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Chronic Lower Back Pain

Chronic Lower Back Pain. Dr Namal Senasinghe MB.BS FFARCS DPMed FFPMCA Consultant in Pain Medicine Centre for Pain Medicine Canterbury Hospital, Kent, UK. Potential sources for lower back pain. Ligaments - Supraspinous Post Longitudinal ligaments

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Chronic Lower Back Pain

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  1. Chronic Lower Back Pain Dr Namal Senasinghe MB.BS FFARCS DPMed FFPMCA Consultant in Pain Medicine Centre for Pain Medicine Canterbury Hospital, Kent, UK

  2. Potential sources for lower back pain • Ligaments - Supraspinous Post Longitudinal ligaments • Muscular - Paraspinal M • Vertebral body and plates • Facets/SIJ

  3. Patient Groups • Genuine back problems • Muscular Skeletal disorders & Fibromyalgia • Pt’s with secondary intentions

  4. 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

  5. Management of Lower Back Pain • Pharmacological • Psychological • Behavioural • Complementary therapy • Interventional

  6. Pharmacological Management • WHO Step Ladder • By the oral route • By the clock

  7. Analgesic Types • Simple analgesics • Moderate • Strong

  8. Simple Analgesics • Paracetamol • NSAIDS – Aspirin/Ibuprofen/Indometacin Diclofenac/ Meloxicam • COX 2 Inhibitors - Celecoxib (Celebrex) Etoricoxib (Arcoxia)

  9. Cautions • All NSAIDS Cardiac/Hepatic/Renal Impairment • COX 2 LVF/Hypertension

  10. Contraindications • Allergy/Hypersensitivity • Bleeding peptic ulcers • Severe heart failure • CVA • IHD • PVD • Moderate ht failure

  11. Moderate Analgesics • Codeine Phos • Co- Codamol (8/500, 30/500) Tylex/Kapake

  12. Strong Analgesics (Opiates)

  13. Anti Neuropathic Medication • Anti Epileptics – Gabapentin Pregablin • Antidepressants – Amitriptyline Dothiopin Duloxetine

  14. Psychological • Psychological assessment • Cognitive behavioural therapy • Counselling • Supportive psychotherapy • Group therapy • Relaxation • Reflexology

  15. Behavioural therapy • Pain management programmes • Back schools

  16. Complimentary Therapy • Acupuncture • Tai Chi • TENS/SCENAR (self controlled electro neuro adaptive regulation) • Reflexology • Alexandra • Aromatherapy – oil

  17. 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

  18. Epidural Steroid Injections

  19. Indications Radiculopathy / Radiculitis MRI Scan – Positive findings of a disc prolapse Nerve root compression

  20. Drugs • Methylprednisolone 80mg • Triamcinolone 60mg • Local anaesthetic solution

  21. 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.

  22. Contrast in the epidural space Lumbar Epidurogram

  23. 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

  24. 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

  25. Complications • Flashing • Nausea • Vomiting • Sweating • Hypotension • Dural puncture • Retinal haemorrhage • Epidural haematoma

  26. Facet Joint Injections ( FJI )

  27. 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

  28. Indications for FJI • Diagnostic • Therapeutic

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

  30. Positive Predictors • Acute onset of pain • Absence of leg pain • Absence of muscle spasm • Normal gait

  31. RadiofrequenzyDenervation

  32. Radiofrequency Lesion Generator (Radionics)

  33. 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

  34. 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

  35. IDET (IntradiscalElectrothermalAnnuloplasty) • To treat discogenic back pain • Procedure works by cauterizing the nerve endings within the disc wall • Minimally invasive out patient procedure

  36. Spinal Cord Stimulator

  37. 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

  38. 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.

  39. 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.

  40. Other uses of SCS • Complex regional pain syndrome • Ischaemic leg pains • Unstable angina • Phantom limb pain • Muscle spasm in MS

  41. Surgical Option Refer to Orthopaedic and Neurosurgical colleagues Red flags Disc prolapses Neurological Symptoms Ct back pain not responding to interventions

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