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BACK PAIN AND LUMBAR STENOSIS IN OLDER ADULTS RESEARCH GROUP University of Pittsburgh Shervadalonna Brown, MD Jane A. Cauley, DrPH William F. Donaldson, MD James D. Kang, MD Douglas Musgrave, MD Terence Starz, MD Mark Chirumbole, BS Anthony DeLitto, PhD Julie Fritz, PhD Lewis H. Kuller, MD Molly T. Vogt, PhD University of California at San Francisco Michael Nevitt, PhD Ria San Valentin, MD Lisa Palermo, MS Georgetown University William C. Lauerman, MD Dartmouth Medical Center Brett Hanscom, MS James Weinstein, DO Washington University, St Louis David Rubin, MD INTRODUCTION 80% of US population experience one or more episodes of low back pain during lifetime. One of leading causes for physician office visits and for filing disability claims. During last 3 decades disability claim rate has increased 13 fold. Annual medical costs related to back pain are estimated to be $8 - $18 billion. INTRODUCTION Low back pain (LBP) affects 90% of individuals. Initial episode of LBP Persistent LBP after 4-6 weeks-10% Recovery in 4-6 weeks 90% Recurrence in one year- 30% LBP impacts quality of life & health care expenditures. INTRODUCTION National guidelines have recommended the use of analgesics as the primary pharmacologic treatment for LBP. The choice of analgesic agent has major implications for health care costs. UPMC Health Plan (Commercial) • 17,228 (14.8% of total) health plan members had at least one claim for service (pharmacy, inpatient, outpatient, laboratory, and physical /occupational therapy) for LBP management. Total cost = $6,419,696 • 9,566 (56% of members with LBP claims) had pharmacy claims for narcotics, NSAID’s, Cox2’s or other analgesics. Total cost = $1,403,837 UPMC-HP Member Resource Utilization for LBP 40% 35% Narcotics X-rays NSAIDs 30% 25% 20% 15% 10% 5% 0% MRI PT/OT Cox2s analgesics Narcotic costs for UPMC-HP members with LBP or cancer $ 1000000 800000 600000 400000 200000 0 LBP 48% of total narcotic costs attributed to members with LBP, 21% to members with cancer Cancer Utilization Pattern of Pain Medications among LBP patients in UPMC-HP Narcotics+ other analgesics Narcotics alone Narcotics+nonselective NSAID analgesic alone Cox2 alone NSAIDs alone INTRODUCTION Back pain in adult patients linked with: • lifestyle factors (smoking, obesity, physical activity, education) • anatomic abnormalities of lumbar spine Back pain in the elderly related to: • degenerative changes due to aging • lifestyle less important Back pain in older persons Increasing age is associated with an increase in musculoskeletal symptoms In the US back pain is the 3rd most frequent symptom reported to MDs by persons 75+ years 17% of back problem visits occur in those aged 65+ years BUT neither prevalence nor health burden is known Prevalence of back pain in older persons # studies % prevalence Community 9 13 - 49 Primary practice 3 23 - 51 Nursing home 1 40 Bressler, et al. Spine 1999 Prevalence of back pain in older persons Prevalence seems to decrease a little with age Women usually report a higher prevalence than men A major problem is the definition of back pain “no gold standard” No studies of the validity/reliability of dx orthopaedic testing procedures, no validity studies of clinical or self report of location of back pain Bressler, et al. Spine 1999 Patient factors contributing to the variability of prevalence of back pain in older persons • cognitive impairment • depression • decreased pain perception • increased pain tolerance • comorbid conditions • decreased physical activity • resignation to aging effects • selective participation in studies Overall seems likely that back pain is often under-reported Relationship between history of CVD at baseline and back problems at the 3rd clinic visit Age-adj OR (95% CI) ______________________________________________ Back pn since 1st clin vis none mild/mod severe 1.0 1.3 (1.0, 1.6) 2.6 (1.7, 4.0) One + days of lim act due to back pain 2.3 (1.6, 2.3) One + days in bed due to back pain 1.2 (0.6, 2.3) Vogt, et al, Spine 1997 Odds ratio for back pain at baseline in SOF women (65+ yrs) by estrogen usage 1.6 1.4 * * * * 1.2 Never Former Current 1 0.8 0.6 0.4 0.2 0 baseline follow-up Visit Musgrave, et al. Spine 2001 Causes of