12/12/2015 Disclosures Low Back Pain…Pathophysiology Depuy/Synthes Spine honoraria and Management Stryker Spine consultant, honoraria, royalties Bobby KB Tay MD Clinical Professor Department of Orthopaedic Surgery Fellowship support: AOSpine, Nuvasive, University of California at San Francisco Globus Director UCSF Spine Fellowship Medical Director UCSF Spine Center US Expenditures for Spine Patients Low Back Pain (Zdeblik, Rothman-Simeone, The Spine, 1999) 4 30% point prevalence 4 Annual incidence 15% 4 80-90% lifetime prevalence 4 13 million visits for chronic LBP 4 most frequent cause of activity limitation in persons under 45 4 only 1% require prolonged treatment Martin, JAMA 2008 4 Primary cause of disability in pts < 50 y 1
12/12/2015 Normal Disc Biomechanics The Aging Disc 4 vertical loading 4 first two decades 4 nucleus is 4 fluid content of nucleus is compressed and high absorbs load 4 annulus intact 4 annulus on tension 4 26% of asymptomatic 15 4 segmental motion year olds have MR 4 flexion/extension evidence of disc degeneration (Tertti et 4 bending al, Radiology 1991) 4 axial rotation The Aging Disc The Aging Disc 4 third decade 4 fourth decade 4 dehydration of the nucleus 4 continued dehydration and 4 loss of clear distinction collapse of the nucleus between nucleus and annulus 4 loss of disc height 4 with loss of disc 4 annular tears compressibility, the annulus is 4 internal disc derangement more susceptible to tearing 4 dark disc disease 2
12/12/2015 The Aging Disc Pathophysiology of LBP 4 age 50 4 Relationship between DDD and LBP is poorly 4 at autopsy, 85% have disc understood degeneration (Tertti, Spine 1991) 4 Pain may be caused by 4 spondylosis 4 Alteration in biomechanics 4 normal degenerative process 4 Sensitization of nerve endings by chemical mediators of the spine 4 Neurovascular ingrowth 4 unclear why only some have pain Chemical irritation 4 NP can incite inflammatory and degenerative changes consistent with chemical damage. 4 NO, phospholipaseA2, 4 Cytokines 4 IL-1, IL-6, 4 TNF-alpha, PGE2 4 MMP1 and MMP3 3
12/12/2015 Role of DRG Role of DRG 4 Link between intrathecal 4 Dorsal portions of DRG spinal nerve and extrathecal receive segmental sensory peripheral nerve innervation from upper 4 Abundant blood supply DRG via the sympathetic 4 Secrete calcitonin-gene trunk and lower DRG via related peptide, substance-P the Sinuvertebral nerve 4 High density of glutamate receptors 4 Degradation of HNP by endogenous enzymes may potentiate pain at DRG. Role of SVN Facet Joints 4 Arises from ventral root 4 Innervated by medial and gray rami branches of dorsal primary communicantes rami at the segmental level 4 Innervates vertebral 4 Medial descending branch canal, PLL, ventral travels caudally and dura, posterior annulus, innervates muscles, blood vessels ligaments, and facet joint below. 4
12/12/2015 Common causes of LBP and LE pain in adults 4 Intervertebral Disc Herniation 4 Degenerative Spondylolisthesis 4 Spinal Stenosis 4 Lumbar Degenerative Disc Disease 5
12/12/2015 SPORT Studies 4 Pooled population of randomized and observational pts 4 775 treated surgically, 416 non-op 4 Difference in QALYs over 2 years was 0.21 in favor of surgery. 4 Surgery was more costly than nonoperative care 4 difference in total cost was $14,137 4 The cost per QALY gained for surgery relative to nonoperative care 4 $34,355 (95% CI: $20,419–52,512) using Medicare population surgery costs. 6
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12/12/2015 SPORT Trial 4 Randomization of patients with degenerative spondylolisthesis/ spinal stenosis to operative vs. non-operative care 4 Observation cohort 4 Operative care: 4 Limited decompression 4 Open or Endoscopic 4 Non-operative care 4 PT, ESI, Pain medications 4 Journal to track care SPORT Studies 4 Stenosis- with and without spondylolisthesis 4 Tosteson A, et al: Ann Int Med 16 December 2008 Volume 149/ 12,| Pages 845-853 4 Surgery for stenosis (decompressive laminectomy 81%) improved QALY more than non-operative care 4 634 patients with stenosis, 394 (62%) had surgery 4 QALY gain 0.17 4 Cost of $77 600 (CI, $49 600 to $120 000) per QALY gained 4 Surgery for degenerative spondylolisthesis (fusion 93%) improved QALY more than non-operative care 4 601 patients with degenerative spondylolisthesis, 368 (61%) had surgery, 4 QALY gain 0.23 4 Cost of $115 600 (CI, $90 800 to $144 900) per QALY gained. 8
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12/12/2015 61 y.o woman Eosinophilic granuloma Osteoid Osteoma 10
