Disc disease

Background

• If no Cauda equina syndrome or progressive neuro deficit → delay surgery for a month
• Epidural steroids for temporary symptomatic relief
• Discetomy gives better pain control over 4 yrs but not past 10
• Microdiscectomy similar to standard discectomy but percutaneous or laser discetomy less effective than standard surgery

Spinal Stenosis

• Low back pain that gets progressively worse over time
  • Check ankle-brachial index (ABI) to rule out vascular claudication
• Avoid alcohol and strengthen legs to prevent falls
• Exercise bike or walking recommended with rest when pain comes
  • Pain relieved with forward flexion (walking uphill)
  • Pain worse with extension (walking downhill)
• Decompressive laminectomy for severe persistent pain
• Adding spinal fusion to decompression improves outcome
• Even with surgery, symptoms may reoccur in a few years

Chronic Back Pain

• Neural remodeling and neuro-plasticity may explain chronic pain in absence of ongoing tissue injury - alters perception of pain
• Intensive exercise helps
• Antidepressants, especially tricyclics (better than SSRI), also helpful
• No long term opioids
• Goals may need to be refocused
• Multiple surgical procedures are not helpful

Prevention

• Corsets and education not helpful
• Weight loss, exercise, smoking cessation helpful