Download pain management perspective on low back pain

HAZEM EISSA, MD
Introduction
 One of the most common reason for healthcare & lost
work $$$
 The majority will suffer with LBP at some point in
their life
 Variable etiologies
Etiology
 Injury
 Degenerative disease
 Psychological
 Tumor
 Infection
 Idiopathic
Anatomy
Anatomy
Sagittal graphic of lumbar spine through neural foramen shows position of exiting nerves within the superior aspect of the neural foramen. The
segmental vessels are located inferior to the exiting nerve. Neural foramina are bounded anteriorly by dorsal vertebral body above and intervertebral disc
below, pedicle above and facet joint and ligamentum flavum posteriorly. The lumbar vertebral bodies are large with a large intervening intervertebral
disc. The pedicles are directed posteriorly, giving rise to large superior and inferior articular facets.
Pain Generators
 Facet Joint Disease
 Degenerative
 Disc
 Sacroiliac Joint Dysfunction
 Soft Tissue
 Compression fracture
 (Radicular)
History
 Acute or chronic
 Functional impact
 Location of pain
 Type of pain
 Radiation or referral patterns
 Time of pain
 Associated symptoms
 Previous treatments
Physical Exam
 Gait/cadence
 Toe walking
 Muscle strength
 Reflexes
 Provocative maneuvers.
Management
 Physical therapy
 Lifestyle/ergonomic changes
 Medication
 Intervention depending on etiology/pain generator
Facet/Zygapophysial joint Pain
 Injections intraarticular or medial branch
 Radiofrequency ablation/Rhizotomy
Facet Joint Injection
Medial Branch RFA
Facet Synovial Cyst
 May compress surrounding structures
 Aspiration/lysis/injections
 In recurrent cases surgical management
Interspinus Ligament
Spinous processes (Baastrup’s Dz)
 Local steroid injection
Compression fracture
 Always check & manage osteoporosis
 Conservative management (PT, Pain meds, Bracing)
 Interventions Kyphoplasty/vertebroplasty (better
results expected in acute & subacute fractures)
 What happens if not treated?
Kyphoplasty
Sacral Fractures
 Conservative (same as Compression fractures)
 Sacroplasty for alar fractures
Sacroiliac dysfunction
 Conservative (PT, belt, meds)
 Injection
 Radiofrequency ablation
 Surgical fusion
Bertolotti’s Syndrome
 Pseudoarticulation between L5 & sacral/iliac bones
 Injection
Spinal Stenosis
 Classic presentation
 PT and medications
 ESI
 Surgical decompression
Lumbar Radiculopathy
 Does NOT usually cause LBP
 Specific radicular dermatomal pattern
 ESI
 Surgical management
Epidural Steroid Injections
Caudal ESI with Catheter
Discogenic pain
 Sometimes hard to manage
 Clinical picture
 ESI, Intradiscal diathermy/regenerative medicine
injections
Spinal Cord Stimulator
 Indications
 New technology
Thank you