Spotlight on Pain Management: 

Patsi Sinnott, PT, PhD, MPH

Sharon Dally, MS, Tigran Avoundjian, MPH, 

Jody Trafton, PhD, Todd Wagner, PhD

Dec. 3, 2013

Neck and Back Pain in VA

Incidence and Prevalence in VA Users
Outline 

 Background 

 Data and Methods 

 Prevalence 

 Incidence 

 Next steps 

2 
Background 

 Neck and back pain are pervasive

 Poor understanding of the origins or 

source of pain 

 Highly recurrent and each recurrence 

associated with increasing severity and 

disability

 High healthcare utilization. 

3 
Background 

 Evidence both within VA and in the 

general population of 

– increasing prevalence

– rising costs

 Little known about incidence 

4 
Whiteboard/Poll 

 What proportion of Veterans in general 

medical clinics report chronic neck or back 

pain.

 What proportion of Veterans report back pain 

in the Veterans Health Study?

 Where does chronic low back pain rank in 

prevalence in VA?

5 
Background 

 Few studies in VA about back or neck 

pain 

– Association of lower extremity amputation and 

back pain (Kusljugic et al., 2006) and back pain 

and diagnostic imaging (Selim et al., 2000) 

– Use of bipolar magnets and postop medications 

(Collacott et al., 2000)

– Veterans walk to beat back pain (Krein, S.L.) 

6 
Background 

 More information is needed 

– to understand the natural history of back or 

neck pain

– to understand progression/regression from 

acute to chronic pain

– for strategic program planning

7 
Previous work

 Musculoskeletal Spine Pain in VA, 

Description and Guideline Adherence (IIR 09-

062)

– Observational study: Administrative data

– Spine vs. neck vs. back

– Acute, mechanical or non-specific spine 

pain

8 
Previous work

 First step: define codes to be used to identify 

patients with neck or back pain in 

administrative data.

– Review methods used to identify patients with 

neck and back pain in administrative data.

– Found inconsistency in definitions of back and low 

back

– Found inconsistent coding algorithms.

9 
Previous work

 Establish a standard methodology to 

identify patients with spine pain in 

administrative data

10 
Objectives 

 Describe the prevalence of neck and back 

pain among VHA users between 2002 

and 2011 

 Describe the incident neck or back pain 

event for these VHA users 

 Describe the physical and mental health 

co-morbidities of these patients

11
Methods 

 Data: 

– VA inpatient (Patient Treatment Files) 

outpatient (Outpatient Event) and Fee Basis 

utilization files in FY2002-2011

– DSS Outpatient National Data Extracts 

(OPAT and OPAT2), FY2002-2012

– Vital status file

12 
Methods 

 Patient identification

– ICD codes from the literature

– Categorized as: No spine pain, back pain, 

neck pain, non-specific spinal pain

13 
Methods 

 ICD-9 codes 

14 
ICD-9 All Spine Codes

ICD-9 Code 2009 ICD-9 Code Descriptions Back, Neck, or Non-specific Spine Segment

