Management of Low back pain

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1 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)

2 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%

3 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.

4 Causes of Back pain- evolution

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

6 Poor posture

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

8 Is there a serious systemic disease? Redflags Disease Vertebral fracture Vertebral metastasis Inflammatory arthritis Infections Cauda Equina History Age <20 and >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

9 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.

10 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%

11 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

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

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

14 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

15 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

16 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

17 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

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

19 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

20 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

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

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

23 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.

24 Goals of the treatment Symptom Function

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

26 Back Care

27 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

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

29 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??

30 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

31 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

32 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

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

34 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

35 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

36 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

37 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

38 Epidurals Transforaminal Better success rate Longer duration

39 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

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

41 Epidurogram- filling defect

42 Thank you

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