Non-Operative Management of Low Back Pain in the Elderly

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2 Non-Operative Management of Low Back Pain in the Elderly Brian Kahan, D.O., FAAPMR

3 Low Back Pain Outline Etiologies Initial Assessment Physical examination and Diagnostic work-up Clinical Care Methods Medications Therapeutic Interventions

4 Etiologies Discogenic Pain Degenerative Spinal Stenosis Spondylosis Facet Syndrome Diffuse Idiopathic Skeletal Hyperostosis Compression Fractures Spinal Tumors Failed Back Syndrome

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6 Degenerative Disc Disease Chronic, Cumulative, recurrent Annular tears - Circumferential/radial Endplate ridging Disc herniation,bulging, extrusions Loss of disc height ---> Abnormal motion due to ligament laxity Facet joint pain, arthrosis and hypertrophy Ligmentum thickening Osteophyte formations with foraminal narrowing

7 Risk Factors For Degenerative Disc Disease Age Gender Familial Anthropometrics Work related heavy loading, twisting loads, prolonged sitting, body vibration Trauma - MVA Cigarette smoking? Diabetes Mellitus Deconditioning High protein diet

8 Compression Fractures Acute Management Rest Avoid NSAID s due to delayed healing of fracture Bracing ( flexion vs. extension)? External bone growth stimulator Ventral rami blocks for pain management

9 Compression Fractures Chronic ( greater than 6-12 weeks) Monitor Try NSAID s Physical therapy Vertebroplasty Less than 50% reduction in height

10 Facet Mediated Arthropathy Axial pain with radiation to buttock or sclerotomal pattern Pain generally increased by extension and extension combined with rotation Diagnosed by MRI and radiographs

11 Adult Degenerative Scoliosis Chronic and progressive Related to multi-level disc degeneration over a period of time Combination of discogenic pain and facet mediated pain Treatment concentrates on facets as the primary source of pain

12 Spinal Stenosis Chronic and progressive. Original literature supported non-operative treatment with therapy concentrating on flexion Currently a 10 year cohort study found that eventually all go to surgery and have a better outcome If neurologic deficits occur prior to surgery chances are they will remain even though pain is relieved Non-surgical candidates may try epidural steroids however only works 25-50%

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14 Treatment NSAID s Physical therapy Physical modalities Short acting opioids Epidural steroid injection IDET

15 New Physical therapy programs Originally we concentrated on flexion and extension programs Current literature emphasizes the addition of hip extensors and knee flexors (hamstrings) Addition of corticosteroid injections does not cure the problem but can reduce pain so that patient can partake in exercise programs. Generally not recommended for patent to exercise without supervision after corticosteroid injections.

16 Facet Treatment Physical therapy consisting of neutral stabilization exercises Corset for what it s worth NSAID s Facet joint injection or medical branch blocks Rhizotomy

17 Candidates for Facet Corticosteroid Injections Poor response to oral medication and therapy Inability to tolerate pain Pain that is axial or radicular but not to leg No evidence of neurologic deficit.

18 Candidates for Medial Branch Blocks Patient with partial response to facet joint injections Patient who are considering rhizotomy Patient with severe hypertrophy of the facet joint where exact placement can not be obtained.

19 Candidates for Rhizotomy Persistent pain in the region Positive response to medial branch blocks and facet joint injections.