Management of Low Back Pain - Dr Prabhu ... - Parkside Hospital

Management of Low back pain
Dr Prabhu Gandhimani
MD;FRCA;FIPP;FFPMRCA
Kingston Hospital
Queen Mary’s Hospital, Roehampton
New Victoria ,Parkside Hospital and
Putney ( NHS Choose and Book)

Incidence
• About 80% will suffer with low back pain at some
point in their life
• 90% of these attacks are self limiting and resolve
within 1 months.
• 30% of patients report moderate pain at 1 year after
the initial episode
• 1 in 5 report substantial limitations in activity.
• The 1 year prevalence of chronic back pain is 6-15%

Economic Burden
• Health care costs- £1.6 billion/year
• Equivalent to 1-2% of GDP of UK
• Second commonest reason for long term
sickness
• 1% of popln are off sick at any one day.

Causes of Back pain- evolution

Causes of back pain
• Lack of exercise
• Poor posture Poor
posture
• Manual labor
• Osteoporosis
• Genetic

Poor posture

The first question…
Is the back pain coming from the back
Abdomen
Pelvis
Hip
GIT, Urinary tract, Vascular
Genito-urinary
Functional pain

Is there a serious systemic disease “Redflags”
Disease
• Vertebral fracture
• Vertebral metastasis
• Inflammatory arthritis
• Infections
• Cauda Equina
History
• Age 50
• H/o Trauma
• H/o Malignancy
• H/o Loss of weight/appetite
• Poly arthritis
• Unremitting night time pain
• Fever, Night sweats
• IV drug use
• H/O steroid use
• Bladder / Bowel Disturbance

Is there any psychosocial distress that hinders
recovery/ amplifies symptoms
“Yellow flags”
– Belief that back pain is potentially disabling
– Fear avoidance behaviour with reduced activity
– Tendency to low mood or withdrawal from social
interaction
– An expectation that passive treatment rather than
active participation will help.

Etiology
Definitive pathological diagnosis is made only in 15%
• Triage -
– Simple Mechanical LBP-
80 to 90%
– Nerve root (radicular)
pain“sciatica”-5 to 15%
– Serious spinal pathology
– 1 to 2%

Simple Mechanical LBP( 80 – 90%)
• Idiopathic (65%-70%)
– Muscle strain or
ligamentous injury
• Degenerative disc
• Facet joint disease
• Congenital deformity
(scoliosis, kyphosis,
transitional vertebrae)
• osteoporosis

Simple mechanical back pain
(Ordinary backache)
•Clinical presentation usually at age 20-55 years
•Lumbosacral region, buttocks, and thighs
•Pain is mechanical in nature
•Varies with physical activity
•Varies with time
•Patient well

Nerve root pain(5-15%)
• Annular tear
• Herniated disc
• Foraminal stenosis
• Spinal stenosis
• Epidural scar/
adhesion
• Infection (such as
herpes zoster)

Nerve root pain
•Unilateral leg pain is worse than back pain
•Pain generally radiates to foot or toes
•Numbness or paraesthesia in the same distribution
•Nerve irritation signs
‣Reduced SLR which reproduces leg pain
•Motor, sensory, or reflex changes
‣Limited to one nerve root

Chronic low back pain might be a case
of mixed pain
3
37% of cases of chronic low back pain have a neuropathic component 2
Low back pain with radiating pain to the leg (radiculopathy) is one
of the most common variations of low back pain 3
Screening tools can help to identify patients with
neuropathic back pain - LANS,Pain Detect
Typical causes of radiating pain 3,4
Spinal
canal stenosis
Disc
herniation
Typical symptoms of radiating pain include: 2
Electric
shocks
Burning
Tingling
or prickling
NSAIDs do not generally have an effect on
neuropathic pain 1

Leg pain
Mechanical( referred)
• Constant
• Aching
• Diffuse
Neuropathic
• Intermittent
• Shooting,pins and
needles,stabbing
• Localised
• No abnormal neurology
• Usually above knee
• May be abnormal
• Usually below knee

Example of co-existing pain: herniated disc causing
low back pain and lumbar radicular pain
Nociceptive
Neuropathic
Activation
of local
nociceptors 1
Ectopic discharges
from nerve
root lesion 3
Lesion
Constant ache, throbbing
pain in the low back 2
Patient presents
with both types
of pain
Shooting, burning
pain in the foot 2,3
1. Brisby H. J Bone Joint Surg Am 2006;88 (Suppl 2):68–71; 2. McMahon SB and Koltzenburg M. Wall and Melzack’s
Textbook of Pain. 5th ed. London: Elsevier; 2006; pg 1032; 3. Freynhagen R, Baron R. Curr Pain Headache Rep
2009;13:185–90

When to Investigate
• Possible serious spinal pathology( Redflags)
• Non mechanical LBP
• Targeted injections
• Persistent mechanical LBP.

