The Northwestern Mutual Life Insurance Company – Milwaukee, WI

Oh My Aching Back

Deborah Van Dommelen, MD/MPH

Northwestern Mutual

Epidemiology of Back Pain

• Second most prevalent neurologic condition in the US (#1 for men)

• Second most common symptom that prompts MD visit in the US

• Typical age of onset is 30-50, but affects some people into later years

• 80% of US population will have “disabling” back pain in their lifetime

YOU WILL SEE THIS A LOT

Diagnosis Frequency by Age

1. Hypertension2. URI3. Diabetes4. LBP

1. Hypertension2. COPD3. CAD4. URI5. Diabetes6. Arthritis7. LBP

Age 45-64

Age >65

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 contributor

– Of those with back pain, 75% sought medical evaluation and 25% had a related hospitalization

– LTC 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 LBP

• Herniated Disc

• Compression Fracture

• Spinal Stenosis

• Ankylosing Spondylitis

• Cauda Equina Syndrome

• Nonspecific LBP (85%)

Lumbar Disc Disease

Imaging- MRI of Lumber Spine

Compression Fracture

Osteoporosis

Spinal Stenosis

• More common in men

• More common in older ages

• Postural versus Ischemic

Differentiating Vascular and Neurologic Symptoms

Neurologic Vascular

Location Thighs, Calves, Back, Buttocks

Buttocks, Calves

Quality Burning, Cramping Cramping

Exacerbation Standing, Back Extension

Physical Activity with Legs

Relief Sitting, Bending Forward, Squatting

Rest

Blood Pressure/Pulses

Normal Extremities with low BP’s and decreased or absent pulses

Skin Changes None Pallor, Cyanosis, Nail Dystrophy

Autonomic Possible Bladder Incontinence

Possible Impotence

Spinal Stenosis- Bone/Ligament

Spinal Stenosis- Disc

Ankylosing Spondylitis

Ankylosing Spondylitis

Factors Determining Morbidity Risk• Duration of Symptoms (acute vs. chronic)

• Recurrence

• Level of Function

• Imaging and Other Testing (EMG, ABI, etc)

• Treatment–Medications– Procedures– Therapies

Factors Determining Morbidity Risk

•Duration of Symptoms (pain)

Chronicity of Back Pain

• Acute (< 6 weeks)– Lumbar Strain/Sprain– Osteoporotic Fracture– Traumatic

• Subacute/Chronic (6-12 weeks/>12 weeks)– Degenerative Disc Disease– Degenerative Joint Disease– Fibromyalgia– Polymyalgia Rheumatica– Parkinsons– Lumbar Stenosis

Chronic LBP

• Prior studies reported 90% of back pain resolved within 4 weeks

• Recent research indicates that 62% still have back pain after 12 months

• Over age 70, severity and duration of pain are strongest predictors of function and disability.

Factors Determining Morbidity Risk

•Duration of Symptoms (pain)•Recurrence

Recurrence

• Single Episode

• Recurrent Symptoms– Asymptomatic Periods– Recurrence rate in 60-80% within 2 years

• Persistent Symptoms– Never resolves– Stability– Effect on current activities (does it

correlate with severity?)

Case Example #1

• 57yo female 5’ 6” 140# (22.5). Works FT. NT

• Horse 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 sx’s while taking Neurontin. Currently pain free with daily workouts.

• Meds- Neurontin (weaned off within 6 months)

Factors Determining Morbidity Risk

•Duration of Symptoms (pain)•Recurrence•Level of Function

Function

• Unfavorable- General aging effects on the ability to compensate for pain (physiology)– Fall risk– Cognition– Tolerance of pain meds– Ability to participate in therapy

• Favorable- Underwrite the specifics of this applicant– Golfing daily– Still 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 #2

• 60yo 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 NSAID’s 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 Risk• Duration of Symptoms (pain)

• Time to Recovery (function)

• Recurrence

• Level of Function

• Imaging and Other Testing (EMG, ABI, etc)

Testing

• Imaging– X-Rays (radiation exposure)– CT Scan–MRI

• Nerve Conduction Studies (EMG)

• Ankle Brachial Indices (ABI)

• Bone Mineral Density (BMD)

Why so much Imaging??

• Between 1994 and 2005, Lumbar MRI’s increased by 400% in the Medicare population

• Use of imaging directly affected patient satisfaction scores for providers

• Scanners are more available• Medicare reimbursement much higher

for MRI than traditional films• Defensive medicine (more cancer in

older population)

Imaging of the Spine

• Probability of identifying specific cause of back pain on radiographs < 1%.

• Age contributes to false-positive findings on radiographic studies– 50% of asymptomatic people over age

40 will have an abnormal CT or MRI– Gets worse with age

*Do NOT read too much into imaging*

Asymptomatic at Age 60

• Herniated Disc

• Spinal Stenosis

• Degenerative/Bulging Disc

36%

21%

90%

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 #3

• 57yo 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 continued

• Works 50 hours a week as an executive and volunteers in his free time.

• Prior disc surgeries in 1980’s. No issues since then. No current symptoms.

• Appears agile on exam with no gait abnormalities. Able to rise out of chair without assist.

Treatment

• Chiropractic Adjustments

• Adaptive Devices

• Epidural Injections

• Nerve Stimulation (TENS)

• High Risk Medications

• Surgery

Beers Criteria

• Potentially “inappropriate” medications for older adults (65+).– Higher risk for toxicity– Higher risk for side-effects– Generally ineffective

• For 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?• Tylenol

• Narcotics – Oral vs. parenteral/patch/cocktail– Potency– Scheduled vs. intermittent use

• Neurotin/Lyrica

Surgical Outcomes

• Discectomy improvement demonstrated at 1 year, but not at 4 years or 10 years.

• 70% will develop recurrent back pain years later

• Risk of disc herniation is 10X higher in this population

What is underlying anatomic abnormality that allowed the initial lesion?

Case Example #4

• 55yo 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 Continued

• Comorbids- Osteopenia treated with fosamax, but stopped due to GI sx’s. No follow-up BMD.

• Meds- tried neurotin and lyrica (too sedating). GI upset with NSAID’s. 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 Pearls……………………• Is 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……….