Chronic Low Back Pain

Chronic Low Back Pain (CLBP)

Vertebrogenic and Discogenic Low Back Pain

About Chronic Low Back Pain

• 1 in 6 US adults have CLBP.
• The lifetime prevalence of low back pain is estimated at 60-85%
• The highest prevalence of low back pain is between ages of 40-60 years.
• CLBP is the leading cause of global disability and absenteeism from work for persons between 30 and 64

Cause of Chronic Low Back Pain

• Diagnosis of CLBP has been based on subjective test and exclusion of:
  • Radicular pain neuropathy 6 million people
  • Stenosis
  • Instability
  • Radiculopathy
  • Other causes of axial back pain 8 million people
  • Facet joint disorders
  • Sacroiliac joint disorders
  • Spondylolisthesis
  • Scoliosis

Science and anatomy basis of chronic low back pain

• Low back pain originates from the vertebral endplate in many patients.
• Pain receptors present and normal endplates and increased and damaged endplates cause CLBP.
• The density of nerve receptors in the endplate and vertebral body is higher than that of the disc
• 90% of adjacent endplates have new nerve endings after a radial annular tear of the disc while only 30% of the disc have new nerve endings form after radial annular tear.
• Twice the nerve density of the implant following endplate defect versus radial tear of the disc
• Endplate defects (Schmorls nodes) allow inflammatory disc tissue to leak into the bone marrow causing further inflammation.
• Chronic endplate inflammation leads to Modic changes and increased receptor density called “Active Discopathy” or “the Modic Disc”

Anatomical studies and immune chemical assays demonstrate the pain receptors at the endplate traced back to the basivertebral nerve

• Modic changes are associated with CLBP in multiple clinical studies
• Modic changes historically were associated with CLBP and severity and duration of symptoms
• 1 in 6 US adults suffer from vertebrogenic pain originating from the vertebral body endplate
• CLBP patient seek care more often
• Modic changes with CLBP associated with poor outcomes to conservative treatments
• Modic type I patient's had worse outcomes after discectomy underscoring the role of the endplate as the pain generator

Symptoms of Chronic Low Back Pain

• 11 million patients of CLBP patients are unable to find relief with conservative care or surgery
• 70% of CLBP failed to find relief. 28% have other symptoms controlled.  1% have surgery

Diagnosing Chronic Low Back Pain

• Low back pain> 6 months duration
• Low back pain that has not responded to conservative treatment (6 months)
• Presence of Modic changes on MRI in the L3, L4, L5 and/or S1 vertebral bodies (VBs):
• Modic type 1and/or type 2
  • End plate changes, inflammation, edema, disruption, and/or fissuring
  • Fibrovascular bone marrow changes (hypointensive signal for Modic type 1)
  • Fatty bone marrow replacement (hyperintensive signal for Modic type 2)

Treatment of Chronic Low Back Pain

• Vertebrogenic pain patient is indicated for the Intracept procedure
• Of an estimated 30 million people with back pain 14 million developed CLBP greater than 6 months with Modic changes on the MRI.
• 4 million can be excluded with low disability levels
• Another 5 million can be excluded with other etiologies of back pain
• That leaves 4 million people with pure vertebrogenic back pain that can be treated with intracept

Alternative treatment Chronic Low Back Pain

• Physical Therapy
• Cortisone injections
• Massage
• Stretching Yoga or Pilates

Prevention of Chronic Low Back Pain

Risk Factors of Chronic Low Back Pain

• Injury or primary without cause disc degeneration leading to discal inflammation edema or disruption/fissuring

Sciatica with Chronic Low Back Pain

• Profound foraminal or central stenosis may occur with CLBP
• When present the stenosis may be treated with Laminotomy or Laminectomy if indicated.