OHSU Spine Center

OHSU Spine CenterLow Back Pain: Myth vs. Reality

OHSU Spine Center

OHSU Spine Center

• Orthopaedic Spine Surgeons

OHSU Spine Center

• Orthopaedic Spine Surgeons

• Neurosurgeons

OHSU Spine Center

• Orthopaedic Spine Surgeons

• Neurosurgeons• Physical Medicine &

Rehabilitation Specialists

OHSU Spine Center

• Orthopaedic Spine Surgeons

• Neurosurgeons• Physical Medicine &

Rehabilitation Specialists

• Pain Management Specialists

OHSU Spine Center

• Orthopaedic Spine Surgeons

• Neurosurgeons• Physical Medicine &

Rehabilitation Specialists

• Pain Management Specialists

• Spine Physical Therapists

OHSU Spine Center

• Orthopaedic Spine Surgeons

• Neurosurgeons• Physical Medicine &

Rehabilitation Specialists

• Pain Management Specialists

• Spine Physical Therapists

• Spine Center Gym

OHSU Spine Center

• Orthopaedic Spine Surgeons

• Neurosurgeons• Physical Medicine &

Rehabilitation Specialists • Pain Management

Specialists• Spine Physical Therapists• Spine Center Gym• Spine Center

Identifying the Source of Low Back Pain

Diagnostic Tools:– History– Physical Exam– Diagnostic Studies

• Imaging• Labs• Electrodiagnostic Studies

– Spinal Injections

Diagnoses:• Radiculopathy• Spinal Stenosis• Non-Specific Benign LBP

• Disc Degeneration• Myofascial Pain• Piriformis Syndrome• Sacroiliac Pain• Malalignment

Myth vs. Reality? Back pain …

• Affects everybody at some point

Myth vs. Reality? Back pain …affects everybody

– Individual lifetime occurrence rate

– 60-90%

– Yearly prevalence rate

– 15-20%

Myth vs. Reality? Back pain …affects everybody and gets better!

– Individual lifetime occurrence rate

– 60-90%

– Yearly prevalence rate

– 15-20%

– 50% better at 1 week

– 90% better at 6-12 weeks

– Dillane, Brit Med J, 1966

– Waddell, Spine, 1987– Berquist, 1977

Myth vs. Reality? Back pain …

• Affects everybody at some point • Is result of poor design of the spine

Myth vs. Reality? Back pain …is result of poor design of the spine

Myth vs. Reality? Back pain …

• Affects everybody at some point• Is result of poor design of the spine• Is caused by disk degeneration

Myth vs. Reality? Back pain …is caused by disk degeneration

• 98 asymptomatic L-Spine MRIs– 52% bulges, 27%

protrusions, 1% extrusion

– 14% ALT, 8% facet – 38% with multilevel

abnormalities» Jensen, NEJM

1994

Myth vs. Reality? Back pain …

• Affects everybody at some point• Is result of poor design of the spine• Is caused by disk degeneration• Requires activity limitations

Myth vs. Reality? Back pain …requires activity limitations

• Earlier resumption of work and activities did not have an effect on pain and was associated with improved function

– Gilbert, Deyo, Malmivaara

Myth vs. Reality? Back pain …

• Affects everybody at some point• Is result of poor design of the spine• Is caused by disk degeneration• Requires activity limitations• Implies damage to the spine

Myth vs. Reality? Back pain …implies damage to the spine

Myth vs. Reality? Back pain …

• Affects everybody at some point• Is result of poor design of the spine• Is caused by disk degeneration• Requires activity limitations• Implies damage to the spine• Is better with rest

• Bedrest trials– 0 vs 4 days (n=125)– 2 vs 7 days (n=203)

• Shorter bedrest– 45% fewer lost

workdays– 42% fewer days of

decreased activity– No difference in pain

» Deyo, 1986» Gilbert, 1985

Myth vs. Reality? Back pain …is better with rest

WHAT ABOUT MY ACTIVITIES?

Golfing? Running? Yardwork? Backpacking? Skiing? Firewood? Hunting? Fishing? Camping? Driving? Horseback Riding? Marathons? Lifting? Bending? Weight Training? Biking? Bowling? Working? Basketball? Softball? Grandkids? Kids? Hiking? Climbing? Woodworking? Painting? Kayaking? Mountain Biking?

