the northwestern mutual life insurance company – milwaukee, wi oh my aching back deborah van...
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Epidemiology of Back PainSecond most prevalent neurologic condition in the US (#1 for men)Second most common symptom that prompts MD visit in the USTypical age of onset is 30-50, but affects some people into later years80% of US population will have disabling back pain in their lifetimeYOU WILL SEE THIS A LOT
Diagnosis Frequency by Age
Annual Costs of Low Back Pain$40 Billion in Direct Costs
>$100 Billion in Indirect Coasts
Rapid increase in technology for imaging and procedures is a significant contributorOf those with back pain, 75% sought medical evaluation and 25% had a related hospitalizationLTC Claims coverage could be part of these costs
Causes of Low Back Pain (LBP)Mechanical (97%)Spinal StenosisDegenerative Disc
Visceral (2%)Aortic AneurysmKidney Disease
Cancer (1%), increases with age up to 7%
Mechanical LBPHerniated DiscCompression FractureSpinal StenosisAnkylosing SpondylitisCauda Equina Syndrome
Nonspecific LBP (85%)
Lumbar Disc Disease
Imaging- MRI of Lumber Spine
Spinal StenosisMore common in men
More common in older ages
Postural versus Ischemic
Differentiating Vascular and Neurologic Symptoms
NeurologicVascularLocationThighs, Calves, Back, ButtocksButtocks, CalvesQualityBurning, CrampingCrampingExacerbationStanding, Back ExtensionPhysical Activity with LegsReliefSitting, Bending Forward, SquattingRestBlood Pressure/PulsesNormalExtremities with low BPs and decreased or absent pulsesSkin ChangesNonePallor, Cyanosis, Nail DystrophyAutonomicPossible Bladder IncontinencePossible Impotence
Spinal Stenosis- Bone/Ligament
Spinal Stenosis- Disc
Factors Determining Morbidity RiskDuration of Symptoms (acute vs. chronic)RecurrenceLevel of Function Imaging and Other Testing (EMG, ABI, etc)TreatmentMedicationsProceduresTherapies
Factors Determining Morbidity RiskDuration of Symptoms (pain)
Chronicity of Back PainAcute (< 6 weeks)Lumbar Strain/SprainOsteoporotic FractureTraumatic
Subacute/Chronic (6-12 weeks/>12 weeks)Degenerative Disc DiseaseDegenerative Joint DiseaseFibromyalgiaPolymyalgia RheumaticaParkinsonsLumbar Stenosis
Chronic LBPPrior studies reported 90% of back pain resolved within 4 weeksRecent research indicates that 62% still have back pain after 12 monthsOver age 70, severity and duration of pain are strongest predictors of function and disability.
Factors Determining Morbidity RiskDuration of Symptoms (pain)Recurrence
RecurrenceSingle EpisodeRecurrent SymptomsAsymptomatic PeriodsRecurrence rate in 60-80% within 2 yearsPersistent SymptomsNever resolvesStabilityEffect on current activities (does it correlate with severity?)
Case Example #157yo female 5 6 140# (22.5). Works FT. NTHorse injury 2 yrs ago with period of paralysis (spinal cord bruising). Neurosurgeon- Immediate quadraparesis after fall on neck. Imaging- Vertebral fracture and cord edema. Mod stenosis multiple levels of cervical spine. Comorbids- Osteopenia (fractured wrist due to fall off horse)Function- Back to work within 2 months. No sxs while taking Neurontin. Currently pain free with daily workouts.Meds- Neurontin (weaned off within 6 months)
Factors Determining Morbidity RiskDuration of Symptoms (pain)RecurrenceLevel of Function
FunctionUnfavorable- General aging effects on the ability to compensate for pain (physiology)Fall riskCognitionTolerance of pain medsAbility to participate in therapyFavorable- Underwrite the specifics of this applicantGolfing dailyStill working
The Back Pain Function Scale (BPFS) (Stratford et al)
Able to do usual work housework?What are usual hobbies recreational or sporting activities?Is sleep disturbed by pain?Able to do the following for 1 hour: lifting, standing, walking, sitting, and driving?Able to go up or down 2 flights of stairs?Any problems putting on socks or shoes?Working outside home? FT?
