3/4/03Steven Stoltz, M.D. Back Pain 2 nd most 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

Oh My Aching Back Treatment Options for Back Pain Steven Stoltz, M.D. Assistant Clinical Professor of Medicine UCSF-Fresno

3/4/03Steven Stoltz, M.D. Outline Part 1: – Introduction – Review of anatomy Part 2: – Acute low back pain Part 3: – Chronic low back pain – Prevention Questions ??

3/4/03Steven 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:

3/4/03Steven Stoltz, M.D. - Anatomy Lesson #1

3/4/03Steven Stoltz, M.D. - Anatomy Lesson #2

3/4/03Steven Stoltz, M.D. 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?

3/4/03Steven 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.

3/4/03Steven Stoltz, M.D. % of Back Pain due to Herniated Disk? 1. 4% 2. 14% 3. 40% 4. None of the above

3/4/03Steven Stoltz, M.D. 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%

3/4/03Steven Stoltz, M.D. 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%

3/4/03Steven Stoltz, M.D. Red Flags History of cancer Unexplained weight loss Intravenous drug use Prolonged use of corticosteroids Older age Major Trauma Osteoporosis Fever Back pain at rest or at night Bowel or bladder dysfunction

3/4/03Steven Stoltz, M.D. 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

3/4/03Steven Stoltz, M.D. 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

3/4/03Steven Stoltz, M.D. 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

3/4/03Steven Stoltz, M.D. Massage & Physical Therapy Might be beneficial More quality research is needed Different types of massage

3/4/03Steven Stoltz, M.D. Acupuncture Very little quality research and data Seems to indicate that acupuncture is not effective for the treatment of back pain

3/4/03Steven Stoltz, M.D. Other Modalities Back Brace/Corset/Lumbar Support: Traction: Injections: Inconclusive evidence TENS: Hot/Cold: Ultrasound:

3/4/03Steven Stoltz, M.D. 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?

3/4/03Steven 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

3/4/03Steven Stoltz, M.D. New England Journal of Medicine (February 2001)

3/4/03Steven Stoltz, M.D. Medications Similar to acute pain…. Antidepressant medications can improve pain relief

3/4/03Steven Stoltz, M.D. Exercises Improves pain and function Many programs available, but difficult to make any scientific recommendations for one type versus another

3/4/03Steven Stoltz, M.D. Injections Epidural injections: – Insufficient and conflicting evidence Facet joint injections: – No improvement Local/Trigger point injections: – Possibly some benefit

3/4/03Steven 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

3/4/03Steven Stoltz, M.D. Other Modalities Back Schools: - possibly effective Multidisciplinary Therapy: - probably yes TENS: - no Spinal manipulation: - conflicting data Massage: - probably yes IDET:

3/4/03Steven Stoltz, M.D. Intradiscal Electrothermal Therapy

3/4/03Steven Stoltz, M.D. 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)

3/4/03Steven Stoltz, M.D. Prevention Exercise: – Aerobic, back/leg strengthening Back braces and education about proper lifting techniques are ineffective ? weight loss and smoking cessation

3/4/03Steven Stoltz, M.D. Web Resources (“Helping people make well-informed decisions about health care.”)