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Teenage Disc DISC DEGENERATION FRANCIS P. LAGATTUTA M.D. FELLOWSHIP DIRECTOR LAGS SPINE AND SPORTSCARE Blood Supply to Disc End Plates Dorsal Roots Facet Joints Muscles and Fascia Disc Degeneration Evidence Based Back pain is complicated and does not fit into disease model. Only fractures and acute disc herniations fit the category Active disc disease only lasts 6 weeks, afterwards falls into subacute pain and then chronic pain Disc Degeneration Degenerative Disc Disease Disc Protrusion Degenerative Disc Disease Degenerative Disc Disease Degenerative Disc Disease Treatments will not fall under evidence based because there are too many factors in play with chronic pain Pain is 50% psychological, 30% pathology 10% insomnia, 10% myofacial History of Back Pain Physical Exam Depends on what structures are irritated Nerves - leg pain Facets - back pain more with rotation Myofascial - back pain non radicular leg pain Disc pain - sitting intolerance ROM Neuro exam Orthopedic signs Palpation Imaging Flexion extension radiographs MRI with or without gadolinium Discogram Post CT discogram Diagnostic Injections Medial branch blocks Transforaminal epidurals Trigger point injections Electrodiagnosis EMG NCV Medial Branch Block Transforaminal Epidurals Diagnostic Therapeutic Myofascial Pain Case Study 47 year old civilian male injured in Operation Iraqi Freedom war while acting as a “Contractor in the Battlefield” in 2003 Prolotherapy Ultrasound guided PRP 2003 Lower Back and Leg pain September 2nd : MRI showed L4-5, L5-S1 degenerative disc disease with a central possibly left-sided herniated nucleus pulposus at L5-S1. September: Physical Therapy x 6 weeks Regressed December – Three epidural injections performed by an Anesthesiologist Caudal Epidurals completed every other day (Wed-Fri-Mon) Reported Minimal help December: CT and Myelogram- showed spinal stenosis at L4S1 2004 2005 February: L4, L5, S1 Bilateral decompressive laminectomy, bilateral foraminotomy/facetectomy Feb-March: Physical therapy x 4 weeks July: Caudal Epidural Did not help Worse short term relief April: MRI Lumbar Spine showed disc desiccation and disc bulges at L4-5 and L5-S1 November: Water Therapy x 4 weeks Pain medications No relief Initial relief for 2 weeks 2006 August: visit with primary care doctor January: Physical therapy x 4 weeks January: Bilateral Lumbar 345 Medial Branch Blocks #2 February 2nd: Bilateral Lumbar 345 Neurolysis February 22nd : Lumbar Sympathetic block and Caudal Epidural March: Physical Therapy x 6 weeks Did not help. December: Bilateral Lumbar 345 Medial Branch Blocks 2007 Temporary relief Temporary relief for a short period of time Helped with rotation – 50% Temporary relief Did not help 2007 July: MRI Lumbar Spine February: Physical Therapy x 4 weeks April – June: Lumbar Prolotherapy Trigger Point Injections showed mild central spinal stenosis at L5-S1 September 7th : Left Lumbar 4 and 5 TFE 2008 Temporary relief September 21st: Left Lumbar 4 and Sacral 1 TFE Temporary relief Good relief for myofascial pain December: Right Lumbar 4 and 5 TFE January 2009 Worse Better Current Story January: Left Lumbar 5 and Sacral 1 TFE Better Built fountain in house and increase pain putting wet clothes into dryer Pain with extension and rotation “spasms” primary care doc- cyclobenzaprine Possible mbbs or trigger point injections Disc Degeneration Symptomatic Treatme Costs Medications: Cost of Opioids Medications Physical therapy Injections Spinal surgery Alternative treatments Medications: Cost of Opioids Medications Analgesics Opioids Thank God judicious use of them again Look out for previous drug abuse-no ceiling If on long acting and needs breakthrough then not working as long acting Morphine causes hypersensitivity after time Do not use more than 160 mgs of anything Tramadol Costs vs. efficacy Safety with antidepressants Best starter drug NSAIDs Compliance better once a day Celecoxib over 65, warfarin, aspirin, Meloxicam Piroxicam Others NSAIDs Cardio risk factors Muscle Relaxants Only for 2 weeks!!!!!!! We need to stop using them Soma never True ones: Benzodiazapines Lioresel Calcium Channel Blockers Gapapentin seems to be miracle drug of this decade Pre-gabapentin better absorbed than gabapentin Cheaper after 600mgs of gapapentin My experience significant weight gain over 150 mgs bid on pre-gabapentin Psych Drugs Always see what psych drugs they are taking The chronic painers always