OHSU Spine Center
Transcript of OHSU Spine Center
OHSU Spine CenterLow Back Pain: Myth vs. Reality
OHSU Spine Center
OHSU Spine Center
• Orthopaedic Spine Surgeons
OHSU Spine Center
• Orthopaedic Spine Surgeons
• Neurosurgeons
OHSU Spine Center
• Orthopaedic Spine Surgeons
• Neurosurgeons• Physical Medicine &
Rehabilitation Specialists
OHSU Spine Center
• Orthopaedic Spine Surgeons
• Neurosurgeons• Physical Medicine &
Rehabilitation Specialists
• Pain Management Specialists
OHSU Spine Center
• Orthopaedic Spine Surgeons
• Neurosurgeons• Physical Medicine &
Rehabilitation Specialists
• Pain Management Specialists
• Spine Physical Therapists
OHSU Spine Center
• Orthopaedic Spine Surgeons
• Neurosurgeons• Physical Medicine &
Rehabilitation Specialists
• Pain Management Specialists
• Spine Physical Therapists
• Spine Center Gym
OHSU Spine Center
• Orthopaedic Spine Surgeons
• Neurosurgeons• Physical Medicine &
Rehabilitation Specialists • Pain Management
Specialists• Spine Physical Therapists• Spine Center Gym• Spine Center
Identifying the Source of Low Back Pain
Diagnostic Tools:– History– Physical Exam– Diagnostic Studies
• Imaging• Labs• Electrodiagnostic Studies
– Spinal Injections
Diagnoses:• Radiculopathy• Spinal Stenosis• Non-Specific Benign LBP
• Disc Degeneration• Myofascial Pain• Piriformis Syndrome• Sacroiliac Pain• Malalignment
Myth vs. Reality? Back pain …
• Affects everybody at some point
Myth vs. Reality? Back pain …affects everybody
– Individual lifetime occurrence rate
– 60-90%
– Yearly prevalence rate
– 15-20%
Myth vs. Reality? Back pain …affects everybody and gets better!
– Individual lifetime occurrence rate
– 60-90%
– Yearly prevalence rate
– 15-20%
– 50% better at 1 week
– 90% better at 6-12 weeks
– Dillane, Brit Med J, 1966
– Waddell, Spine, 1987– Berquist, 1977
Myth vs. Reality? Back pain …
• Affects everybody at some point • Is result of poor design of the spine
Myth vs. Reality? Back pain …is result of poor design of the spine
Myth vs. Reality? Back pain …
• Affects everybody at some point• Is result of poor design of the spine• Is caused by disk degeneration
Myth vs. Reality? Back pain …is caused by disk degeneration
• 98 asymptomatic L-Spine MRIs– 52% bulges, 27%
protrusions, 1% extrusion
– 14% ALT, 8% facet – 38% with multilevel
abnormalities» Jensen, NEJM
1994
Myth vs. Reality? Back pain …
• Affects everybody at some point• Is result of poor design of the spine• Is caused by disk degeneration• Requires activity limitations
Myth vs. Reality? Back pain …requires activity limitations
• Earlier resumption of work and activities did not have an effect on pain and was associated with improved function
– Gilbert, Deyo, Malmivaara
Myth vs. Reality? Back pain …
• Affects everybody at some point• Is result of poor design of the spine• Is caused by disk degeneration• Requires activity limitations• Implies damage to the spine
Myth vs. Reality? Back pain …implies damage to the spine
Myth vs. Reality? Back pain …
• Affects everybody at some point• Is result of poor design of the spine• Is caused by disk degeneration• Requires activity limitations• Implies damage to the spine• Is better with rest
• Bedrest trials– 0 vs 4 days (n=125)– 2 vs 7 days (n=203)
• Shorter bedrest– 45% fewer lost
workdays– 42% fewer days of
decreased activity– No difference in pain
» Deyo, 1986» Gilbert, 1985
Myth vs. Reality? Back pain …is better with rest
WHAT ABOUT MY ACTIVITIES?
Golfing? Running? Yardwork? Backpacking? Skiing? Firewood? Hunting? Fishing? Camping? Driving? Horseback Riding? Marathons? Lifting? Bending? Weight Training? Biking? Bowling? Working? Basketball? Softball? Grandkids? Kids? Hiking? Climbing? Woodworking? Painting? Kayaking? Mountain Biking?
