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

2. 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

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

4. 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

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

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

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

8. DRX 9000

9. 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.

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

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

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

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

14. 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.

15. Low Back Pain Long-Term Management

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

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

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

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

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

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

22. All injections should be done with x-ray guidance!

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

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

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

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

27. Surgery for Chronic Low Back Pain
Traditional:
Fusion

28. Lumbar Fusion
Posterior

29. Lumbar Fusion
Anterior

30. Lumbar Fusion
Combined

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

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

33. IDET

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

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

36. 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.

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

38. Kyphoplasty / Vertebroplasty
Cement is injected into a broken vertebrae.

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

41. Resources Puget Sound Spine Institute WebMD North American Spine
Society
American Academy of
Orthopedic Surgeons.

42. Thank-you!