SSM HealthSpinal Causes and Management

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Richard A Covert MD, MPHMedical Director- SSM Health Comprehensive Back Pain Program

Neuroscience Institute

Disclosures

• I am employed by the SSM Medical Group• Nothing to disclose• I am not reimbursed for any lectures, articles, medication

usage, etc.• I have no financial relationships in any imaging,

rehabilitation or other 3rd party providers, nor any investments in products

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Overview

• Epidemiology of Back Pain• Causes of LBP

– Multiple sources– Top 3 Dx’s seen in the Back Pain Program

• Treatment Approach• Outcomes of SSM Program

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Epidemiology

• Prevalence/yr 25-28%1,2

• Prevalence/lifetime is 79-84% 1,2

• # ED Visits/yr in US 2015 136.9 million (all causes) • 3.5 million are for back pain (2.6%) as 10 cause of visit

– Men 15-64 -> 1.23 M ED visits– Women 15-64 -> 1.68 M ED visits– Adults ≥ 65 -> 600,000 ED visits 3

• ED visits for Chronic Disorders (ICD-9 Codes) LBP 20 Dx• Spinal Disorders (720-724) -> 4.28 million visits• Sprains/Strains of Back (846,847) -> 2.08 million visits

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Financial Burden of Back Pain

• Most Common Cause of Disability in adults (18-64y/o)• Accounts for 40% of all Missed Workdays (AAOS)• #2 Reason for OP visits to doctors• Hosp Admission for Back Pain as 1⁰ Dx 1.7% (663,402) 2008

– Financial Cost $9.52 B (2008) => $11.17 B (2019) 4

• Hospital LOS for Pts. With Back Problems = 2.3 days longer– Financial Cost $25.97 B (2008) => $30.05 B (2019)4

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Common Causes of LBP

• Mechanical Low Back Pain

• Sprains/Strains• Degenerative Disc

Disease• Herniated Discs• Spinal Stenosis

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• Skeletal Deformities (Scoliosis, Kyphosis, Lordosis)

• Spondylolisthesis• Compression

Fractures (traumatic, osteoporotic)

• Myofascial Pain/Fibromyalgia

Less Common Causes of LBP

• Kidney Stones• Aortic Aneurysms• Tumors• Infections• Facet Cysts• Ankylosing Spondylitis

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Risk Factors for LBP

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Risk Factors for LBP

• Age – Impacts Discs, Muscle Elasticity, Injury Recovery, Spinal Stenosis, Bone Loss, Balance

• Poor Fitness – Weak Core Muscles, Loss of Flexibility, Strength, Endurance

• Pregnancy – Especially 3rd Trimester due to Weight Gain, Ligamentous Laxity, Decreased Core Strength

• Obesity – Increases Loading of Spine with Decreased Core Strength• Genetics• Occupational Stresses – Excess Activity or Desk Work• Sports / Hobbies – Biking, Golf, Back Packing, Gymnastics, Football• Smoking

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Distribution of Back Disorders by Age

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• Disc Herniation• Degenerative Disc Disease• Spinal Stenosis

Most Common Problems @ Back Clinic

• Mechanical Low Back Pain• Spinal Stenosis• Sacroiliitis• Piriformis Syndrome

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Structures of the Lumbar Spine

• Muscles• Discs• Vertebrae• Ligaments• Facet Joints• Spinal Cord• Nerve Roots

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Spinal Causes of Pain

Video of Spinal Structures

• Spinal Anatomy

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Mechanical Low Back Pain

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Normal Motion

Zygotebody.com

Mechanical Factors

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• Flexibility – Limit Mobility of Hips, Pelvis → Incr. Stress to spine– Tight Hamstrings– Tight Hip Flexors– Tight Calf Muscles– Tight Piriformis / Gluteal Muscles

• Lack of Core Muscle Strength – decr. Spine Stabilization– Abdominals – Paraspinals– Hip Abductors

• Leg Length Discrepancy• Pelvic Asymmetry

Symptoms of Mechanical Low Back Pain

• Aching/Stiffness in low to mid back• Tightness/Spasm• Limited ROM• Pain with Bending• Pain upon arising from chairs or bed• Occasional Hamstring Pain but NO Radicular Symptoms down

the legs• Pain with Fatigue• Pain can be bilateral or unilateral

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Treatment of Mechanical LBP

• Stretching of key muscle groups (Hamstrings, Hip Flexors, Gluteals)

• Strengthening of Core Muscles, Legs and Hips• Massage to break up old Adhesions• Heat/Ice• Myofascial Release• Aerobic Fitness

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Useful Stretches for Mechanical LBP

Sacroiliac Joint Anatomy

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SI Dysfunction

• Symptoms and Signs– Unilateral Pain

• Sharp or dull• Waxes and Wanes• Can vary sharply with position (arising from a chair, twisting, sex)• Aggravated by prolonged standing (go to a bar)• Refers Sx down the buttocks, thigh or groin (mimics sciatica without

lower leg Sx)

– Localized Tenderness

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SI Dysfunction

• Clinical Exam– Pelvic Asymmetry

• Leg Length Discrepancy• Muscle Spasm• Pelvic Rotation due to muscle imbalance, falls, MVA’s, etc.• Ligamentous Laxity from pregnancy, repeated mobilization of the joint