Myth vs. Reality? Exercise/Activity…

• Is bad for your back

Myth vs. Reality? Exercise/Activity…is bad for your back

– Exercise:• Focused on identifying and improving impairments

in flexibility and strength.– Results:

• People with chronic LBP can substantially improve back flexibility and strength through exercise. This frequently translates into improved ability to function and less daily pain.

» Mayer et al. JAMA 1987; Hazard et al. Spine 1989; Estlander et al. Scan J Rehab Med 1991; Manniche et al. Pain 1991; Rainville et al. Spine 1992; Nelson et al. Orthopedics 1995;

Myth vs. Reality? Exercise/Activity…

• Is bad for your back• Is associated with spine degeneration

Myth vs. Reality? Exercise/Activity…is associated with spinedegeneration

• 67 asymptomatic L-Spine MRIs– 20-39 y.o.:

• 35% Disc degeneration

– <60 y.o.: • 20% Disc herniation

– >60 y.o.:• 36% Disc herniation• 21% stenosis

» Boden, JBJS 1990

Myth vs. Reality? Exercise/Activity…

• Is bad for your back• Is associated with spine degeneration• Should be avoided with back problems

Myth vs. Reality? Exercise/Activity…should be avoided with back problems• “Proper Mechanics”

– “… learn to sit, stand, lie, and do ADLs with LB in proper position”

– Grant, 1975

• Increased LBP risk?– “… difficult recovery

in patients using the wrong muscles to bend, lift”

– Marras, Spine 2001

NO PAIN ----- NO GAINand the role of common sense

Myth vs. Reality? Exercise/Activity…

• Myths (traditional advice)– avoid activity, be

passive– spine easily damaged– often damage is

permanent– focus on pain

• Reality– no serious disease– spine is strong, rarely

damaged– pain does not mean

harm– activity is important to

recovery– focus on function

Burton, Waddell et al; Spine 1999

Exercise and Back Pain…

• Degenerative changes are inevitable

Exercise and Back Pain…degenerative changes are inevitable

• Degenerative changes increase with age

• Back pain levels off with age

• McNab 1977

Exercise and Back Pain…

• Degenerative changes are inevitable• Muscle are shock absorbers

Exercise and Back Pain…muscle are shock absorbers

• Restore– Strength– Flexibility– Endurance

Exercise and Back Pain…muscle are shock absorbers

• Restore– Strength– Flexibility– Endurance

Exercise and Back Pain…muscle are shock absorbers

• Restore– Strength– Flexibility– Endurance

Exercise and Back Pain…

• Degenerative changes are inevitable• Muscle are shock absorbers• Muscles are modifiable and measurable

Exercise and Back Pain…muscles are modifiable and measurable

Reality! Exercise and back pain…

• Back pain is common• Degenerative changes don’t correlate well

to pain• Any activity is better than no activity for the

back

TREATMENT OPTIONSTherapy Medications Injections Surgery

Myth vs. Reality? Spinal Surgery…

• Spine surgery won’t help me because I know too many people who still have pain after surgery

Myth of Spine SurgeryJung U. Yoo, M.D.

Upright Balance

Provide Motion

Shock Absorption

House Neural Elements

Myths

• Minimally invasive surgery is better• Those who have surgery have more pain

after the surgery than before• Latest technology is better• Doctors will make me better

Arthroscopic or laser surgery?

Exposure

• Minimally invasive may require longer surgery

• Surgeon may have limited view• Small incision does not mean small

surgery• There are many type of minimally invasive

surgery

Laser Discectomy

Thermal Disc Coagulation

Protein Denaturation

THOSE WHO HAVE SURGERY HAV

Those who have surgery have more pain after the surgery than before.

Why things fail

• Wrong diagnosis• Wrong patient• Wrong surgery• Life is a percentage

• Conditions that we have to fix• Conditions that we can fix• Conditions that we cannot fix

Broken

Cancer

Herniated Disc

Spinal Stenosis

Deteriorated

I I want the latest technology.TECHNOLO

Wrong Surgery

Increased Stability

Artificial Disc

salvage

Thank you