724 Other and unspecified disorder of back Back Back_Nonspecific

724.0 Spinal stenosis, other than cervical Back Back_Nonspecific

724.00 Spinal stenosis - unspecified region Back Back_Nonspecific

724.09 Spinal stenosis, other than cervical- other Back Back_Nonspecific

724.8 Other symptoms referable to back Back Back_Nonspecific

724.9 Other unspecified back disorders Back Back_Nonspecific

737 Curvature of the spine Back Back_Nonspecific

737.0 Adolescent postural kyphosis Back Back_Nonspecific

737.1 Kyphosis acquired Back Back_Nonspecific

737.10 Kyphosis (acquired)(postural) Back Back_Nonspecific

737.11 Kyphosis due to radiation Back Back_Nonspecific

737.12 Kyphosis, postlaminectomy Back Back_Nonspecific

737.19 Kyphosis acquired-other Back Back_Nonspecific

737.3 Kyphoscoliosis and scoliosis Back Back_Nonspecific

737.30 Scoliosis [and kyphoscoliosis], idiopathic Back Back_Nonspecific

737.31 Resolving infantile idiopathic scoliosis Back Back_Nonspecific

737.32 Progressive infantile idiopathic scoliosis Back Back_Nonspecific

737.33 Scoliosis due to radiation Back Back_Nonspecific

737.39 Other kyphoscoliosis and scoliosis Back Back_Nonspecific

737.4 Curvature of the spine associated with other conditions Back Back_Nonspecific

737.40 Curvature of the spine associated with other conditions, unspecified Back Back_Nonspecific

737.41 Curvature of the spine associated with other conditions, kyphosis Back Back_Nonspecific

737.43 Curvature of the spine associated with other conditions, Scoliosis Back Back_Nonspecific

15 
ICD-9 Codes, con’t 

ICD-9 Code 2009 ICD-9 Code Descriptions Back, Neck, or Non-specific Spine Segment

737.8 Other curvatures of the spine Back Back_Nonspecific

737.9 Unspecified curvature of the spine Back Back_Nonspecific

738.4 Acquired spondylolisthesis Back Back_Nonspecific

724.7 Disorders of the coccyx Back Coccygeal

724.70 Unspecified disorder of coccyx Back Coccygeal

724.71 Hypermobility of coccyx Back Coccygeal

724.79 Disorders of coccyx- other Back Coccygeal

847.4 Sprains and strains of other and unspecified parts of back- coccyx Back Coccygeal

721.42 Lumbar spondylosis w/o myelopathy Back Lumbar

722.93 Other and unspecified disc disorder, lumbar region Back Lumbar

724.02 Spinal stenosis, other than cervical- lumbar region Back Lumbar

724.2 Lumbago Back Lumbar

724.3 Sciatica Back Lumbar

737.2 Lordosis (acquired) Back Lumbar

737.20 Lordosis (acquired)(postural) Back Lumbar

737.21 Lordosis, postlaminestomy Back Lumbar

737.22 Other post surgical lordosis Back Lumbar

737.29 Lordosis acquired other Back Lumbar

737.42 Curvature of the spine associated with other conditions, Lordosis Back Lumbar

739.3 Nonallopathic lesions, lumbar region Back Lumbar

847.2 Sprains and strains of other and unspecified parts of back- lumbar Back Lumbar

721.3 Lumbosacral spondylosis w/o myelopathy Back Lumbar-Sacral

722.10 Displacement of lumbar inter-vertebral disc w/o myelopathy Back Lumbar-Sacral

722.32 Schmorl’s nodes lumbar region Back Lumbar-Sacral

16 
ICD-9 Codes (49-72) 

ICD-9 Code 2009 ICD-9 Code Descriptions Back, Neck, or Non-specific Spine Segment

