LOW BACK PAIN

Dr Gaurav Kuthiala M.D. Consultant ,Deptt. Of Anaesthesia S.P.S. Apollo Hospitals Ludhiana

DEFINITION

Acute, Subacute or chronic discomfort localised to the anatomic area below the posterior ribs and above the lower margins of the buttock.

Pain Generators

Sources of low back pain

Structural: Myofascial: Neural Tissue
Joints Intervertebral discs: Skeletal bone abnormalities Emotional Factors: Functional Changes:

Muscles, Tendons, ligaments, fascia Nerve root irritation, epidural inflammation, epidural fibrosis, arachnoiditis Facet joints, sacro iliac joints Disc degeneration/disruption, disc herniation
Osteoporosis, compression fractures, spinal stenosis, spondylosis, spondylolysis, spondylolisthesis, space occupying legions benign and malignant Stress, chronic pain, personality changes, somatization, etc. Posture, deconditioning

COMMON CAUSES

LUMBAR RADICULAR SYNDROME HERNIATED DISC LUMBAR CANAL STENOSIS FACET SYNDROME FAILED BACK SURGERY SYNDROME (FBSS) MYOFASCIAL SYNDROME SACROILIAC JOINT SYNDROME SPONDYLOSIS/ SPONDYLOLISTHESIS INFECTIVE, NEOPLASTIC, RHEUMATIC

LUMBAR RADICULAR SYNDROME

Radicular symptoms of pain , paresthesias and numbness . Dermatomal Distribution Objective signs

Weakness reflexes + SLR, lasegue, Crossed leg raise test , Femoral stretch test

RED FLAGS !Significant threat to Life or Neurologic Function

AGE<20 or >50 yrs DURATION OF SYMPTOMS <3 mths

Acute/subacute, >3 mths chronic & less serious

CONSTITUTIONAL SYMPTOMS (fever, chills,wt loss) SYSTEMIC ILLNESS eg. Cancer, UTI,RTI,STEROIDS,IMMUNOSUPPRESION UNRELENTING PAIN CAUDA EQUINA SYNDROME

IMAGING STUDIES
MRI : Gold Standard CT Scan Plain Radiography Myelography

Electrodiagnostic Testing
EMG

&NCS

Minimally

invasive and very useful in identifying nerve root lesions

in evaluating radiculopathy

Useful

HERNIATED LUMBAR DISC

Displacement of disc material beyond the confines of IVD Incidence in general population 1-2 % Types of Disc herniations:

Protruded disc Disc extrusion Disc sequestration

Most commonly involves L 4-5 disc(L5 NR)

Chemical Irritants
The

nucleus of the disk contains high levels of phospholipase A2 (PLA2) which initiates the inflammatory cascade Other inflammatory mediators include prostaglandins, leukotrienes, histamine, and bradykinin, which act as inflammatory and immune mediators

FEATURES OF HERNIATED LUMBAR DISC :

Radicular leg pain with or without back pain Motor weakness: L4 Ant. Tibial weakness L5 EHL weakness Asymmetric Reflexes Knee Jerk-L4 Ankle Jerk-S1 Signs of NR impingement +ve Sig.Resolution of symptoms in 60% within first few months

NON OP.TREATMENT FOR HERNIATED DISCS

Systemic steroids Bed rest Bracing Traction Acupuncture Chiropractic manipulations, magnets,massage,Tens Physical & Behavioral therapy

Insufficient Literature Untested Unproven Limited role in CLBP

LUMBAR SPINAL STENOSIS

CLINICAL SYND. OF NEUROGENIC CLAUDICATION AND/OR RADICULAR PAIN SECONDARY TO NARROWING OF SPINAL OR NERVE ROOT CANAL AND COMPRESSION OF ITS NEURAL ELEMENTS.

Pts of LSS tend to walk with stooped forwards gait

Loss of lumbar lordosis

Decreased range of lumbar extension Ankle (43%) or knee (18%) reflex

TREATMENT (NON OPERATIVE)

Medications:Nsaids, acetaminophen ,opioids reserved for flare ups Activity modification :relative rest during flareups Bracing: binders reduce load across L-spine Physical Therapy: flexion based exercises Interlaminar epidural steroid injections Fluro. guided transforaminal E.S.I. provide both short & long term relief in radicular symptoms.

Selective Lumbar Injections

Selective injection in the spine is one of the most powerful diagnostic and therapeutic modalities available to the practitioner. Gives us information about the structures generating pain, less reliably obtained from PE, spinal imaging, or electrodiagnostic testing. 90% of spinal diagnosis depends on history and physical exam with testing to confirm the diagnosis. Most useful in those patients with residual pain and restricted ROM and function, despite 4-6 weeks of aggressive rehabilitation.

Diagnostic Selective Blocks

Many lumbar pain syndromes are diagnosed solely by means of diagnostic blocks.eg facet synd. , SI joint arthropathy Assess structural pain generators and quantify their relative contribution to a patients pain. Pain provocation through the stimulation of a structure by an anesthetic block, the similarity of the provoked pain to the patients normally perceived pain, and the relief of pain by local anesthetic are well-accepted medical diagnostic tools. The data obtained from a block must be congruent with other patients data.