are on something Descending Tract Modulaters Duloxetine Milnacipran HCl Tricyclics All of these helpful but not home runs Medical Marijuana Almost legal in California Santa Cruz balm for $15 for a month Only patients over 50 or really screwed up You know what I mean It helps if they are not selling it! Physical Therapy Physical Therapy Whats new? Functional 3D rehab Gary Grey Taping for myofacial pain McKenzie exercises Spinal stabilazation Manual therapy Physical Therapy Physical Therapy Physical Therapy Physical Therapy Cognitive Behavioral Programs Life with Purpose Find out if underlying psych and treat it Program teaches patients to live with the pain Wk 1 WHAT IS PAIN? Wk 2 OWNING YOUR PAIN Creating a personal diary to reflect on physical and emotional responses Exploring your pain and its effect on daily activities Wk 3 DIFFERENT TYPES OF PAIN Wk 4 SELF IMAGE Wk 5 UNHEALTHY APPROACHES Wk 6 HEALTHY APPROACHES Learning about pain and emotions associated to situations Negative and Positive Self-Talk Different Coping Styles: Hopeless, Denial, Avoidance and Wishful Thinking Changing your mood by facial expressions Distinguish between positive and negative expressions Life with Purpose Wk 7 COMMUNICATION Steps of Conflict Resolution Effective Problem Solving Wk 8 GOALS Wk 9 BOUNDARIES Physical, Emotional and Problem-Focused Coping Skills Distinguish the different types of boundaries: physical, emotional/verbal, time and sexual. Wk 10 WELLNESS Wk 11 WELLNESS TOOLS Wk 12 STRESS REDUCERS Time Management Spinal cord stimulation Analgesic cream Acupuncture/pressure Massage Leeches Nutrition Sleep, creativity, friendship, pet therapy, pleasurable activities, humor and laughter Breathing techniques, stretching, music therapy, visualization, relaxation, aromatherapy Spinal Cord Stimulation Alternative Health Care $6000 for a trial------abusive Not for axial back pain Peripheral stimulation For myofascial pain $30k to $50k too much Surgery Trauma Spondylolisthesis Instability Pure Disc Pain MRI Sitting sign MRI end plates lit up Discography Discogram Disc Procedures Idet Successful in correct patient population Pauza study showed less than 10 % needed a fusion in the next 5 years Evidence Based Results for Surgery Plasma Enriched Protein 26; Delgado-Lopez PD, Rodriguez-Salazar A, Castilla-Di Ez JM, Marti N-Velasco V, FernandezArconada O. Role of Surgery in spinal degenerative disease. Analysis of systematic reviews on surgical conservative treatments from an evidence-based approach. Neurocirugia (Astur), 2005 Apr; 16 (2): 142-57 Pauza FDA approved injecting discs Fibrin grows and enlarges disc Evidence Based Results for Surgery 27; F.J. Robaina-Padron, Controversies of instrumented surgery and pain relief in degenerative lumbar spine. Results of scientific evidence Neurocirugia 2007; 18: 406-413. 28; F.J. Robaina-Padron, Controversies of instrumented surgery and pain relief in degenerative lumbar spine. Results of scientific evidence Neurocirugia 2007; 18: 468-477. Evidence Based Results for Surgery SPORT research papers from Weinstein in Iowa compared a specific surgical procures for a specific diagnosis compared to a nonspecific nonoperative treatment Like doing nonspecific surgery for any diagnosis Weinstein J.N., Lurie .JD., Tosteson T.D., Zhao W, Blood E.A., Tosteson A.N., Birkmeyer N., Herkowitz H., Longley M., Lenke L., Emery S., Hu S.S. “Surgical compared with nonoperative treatment for lumbar degenerative spondylolisthese, four year results in the Spine Patient Outcomes Research Trial (SPORT) randomized and observational cohorts.” J Bone Joint Surg Am. 2009 Jun; 91(6):1295-304.http://www.ncbi.nlm.nih.gov/pubmed Surgical Rate when Physiatrist is Gatekee My practice: back pain greater than 6 months 2000 patients/year 6 fusions/year 5 of my fellows trained in last 15 years Less than 10% of the patients need surgery Most surgeries are Spinal Stenosis Occasional – Herniated Nucleus Pulposus Rarely – Degenerative Disc Disease Costs This model has been done by insurance companies in the midwest No matter how many blocks by avoiding surgeries cost savings in the millions Patient satisfaction the same Evidence Based Disc disease is a fluid diagnosis Pain is generated from muscles, nerves, facet joints, and finally the disc itself Treat the current symptoms Avoid opioids Avoid surgery Conclusion Treat symptomatically Identify the psyche issues Treat myofacial pain Treat nerve pain Treat posterior element pain Treat disc pain?