back pain in older patients Acute (< four weeks) lumbar strain/sprain osteoporotic fracture, vertebral or pelvic abdominal aortic aneurysm Subacute/Chronic (> four weeks) degenerative disc and joint disease malignancy fibromyalgia polymyalgia rheumatica Parkinson’s disease Predictors of chronicity of low back pain in adults (n=1246) Better function at Chronic LBP 12 weeks n=1150 n=96 Age (yrs) 42.5 44.6* Nonwhite race (%) 14 23* Income>$20K/yr 73 50* 10.5 17.4* 22 47* Baseline Roland score Baseline sciatica (%) Carey, et al, Spine 2000 Primary location of pain 1. Lower back pain alone 2. Pain radiating into buttocks and leg * upper anterior thigh/groin * lateral hip * below knee Malignant, infectious or visceral pain is constant whatever position of body. Mechanical, myofascial or degenerative pain varies by body position usually lessens when person is supine Radicular pain spinal nerve entrapment by disc herniation or spinal stenosis pain in leg, paresthesia, weakness Causes of leg pain in older patients True radicular pain lumbar stenosis lumbar disc herniation Pseudosciatica trochanteric bursitis osteoarthritis of the hip diabetic neuropathy ANATOMY Normal human spine is lordotic in the lumbar region. During typical movements upper lumbar vertebrae - posterior shear lower lumbar vertebrae - anterior shear Stability maintained by facet joints, intervertebral discs, ligaments, related muscle groups PATHOLOGY Degenerative changes in the lumbar spine disc degeneration vertebral compression deformities ligamentous laxity deterioration of facet joint cartilage May cause instability and subluxation of one vertebra on another (degenerative spondylolisthesis) Anterolisthesis at L4-L5 PATHOLOGY Backward slippage (retrolisthesis) is generally believed to be asymptomatic and of little clinical significance. Forward slippage (anterolisthesis) may result in narrowing of vertebral canal and neural foramina (spinal stenosis) leading to development of chronic back pain (with or without leg pain). Compression of L5 spinal nerve may be involved. PATHOLOGY When LS joint is particularly stable, L4 and L5 are more vulnerable to stress forces. If degenerative changes have occurred, anterolisthesis at L4 is more likely. Clinical symptoms associated with anterior subluxation at L4-L5 at L3-L4 80% 10-20% PATHOLOGY Spinal stenosis symptoms: back pain progressing to leg pain functional independence deteriorates reduced ability to walk reduced ability to carry out ADLs Symptoms often episodic, no natural resolution over time EPIDEMIOLOGY Several clinical and cadaveric studies suggest that anterolisthesis is 5 times more common in women vs men 2-4 times more common in blacks than whites 4 times more prevalent in diabetics 3 times more common in oophorectomized women compared to controls Prevalence of lumbar listhesis (L3-S1) in elderly white women (SOF) % prevalence listhesis defined as subluxation > 3mm 45 40 35 30 25 20 15 10 5 0 anterolisthesis retrolisthesis p for trend = 0.027 p for trend = 0.75 65-69 70-74 75-79 Age in years 80+ CLINICAL RELATIONSHIPS Relationship between radiographic abnormalities and spinal symptoms is unclear. People with no back pain show disc abnormalities (64%), stenosis (7%) and anterolisthesis (7%) (Boden, JBJS 1990, Jensen NEJM 1994 ). Not known whether people with sub-clinical disease later develop symptoms. Veteran’s Health Study n= 428 men % of cohort 45 40 35 30 25 20 15 10 5 0 LBP only LBP+LP to thigh LBP+LP below knee Selim, et al. Spine 1998 Veteran’s Health Study Medic use MRI Surgery LBP alone 1.0 1.0 1.0 LP to thigh 1.5 3.2 0.9 (0.7,3.1) (1.5,6.7) (0.3,3.0) 1.8 3.5 3.7 (1.0,3.4) (1.9,6.5) (1.7,8.1) 5.1 6.8 3.9 (1.2,22.9) (2.7,17.2) (1.3,11.4) LP below knee (-ve SLR) LP below knee (+ve SLR) Selim, et al. Spine 1998 SF-36 scores for men with LBP enrolled in the Veteran’s Health Study 70 p for trend <0.05 for all domains 60 Score 50 40 30 LBP only LBP/LP to thigh LBP/LP below knee (-ve SLR) LBP/LP below knee (+ve SLR) 20 10 0 PF RP BP GH VT MH SF RE Selim, et al. Spine 1998 Distribution of lower back and leg pain symptoms w/in last month among white WHI women aged 50 years and older 60 % of cohort 50 40 30 20 10 0 No LBP n=295 LBP only n=47 LBP+LP n=182 LBP+LP impr by sitting n=49 Vogt et al. J