Approaches to Low Back Pain

Transcription

1 Approaches to Low Back Pain NECOM/MaAOHN Annual Conference December 4, 2014 Moderator: John W. Burress, MD, MPH, FACOEM Panelists: Mark Crislip, MD Kathryn Mueller, MD, MPH, FACOEM Tony Tannoury, MD Donald Murphy, DC John Keel, MD Robert Banco, MD

2 Case #1. Utility Inspector 55 yo long-term employee; 6 feet, 325# MOI 7/21/14 stepped in pothole right foot, jarring low back experiencing abrupt low back pain and pain right leg to foot ROM near full except FF hands to knees without evoking radiation Foot drop/dorsiflexion weakness can toe but not heel walk Subtle weakness to eversion; sensory to sharp dull lateral foot Babinski reflexes are not present

3 Case #1. Utility Inspector, Cont. 26 year employee, 10 years from retirement Job entails walking to and around job sites including uneven terrain, loose gravel, and heavy equipment being operated Past History 2006 stepped in hole right foot jarring low back experiencing pain in low back and right sciatic leg pain MRI with disc, ESI #1 helped, ESI#2 did not, recovered 2010 slipped while walking on stairs got LBP but also pins and needles bilateral lower extremities, PT, ESI but this time without benefit Intermittent pain associated with over doing it Avid competitive sailor

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6 Case #2. Ship Mechanic 40 yo 5 11, 245#; 11 years service DOI 2/13/14 MOI: 4 inch hose under pressure swung round striking thigh knocking him 8 feet to land on side and back ED, seen in f/u OEM, ecchymosis at thigh and knee, not able to bear full weight, complains of LBP

7 Case #2. Ship Mechanic, Cont. Secondary Consult 7/2014 Knee/thigh fine, low back 50% better, Chiro three times a week, asked how was PT replies, They were nice. Exam with neg neuro and facet loading Asked to show stretches cannot with confidence Shown basic stretches grimace, hesitancy, apprehension Spine program 10/23/14 Returns to OEM, failed trial RTW, + facet loading refer for dx/tx facet injections

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9 Changes Spinal Injections KATHRYN MUELLER, MD, MPH, FACOEM 9 PROFESSOR, SCHOOL OF PUBLIC HEALTH & DEPARTMENT OF PHYSIATRY - UNIVERSITY OF COLORADO PRESIDENT - AMERICAN COLLEGE OF OCCUPATIONAL AND ENVIRONMENTAL MEDICINE

10 Awareness of Lack of Effectiveness of Spinal Injections Cochrane, British Medical Journal, ACOEM, Academy of Neurology, JAMA editorial recommends against New York Times Sunday magazine recommends against use

11 Epidural Steroid Injections (ESIs) Strong evidence ESI has no short or long term benefit for non-specific low back pain (Pinto 2012). Good evidence ESIs against low back pain (Cochrane, Staal, 2008). Colorado CP

12 Epidural Steroid Injections (ESIs) - Colorado Strong evidence epidural steroid injections have a small average short term benefit for leg pain and disability for those with sciatica (Pinto, 2012). Good evidence the addition of steroids to a transforaminal bupivacaine injection has a small effect on patient reported pain and disability (Ng, 2005; Tafazal, 2009).

13 Epidural Steroid Injections (ESIs) Some evidence additional steroids may reduce the frequency of surgery in the first year after treatment in patients with neurologic compression and corresponding imaging findings. Patients were strong candidates for surgery and have completed 6 weeks of therapy without adequate benefit (Riew, 2000). Some evidence the benefits for the non-surgical group persisted for at least 5 years in most patients, regardless of the type of block given (Riew, 2006) Colorado CP

14 A Random Trial of Epidural Glucocorticoid Injections for Spinal Stenosis METHODS: DOUBLE-BLIND, MULTISITE TRIAL PATIENTS WITH CENTRAL SPINAL STENOSIS, MODERATE TO SEVERE LEG PAIN AND DISABILITY. RECEIVED EPIDURAL INJECTIONS OF GLUCOCORTICOIDS PLUS LIDOCAINE OR LIDOCAINE ALONE. ONE OR TWO INJECTIONS BEFORE THE PRIMARY OUTCOME EVALUATION, PERFORMED 6 WEEKS AFTER RANDOMIZED FIRST INJECTION. OUTCOMES: PRIMARY OUTCOME WAS THE SCORE ON THE ROLAND-MORRIS DISABILITY (RMDQ) QUESTIONNAIRE.

