Management of Low back pain

Management of Low back pain

Dr Prabhu Gandhimani

MD;FRCA;FIPP;FFPMRCA

Kingston Hospital

Queen Mary’s Hospital, Roehampton

New Victoria ,Parkside Hospital and

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.

Economic Burden

•

Health care costs- £1.6 billion/year

•

Equivalent to 1-2% of GDP of UK

•

Second commonest reason for long term

sickness

Causes of back pain

• Lack of exercise

• Poor posture Poor posture

• Manual labor

• Osteoporosis

The first question…

Is the back pain coming from the back?

Abdomen GIT, Urinary tract, Vascular Pelvis Genito-urinary

Hip

Is there a serious systemic disease?

“Redflags”

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

Disease • Vertebral fracture • Vertebral metastasis • Inflammatory arthritis • Infections • Cauda Equina

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 ligamentousinjury

• Degenerative disc

• Facet joint disease

• Congenital deformity (scoliosis, kyphosis,

transitional vertebrae)

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

Nerve root pain(5-15%)

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

3

Chronic low back pain might be a case of mixed pain

37% of cases of chronic low back pain have a neuropathic component2

Low back pain with radiating pain to the leg (radiculopathy) is one of the most common variations of low back pain3

Screening tools can help to identify patients with neuropathicback pain- _{LANS,Pain Detect}

Spinal canal stenosis

Disc herniation

Typical causes of radiating pain3,4

Electric shocks

Burning Tingling or prickling

Typical symptoms of radiating pain include:2

NSAIDs do not generally have an effect on neuropathic pain1

Leg pain

• Usually above knee

Neuropathic • Intermittent • Shooting,pins and needles,stabbing • Localised • May be abnormal

Activation of local

nociceptors1 Ectopic discharges

from nerve root lesion3

Lesion

Constant ache, throbbing

pain in the low back2 _{Shooting, burning}

pain in the foot2,3

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

Example of co-existing pain: herniated disc causing

low back pain and lumbar radicular pain

Nociceptive Neuropathic

Patient presents with both types

When to Investigate?

•

Possible serious spinal pathology( Redflags)

•

Non mechanical LBP

•

Targeted injections

What Investigations?

•

Xray –

• DEXA scan- osteoporosis

• MRI- Nerve impingement

•

Bone scan-

– Inflammatory arthritis

– Metastasis

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

When To Refer

•

Serious spinal patholgy

•

Significant yellow flags

•

Persistant Neuropathic pain after 2to 4 weeks.

Management options

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

burden1

1. Haanpää ML et al. Am J Med 2009;122:S13–21.

Diagnosis

Treatment of underlying conditions and symptoms

Reduced pain Improved physical functioning Improved psychological state Improved quality of sleep Improved overall quality of life

Goals of the treatment

Symptom Function

Simple mechanical back pain

only reassurance

• Early Physio-Back care advice

• Encourage activity

• Hurt is not equal to harm

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

Disease specific Etiology

• Discogenic pain

• Facetogenic pain

• Spinal canal stenosis

• Sacro iliac joint pain

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

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

Radiculopathy

• Leg pain in dermatomal distribution

• 85% will recover in 6 weeks

• Treatment

– Anti neuropathic drugs

– Epidural

– Nerve root block

NICE – 2010

Neuropathic Pain( Radiculopathy).

Third Line

Consider tramadol.

DO NOT start strong opioids Referral to pain clinic

Review- Second Line Treatment

If first line was amitryptiline try

pregabalin and vice versa. Try a combination of pregabalin and amitryptiline

First Line Treatment

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

Gabapentin

• 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 increased-

monitor closely until dose is stabilised.

Pregabalin

• 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

Epidurals

• Transforaminal

– Better success rate

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

Failed Back Sugery Syndrome(FBSS)

Epiduroplasty

•

Pain comes back after back surgery

•

Usually due to scar tissue

•

Exclude pain from another level.

Thank you