– Local Tenderness over Sciatic Notches– (+) Gaenslen’s Test (hip thrust)– (+/-) Patrick FABER test– Limited Mobility of the SI region on forward flexion

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Posterior View of Iliac Crests and Sciatic Notches

SI Dysfunction

• Contributing Factors– Tight Hip Flexors and Quads– Tight Lower Back Muscles– Tight Hamstrings– Weak Core Muscles and Weak Gluteal Muscles– Pregnancy– Obesity with Increase Shear Forces

• Unilateral Sacralization or Lumbarization of L5 or S1 (Bertolotti’sSyndrome)

• DJD• Ankylosis Spondylitis and other autoimmune diseases

23Zygotebody.com

Treatment of Sacroiliitis

• Treatment– Physical Therapy to address muscle strength, flexibility, pelvic rotation– Correction of Leg Length discrepancy with heel lifts, orthotics– Pillow behind or between knees when sleeping– Medications

• NSAID’s• Muscle relaxers for spasm• Avoid Narcotics• Gabapentin, Amitriptyline, Duloxetine have no benefit

– Injection into SI joint under fluoroscopy

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Spinal Stenosis

• What is it?• What causes it?• What are typical symptoms?• What treatments are available?

– Therapy – Medication– Injections– Surgery

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Risk Factors• Age > 50 • Congenital Stenosis (Short

Pedicles)• Scoliosis• Bulging or Herniated Discs• Thickened Ligaments (Lig. Flav.)• OA / Spondylosis• Traumatic Injuries to vertebrae6

Prevalence by Age7

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Symptoms of Spinal Stenosis• Numbness or tingling in a foot or leg• Weakness in a foot or leg • Pain or cramping in one or both legs when you stand for long

periods of time or when you walk, which usually eases when you bend forward or sit (Shopping Cart Sign)

• Back pain

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Imaging

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Treatment of Spinal Stenosis• Non Surgical

– PT to address Mechanical Issues– Medications

• NSAID’s• Gabapentin (Neurontin)• Pre-Gabalin (Lyrica)• Duloxitine (Cymbalta)• Venlafaxine (Effexor)• Amitriptyline / Nortriptyline• Medrol Dosepak

– Injections• ESI• Transforaminal Steroids

• Surgical– Laminectomy– Foraminotomy– Decompression with Fusion– Insertion of Spacers

• Indications for Surgery– Bowel / Bladder control issues– Intractable pain– Inability to Ambulate– Progressive Weakness– Increasing Numbness

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Spinal Stenosis

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Back Pain Program Outcomes

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5.26

2.322.94

0.00

1.00

2.00

3.00

4.00

5.00

6.00

PHQ9-Init PHQ9-Exit PHQ9 Net

PHQ 9 Outcomes

0-4 Minimal Depression

5-9 Mild Depression

33.18%

15.18%18.00%

0.00%

5.00%

10.00%

15.00%

20.00%

25.00%

30.00%

35.00%

ODI-Init ODI-Exit ODI net

ODI Outcomes

Depression and Disability ChangesScoring Range 0 to 100 %Scoring Range 0 to 27

21-40% mod. Dis.

0-20% Min. Dis.

Back Pain Program Outcomes

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15.29

7.588.32

0.00

2.00

4.00

6.00

8.00

10.00

12.00

14.00

16.00

18.00

FABQa-Init FABQa-Exit FABQa-Net

FABQa Outcomes9.32

5.54

3.82

0.00

1.00

2.00

3.00

4.00

5.00

6.00

7.00

8.00

9.00

10.00

FABQw-Init FABQw-Exit FABQw-Net

FABQw Outcomes

Fear Avoidance Behavior Changes for Personal Activity and Work

Scoring Range 0 to 24 points (Threshold > 15) Scoring Range 0 to 42 points (Threshold >34)

Thanks for your time and attention!

Thanks for Staying Awake after Lunch!

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CannabisUpside DownsideMay Help Reduce Neuropathic Pain (CB1 receptors in Brain)10

Lung Disease if Smoked

Improved Sense of Wellbeing Pancreatitis

Better Appetite Cannabinoid Hyperemesis Syndrome

Relaxation - Sleep Acute Cognitive Impairment - short term use

Anti-Inflammatory Effect (CB2 receptors on immune cells) Long Term Cognitive Deficits in Younger Persons

CBD legal in most states (THC legal in 23 states and DC) (see Wikipedia)

Exacerbation of Psychosis/Schizophrenia/Agitation

CBD (Epidiolex) approved for 2 types of Sz disorders Cannabinoid W/D syndrome

Adverse Effects on Fetus if user is pregnant

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Research Limitations: No Double Blind Studies of THC, Conc. Of THC varies from 5% to 90%, Dose of THC or CBD/CC varies among suppliers, format of delivery is variable (drops, inhalation, creams, oils) so pharmacokinetics is variable, purity of preparations is variable (No USP control), No Guidelines for dosing 9

Cannabinoid Alleged Benefits

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CBD is the Greatest Thing!

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Use Common Sense Don’t believe everything you read on the WebJust be careful – start low… go slow