1. Low Back Pain Tony Reece Western Infirmary Glasgow

2. Objectives Mechanical (simple) pain Current knowledge Ongoing / Future developments

3. Acute Back Pain Prevalence 80% 2nd commonest cause of medical consultations 3rd commonest reason for disability in 45-65 Vast majority self limiting

4. Return to Work 6/1250% 1 year25% 2 years <5%

5. Adolescent Back Pain 80% non-specific Females Family history Smoking Backpacks TV 20% pathological Males Younger Competitive athletes Night pain Hard signs / neuro

6. Low Back Pain Diagnostic Triage Mechanical Back Pain Nerve Root Entrapment Serious Pathology

7. GGBPS launched Sept 2002 Physio reassessment Liaise with GP re further management

8. Discharge Outcomes (random sample 1329) Discharge self 974 73% Discharge GP 47 4% Physio class 93 7% Coach class 85 6% Psychology 21 1.5% Surgery 14 1% Pain clinic 10 1% Other 85 6%

9. Red Flags Fracture Falls RTA Heavy lift in elderly Action ?

10. Red Flags Fracture Falls RTA Heavy lift in elderly Action ? Xray +/- further imaging

11. Red Flags Caudae Equina Saddle anaesthesia Sensory level Motor weakness Bladder dysfunction Action ?

12. Red Flags Caudae Equina Saddle anaesthesia Sensory level Motor weakness Bladder dysfunction Action ? Immediate referral

13. Red Flags Cancer / Infection Previous cancer Wt loss Immunosuppression IV drug use Fever Bony tenderness Severe loss of flexion Action ?

14. Red Flags Cancer / Infection Previous cancer Wt loss Immunosuppression IV drug use Fever Bony tenderness Severe loss of flexion Action ? FBC CRP Myeloma screen Imaging

15. Mechanical Back Pain Low back/buttock/thigh Stiff on rising Gets worse over day Worse with activity Worse with sitting Sleep well after settling Wake on turning Not a diagnosis of exclusion. Refers to a pattern of symptoms and not to any putative mechanism

16. Biggest Problem Still unable to identify source in majority of cases

17. Low Back Pain Imaging Plain x rays CT MRI Discography EMGs

18. Low Back Pain Imaging Plain x rays CT MRI Discography EMGs

19. Low Back Pain Imaging Plain x rays CT MRI Discography EMGs

20. Low Back Pain Imaging CT No evidence that CT is of any value in assessment of mechanical low back pain

21. Low Back Pain Imaging MRI Prolapsed Discs in Asymptomatics 20%< 60 36%> 60 Boden et al, JBJS 1992

22. Low Back Pain Imaging MRI “Degeneration” at L5/S1 27% men between 20 - 30 52% men between 31 - 58 Savage et al, Eur Spine J 1994

23. Low Back Pain Imaging MRI No predictive value for: Back pain duration Consultation Time off work Boos et al, Spine 2000

24. Low Back Pain Imaging Discography

25. Low Back Pain Imaging EMGs Evidence these can distinguish between normal and chronic back pain sufferers ? predictive

26. Mechanical Back Pain Treatment

27. Manipulative Px effective at 6 weeks

28. Mechanical Back Pain Treatment Passive therapies Facet injection Epidural Trigger point injections NO benefit with any of above

29. Mechanical Back Pain Treatment Education Discharge

30. Failure to Discharge Reinforcement of sickness role and of presence of serious pathology Continued empirical (and ineffective!) changes of treatment reinforce belief that there is a “cure”

31. Failure to Discharge Conservative Treatment of Acute Back Pain Control Study Patients669769 Recomm RTW44%81% Actual RTW39%68% Hall et al Spine 1995

32. Swedish Fusion Study Prospective Randomised Controlled Trial Outcome measures up to 2 yrsVAS Oswestry disability Million Zung Global – subjective/independent Fritzell et al, Spine 2001

33. Swedish Fusion Study Main Finding Surgery Conservp< Mean pain 2.1 (33%)0.5 (7%) 0.0002 Oswestry 11 (25%)2 (6%) 0.015 Zung 8 (20%)3 (7%) NS Net RTW 36%13% 0.02

34. Swedish Fusion Study Surgery Performed 68 postero-lateral fusion 62 instrumented pl fusion 75 360 fusion (56 ALIF, 19 PLIF)

35. Swedish Fusion Study Surgery Performed 68 postero-lateral fusion 62 instrumented pl fusion 75 360 fusion (56 ALIF, 19 PLIF)

36. Swedish Fusion Study Radiological fusion PLF Instr PLF360 Fused7287 91 Doubt 2813 9 No significance in any of above

37. Swedish Fusion Study Improvement post surgery PLFInstr PLF360 Pain1.92.3 2 Oswestry1115 9 Zung 9 8 7 No significance in any of above

38. Swedish Fusion Study Surgical Implications PLF Instr PLF 360 Duration 110 194 335 Blood loss 6651284 1433 Inpatient 8.5 9.7 11.5 Comps 3 5 10

39. Swedish Fusion Study Complications 17% 3 root impingements needing surgery 6 nerve root symptoms 5 deep infections 2 major haemhorrage 2 thrombosis/embolism 9 donor site pain

40. Swedish Fusion Study Weaknesses Conservative limb not specified and variable Multi centre Only 2 year follow up Difficulty in assessing fusion No limb without posterior damage

41. IDET

42. IDET Mechanisms Alteration of collagen & mechanics Appears to decrease stiffness Kleinstueck et al, Spine 2001 Lee et al, Acta Phy Med Rehab 2001

43. IDET Mechanisms Healing of posterior fissures Not seen Narvani et al J Spine Dis Tech 2003 No correlation with side of pain Slipman et al Spine 2001

44. IDET Mechanisms Denervation - Temp insufficient Houpt at al, Spine 1996 Freeman et al, ISSLS 2001 - Not seen in ovine model - Clinically relief is delayed

45. IDET Evidence Balance of evidence that there is no significant effect Barendse et al, Spine 2001 Freeman et al, ISSLS 2003 “Limited evidence that IDET is ineffective” Cochrane Collaboration

46. Total Disc Arthroplasty

48. Total Disc Arthroplasty Potential Benefits Preservation of “motion segment” and stress transfer Avoids destructive fusion Avoids donor site morbidity

49. Total Disc Arthroplasty Variable evidence base Complications-17% extrusion -25% end plate sinkage

50. Total Disc Arthroplasty 4000+ now implanted RCTs underway Initial case series seem as good as fusion Long term complications unknown -Wear debris -Effect on facets -Revision ? -Are benefits real?

52. Questions?

53. Summary Mechanical pain is a description NOT a disease Unable to make a diagnosis in majority Majority will improve with effective triage and advice Surgery shown to be effective for some patients but patient selection remains difficult and contraversial