Low Back Pain Low Back Pain 4 70-80% of adults experience at least 1 - - PowerPoint PPT Presentation

5/31/2013 1 Sibel Demir-Deviren, MD Associate Clinical Professor Spine Center University of California, San Francisco

Do We Know Everything About LBP?

8TH ANNUAL UCSF SPINE SYMPOSIUM San Francisco, 2013

DEPARTMENT OF ORTHOPAEDIC SURGERY UNIVERSITY OF CALIFORNIA SAN FRANCISCO DEPARTMENT OF ORTHOPAEDIC SURGERY UNIVERSITY OF CALIFORNIA SAN FRANCISCO

Department Support Disclosure

AIOD-Assn Intl l'Osteosynthese Dynamique Aleeva Medical, Inc. American College of Sports Medicine Fdn American Orthopaedic Soc for Sports Med Agency for Healthcare Research and Quality AO Foundation Arthritis Foundation Arthrocare Corporation Arthroscopy Association of North America Biomet, Inc. Canadian Academy of Sports Medicine Columbia University Deafness Research Foundation DePuy Inc., a Johnson & Johnson Company Hacettepe University Harold K. L. Castle Foundation Histogenics Corporation Intl Spinal Injection Society ISTO Technologies, Inc. Kyphon March of Dimes Birth Defects Foundation Medtronic, Inc. Musculoskeletal Transplant Foundation NIH Natl Inst Arthr, Musculoskel & Skin NIH Natl Inst Dental & Craniofacial Res. North American Spine Society North Shore-Long Island Jewish Hlth Sys Novo Nordisk Orthologic Corporation Orthopaedic Research and Education Fdn. Orthopaedic Trauma Association Scios, Inc., a Johnson & Johnson Co. Scoliosis Research Society Smith and Nephew, Inc. Spinal Kinetics, Inc. SpinalMotion, Inc. Stryker Corporation Stryker Howmedica Osteonics Synthes USA TissueLink Medical, Inc. TranS1, Inc. UC Berkeley United Health Group Company University of Minnesota University of Texas at Dallas Wisconsin Alumni Research Foundation Zimmer, Inc.

10/15/2007

Low Back Pain Low Back Pain

470-80% of adults experience at least 1 episode

• f LBP

440% experience a second episode within 6 months 4Patients suffering from LBP consume more than $90 billion annually 470-80% of adults experience at least 1 episode

• f LBP

440% experience a second episode within 6 months 4Patients suffering from LBP consume more than $90 billion annually

Paraspinal Muscles in Patients with LBP Paraspinal Muscles in Patients with LBP

Several studies have emphasized the important role

• f paraspinal

muscle morphology on the etiology, prognosis and management Several studies have emphasized the important role

• f paraspinal

muscle morphology on the etiology, prognosis and management

5/31/2013 2 4Theories on the role of these muscles arose from imaging studies suggesting hsmaller multifidus cross-sectional area (CSA) hmore fatty infiltration as compared with healthy asymptomatic controls. 4Theories on the role of these muscles arose from imaging studies suggesting hsmaller multifidus cross-sectional area (CSA) hmore fatty infiltration as compared with healthy asymptomatic controls.

Multifidus Muscle Multifidus Muscle

4The lumbar multifidus is considered to be a vital stabilizer of lumbar spine 4Multifidus alone is responsible for more than two thirds of the muscular stiffness in the sagittal plane 4The lumbar multifidus is considered to be a vital stabilizer of lumbar spine 4Multifidus alone is responsible for more than two thirds of the muscular stiffness in the sagittal plane

Multifidus Muscle Multifidus Muscle

4Control the intersegment motion of the individual vertebrae 4Any atrophy or injury to the multifidus muscle is expected to compromise spinal function 4Control the intersegment motion of the individual vertebrae 4Any atrophy or injury to the multifidus muscle is expected to compromise spinal function

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Multifidus Muscle Multifidus Muscle

4Chronic denervated muscle is best seen on magnetic resonance images (MRI) as loss of muscle bulk and widespread areas of increased signal intensity resulting from fatty infiltration 4Chronic denervated muscle is best seen on magnetic resonance images (MRI) as loss of muscle bulk and widespread areas of increased signal intensity resulting from fatty infiltration

Multifidus and paraspinal muscle group are smaller in patients with chronic LBP than healthy controls Multifidus and paraspinal muscle group are smaller in patients with chronic LBP than healthy controls 4Fatty Infiltration in the lumbar extensors is a common finding in patients with CLBP which correlates with poor physical performance, and disability 4Fatty Infiltration in the lumbar extensors is a common finding in patients with CLBP which correlates with poor physical performance, and disability