722.52 Degeneration of lumbar or lumbosacral intervertebral disc Back Lumbar-Sacral

722.73 Intervertebral disc disorder with myelopathy, lumbar region Back Lumbar-Sacral

722.83 Postlaminectomy syndrome lumbar region Back Lumbar-Sacral

756.11 Spondylolysis, lumbosacral region Back Lumbar-Sacral

756.12 Spondylolisthesis Back Lumbar-Sacral

846.0 Sprains and strains of the lumbosacral (joint) (ligament) Back Lumbar-Sacral

720.1 Spinal enthesopathy Back Sacral

720.2 Sacroilitis, not elsewhere classified Back Sacral

724.6 Disorders of sacrum Back Sacral

739.4 Nonallopathic lesions, sacral region Back Sacral

846 Sprains and strains of sacroiliac region Back Sacral

846.1 Sacroiliac ligament Back Sacral

846.2 Sacrospinatus (ligament) Back Sacral

846.3 Sacrotuberous (ligament) Back Sacral

846.8 Other specified sites of sacroiliac region Back Sacral

846.9 Unspecified site of sacroiliac region Back Sacral

847.3 Sprains and strains of other and unspecified parts of back- sacrum Back Sacral

721.2 Thoracic spondylosis without myelopathy Back Thoracic

721.41 Thoracic spondylosis with myelopathy Back Thoracic

722.11 Displacement thoracic intervertebral disc without myelopathy Back Thoracic

722.31 Schmorl's nodes- thoracic region Back Thoracic

722.72 Intervertebral disc disorder with myelopathy- thoracic region Back Thoracic

722.82 Postlaminectomy syndrome- thoracic region Back Thoracic

722.92 Other and unspecified disc disorder- thoracic region Back Thoracic

17 
ICD-9 codes (73-96)

ICD-9 Code 2009 ICD-9 Code Descriptions Back, Neck, or Non-specific Spine Segment

724.01 Spinal stenosis, other than cervical- thoracic region Back Thoracic

724.1 Pain in thoracic spine Back Thoracic

737.34 Thoracogenic scoliosis Back Thoracic

739.2 Nonallopathic lesions, thoracic region Back Thoracic

847.1 Sprains and strains of other and unspecified parts of back- thoracic Back Thoracic

721.4 Thoracic or lumbar spondylosis with myelopathy Back Thoracic-Lumbar

722.1 Displacement of thoracic or lumbar inter-vertebral disc w/o myelopathy Back Thoracic-Lumbar

722.5 Degeneration of thoracic or lumbar intervertebral disc Back Thoracic-Lumbar

722.51 Degeneration of thoracic or thoracolumbar intervertebral disc Back Thoracic-Lumbar

724.4 Thoracic or lumbosacral neuritis or radiculitis, unspecified Back Thoracic-Lumbar

724.5 Backache, unspecified Back Thoracic-Lumbar

721.0 Cervical spondylosis without myelopathy Neck Cervical

721.1 Cervical spondylosis with myelopathy Neck Cervical

722.0 Displacement of cervical intervertebral disc without myelopathy Neck Cervical

722.4 Degeneration of cervical intervertebral disc Neck Cervical

722.71 Intervertebral disc disorder with myelopathy- cervical region Neck Cervical

722.81 Postlaminectomy syndrome- cervical region Neck Cervical

722.91 Other and unspecified disc disorder- cervical region Neck Cervical

723 Other disorders of the cervical region Neck Cervical

723.0 Spinal stenosis of cervical region Neck Cervical

723.1 Cervicalgia Neck Cervical

723.2 Cervico-cranial syndrome Neck Cervical

723.3 Cervicobrachial syndrome (diffuse) Neck Cervical

723.4 Brachial neuritis or radiculitis Neck Cervical

18 
ICD-9 Codes (97-120)

ICD-9 Code 2009 ICD-9 Code Descriptions Back, Neck, or Non-specific Spine Segment

723.5 Torticollis, unspecified Neck Cervical

723.6 Panniculitisspecified as affecting neck Neck Cervical

723.7 Ossification of posterior longitudinal ligament in cervical region Neck Cervical

723.8 Other syndromes affecting cervical region Neck Cervical

723.9 Unspecified musculoskeletal disorders and symptoms referable to neck Neck Cervical

738.2 Acquired deformity of the neck Neck Cervical

739.1 Non allopathic lesions cervical Neck Cervical

756.16 Congenital anomalies of the spine - Klippel-feil Neck Cervical

847.0 Sprains and strains of other and unspecified parts of back- neck Neck Cervical

720 Ankylosing spondylitis and other inflammatory spondylopathies Non-specific Non-specific

720.0 Ankylosing spondylitis Non-specific Non-specific

720.8 Other inflammatory spondylopathies Non-specific Non-specific

720.81 Other inflammatory spondylopathies in diseases classified elsewhere Non-specific Non-specific

720.89 Other inflammatory spondylopathies - other Non-specific Non-specific

720.9 Unspecified inflammatory spondylopathy Non-specific Non-specific

721 Spondylosis and allied disorders Non-specific Non-specific

721.5 Spondylosis and allied disorders - Kissing Spine Non-specific Non-specific

721.6 Spondylosis and allied disorders - Ankylosing vertebral hyperostosis Non-specific Non-specific

721.7 Traumatic spondylopathy Non-specific Non-specific

721.8 Other allied disorders of the spine Non-specific Non-specific

721.9 Spondylosis of unspecified site Non-specific Non-specific

721.90 Spondylosis of unspecified site without mention of myelopathy Non-specific Non-specific

721.91 Spondylosis of unspecified site with myelopathy Non-specific Non-specific

722 Intervertebral disc disorders Non-specific Non-specific

19 
ICD-9 (121-142)

ICD-9 Code 2009 ICD-9 Code Descriptions Back, Neck, or Non-specific Spine Segment

