Management of Low back pain

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Management of Low back pain

Dr Prabhu Gandhimani


Kingston Hospital

Queen Mary’s Hospital, Roehampton

New Victoria ,Parkside Hospital and



• 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



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



Is there a serious systemic disease?



• 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.



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%)

• 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



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

Mechanical( referred) • Constant • Aching • Diffuse • No abnormal neurology

• Usually above knee

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


Activation of local

nociceptors1 Ectopic discharges

from nerve root lesion3


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 –

Fracture, metastasis

• DEXA scan- osteoporosis

• MRI- Nerve impingement

Bone scan-

“ Bone activity”- Hot spots

– 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)



When To Refer

Serious spinal patholgy

Significant yellow flags

Persistant Neuropathic pain after 2to 4 weeks.


Management options

Pharmacological Functional rehabilitation Psychological Interventional Conservative non-pharmacological Pain Management


Implementing pain management


Early implementation of an appropriate individual pain

management strategy may result in quicker pain relief, and thus less disability, improved productivity and reduced economic


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


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

• 20% of patients need

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



• 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



• 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.



• 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


• Used for anxiety disorders



• 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)


Pain comes back after back surgery

Usually due to scar tissue

Exclude pain from another level.


Thank you