Pain Incidence: Sciatica: 60-90% Lifetime prevalence 5% Annual incidence 1:1 Female/Male ratio except after age 60 Sciatica: 40% Lifetime prevalence 10% of patients with low back pain

Low Back Pain Natural History 33% Pain free after one week 75% Pain free after one month >90% Pain free after three months

Low Back Pain Acute Low Back Pain: Chronic 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

Acute Low Back Pain Initial Management Mechanical vs. Non-mechanical X-rays Exam

Acute Low Back Pain Management Bed rest (2-7 days) Early mobilization Anti-inflamatories, muscle relaxants and narcotics Ice Bracing

Acute Low Back Pain Management Physical Therapy Spinal manipulation: May speed recovery but no long term efficacy. Massage Therapy: Feels good but unproven.

DRX 9000

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.

Chronic Low Back Pain Long-term management and treatment Determine source of symptoms Treatment

Low Back Pain Determine source of symptoms: Lumbar disk Facet joint Spinal nerves Vertebral body Soft tissues Hip or sacroiliac joint

Low Back Pain Diagnostic Tests X-Rays MRI CAT scan +/- myelogram Discogram EMG Bone scan Injections

Low Back Pain Long-Term Management Therapy/Conditioning Lifestyle changes Medication Injections Surgery

Low Back Pain Long-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.

Low Back Pain Long-Term Management

Low Back Pain Long-Term Management Passive care directed at symptom relief does not address the underlying dysfunction.

Low Back Pain Long-Term Management EXERCISE ! Walk, Bike, Swim, Treadmill, Elliptical trainer Stretching Avoid impact and twisting activities: Running, Tennis, Golf

Low Back Pain Long-Term Management Increased pain during the initial phases of rehabilitation is common and should not cause alarm.

Low Back Pain Long-Term Management Quit smoking Osteoporosis: Consult your doctor regarding diet, hormonal replacement and bone building drugs.

Treatment Medications Anti-Inflammatories: Motrin, Advil, Aleve, Aspirin, Tylenol Prescription NSAID’s: Lodine, Arthrotec, Mobic, Celebrex Narcotics Anti-Depressants Anti-Convulsants

Treatment Injections Epidural Selective nerve root block (SNRB) Facet joint block

All injections should be done with x-ray guidance!

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

Low Back Pain Surgical Treatment of Sciatica Laminectomy Discectomy Sometimes fusion is also performed.

Low Back Pain Surgical Treatment of Sciatica Short procedure (1hr. Average) < 24 hour hospital stay Good-excellent results in most patients

Surgery for Chronic Low Back Pain Traditional Lumbar fusion New Options IDET Kyphoplasty/vertebroplasty Artificial disc replacement (ADR)

Surgery for Chronic Low Back Pain Traditional: Fusion

Lumbar Fusion Posterior

Lumbar Fusion Anterior

Lumbar Fusion Combined

Surgical Treatment of Low Back Pain New Options Intradiscal Electrothermal Annuloplasty (IDET) Artificial disc replacement (ADR) Vertebroplasty / Kyphoplasty

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

IDET

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

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

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.

Artificial Disc Replacement Best results seem to correlate with less motion (I.e. fusion).

Kyphoplasty / Vertebroplasty Cement is injected into a broken vertebrae.

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

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

Thank-you!