722.2 Displacement of intervertebral disc, site unspecified, w/o myelopathy Non-specific Non-specific

722.3 Schmorl’s nodes Non-specific Non-specific

722.30 Schmorl's nodes- unspecified region Non-specific Non-specific

722.39 Schmorl's nodes- other Non-specific Non-specific

722.6 Degeneration of intervertebral disc site unspecified Non-specific Non-specific

722.7 Intervertebral disc disorder with myelopathy Non-specific Non-specific

722.70 Intervertebral disc disorder with myelopathy- unspecified region Non-specific Non-specific

722.8 Postlaminectomy syndrome Non-specific Non-specific

722.80 Postlaminectomy syndrome- unspecified region Non-specific Non-specific

722.9 Other and unspecified disc disorder site unspecified Non-specific Non-specific

722.90 Other and unspecified disc disorder- unspecified region Non-specific Non-specific

738.5 Other acquired deformity of the back or spine Non-specific Non-specific

756.1 Anomaly of spine Non-specific Non-specific

756.10 Anomaly of spine, unspecified Non-specific Non-specific

756.13 Congenital anomalies of the spine - absence of a vertebra Non-specific Non-specific

756.14 Congenital anomalies of the spine - hemivertebra Non-specific Non-specific

756.15 Congenital anomalies of the spine - congenital fusion of the vertebrae Non-specific Non-specific

756.17 Congenital anomalies of the spine - spina bifida occulta Non-specific Non-specific

756.18 Congenital anomalies of the spine Non-specific Non-specific

756.19 Congenital anomalies of the spine - other Non-specific Non-specific

847 Sprains and strains of other and unspecified parts of back Non-specific Non-specific

847.9 Sprains and strains of other and unspecified parts of backunspecified Non-specific Non-specific

20 
Methods – Definitions 

 Neck pain = cervical spine ICD codes 

 Back pain = thoracic, lumbar, sacral or 

coccygeal spine codes. 

 Non-specific = codes that referred to the 

spine, but without reference to the spinal 

segment, or had encounters with both 

back and neck pain diagnoses. 

21 
Methods - Exclusions 

 Non-Veterans 

 Fee-Basis inpatient records where the 

duration of care was >10 years 

22 
Prevalent cases

 VHA users who presented for care in 

CY2002-2011 

 Neck, back or non-specific spine pain 

condition compared to no spine care 

 Annual totals 

23 
Incident cases

 First encounter for each Veteran, 

following a two year “clean period”

 CY2004 - 2011 

 Veteran may have more than one incident 

event (each with a two year clean period) 

 Veteran has used VA services within 

preceding two years 

24 
Comparisons 

 Change rates

 Prevalence to incidence 

 Demographics, co-morbidities of general 

population 

25 
Results 

26 
Demographics 

cy2004 cy2005 cy2006 cy2007 cy2008 cy2009 cy2010 cy2011

N

 

833,214 

 

888,998 

 

945,255 

 

1,004,690 

 

1,074,483 

 

1,173,908 

 

1,256,975 

 

1,316,365 

Age 58.7 58.7 58.7 58.6 58.2 57.9 57.8 57.9

Age (SD) 14.2 14.4 14.6 14.7 15.0 15.1 15.2 15.2

Age 

(n msg) 21 19 10 21 21 27 55 279

Sex 

(% Male) 93.7% 93.4% 93.2% 93.0% 92.7% 92.5% 92.3% 92.0%

Homeless 

(%) 3.2% 3.2% 3.1% 3.3% 3.5% 3.9% 4.5% 5.1%

27 
Prevalence in VHA Users

Calendar 

Year

Total Veterans 

Seeking Care

Prevalence of 

Back Pain (%)

