Back Pain
 2nd
most common cause for office visit
 60-80% of population will have lower back
pain at some time in their lives
 Each year, 15-20% will have back pain
 Most common cause of disability for
persons < 45 years
 1% of US population is disabled
 Costs to society: $20-50 billion/year
3/4/03
Steven Stoltz, M.D.
Oh My Aching Back
Treatment Options for Back
Pain
Steven Stoltz, M.D.
Assistant Clinical Professor of Medicine
UCSF-Fresno
Outline

Part 1:
– Introduction
– Review of anatomy

Part 2:
– Acute low back pain

Part 3:
– Chronic low back pain
– Prevention

Questions ??
3/4/03
Steven Stoltz, M.D.
Low Back Pain

“One would have thought by now that the
problem of diagnosis and treatment would
have been solved, but the issue remains
mysterious and clouded with uncertainty.”
– Rosomoff HL, Rosomoff RS. Low back pain: Evaluation
and management in the primary care setting. Med Clin
North Am 1999;83:643-62.
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Steven Stoltz, M.D.
- Anatomy
Lesson #1
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Steven Stoltz, M.D.
- Anatomy
Lesson #2
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Steven Stoltz, M.D.
Introduction to Ed

Ed has had lower back pain for the past 24
hours that he feels is related to yard work
that he did over the weekend. He missed
work today, Monday.
 He wants to know what can be done for his
back pain?
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Steven Stoltz, M.D.
What should Ed expect from
his health care professional?
1.
2.
3/4/03
Be able to recognize the difference
between routine lower back pain and
dangerous forms of lower back pain.
Provide information, advice, and a plan of
action.
Steven Stoltz, M.D.
% of Back Pain due to
Herniated Disk?
1.
2.
3.
4.
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4%
14%
40%
None of the above
Steven Stoltz, M.D.
Causes of Low Back Pain
Lumbar “strain” or “sprain” – 70%
 Degenerative changes – 10%
 Herniated disk – 4%
 Osteoporosis compression fractures – 4%
 Spinal stenosis – 3%
 Spondylolisthesis – 2%

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Steven Stoltz, M.D.
Causes of Low Back Pain…

Spondylolysis, diskogenic low back pain or
other instability – 2%
 Traumatic fracture - <1%
 Congenital disease - <1%
 Cancer – 0.7%
 Inflammatory arthritis – 0.3%
 Infections – 0.01%
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Steven Stoltz, M.D.
Red Flags





History of cancer
Unexplained weight
loss
Intravenous drug use
Prolonged use of
corticosteroids
Older age
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




Major Trauma
Osteoporosis
Fever
Back pain at rest or at
night
Bowel or bladder
dysfunction
Steven Stoltz, M.D.
Medications

Anti-inflammatory medications (NSAID’s):
– Beneficial; no differences; watch side-effects

Tylenol:
 Narcotic Pain Relievers:
– No more effective than NSAID’s
– Many side effects

Muscle Relaxants (ie. Flexeril®):
– Can decrease pain and improve mobility
– 70% with drowsiness/dizziness
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Steven Stoltz, M.D.
Chiropractic/Osteopathic

Davenport, Iowa in 1895 by David Palmer;
‘done by hand’ (Greek)
 Spinal manipulation
 Conflicting evidence on the effects of spinal
manipulation
– ~75-90% improvement anyway within 4 weeks

Greater patient satisfaction
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Steven Stoltz, M.D.
Exercise & Bed Rest

Advice to stay active:
– ‘There is no evidence that advice to stay active
is harmful for either acute low back pain or
sciatica.’
– Hurt does not equal harm

One or two days of bed rest if necessary
 Light activity, avoiding heavy lifting,
bending or twisting (ie. walking)
 No data on any particular exercises
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Steven Stoltz, M.D.
Massage & Physical Therapy

Might be beneficial
 More quality research is needed
 Different types of massage
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Steven Stoltz, M.D.
Acupuncture

Very little quality research and data
 Seems to indicate that acupuncture is not
effective for the treatment of back pain
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Steven Stoltz, M.D.
Other Modalities

Back Brace/Corset/Lumbar Support:
 Traction:
 Injections: Inconclusive evidence
 TENS:
 Hot/Cold:
 Ultrasound:
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Steven Stoltz, M.D.
Ed, again…

Now, Ed has not had improvement in his
lower back pain and 6 weeks have gone by
since the initial painful event.
 What types of therapies might be beneficial
for Ed now?
3/4/03
Steven Stoltz, M.D.
Role of X-rays (Radiology)

Usually unnecessary and not helpful
 Plain X-ray:
– Age>50 years
– No improvement after 6 weeks
– Other worrisome findings

MRI:
– After 6 weeks if have sciatica
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Steven Stoltz, M.D.
New England Journal of Medicine (February 2001)
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Steven Stoltz, M.D.
Medications
Similar to acute pain….
 Antidepressant medications can improve
pain relief

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Steven Stoltz, M.D.
Exercises

Improves pain and function
 Many programs available, but difficult to
make any scientific recommendations for
one type versus another
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Steven Stoltz, M.D.
Injections

Epidural injections:
– Insufficient and conflicting evidence

Facet joint injections:
– No improvement

Local/Trigger point injections:
– Possibly some benefit
3/4/03
Steven Stoltz, M.D.
Surgery

Diskectomy improves pain in short term but
not long term (ie. 10 years)
 Microdiskectomy similar to standard
diskectomy
 Automated percutaneous diskectomy and
laser diskectomy both less effective
 ? Arthroscopic diskectomy
3/4/03
Steven Stoltz, M.D.
Other Modalities

Back Schools: - possibly effective
 Multidisciplinary Therapy: - probably yes
 TENS: - no
 Spinal manipulation: - conflicting data
 Massage: - probably yes
 IDET:
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Steven Stoltz, M.D.
Intradiscal Electrothermal Therapy
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Steven Stoltz, M.D.
IDET

No convincing evidence that shows the
short or long-term clinical efficacy of this
procedure.
 Safe with few adverse effects
 ? Long-term effects
 Wall Street Journal (Feb. 11, 2003)
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Steven Stoltz, M.D.
Prevention

Exercise:
– Aerobic, back/leg strengthening

Back braces and education about proper
lifting techniques are ineffective
 ? weight loss and smoking cessation
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Steven Stoltz, M.D.
Web Resources

www.mayo.edu
 www.cochraneconsumer.com (“Helping
people make well-informed decisions about
health care.”)
 www.library.ucsf.edu
3/4/03
Steven Stoltz, M.D.