Therapeutic Blocks

The rationale for utilizing local anesthetic and corticosteroid injections for treatment of the lumbar spine was based on the efficacy of these injections to control inflammation. Corticosteroids (CS) relieve pain related to inflammation resulting from disk degeneration or injury due to chemical and immunological factors
Seen in patients without a compressive lesion on radiological evaluation.

Suppress ectopic discharges in the injured nerve- nociceptive axon activity Facilitate recovery from conduction block in nerve compression injury Prevent and suppress edema, production of chemical inflammatory mediators, fiber deposition, capillary dilatation, cellular migration and phagocytic activity Inhibits scarring and promotes lysis of adhesions

Epidural Blockade

Been around for 40 years. The epidural space is accessed throughout the caudal, Interlaminar & transforaminal approach.

Caudal Epidural Blocks

Simplest Low risk for thecal puncture. Dura ends at S2. Unreliable above the L4-5 levels. Requires higher volumes of medication (10-15cc to reach L4-L5 levels). Large area that is anesthetized limits the use of this block for diagnosis. Useful for paracentral disc protrusion at L4-L5, L5-S1 and subsequent radicular pain of both lower extremities.

Caudal Block

Caudal Block

Translaminar Epidural Blocks

Intermediate difficulty. Close to the targeted pathology Lower volume/higher concentration delivered. Higher risk of puncture of dural sac. Spread of medication is usually unilateral - symptomatic side.

Translaminar Epidural Block

Translaminar Epidural Block

Transforaminal Epidural Block

Most

difficult. Very diagnostic as a selective nerve root block. Useful for large disk herniation, foraminal stenosis, lateral disk herniation. Can be used in conjunction with caudal or lumbar epidurals.

Transforaminal Epidural Block

Transforaminal Epidural Block

Efficacy of Epidural Blocks

Poor

patient selection. Questionable technique. Correct pain generator The period of pain relief given by the ESI must be used in conjunction with an active rehabilitation program.

Indwelling Epidural Catheters

Placed

for diagnostic and therapeutic purposes. Used mainly for central pain states, non-physiological pain syndromes, CRPS.

How Many Injections?

Generally accepted that no further injections need to be performed in the same area if the first injection was not beneficial.(CONSIDER OTHER MODALITIES) If the initial response is favorable, but short lived, a second injection is reasonable. A maximum of 3 epidural injections per year is generally reported. Spacing - varies from days to weeks(3-4) generally for a series of injections.

Complication to Epidural Injections

Consent must be obtained. Infection - epidural abscess, meningitis. Bleeding - (No ASA) 7-10 days, NSAIDS 48-72 hrs. Thecal sac puncture 0.5-2.5% - spinal headache. Post-injection exacerbation of pain 1%. Epidural hematoma Arachnoiditis with certain preparations of Depo-steroids Chemical meningitis (P.E.G) Suppression plasma cortisol levels up to 2 weeks. Increase in blood sugars Exacerbation of CHF due to reduction of fluids Vasovagal response.

Facet Blocks

Related to physical stress or anatomic derangement at the facet joint (young males 20-40 yrs) Unilateral dull pain in the paraspinal region, nonradicular, occ to buttocks and rarely below the knees (PE) - pain with extension and rotations, side bending, return to standing from flex position with local tenderness to palpation over the facet joint. Radiographic - joint space narrowing, hypertrophy, sclerosis, trophism Diagnosis Facet joint injection ( gold standard )

Facet Blocks
Fluorocsopic

localization is a prerequisite for performing these blocks. Use of radiopaque dye confirms placement of the needle intraarticularly. Volume of joint 1.5cc Most common levels L4-L5, L5S1.

Facet Blocks - Types

Facet Blocks - Types

Medial Brand of the dorsal ramus (MBDR)

anesthetize the entire capsule complex

<1 ml of LA at Eye of the Scotty dog Useful if joint entry difficult eg degeneration, post surgical Diagnostic inj. Before Rf MB rhizotomy.

Sacral Iliac Joint Injection

History: usually follows a fall, or high velocity trauma ,prolonged loading(sitting ,standing), sacral base alteration(leg asymmetry, ligament injury) PE: pain over SI joint, Patricks test, Gaenslens test,Pelvic rock test,compression,pubic symph.test,Extn. test Radiology: not very useful unless there is sclerosis or partial fusion Diagnosis: Gold Standard is flouroscopic guided injection of SI joint using dye and L/A Treatment: SI joint injection with lignocaine and steroid and physical therapy

Sacral Iliac Joint Injection

Diskography

The only test that can assess pain from the disk. Nociceptive nerve fibers have been found in the outer annulus and granulation of tissue growing into disk fissures.

Figure 19-3 E. Normal L5-S1 nucleogram in the lateral projection. F. L5-S1 nucleogram in anteroposterior projection. There is a slight lateral annular fissure (arrows), which was asymptomatic, to the mid-annulus on the right.

Conclusion

Complete history and physical Differential diagnosis Radiographic and/or electrophysiological conformation Locate the pain generator Selective Lumbar injections used for diagnosis and treatment The period of pain relief afforded by selective injections must be used in conjuction with an active rehabilitation program and is not an end in itself Selective injections are a valuable tool in rehabilitation and provides enormous cost savings in hospitalization, physical therapy, medication, and time lost from work.

Algorithm for Lumbar Spine Injection

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