15 REFERENCE: FRIEDLY, JL ET AL, N. ENGL J MED JUL 3 RESULTS: AT 6 WEEKS NO SIGNIFICANT BETWEEN GROUP DIFFERENCES IN THE RMDQ SCORE. 95% CONFIDENCE INTERVAL [CI], -2.1 TO 0.1; P=0.07); OR THE INTENSITY OF LEG PAIN (ADJUSTED DIFFERENCE IN THE AVERAGE TREATMENT EFFECT, 95% CI, 0.8 TO 0.4; P=0.48). INTERLAMINAR VS. TRANSFORAMINAL SHOWED NO SIGNIFICANT DIFFERENCES AT 6 WEEKS. CONCLUSIONS: FOR LUMBAR SPINAL STENOSIS, EPIDURAL INJECTION OF GLUCOCORTICOIDS PLUS LIDOCAINE OFFERED MINIMAL OR NO SHORT-TEM BENEFIT AS COMPARED WITH LIDOCAINE ALONE.

16 Single Dose of Intravenous Dexamethasone in Emergency Department Patients Methods - double-blind randomized controlled trial 58 Adult ED patients with Low back pain with radiculopathy given 8 mg of intravenous Dexamethasone Results 1.86 point (95% CI 0.32 to 3.42, p=0.19) reduction in VAS pain scores at 24 h

17 Single Dose of Intravenous Dexamethasone in Emergency Department Patients Results Dexamethasone had a significantly shorter ED stays 3.5h vs 18.8h and no difference in functional scores. 6 weeks, both groups had similar significant and sustained decrease in VAS scores compared with baseline Balakrishnamoorthy R, Emergency Medicine 8/22/2014

18 Awareness of Lack of Effectiveness of Spinal Injections 18 Multiple evidence based studies find no evidence for long term benefits of spinal injections exception surgical radiculopathy candidates after 6 weeks of treatment

19 Epidural Steroid Injections (ESIs) No proven benefit from adding steroids to local anesthetic spinal injections for most injections based on multiple blinded studies. Steroids are currently used routinely in spinal injections due to a presumed physiologic effect. Therapeutic spinal injections have not been proven to change the long term course of most patients with spinal pain.

20 Injections Epidural Steroid Injections (ESIs) Eval For rare, acute ruptured (herniated) disc with clear objective radiculopathy if, after one to two weeks of initial oral analgesic and conservative treatment, the patient: Has continued pain interfering with most ADL function; and Unable to tolerate the required movements to participate in therapy, and Pain greater in the leg than in the back, and Pain following a correlated radicular pattern &

21 Injections Epidural Steroid Injections (ESIs) Eval Herniated disc on the MRI at the level of subjective and objective findings, and had either Dural tension, signs resulting in radicular symptoms and/or One of the following documented, reproducible findings: Decreased reflexes, or Radicular sensation deficits, or Motor weakness on testing

22 Spinal Stenosis or Herniated Disc Injection Patients with radicular findings Complete 6-8 weeks of active therapy, Has persistent radicular findings and difficulty with some activities, The patient may have one diagnostic injection. Stenosis is not likely to change anatomically, unlike herniated discs

23 Awareness of Lack of Effectiveness of Spinal Injections 23 Multiple evidence based studies find no evidence for long term benefits of spinal injections exception surgical radiculopathy candidates after 6 weeks of treatment

24 Evidence based Practice Changes Spinal Injections Kathryn Mueller, MD, MPH, FACOEM Professor, School of Public Health & Department of Physiatry - University of Colorado President - American College of Occupational Environmental Medicine and 24

25 Awareness of Lack of Effectiveness of Spinal Injections Cochrane, British Medical Journal, ACOEM, Academy of Neurology, JAMA editorial recommends against New York Times Sunday magazine recommends against use

26 Epidural Steroid Injections (ESIs) Strong evidence ESI has no short or long term benefit for non-specific low back pain (Pinto 2012). Good evidence ESIs against low back pain (Cochrane, Staal, 2008). Colorado CP

27 Epidural Steroid Injections (ESIs) - Colorado Strong evidence epidural steroid injections have a small average short term benefit for leg pain and disability for those with sciatica (Pinto, 2012). Good evidence the addition of steroids to a transforaminal bupivacaine injection has a small effect on patient reported pain and disability (Ng, 2005; Tafazal, 2009).

28 Epidural Steroid Injections (ESIs) Some evidence additional steroids may reduce the frequency of surgery in the first year after treatment in patients with neurologic compression and corresponding imaging findings. Patients were strong candidates for surgery and have completed 6 weeks of therapy without adequate benefit (Riew, 2000). Some evidence the benefits for the non-surgical group persisted for at least 5 years in most patients, regardless of the type of block given (Riew, 2006) Colorado CP

29 A Random Trial of Epidural Glucocorticoid Injections for Spinal Stenosis Methods: Double-blind, multisite trial Patients with central spinal stenosis, moderate to severe leg pain and disability. Received epidural injections of glucocorticoids plus lidocaine or lidocaine alone. One or two injections before the primary outcome evaluation, performed 6 weeks after randomized first injection. Outcomes: Primary outcome was the score on the Roland-Morris Disability (RMDQ) questionnaire.