Gerontol 2002 SF-36 scores for white women enrolled in WHI (adjusted for age and BMI) Vogt et al. J Gerontol 2002 100 90 Score 80 70 60 50 no LBP LBP LBP/LP LBP/LP improved by sitting 40 30 PF RP BP GH VT MH SF RE Relationship of race to prevalence and use of health care resources for LBP Random digit dialing + structured interview 4,437 households in NC 8067 individuals Whites (%) AAmer (%) Prev acute LBP last yr 8.3 (7.3, 9.3) 5.2 (3.8, 6.6) Prev chronic LBP last yr 4.1 (3.4, 4.7) 3.0 (2.0, 4.0) 36 59 Prev seeking care Carey, et al, Spine 1996 Relationship of race to prevalence and use of health care resources for LBP Cohort study, random group of health care providers Whites AAmer 5.25 5.92 <0.01 Disability score 11 12.1 0.01 X-rays (%) 49 40 0.05 Other imaging 10 6 0.05 Pain score p Carey, et al, 2000 Elderly African American women (SOF) reporting back pain during previous four weeks N=470 severe LBP 7% moderate LBP 20% 50% no LBP mild LBP 23% % frequency Back/leg symptoms in women aged 65 years and older during month prior to clinic visit (white women enrolled in WHISTEN, black women enrolled in SLIP) 100 90 80 70 60 50 40 30 20 10 0 36.1 28.7 9.8 21.6 54.1 49.7 White women N=399 Black women N=470 Back pain, with leg symptoms Back pain, no leg symptoms No back pain Prevalence of lumbar listhesis (L3-S1) in black elderly women by age listhesis defined as subluxation > 3mm % prevalence 80 p for trend = 0.095 70 60 50 40 Anterolisthesis Retrolisthesis 30 20 10 p for trend = 0.207 0 65-69 70-74 75-79 Age in years 80+ % prevalence of listhesis among women 65 years and older Antero Retro White Black White Black L3-L4 4 13 6 1 L4-L5 20 36 4 2 L5-S1 9 30 7 3 L3-S1 29 58 14 4 Vogt, et al, The Spine J 2002 Effect of back pain & leg pain on daily life of black women during previous month 6 expressed as age-adj odds ratio using back pain only as the reference - all p<0.001 5 4 3 2 1 0 mood walk/move sleep work recreation enjoy Vogt, et al, The Spine J 2002 PREVENTION Because most people experience LBP during their lifetime, the distinction between primary and secondary prevention is blurred. • which interventions can prevent occurrence of LBP? • which interventions can prevent development of chronic LBP? PREVENTION Evidence-based medicine categories Level A - strong consistent - multiple RCTs Level B - moderate - one RCT + multiple CCTs Level C - limited - one CCT Level D - no evidence PREVENTION Lumbar supports Level A - ve •provide support • remind to lift properly • intra-abdom pressure and • intradiscal pressure RCTs negative CCTs positive – reduce incidence of LBP and back injury PREVENTION Back Schools and Education Level A -ve • provide knowledge about body mechanics, stress, exercise • aim to influence behavior 9 RCTs - most are negative 5 CCTs - positive PREVENTION Exercises Level A + ve • strengthen back muscles • increase blood supply • improve mood and alter perception of pain 6 RCTs – reduced pain and sick leave PREVENTION Ergonomics Level D - ve • job related interventions No RCTs or CCTs PREVENTION Risk Factor Modification Level D - ve • individual (weight, strength, smoking) • biomechanical (lifting, posture) • psychosocial (job control, job dissatisfaction, depression) No RCTs or CCTs Review of 47 epidemiologic studies concluded that smoking may be a ‘weak risk indicator and not a cause of low back pain’ Le-Bouef-Yde Spine 1999 Smoking may have a systemic effect on the musculoskeletal system - associated with generalized pain. Biological basis unknown - neuroendocrine effect? Decrement in SF-36 scores (compared to age-sex specific norms) for patients with spinal problems by smoking status PF RP BP HP MH EF SF RE SF-36 score 0 -10 -20 -30 -40 -50 Smokers (n = 4249) -60 Non-smokers (n = 21206) -70 General population in US -80 Vogt, et al, Spine 2002 PREVENTION Currently only exercise seems to be helpful in prevention of LBP. Consistent evidence – Level A. Linton, van Tulder, Spine 2001 PREVENTION Why the disappointing results? • small studies, low power, short follow-up, variation in intervention, varying outcome • natural course of back pain, hard to define and categorize, multi-factorial causation • single modal programs studied mostly, maybe multi-dimensional approach needed • timing, compliance