What Investigations
• Xray – Fracture, metastasis
• DEXA scan- osteoporosis
• MRI- Nerve impingement
• Bone scan- “ Bone activity”- Hot spots
– Inflammatory arthritis
– Metastasis
• ESR- Increased in malignancy, inflammation

MRI Study
To rule out sinister causes as opposed to finding the cause of back
pain.
• 98 asymptomatic patients
• 52% had disc bulges
• 27% had disc protrusions
• 1% had disc extrusions (outside the annulus)
• 14% had annular defects
• 8% had facet pathology
• 7% had spondylolithesis
• 7% had stenosis (central or foraminal)
Jensen
NEJM July 1994

When To Refer
• Serious spinal patholgy
• Significant yellow flags
• Persistant Neuropathic pain after 2to 4 weeks.
• Progressive neurosigns.

Management options
Conservative
non-pharmacological
Pharmacological
Pain
Management
Interventional
Functional
rehabilitation
Psychological

Implementing pain management
strategies
• Early implementation of an appropriate individual pain
management strategy may result in quicker pain relief, and thus
less disability, improved productivity and reduced economic
burden 1
Diagnosis
Treatment of underlying conditions and symptoms
Improved physical
functioning
Reduced pain
Improved quality
of sleep
Improved
psychological state
Improved overall
quality of life
1. Haanpää ML et al. Am J Med 2009;122:S13–21.

Goals of the treatment
Symptom
Function

Simple mechanical back pain
• 20% of patients need
only reassurance
• Early Physio-Back care
advice
• Encourage activity
• Hurt is not equal to
harm

Back Care

Simple mechanical backpain +/-
referred leg pain- Drug
• Tramadol – Opioid and seratonin
reuptake inhibitor
• Opioids: best used as part of a
structured, multi-modal approach
rather than unimodal therapy
• Muscle relaxants- short course

Disease specific Etiology
• Discogenic pain
• Facetogenic pain
• Spinal canal stenosis
• Sacro iliac joint pain
• Radiculopathy

Degenerative disc
• 40 to 60% of back pain
• Back pain increased
with flexion activities
• Early morning stiffness
• Cant sit, stand, walk for
too long
• Treatment
–

Facet Joint Arthritis
• 15 to 40% of back pain
• Pain more on extension
and rotation
• MRI non specific
• Diagnostic: facet joint
injections
• Rhizotomy- long term
relief

Spinal canal stenosis
• Back pain and leg pain
• Walking distance is
progressively reduced
• Leg becomes “jelly like”
• Rest for few minutes
improves
• Treatment-
– Epidural
– Surgery

Sacro iliac Dysfunction
• 1 to 20%
• Increases with age
• Pregnancy related
• Pain in sacro iliac area
might radiate to groin
and thigh
• Treatment
– Physio
– Injection
– Surgery

Radiculopathy
• Leg pain in dermatomal
distribution
• 85% will recover in 6
weeks
• Treatment
– Anti neuropathic drugs
– Epidural
– Nerve root block
– Surgery.

NICE – 2010
Neuropathic Pain( Radiculopathy).
First Line Treatment
Amitryptiline or pregabalin.
Amitryptiline helpful but side effects- try Imipramine
or Nortryptiline
Review- Second Line Treatment
If first line was amitryptiline try
pregabalin and vice versa.
Try a combination of pregabalin
and amitryptiline
Third Line
Consider tramadol.
DO NOT start strong opioids
Referral to pain clinic

Which drug..
• Amitryptiline-
– Start at 10 mg/day and increase 10mg/week to 75 mg/day.
– Trial for atleast 4 weeks
• Not Ideal
– Patient above 65 years
– Co existing Closed angle glaucoma, heart problems( atrial
fibrillation)
– Psychiatric medications and anti depressants
– High dose of tramadol
If amitryptiline is effective but patient is too drowsy
-Imipramine, Nortryptiline

• Calcium channel blocker
• 300mg tds increase
300mg every 3 days to
1800 mg max
• Don’t combine with
pregabalin.
• Problems:
– Unreliable absorption
– Drug interaction
– Warfarin-INR is increasedmonitor
closely until dose
is stabilised.
Gabapentin

• Calcium channel blocker
• Start with 75 mg BD 0r
25 mg BD and increase
the dose once in 3 days
to 600mg/day
• Trial for 4 weeks
• Shown to improve REM
sleep
• Used for anxiety
disorders
Pregabalin

Epidurals
• Transforaminal
– Better success rate
– Longer duration

Surgery Vs Epidural
• Riew et al: 5 yr follow up, 55 randomized pts with radiculopathy;
29 avoided surgery; 21 of 29 had f/u at 5 yrs: 17 of 21 still had no
surgery
• At 5 yr f/u all pts who avoided surgery: significant decreases in
neurologic symptoms and back pain
• Conclusion: majority of patients with lumbar radicular pain who
avoid an operation for at least 1 year after receiving nerve root
block with either bupiv + betamethasone will continue to avoid
surgery at 5 yr

Failed Back Sugery Syndrome(FBSS)
Epiduroplasty
• Pain comes back after back surgery
• Usually due to scar tissue
• Exclude pain from another level.
• Epidural adhesiolysis

Epidurogram- filling defect

Thank you
www.controlpain.co.uk