Dr Namal Senasinghe MB.BS FFARCS DPMed FFPMCAConsultant in Pain Medicine

Centre for Pain Medicine

Canterbury Hospital, Kent, UK

Chronic Lower Back Pain

Potential sources for lower back pain

Ligaments - Supraspinous Post Longitudinal

ligaments

Muscular - Paraspinal M

Vertebral body and plates

Facets/SIJ

Patient Groups

1. Genuine back problems

2. Muscular Skeletal disorders & Fibromyalgia

3. Pt’s with secondary intentions

Clinical features

General Features Localized back pain Radiculopathy /

Radiculitis Muscular spasms Difficulty in walking Difficulty in getting

up History of trauma

Red Flags Features of cauda

equina Significant trauma Weight loss IVDA or HIV Severe unremitting

night time pain Fever

Management of Lower Back Pain

Pharmacological

Psychological

Behavioural

Complementary therapy

Interventional

Pharmacological Management

WHO Step Ladder

By the oral route

By the clock

Analgesic Types

1. Simple analgesics

2. Moderate

3. Strong

Simple Analgesics

Paracetamol

NSAIDS – Aspirin/Ibuprofen/Indometacin Diclofenac/ Meloxicam

COX 2 Inhibitors - Celecoxib (Celebrex) Etoricoxib (Arcoxia)

Cautions

All NSAIDS Cardiac/Hepatic/Renal Impairment

COX 2 LVF/Hypertension

Contraindications

Allergy/Hypersensitivity Bleeding peptic ulcers Severe heart failure

CVA IHD PVD Moderate ht failure

Moderate Analgesics

Codeine Phos Co- Codamol (8/500, 30/500) Tylex/Kapake

Strong Analgesics (Opiates)

BuprenorphineBuprenorphine HydromorphoneHydromorphone

CodeineCodeine MeptazinolMeptazinol

DextromoramideDextromoramide MethadoneMethadone

DextropopoxypheneDextropopoxyphene MorphineMorphine

DiamorphineDiamorphine OxycodoneOxycodone

DihydrocodeineDihydrocodeine PentazocinePentazocine

DipipanoneDipipanone PethidinePethidine

FentanylFentanyl TramadolTramadol

Anti Neuropathic Medication

Anti Epileptics – Gabapentin Pregablin

Antidepressants – Amitriptyline Dothiopin Duloxetine

Psychological

Psychological assessment Cognitive behavioural therapy Counselling Supportive psychotherapy Group therapy Relaxation Reflexology

Behavioural therapy

Pain management programmes

Back schools

Complimentary Therapy

Acupuncture Tai Chi TENS/SCENAR (self controlled electro neuro adaptive

regulation)

Reflexology Alexandra Aromatherapy – oil

Interventional Management

Epidural Steroids Facet Joint Injections/SIJ injections Radiofrequency Denervations Discography IDET Dorsal root ganglion denervations Spinal cord Stimulators Intrathecal pumps / Epidural pumps Cordotomy

EPIDURAL STEROID INJECTIONS

Indications

Radiculopathy / Radiculitis

MRI Scan – Positive findings of a disc prolapse

Nerve root compression

Drugs

Methylprednisolone 80mg

Triamcinolone 60mg

Local anaesthetic solution

Mechanism of Action

Samples from herniated discs contain high level of phospholipase A2.

Phospholipase A2 liberates arachidonic acid from cell membrane.

Steroids induce the synthesis of phospholipase A2 inhibitor preventing the release of a substrate for prostaglandin synthesis.

Steroids can block nociceptive input.

Contrast in the epidural space

Lumbar EpidurogramLumbar Epidurogram

Positive Predictors

Presence of nerve root irritation

Recent onset of symptoms

Absence of psychological overlay

Radicular pain and numbness

Short duration (< 6 months)

Advanced educational background

*(White et al)

Motor weakness correlating with the involved nerve root

Positive SLR Abnormality in the

EMG in the affected nerve root

Documentation of a herniated disc in radiological examination

Younger age group

Negative Predictors

Previous back surgery

Pain > 6 months Work related injury Unemployment

due to pain Presence of

pending litigation

Previous multi-drug therapy

Very high pain rating

Frequent sleep disturbances

Smoking

Complications

Flashing Nausea Vomiting Sweating Hypotension

Dural puncture Retinal

haemorrhage Epidural

haematoma

FACET JOINT INJECTIONS ( FJI )

The Lumbar Facet Syndrome

Intrduced by Ghormley in 1933 LBP with or without referred pain Catching/Locking Increased with standing/sitting Decreased with mobility Physical Exam - Inves – X’ray / MRI

Indications for FJI

Diagnostic

Therapeutic

Standard monitoring Local infiltration - 2% Lignocaine Drugs - 0.5% Bupivacaine Prednisolone 25 mg Complications - Intrathecal injections Haematoma Entry into spinal cord

Positive Predictors

Acute onset of pain Absence of leg pain Absence of muscle spasm Normal gait

RADIOFREQUENZY DENERVATION

Radiofrequency Lesion Generator (Radionics)

Uses of RF/Pulse RF denervations Facet & SIJ Denervation - RF Lumbar Sympathectomy - RF DRG – Pulse RF Stellate Ganglion – Pulse RF Suprascapular N – Pulse RF Illioinguinal N – Pulse RF

Discogram

Diagnostic test performed to view and assess the internal structure of a disc and determine if it is a source of pain

Expected results 1. Recreation of painful symptoms

2. Confirmation of diagnosis

IDET (Intradiscal Electrothermal Annuloplasty)

To treat discogenic back pain Procedure works by cauterizing the nerve

endings within the disc wall Minimally invasive out patient procedure

SPINAL CORD STIMULATOR

Used in failed back surgery syndrome (FBSS).

A lead with 2-4 electrodes is introduced into the epidural space @ L1/L2

Threaded up to T8/T9

Equipment

A totally implantable device (Implantable pulse generator - IPG). The patient has control only on the on-off button. The programming is done by the doctor using a special console from outside.

How does it work ?

A pulse is generated which activates the large A -alpha fibres & A -beta fibres in the dorsal horns of the spinal cord.

This inhibits the nociceptive input from the smaller A delta fibres & C fibres closing the gate.

Other uses of SCS

Complex regional pain syndrome Ischaemic leg pains Unstable angina Phantom limb pain Muscle spasm in MS

Surgical Option

Refer to Orthopaedic and Neurosurgical colleagues

Red flagsDisc prolapsesNeurological SymptomsCt back pain not responding to

interventions