Myth vs. Reality? Exercise/Activity…
• Is bad for your back
Myth vs. Reality? Exercise/Activity…is bad for your back
– Exercise:• Focused on identifying and improving impairments
in flexibility and strength.– Results:
• People with chronic LBP can substantially improve back flexibility and strength through exercise. This frequently translates into improved ability to function and less daily pain.
» Mayer et al. JAMA 1987; Hazard et al. Spine 1989; Estlander et al. Scan J Rehab Med 1991; Manniche et al. Pain 1991; Rainville et al. Spine 1992; Nelson et al. Orthopedics 1995;
Myth vs. Reality? Exercise/Activity…
• Is bad for your back• Is associated with spine degeneration
Myth vs. Reality? Exercise/Activity…is associated with spinedegeneration
• 67 asymptomatic L-Spine MRIs– 20-39 y.o.:
• 35% Disc degeneration
– <60 y.o.: • 20% Disc herniation
– >60 y.o.:• 36% Disc herniation• 21% stenosis
» Boden, JBJS 1990
Myth vs. Reality? Exercise/Activity…
• Is bad for your back• Is associated with spine degeneration• Should be avoided with back problems
Myth vs. Reality? Exercise/Activity…should be avoided with back problems• “Proper Mechanics”
– “… learn to sit, stand, lie, and do ADLs with LB in proper position”
– Grant, 1975
• Increased LBP risk?– “… difficult recovery
in patients using the wrong muscles to bend, lift”
– Marras, Spine 2001
NO PAIN ----- NO GAINand the role of common sense
Myth vs. Reality? Exercise/Activity…
• Myths (traditional advice)– avoid activity, be
passive– spine easily damaged– often damage is
permanent– focus on pain
• Reality– no serious disease– spine is strong, rarely
damaged– pain does not mean
harm– activity is important to
recovery– focus on function
Burton, Waddell et al; Spine 1999
Exercise and Back Pain…
• Degenerative changes are inevitable
Exercise and Back Pain…degenerative changes are inevitable
• Degenerative changes increase with age
• Back pain levels off with age
• McNab 1977
Exercise and Back Pain…
• Degenerative changes are inevitable• Muscle are shock absorbers
Exercise and Back Pain…muscle are shock absorbers
• Restore– Strength– Flexibility– Endurance
Exercise and Back Pain…muscle are shock absorbers
• Restore– Strength– Flexibility– Endurance
Exercise and Back Pain…muscle are shock absorbers
• Restore– Strength– Flexibility– Endurance
Exercise and Back Pain…
• Degenerative changes are inevitable• Muscle are shock absorbers• Muscles are modifiable and measurable
Exercise and Back Pain…muscles are modifiable and measurable
Reality! Exercise and back pain…
• Back pain is common• Degenerative changes don’t correlate well
to pain• Any activity is better than no activity for the
back
TREATMENT OPTIONSTherapy Medications Injections Surgery
Myth vs. Reality? Spinal Surgery…
• Spine surgery won’t help me because I know too many people who still have pain after surgery
Myth of Spine SurgeryJung U. Yoo, M.D.
Upright Balance
Provide Motion
Shock Absorption
House Neural Elements
Myths
• Minimally invasive surgery is better• Those who have surgery have more pain
after the surgery than before• Latest technology is better• Doctors will make me better
Arthroscopic or laser surgery?
Exposure
• Minimally invasive may require longer surgery
• Surgeon may have limited view• Small incision does not mean small
surgery• There are many type of minimally invasive
surgery
Laser Discectomy
Thermal Disc Coagulation
Protein Denaturation
THOSE WHO HAVE SURGERY HAV
Those who have surgery have more pain after the surgery than before.
Why things fail
• Wrong diagnosis• Wrong patient• Wrong surgery• Life is a percentage
• Conditions that we have to fix• Conditions that we can fix• Conditions that we cannot fix
Broken
Cancer
Herniated Disc
Spinal Stenosis
Deteriorated
I I want the latest technology.TECHNOLO
Wrong Surgery
Increased Stability
Artificial Disc
salvage
Thank you