Case Example #260yo male 6 1 210 (BMI 28). Works FT.Intermittent back pain for more than 10 years.Imaging- x-ray from 8 years ago showing mild scoliosis.Tx includes: chiro, PT, and NSAIDs for flares. No surgeries or injections. No narcotics due to nausea.Recurrence averages 2-3 times a year. Usually due to lifting activities related to home improvement projects. Takes 3-7 days before back to normal activities.Most recent exacerbation 2 months ago after laying sod on 1/2 acre lot. Now reported to be sx free (completed 4 weeks of chiro).Since then had a GXT as part of application for life insurance (13 minutes, 14 METS)
Factors Determining Morbidity RiskDuration of Symptoms (pain)Time to Recovery (function)RecurrenceLevel of Function Imaging and Other Testing (EMG, ABI, etc)
TestingImagingX-Rays (radiation exposure)CT ScanMRI
Nerve Conduction Studies (EMG)Ankle Brachial Indices (ABI)Bone Mineral Density (BMD)
Why so much Imaging??Between 1994 and 2005, Lumbar MRIs increased by 400% in the Medicare populationUse of imaging directly affected patient satisfaction scores for providersScanners are more availableMedicare reimbursement much higher for MRI than traditional filmsDefensive medicine (more cancer in older population)
Imaging of the SpineProbability of identifying specific cause of back pain on radiographs < 1%. Age contributes to false-positive findings on radiographic studies50% of asymptomatic people over age 40 will have an abnormal CT or MRIGets worse with age
*Do NOT read too much into imaging*
Asymptomatic at Age 60
Does Imaging Mean Anything?Does the location of symptoms match the abnormality on CT/MRI?Is the severity of symptoms consistent with the degree of abnormality on the CT/MRI?
Case Example #357yo male 5 9 195# (BMI 29)No prescription meds. PRN OTC NSAID.End stage DDD. Imaging from 2006 shows loss if disc space at L4-5 with impingement of L5 nerve root. Disc extrusion affecting L3 and L4 nerves. Neck pain in 2009 treated with chiro, then 2 prednisone bursts, followed by an epidural
Case #3 continuedWorks 50 hours a week as an executive and volunteers in his free time.Prior disc surgeries in 1980s. No issues since then. No current symptoms.Appears agile on exam with no gait abnormalities. Able to rise out of chair without assist.
TreatmentChiropractic AdjustmentsAdaptive DevicesEpidural InjectionsNerve Stimulation (TENS)High Risk MedicationsSurgery
Beers CriteriaPotentially inappropriate medications for older adults (65+).Higher risk for toxicityHigher risk for side-effectsGenerally ineffectiveFor full list of medications, refer to this site:http://archinte.ama-assn.org/cgi/content/full/163/22/2716
Beers Criteria (LBP related)Any benzodiazepine (alprazolam, lorazepam, etc)Muscle relaxants (Soma, Paraflex, Skelaxin, Flexeril, etc) Anti-inflammatory (Toradol, Indocin, Naprosyn, Daypro, etc)Narcotics (Demerol)Miscellaneous (Elavil) NO MORE Darvocet
So what medications are left for pain management?TylenolNarcotics Oral vs. parenteral/patch/cocktailPotencyScheduled vs. intermittent useNeurotin/Lyrica
Surgical OutcomesDiscectomy improvement demonstrated at 1 year, but not at 4 years or 10 years.70% will develop recurrent back pain years laterRisk of disc herniation is 10X higher in this population
What is underlying anatomic abnormality that allowed the initial lesion?
Case Example #455yo female 5 7 210# (BMI 33). Works FT. NT.PMH- Osteopenia, hypothyroid, lumbar fusion (15yrs ago).Recent visit- Left LE numbness associated with chronic LBP and radiculopathy (occasional weakness). Has cane and walker at home but does not use them.Treatment- Prior back surgery failed (remote). Radiofrequency ablation little improvement. ESI last month.
Case Example #4 ContinuedComorbids- Osteopenia treated with fosamax, but stopped due to GI sxs. No follow-up BMD.Meds- tried neurotin and lyrica (too sedating). GI upset with NSAIDs. So given narcotics and steroid bursts for exacerbations. Imaging- Mod degenerative changes lumbar and cervical spine (osteophytes and disc space narrowing). Noted hardware for prior fusion causes artifact)
Take Home PearlsIs this really Mechanical back pain?Is my decision overly influenced by Imaging?Does Treatment match the symptoms?Are there any Co-morbid conditions to be considered?What is their Function?
Questions to follow.
Personal teapot storyUlterior motive to convince them people like me and Carl are insurable in a few years.*Number one is URITypically pain affects cervical and lumbar spine due to mechanics. Will focus on LBP, but many of the principles are applicable to neck pain as well.*Prevalence of back pain in geriatric population approaches 70%75% of the elderly that experience back pain report that is started before age 65*15-40% of elderly with back pain reported limitations to walking, sitting, and doing household chores*Usually can determine visceral or cancerous causes acutely*Ankylosing spondylitis is usually diagnosed at a younger age, but has manifestations that can affect function at older ages.*Donut Reference..Herniated and bulging discs more typical at younger ages (can resolve)DDD occ