Back Pain
2ndmost common cause for office visit
60-80% of population will have lower back
pain at some time in their lives
Each year, 15-20% will have back pain
Most common cause of disability for
persons < 45 years
1% of US population is disabled
Costs to society: $20-50 billion/year
3/4/03 Steven Stoltz, M.D.
Oh My Aching Back
Treatment Options for Back
Pain
Steven Stoltz, M.D.
Assistant Clinical Professor of Medicine
UCSF-Fresno
Outline
Part 1:
– Introduction
– Review of anatomy
Part 2:
– Acute low back pain
Part 3:
– Chronic low back pain
– Prevention
Questions ??
3/4/03 Steven Stoltz, M.D.
Low 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.
3/4/03 Steven Stoltz, M.D.
- Anatomy
Lesson #1
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- Anatomy
Lesson #2
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Introduction 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?
3/4/03 Steven Stoltz, M.D.
What should Ed expect from
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.
3/4/03 Steven Stoltz, M.D.
% of Back Pain due to
Herniated Disk?
1. 4%
2. 14%
3. 40%
4. None of the above
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Causes of Low Back Pain
Lumbar “strain” or “sprain” – 70%
Degenerative changes – 10%
Herniated disk – 4%
Osteoporosis compression fractures – 4%
Spinal stenosis – 3%
Spondylolisthesis – 2%
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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%
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Red Flags
History of cancer Major Trauma
Unexplained weight Osteoporosis
loss Fever
Intravenous drug use Back pain at rest or at
Prolonged use of night
corticosteroids Bowel or bladder
Older age dysfunction
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Medications
Anti-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
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Chiropractic/Osteopathic
Davenport, Iowa in 1895 by David Palmer;
‘done by hand’ (Greek)
Spinal manipulation
Conflicting evidence on the effects of spinal
manipulation
– ~75-90% improvement anyway within 4 weeks
Greater patient satisfaction
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Exercise & Bed Rest
Advice 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 harm
One or two days of bed rest if necessary
Light activity, avoiding heavy lifting,
bending or twisting (ie. walking)
No data on any particular exercises
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Massage & Physical Therapy
Might be beneficial
More quality research is needed
Different types of massage
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Acupuncture
Very little quality research and data
Seems to indicate that acupuncture is not
effective for the treatment of back pain
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Other Modalities
Back Brace/Corset/Lumbar Support:
Traction:
Injections: Inconclusive evidence
TENS:
Hot/Cold:
Ultrasound:
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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?
3/4/03 Steven Stoltz, M.D.
Role of X-rays (Radiology)
Usually unnecessary and not helpful
Plain X-ray:
– Age>50 years
– No improvement after 6 weeks
– Other worrisome findings
MRI:
– After 6 weeks if have sciatica
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New England Journal of Medicine (February 2001)
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Medications
Similar to acute pain….
Antidepressant medications can improve
pain relief
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Exercises
Improves pain and function
Many programs available, but difficult to
make any scientific recommendations for
one type versus another
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Injections
Epidural injections:
– Insufficient and conflicting evidence
Facet joint injections:
– No improvement
Local/Trigger point injections:
– Possibly some benefit
3/4/03 Steven Stoltz, M.D.
Surgery
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
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Other Modalities
Back Schools: - possibly effective
Multidisciplinary Therapy: - probably yes
TENS: - no
Spinal manipulation: - conflicting data
Massage: - probably yes
IDET:
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Intradiscal Electrothermal Therapy
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IDET
No convincing evidence that shows the
short or long-term clinical efficacy of this
procedure.
Safe with few adverse effects
? Long-term effects
Wall Street Journal (Feb. 11, 2003)
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Prevention
Exercise:
– Aerobic, back/leg strengthening
Back braces and education about proper
lifting techniques are ineffective
? weight loss and smoking cessation
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Web Resources
www.mayo.edu
www.cochraneconsumer.com (“Helping
people make well-informed decisions about
health care.”)
www.library.ucsf.edu
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