BACK PAIN AND LUMBAR STENOSIS IN OLDER ADULTS

1. BACK PAIN AND LUMBAR STENOSIS IN OLDER ADULTS

2. RESEARCH GROUP University of Pittsburgh Shervadalonna Brown, MD Mark Chirumbole, BS Jane A. Cauley, DrPH Anthony DeLitto, PhD William F. Donaldson, MD Julie Fritz, PhD James D. Kang, MD Lewis H. Kuller, MD Douglas Musgrave, MD Molly T. Vogt, PhD Terence Starz, MD University of California at San Francisco Michael Nevitt, PhD Lisa Palermo, MS Ria San Valentin, MD Georgetown University William C. Lauerman, MD Dartmouth Medical Center Brett Hanscom, MS James Weinstein, DO Washington University, St Louis David Rubin, MD

3. 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.

4. INTRODUCTION Recovery in 4-6 weeks 90% Initial episode of LBP Low back pain (LBP) affects 90% of individuals. LBP impacts quality of life & health care expenditures. Recurrence in one year- 30% Persistent LBPafter 4-6 weeks-10%

5. 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.

6. 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

7. UPMC-HP Member Resource Utilization for LBP Narcotics NSAIDs X-rays % of members MRI PT/OT Cox2s analgesics

8. Narcotic costs for UPMC-HP members with LBP or cancer $ 48% of total narcotic costs attributed to members with LBP, 21% to members with cancer LBP Cancer

9. Utilization Pattern of Pain Medications among LBP patients in UPMC-HP Narcotics+ other analgesics Narcotics alone Narcotics+non-selective NSAID analgesic alone Cox2 alone NSAIDs alone

10. 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

11. 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 BUTneither prevalence nor health burden is known

12. Prevalence of back pain in older persons Bressler, et al. Spine 1999

13. 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

14. 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 backpain is often • under-reported

15. 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 1.0 mild/mod 1.3 (1.0, 1.6) severe 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

16. Odds ratio for back pain at baseline in SOF women (65+ yrs) by estrogen usage * * * * Odds ratio Visit Musgrave, et al. Spine 2001

17. 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

18. Predictors of chronicity of low back pain in adults (n=1246) Carey, et al, Spine 2000

19. 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

20. Radicular pain spinal nerve entrapment by disc herniation or spinal stenosis pain in leg, paresthesia, weakness

23. Causes of leg pain in older patients True radicular pain lumbar stenosis lumbar disc herniation Pseudosciatica trochanteric bursitis osteoarthritis of the hip diabetic neuropathy

25. 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

26. 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)

27. Anterolisthesis at L4-L5

28. 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.

29. 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 80% at L3-L4 10-20%

30. 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

31. 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

32. Prevalence of lumbar listhesis (L3-S1) in elderly white women (SOF) listhesis defined as subluxation > 3mm p for trend = 0.027 p for trend = 0.75

33. 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.

34. Veteran’s Health Study n= 428 men % of cohort Selim, et al. Spine 1998

35. Veteran’s Health Study Selim, et al. Spine 1998

36. SF-36 scores for men with LBP enrolled in the Veteran’s Health Study p for trend <0.05 for all domains Score Selim, et al. Spine 1998

37. Distribution of lower back and leg pain symptoms w/in last month among white WHI women aged 50 years and older n=295 n=47 n=182 n=49 Vogt et al. J Gerontol 2002

38. SF-36 scores for white women enrolled in WHI (adjusted for age and BMI) Vogt et al. J Gerontol 2002 Score

39. 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 Carey, et al, Spine 1996

40. Relationship of race to prevalence and use of health care resources for LBP Cohort study, random group of health care providers Carey, et al, 2000

41. Elderly African American women (SOF) reporting back pain during previous four weeks N=470 severe LBP moderate LBP no LBP mild LBP

42. 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)

43. Prevalence of lumbar listhesis (L3-S1) in black elderly women by age listhesis defined as subluxation > 3mm p for trend = 0.095 p for trend = 0.207

44. % prevalence of listhesis among women 65 years and older Vogt, et al, The Spine J 2002

45. Effect of back pain & leg pain on daily life of black women during previous month expressed as age-adj odds ratio using back pain only as the reference - all p<0.001 Odds ratio Vogt, et al, The Spine J 2002

46. PREVENTION • Because most people experience LBP • duringtheir 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?

47. 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

48. PREVENTION • Lumbar supports • provide support • remind to lift properly •  intra-abdom pressure and •  intradiscal pressure • RCTs negative • CCTs positive – reduce incidence • of LBP and back injury Level A - ve

49. PREVENTION • Back Schools and Education • provide knowledge about body • mechanics, stress, exercise • aim to influence behavior • 9 RCTs - most are negative • 5 CCTs - positive Level A -ve

50. PREVENTION Level A + ve • Exercises • strengthen back muscles • increase blood supply • improve mood and alter perception • of pain • 6 RCTs – reduced pain and sick • leave