12/12/2015 Adult Degenerative Scoliosis 4 Degenerative scoliosis is characterized by: 4 Adult onset of deformity (de novo) 4 Degenerative changes within the deformity: 4 Stenosis 4 Spondylolisthesis 4 Rotatory subluxation 4 Lumbar hypolordosis 4 Osteoporosis 11
12/12/2015 Results Results 4 89% report improvement of pain after surgery 4 43 patients identified with greater than 2 years of clinical follow-up 4 67% report improvement of function after 4 34 female, 9 male surgery 4 Average Age: 63.3yrs (range 40-81) 4 92% would definitely or probably repeat choose 4 Clinical follow-up: 54.9mos (range 24-129) surgery again 4 Radiographic follow-up: 34.9mos (range 1-97) Diagnosis of Discogenic LBP (Zdeblik, Rothman- Diagnosis of Discogenic LBP (Zdeblik, Rothman- Simeone, The Spine, 1999) Simeone, The Spine, 1999) 4 physical examination 4 physical examination 4 plain radiography 4 plain radiography 4 magnetic resonance imagery 4 magnetic resonance imagery 4 provocative discography 4 provocative discography 4 morphology 4 morphology 4 disc pressure 4 disc pressure 4 response at the involved level 4 response at the involved level 4 response at the adjacent levels 4 response at the adjacent levels 12
12/12/2015 Diagnosis of Discogenic LBP (Zdeblik, Rothman- Diagnosis of Discogenic LBP (Zdeblik, Rothman- Simeone, The Spine, 1999) Simeone, The Spine, 1999) 4 physical examination 4 physical examination 4 plain radiography 4 plain radiography 4 MRI 4 magnetic resonance imagery 4 provocative discography 4 provocative discography 4 morphology 4 morphology 4 disc pressure 4 disc pressure 4 response at the involved level 4 response at the involved level 4 response at the adjacent levels 4 response at the adjacent levels Natural History (Rhyne, et al, Spine 1995) 4 25 patients with low back pain and positive discograms followed over five years 4 68% showed clinical improvement 4 24% with worse LBP and disability 13
12/12/2015 Spinal Arthrodesis and Clinical Management-NON OPERATIVE Outcome Surgery for degenerative lumbar spondylosis (Cochrane Review) 4 Physical therapy, lumbar stabilization Gibson JNA, Waddell G, Grant IC 4 r/o sacroiliac and iliolumbar sources 4 Job/behavior modification Reviewers' conclusions: There is no scientific evidence about the effectiveness of any form of surgical decompression or fusion for degenerative lumbar spondylosis compared with natural history, placebo, or conservative treatment. Citation: Gibson JNA, Waddell G, Grant IC. Surgery for degenerative lumbar spondylosis (Cochrane Review). In: The Cochrane Library, Issue 2 2002. Oxford: Update Software. Provocative Discography 4 Comparison of clinical effectiveness of surgical stabilization (Fusion/Ligamentotaxis) to intensive rehabilitation in patients with chronic low back pain 4 Surgical group with statistically better ODI improvement (Estimated mean difference=-4.1) 4 No difference in SF-36 or functional test (Shuttle) 4 No clear evidence that spinal stabilization was better than intensive rehabilitation 14
12/12/2015 Discogenic Pain 4 Nerve endings: outer third & lateral annulus; Results: PLL & ligamentum • 50% (4/8) of patients had a positive PD, but no CLBP. flavum • 85% (7/8) of patients experienced concordant pain on PD to 4 Pain can be provoked their usual discomfort from bone graft sites. when injecting normal • Conclusions: or abnormal disc • The ability of a patient to separate spinal from nonspinal sources of pain on PD is questioned. • A response of concordant pain on PD may be less meaningful than often assumed . Discography and Psychology 4 Carragee Spine 2000 4 47 post-discectomy patients 4 20 asymptomatic, 27 recurrent symptoms 4 Block Spine 1996 4 40% non painful Post-discetomy patients had pain at 4 Pts with elevated scores on hysteria and hypochondriasis on operated segment during discography MMPI were more likely to report pain on injection of a 4 63% of patients with recurrent sx had positive disc nondisrupted disc. 4 15/27 had concordant pain. 4 Ohnmeiss Spine 1995 4 Carragee Spine 2000 4 Pain with unusual pain drawings and elevated MMPI are more 4 Patients with neck pain and no low back pain likley to report pain on injection of non-distrupted disc 4 Positive in 10% with good cervical surgery outcome 4 Carragee 4 Positive in 40% of patients with poor result after neck 4 40% patients with abnormal psych profile reported back pain 12 surgery months after discography. 4 Positive in 80% of patients with somatization disorder 15
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