30 Reference: Friedly, JL et al, N. Engl J Med Jul 3 Results: At 6 weeks no significant between group differences in the RMDQ score. 95% confidence interval [CI], -2.1 to 0.1; P=0.07); or The intensity of leg pain (adjusted difference in the average treatment effect, 95% CI, 0.8 to 0.4; P=0.48). Interlaminar vs. transforaminal showed no significant differences at 6 weeks. Conclusions: For lumbar spinal stenosis, epidural injection of glucocorticoids plus lidocaine offered minimal or no short-tem benefit as compared with lidocaine alone.

31 Single Dose of Intravenous Dexamethasone in Emergency Department Patients Methods - double-blind randomized controlled trial 58 Adult ED patients with Low back pain with radiculopathy given 8 mg of intravenous Dexamethasone Results 1.86 point (95% CI 0.32 to 3.42, p=0.19) reduction in VAS pain scores at 24 h

32 Single Dose of Intravenous Dexamethasone Results in Emergency Department Patients Dexamethasone had a significantly shorter ED stays 3.5h vs 18.8h and no difference in functional scores. 6 weeks, both groups had similar significant and sustained decrease in VAS scores compared with baseline Balakrishnamoorthy R, Emergency Medicine 8/22/2014

33 Awareness of Lack of Effectiveness of Spinal Injections Multiple evidence based studies find no evidence for long term benefits of spinal injections exception surgical radiculopathy candidates after 6 weeks of treatment 33

34 Epidural Steroid Injections (ESIs) No proven benefit from adding steroids to local anesthetic spinal injections for most injections based on multiple blinded studies. Steroids are currently used routinely in spinal injections due to a presumed physiologic effect. Therapeutic spinal injections have not been proven to change the long term course of most patients with spinal pain.

35 Injections Epidural Steroid Injections (ESIs) Eval For rare, acute ruptured (herniated) disc with clear objective radiculopathy if, after one to two weeks of initial oral analgesic and conservative treatment, the patient: Has continued pain interfering with most ADL function; and Unable to tolerate the required movements to participate in therapy, and Pain greater in the leg than in the back, and Pain following a correlated radicular pattern &

36 Injections Epidural Steroid Injections (ESIs) Eval Herniated disc on the MRI at the level of subjective and objective findings, and had either Dural tension, signs resulting in radicular symptoms and/or One of the following documented, reproducible findings: Decreased reflexes, or Radicular sensation deficits, or Motor weakness on testing

37 Spinal Stenosis or Herniated Disc Injection Patients with radicular findings Complete 6-8 weeks of active therapy, Has persistent radicular findings and difficulty with some activities, The patient may have one diagnostic injection. Stenosis is not likely to change anatomically, unlike herniated discs

38 ROBERT J. BANCO, MD ASSOCIATE CLINICAL PROFESSOR TUFTS UNIVERSITY SCHOOL OF MEDICINE NECOEM/MaAOHN ANNUAL THE BOSTON SPINE GROUP CONFERENCE December 4, 2014

39 RECURRENT LUMBAR DISC HERNIATION Rate of recurrent HNP after primary lumbar microdiscectomy is 23% at 2 years. 13% asymptomatic 10% symptomatic Symptomatic recurrent HNP have worse outcomes at 2 years (VAS leg and ODI) Bimodal distribution of recurrent HNP 3 months 12 months

40 EPIDURAL STEROID INJECTIONS FOR LUMBAR SPINAL STENOSIS Double blind, multi-site, randomly assigned 400 patients Roland-Morris Disability Questionnaire and VAS leg Glucocorticoid/lidocaine and lidocaine only At 6 weeks, no significant between group difference in RMDQ and VAS leg Subgroup analysis showed do difference between interlaminar and transforaminal

41 EPIDURAL STEROID INJECTIONS FOR LUMBAR SPINAL STENOSIS Subgroup analysis of SPORT trial ESIs were associated with significantly less improvement at 4 years among all patients with spinal stenosis There was no improvement in outcome with ESI whether patients were treated surgically or nonsurgically ESIs were NOT associated with long term surgical avoidance

42 CERVICAL MYELOPATHY Early surgical management can result in significant improvement in pain reduction, function, gait and quality of life. Poor outcomes are associated with longer duration of symptoms, poorer baseline function, severe gait disorder, and older age. 20% to 60% of patients with symptomatic cervical myelopathy have subsequent neurologic deterioration if the myelopathy is not treated surgically. Asymptomatic patients with cervical spinal cord compression have an 8% chance at one year and 23% chance at 4 yearsto develop symptomatic cervical myelopathy