Multifidus Muscle Multifidus Muscle

4It is difficult to measure cross sectional area with diffuse fatty infiltration 4It is difficult to measure cross sectional area with diffuse fatty infiltration

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MRI IDEAL Images MRI IDEAL Images

Average % fat deposition (1.97 – 2.4%) in paraspinal muscles in a healthy subject Average % fat deposition (1.97 – 2.4%) in paraspinal muscles in a healthy subject

Multifidus Muscle Multifidus Muscle

4Patients with chronic LBP appear to have more multifidus atrophy at L5 than L4 4Patients with chronic unilateral LBP have smaller muscles on the symptomatic side as compared with the asymptomatic side. 4Patients with chronic LBP appear to have more multifidus atrophy at L5 than L4 4Patients with chronic unilateral LBP have smaller muscles on the symptomatic side as compared with the asymptomatic side.

Multifidus Muscle Multifidus Muscle

4Multifidus atrophy is associated with poor functional

• utcomes after disc surgery

4Muscle fatigue leads to changes in muscle recruitment patterns, increases in spinal force, and decreases in spinal stability 4Multifidus atrophy is associated with poor functional

• utcomes after disc surgery

4Muscle fatigue leads to changes in muscle recruitment patterns, increases in spinal force, and decreases in spinal stability

Paraspinal Muscles and LBP Paraspinal Muscles and LBP

4Possible mechanisms for muscle atrophy

hDisuse hMuscle denervation hReflex inhibition hIatrogenic

4Possible mechanisms for muscle atrophy

hDisuse hMuscle denervation hReflex inhibition hIatrogenic

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Innervation of Multifidus Muscle Innervation of Multifidus Muscle

4Multifidus muscles have monosegmental innervation 4L1 multifidus is innervated by L1 medial branch nerve 4L5 MM by L5 medial branch nerve 4Multifidus muscles have monosegmental innervation 4L1 multifidus is innervated by L1 medial branch nerve 4L5 MM by L5 medial branch nerve

Medial branch nerve Medial branch nerve

4Multifidus muscle 4Facet joint 4Pars interarticularis 4Multifidus muscle 4Facet joint 4Pars interarticularis

Radiofrequency ablation of medial branch nerve for facetogenic pain Radiofrequency ablation of medial branch nerve for facetogenic pain

4For L5-S1 facet joint, we ablate L4 and L5 medial branch nerves 4For L4-5 facet joint, we ablate L3 and L4 MBNs 4For L3-4 facet joint, we ablate L2 and L3 MBNs 4For L5-S1 facet joint, we ablate L4 and L5 medial branch nerves 4For L4-5 facet joint, we ablate L3 and L4 MBNs 4For L3-4 facet joint, we ablate L2 and L3 MBNs

Radiofrequency ablation of medial branch nerve for facetogenic pain Radiofrequency ablation of medial branch nerve for facetogenic pain

4On the purpose of helping patients for 6-12 months 4Iatrogenic multifidus atrophy 4We don’t know the long term effects 4On the purpose of helping patients for 6-12 months 4Iatrogenic multifidus atrophy 4We don’t know the long term effects

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Biomechanic Studies at UCSF Biomechanic Studies at UCSF

4Multifidus activation increased lordosis in the unweighted spine 4Reduction in multifidus force decreased lordosis in the weighted spine 4Multifidus activation increased lordosis in the unweighted spine 4Reduction in multifidus force decreased lordosis in the weighted spine

Biomechanic Studies at UCSF Biomechanic Studies at UCSF

4This extent of lordosis loss is consistent with that observed in human subjects with multifidus atrophy 4This extent of lordosis loss is consistent with that observed in human subjects with multifidus atrophy

Biomechanic Studies at UCSF Biomechanic Studies at UCSF

4When the atrophied multifidus was represented, the erector spinae force needed to increase by 46% to maintain trunk posture 4When the atrophied multifidus was represented, the erector spinae force needed to increase by 46% to maintain trunk posture

Biomechanic Studies at UCSF Biomechanic Studies at UCSF

4This caused an increase in overall spine compression

• f 28% percent

NIH Grant 1R01AR060729-01

4This caused an increase in overall spine compression

• f 28% percent

NIH Grant 1R01AR060729-01

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Biomechanic Studies at UCSF Biomechanic Studies at UCSF

4These data demonstrate two potential mechanisms by which multifidus atrophy may trigger back pain

hBy loss of lumbar lordosis hBy increase in spine compression that may result in disc and endplate overloading.

