Low Back Pain Dr. H. Metwally BScAPh, MBChB, MDA, FFARCSI, MRCA, MSc Pain Management Diana Princess of l Pain Medicine, Anaesthesia and Critical Care
Epidemiology Very common disorder Affecting around one-third of the UK adult population each year [NICE guidelines]. Eighty percent of the population had back pain once or twice in their life [Urquhart el al 2008]. Around 20% of people with low back pain (that is, 1 in 15 of the population) will consult their GP about it [NICE guidelines].
Epidemiology The review of the health of Britain's working-age population by Dame Carol Black estimated that the annual costs of sickness absence and worklessness associated with working-age ill health were over 100 billion.
Epidemiology It is estimated that 4.5 million working days are lost each year due to back pain alone. Cost > 14 billions
Early referral is it good? RCT study in Norway Workers, aged between 18 and 60 On long-term sick leave with lower back pain Receive consultations with a physician (specialising in physical medicine and rehabilitation) and a physiotherapist improve skills to cope with their condition
Early referral is it good? Help return to work up to a year after they start sick leave than comparable people who were treated in primary care Conclusion: may be effective. [Nice guidelines]
Mr M S 35 y old business man Presented with Leg and Back Pain 2008 MRI L2/3 disc protrusion Surgeon decided to?? Outcome? EPIDURAL NO BENEFIT! What is next?
Mr M S (cont..) Micorodiscectomy 2008 Outcome? Some relief Review in 2010 Leg Pain return with positive neurology MRI showed satisfactory L2/3 decompression with L3/4 disc protrusion What is next?
Mr M S (cont..) L3/4 decompression Outcome? 2 weeks of Pain Relief What is next? Facet Joint Injection! NO RELIEF PAIN CLINIC!
Mr M S (cont..) In the pain clinic Resent with severe Low Back Pain 90% interfering with his life Treatment history Nothing working On Examination: what do you think we found? Neurologically normal Localized low back pain
Mr M S (cont..) Medications NSAIDS CO-codamol 8/500 6 per day Fentanyl patch 50 mcg/hr/72hr Amitriptyline 50mg nocte Gabapentin 300mg tds Plan?
Mr M S (cont..) Plan Change medications Blood tests MRI
Mr M S (cont..) Medications NSAIDS CO-codamol 8/500 6 per day Fentanyl patch 50 mcg/hr/72hr Amitriptyline 50mg nocte Gabapentin 300mg tds Change to Pregabalin 300mg bd Cocodamol 30/500 8 per day Fentanyl 25mcg/hr/72hr
Mr M S (cont..)
Mr M S (cont..) Blood reuslts IgG 11.26 g/l (6.00) IgA 5.77 g/l (0.8-4.00) IgM 0.78 g/l (0.50-2.00)
Mr M S (cont..) Blood results FBC Total WBC 15.42 (4-11) HB 11.7 (13.5-18.0) Platelets 438 (150-400) RBC 4.21 (4.60-6.20) Haematochrit 0.37 l/l (0.51) Neutrophil 12.48 (2.50-7.50) C-reactive protein 12mg (0-5) What do you think?
Mr M S (cont..) MRI Discitis/osteiomyelitis A- Sagital T1-wieight images of the lumbar spine demonstrate T1 hypointense signal B- post gadolinium sagital fat suppressed T 1- weighted images showed marrow and disc enhancement with endplate erosion.
Mr M S (cont..) How would you treat it? Treated with Antibiotics Surgical fixation
Mr M S (cont..) OUTCOME 6 month later Post fixation L3/4 Much improved Medications Cocodamol 30/500 8 per day Pregabalin 150mg bd
Mr M S (cont..) What is your plan? Decrease Pregabalin and stop in 6 month Physio / ocupational therapy Psychotherapy discharge
Best imaging for osteomylitis?? Plain film X-ray Strengths: sensitive when infection well established, cheap and available Weaknesses: signs do not develop until 10-21 days after infection
Best imaging for osteomylitis?? CT scan Strengths: more sensitive than plain X-ray film for detecting bone and disc erosions Weaknesses: less sensitive than MRI to soft tissue and abscesses + iodinated contrast administered
Best imaging for osteomylitis?? MRI Strengths: most sensitive for early detection (oedema) No radiation exposure Weaknesses: contraindications to MRI Calcium bone scan Strengths: useful if CT scan and MRI are equivocal Weaknesses: low spatial resolution require 2 days
Lessons to learn Early aggressive management is recommended if pain continue after 4 weeks following optimum initial treatment Re-assurance of the patient
Conclusion Multidisciplinary management following algorithms Long term management may include involving clinical psychologist for a coping strategy Sociopsychological approach
Thank you Any question