Prevalence of 

Neck Pain (%)

Prevalence of 

Non-Specific 

Spine Pain (%)

2002 4,353,375 

 

470,609 10.8%

 

69,496 1.6%

 

123,410 2.8%

2003 4,576,881 

 

523,186 11.4%

 

78,003 1.7%

 

138,841 3.0%

2004 4,755,869 

 

582,975 12.3%

 

91,592 1.9%

 

158,647 3.3%

2005 4,848,868 

 

621,571 12.8%

 

95,975 2.0%

 

171,452 3.5%

2006 4,934,847 

 

659,103 13.4%

 

101,193 2.1%

 

184,959 3.7%

2007 4,976,831 

 

696,312 14.0%

 

107,802 2.2%

 

200,576 4.0%

2008 5,038,660 

 

742,028 14.7%

 

114,823 2.3%

 

217,632 4.3%

2009 5,214,776 

 

806,708 15.5%

 

125,008 2.4%

 

242,192 4.6%

2010 5,421,325 

 

863,345 15.9%

 

134,389 2.5%

 

259,241 4.8%

2011 5,580,452 

 

905,346 16.2%

 

139,731 2.5%

 

271,288 4.9%

28 
Co-Morbities of Prevalent Cases

cy2004 cy2006 cy2008 cy2009 cy2010 cy2011

N

 

833,214 

 

945,255 

 

1,074,483 

 

1,173,908 

 

1,256,975 

 

1,316,365 

Hypertension 53.90% 55.86% 56.61% 56.51% 56.44% 56.06%

Arthritis 29.64% 29.01% 27.47% 27.05% 26.69% 26.90%

Diabetes 20.51% 22.09% 22.94% 23.09% 23.42% 23.92%

Ischemic Heart Disease 18.79% 18.41% 17.48% 16.97% 16.54% 16.14%

Chronic Obstructive Pulmonary 

Disease 11.78% 11.72% 11.68% 11.66% 11.66% 12.08%

Congestive Heart Failure 4.16% 4.13% 3.98% 3.88% 3.82% 3.79%

Headache 7.47% 7.79% 8.96% 9.57% 9.85% 9.70%

Renal Failure 2.76% 3.74% 5.04% 5.38% 5.76% 6.08%

Osteoporosis 2.24% 2.36% 2.28% 2.20% 2.11% 1.96%

29 
Mental Health Co-Morbidities 

cy2004 cy2006 cy2008 cy2009 cy2010 cy2011

N

 

833,214 

 

945,255 

 

1,074,483 

 

1,173,908 

 

1,256,975 

 