4These data demonstrate two potential mechanisms by which multifidus atrophy may trigger back pain

hBy loss of lumbar lordosis hBy increase in spine compression that may result in disc and endplate overloading.

Clinical Implication Clinical Implication Before recommend or perform RFA of MBN Before recommend or perform RFA of MBN

4Please look at the paraspinal muscles on lumbar spine MRI 4RFA of MBNs cause iatrogenic atrophy of multifidus muscles 4If the multifidus muscle is intact, please avoid RFA of MBN especially for L4-5 and L5-S1 facet joints. 4Please look at the paraspinal muscles on lumbar spine MRI 4RFA of MBNs cause iatrogenic atrophy of multifidus muscles 4If the multifidus muscle is intact, please avoid RFA of MBN especially for L4-5 and L5-S1 facet joints.

Before recommend or perform RFA of MBN Before recommend or perform RFA of MBN

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There is a need to change the location of RFA of MBN There is a need to change the location of RFA of MBN

4Articular branches of MBN run cranially to caudal parts and caudally to cranial parts of each facet joint capsule. 4Selective RFA of articular branches 4Articular branches of MBN run cranially to caudal parts and caudally to cranial parts of each facet joint capsule. 4Selective RFA of articular branches

Lumbar degenerative flat back Lumbar degenerative flat back

4Multifidus and paraspinal muscle group are smaller in patients with flat back than healthy controls 4Fatty Infiltration within the paraspinal muscles are significantly increased 4Multifidus and paraspinal muscle group are smaller in patients with flat back than healthy controls 4Fatty Infiltration within the paraspinal muscles are significantly increased

Lumbar degenerative flat back Lumbar degenerative flat back

464 years old 4Laminectomy at L1-5 in 2009 4Flatback in 2012 4Developed proximal junctional kyphosis 464 years old 4Laminectomy at L1-5 in 2009 4Flatback in 2012 4Developed proximal junctional kyphosis

Lumbar degenerative flat back Lumbar degenerative flat back

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Paraspinal Muscles and LBP Paraspinal Muscles and LBP

4More studies are needed to better understand the role of the multifidus and paraspinal muscle group

hin the etiology and hmanagement of common spinal disorders

• Deformity
• Degenerative flat back
• PJK

4More studies are needed to better understand the role of the multifidus and paraspinal muscle group

hin the etiology and hmanagement of common spinal disorders

• Deformity
• Degenerative flat back
• PJK

Is Discogenic Low Back Pain a Subclinical Disc Infection? The BackBug Study Is Discogenic Low Back Pain a Subclinical Disc Infection? The BackBug Study 4162 patients with chronic LBP and Modic I DDD 4Randomized in to placebo and amoxicillin- clavulanate for 100 days 461 patients underwent disc biopsy 4Cultures were positive in 46% 480% of positive cultures developed new Modic I DDD at the adjacent vertebrae Is Discogenic Low Back Pain a Subclinical Disc Infection? The BackBug Study Is Discogenic Low Back Pain a Subclinical Disc Infection? The BackBug Study

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Is Discogenic Low Back Pain a Subclinical Disc Infection? The BackBug Study Is Discogenic Low Back Pain a Subclinical Disc Infection? The BackBug Study

1. Stirling A, Worthington T, Rafiq M et al (2001) Association between sciatica and Propionebacterium acnes. Lancet 357:2024–2025 2. Stirling AJ, Jiggins M (2002) Association between sciatica and skin commensals. International Society for the Study of the Lumbar Spine 3. Corsia MF, Wack M, Denys G. (2003).Low virulence Bacterial infections of intervertebral discs and the resultant spinal disease processes. Abstract from Scoliosis Research Society (SRS) annual meeting

Is Discogenic Low Back Pain a Subclinical Disc Infection? The BackBug Study Is Discogenic Low Back Pain a Subclinical Disc Infection? The BackBug Study

• 4. Agarwal VJ, Golish SR, Alamin TF (2011)

Bacteriologic culture of excised intervertebral disc from immunocompetent patients undergoing single level primary lumbar microdiscectomy. J Spinal Disord Tech 24:397–400

• 5. Fritzell P, Bergstro ̈m T, Welinder-Olsson C (2004)

Detection of bacterial DNA in painful degenerated spinal discs in patients without signs of clinical

• infection. Eur Spine J 13:702–706

Modic I DDD Modic I DDD Modic I DDD Modic I DDD

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Thank you