1,316,365 

Tobacco/Nicotine Dep. 17.94% 19.12% 21.77% 22.30% 22.10% 21.75%

Alcohol Dep/Abuse 6.96% 7.02% 7.72% 8.20% 8.43% 8.47%

Any Drug Dep/Abuse 5.02% 5.24% 5.90% 6.28% 6.51% 6.89%

Opium Dep/Abuse 1.18% 1.19% 1.37% 1.49% 1.60% 1.68%

Cannabis Dep/Abuse 1.43% 1.54% 1.85% 2.06% 2.32% 2.45%

Sedatives Dep/Abuse 0.24% 0.24% 0.28% 0.32% 0.35% 0.39%

Cocaine Dep/Abuse 2.13% 2.16% 2.24% 2.23% 2.18% 2.13%

Depression 23.52% 23.90% 26.42% 27.68% 28.86% 29.32%

Post Traumatic Stress Disorder 11.14% 12.88% 15.74% 16.85% 17.77% 18.59%

Manic Depression 2.91% 3.03% 3.41% 3.54% 3.65% 3.65%

Schizophrenia 2.23% 2.08% 2.00% 1.97% 1.90% 1.84%

30 
Comparisons CY2011

 All Veterans Spine Pain

N 5,580,452 1,316,365 

Age (mean) 61.8 57.9

Age (SD) 16.1 15.2

Sex (Percent Male) 92.9% 92.0%

Homeless (Percent) 3.2% 5.1%

31 
Comparisons CY2011

 All Veterans Spine Pain

N 5,580,452 1,316,365 

Hypertension 55.0% 56.06%

Arthritis 18.3% 26.90%

Diabetes 24.7% 23.92%

Ischemic Heart Disease 17.5% 16.14%

COPD 10.2% 12.08%

Congestive Heart Failure 4.0% 3.79%

Headache 5.0% 9.70%

Renal Failure 6.3% 6.08%

Osteoporosis 1.4% 1.96%

32 
Comparisons CY2011

All Veterans Spine Pain

Tobacco/Nicotine Dep 15.4% 21.75%

Alcohol Dep/Abuse 6.1% 8.47%

Any Drug Dep/Abuse 3.9% 6.89%

Opium Dep/Abuse 0.8% 1.68%

Cannabis Dep/Abuse 1.4% 2.45%

Sedatives Dep/Abuse 0.2% 0.39%

Cocaine Dep/Abuse 1.2% 2.13%

Depression 18.4% 29.32%

PTSD 11.5% 18.59%

Manic Depression 2.3% 3.65%

Schizophrenia 1.7% 1.84%

33 
Incidence 2004 - 2011

Calendar 

Year

Total Veterans 

Seeking Care

Incidence of 

Back Pain (%)

Incidence of 

Neck Pain (%)

Incidence of 

Non-Specific 

Spine Pain (%)

2004 4,755,869 

 

233,050 4.9% 52,924 1.1%

 

27,394 0.6%

2005 4,848,868 

 

229,732 4.7% 51,232 1.1%

 

27,523 0.6%

2006 4,934,847 

 

237,477 4.8% 52,708 1.1%

 

28,866 0.6%

2007 4,976,831 

 

247,053 5.0% 56,440 1.1%

 

29,990 0.6%

2008 5,038,660 

 

261,049 5.2% 59,742 1.2%

 

30,990 0.6%

2009 5,214,776 

 

282,599 5.4% 65,046 1.2%

 

33,768 0.6%

2010 5,421,325 

 

294,535 5.4% 67,856 1.3%

 

35,065 0.6%

2011 5,580,452 

 

300,526 5.4% 69,006 1.2%

 

35,745 0.6%

Incidence is calculated among Veterans seeking care.

Incident cases are defined as having no spine pain diagnoses in the 2 years prior to the index event

but patient has received some form of VA or Fee-Basis care within the prior 2 years. 34 
Comparisons 

35 

0.0%

2.0%

4.0%

6.0%

8.0%

10.0%

12.0%

14.0%

16.0%

18.0%

2002 2003 2004 2005 2006 2007 2008 2009 2010 2011

Percent

Calendar Year

Back Pain

Prevalence Incidence

0.0%

0.5%

1.0%

1.5%

2.0%

2.5%

3.0%

2002 2003 2004 2005 2006 2007 2008 2009 2010 2011

Percent

Calendar Year

Neck Pain

Prevalence Incidence

0.0%

1.0%

2.0%

3.0%

4.0%

5.0%

6.0%

2002 2003 2004 2005 2006 2007 2008 2009 2010 2011

Percent

Calendar Year

Non-Specific Spine Pain

Prevalence Incidence
Change rates

 Annual change rates CY2004 – 2011 

36 

Back Pain Neck Pain Non-specific 

Prevalence 4.70% 4.68% 6.81%

Incidence 1.63% 1.46% 0.00%
Whiteboard 

 What does this suggest? 

37 
Next steps

 Compare care to VHA/DOD Clinical Practice 

Guideline for the Management of Low Back Pain or 

Sciatica in the Primary Care Setting. 

 Assess influence of guideline concordant care on 

recovery*

 Assess influence of therapies on recovery

 Compare administrative data findings to chart review

38 
Questions 

39