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Back Pain: Why it hurts so much
Muhammad A. Munir, MDDiplomat American Board of Anesthesiology
and Pain Management
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Overview of today’s talk• How common is Back Pain• What causes Back Pain• How do we diagnose Back Pain• What are the treatments for Back Pain• Is there any thing that I can do to prevent
back pain?
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Economics of Low Back Pain
• Second to HA for pain complaints• Most common reason for disability in the
working years• 75% of US population will have low back
pain• 10-15% of work absences• 2-8% of the workforce is disabled by LBP
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Causes of Low Back Pain: Aging of the Lumbar Spine
• First visible sign of aging • Holt – Discograms
– 34% of subjects showed elements of aging by age 23 in one of the two lower L-spine discs
– Necroscopy studies – aging changes 75% by age 28
Holt et al. J Bone Joint Surg 1968
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Anatomy• Vertebral body• Pedicle• Transverse process• Spinous process• Facet• Disc
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Muscle Strain and Spasm• Usually respond to
conservative measures
• Muscle injury leads to spasm
• Diagnosed by History and exam
• Acupuncture• Massage• Trigger point
injections
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Musculoskeletal back pain Facet
• Capsule can be stretched/damages with axial loads – esp. extension
• Richly innervated by branches from dorsal ramus (posterior nerves)
• Limits axial rotational movements
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DISC
• Central portion• Peripheral portion• Degeneration of the
outer portion and loss of water from the inner portion
• Disc bulges and herniation
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Disc Herniation• History of
sciatica/radiculopathy• Classically low back pain
precedes leg pain• May be asymptomatic (21-
28%)• Most common at L4/L5• Webers study of conservative
versus surgical mgmt.– No statistical difference at 4
and 10 year intervals.
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Disc Herniation
• L5/S1 Herniation
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Spinal Stenosis• Osteoarthritis of the spine
resulting in narrowing of spinal canal
• Intermittent back pain – radiating to one or both legs especially with walking upright
• Calf pain/tightness• Worse with standing/walking• Better with leaning forward
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Spondylolisthesis• 3.5 % of population have
slippage of either L4 or L5
• Due to bony disruption between the facets
• Limb findings can be vague
• Often asymptomatic until superimposed on spinal stenosis
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Sacroiliac Joint Dysfunction• Pain in the low back and
thigh• Pain in the buttocks that
is worse by crossing the legs
• Also worse with pressure from hip pocket wallet.
• May sometimes mimic sciatica
• Usually from arthritis• TB/Tumor/Ank.Spon./Reit
ers.
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Vertebral Compression Fractures
• Associated with osteoprosis and bone weakening, trauma, tumor, infection
• Localized pain on deep palpation
• May affect patients breathing abilities and daily life activities, increase risk of lung infections
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Fibromyalgia• Musculoskeletal pain of
unknown etiology• Widespread pain• Decreased pain thresholds• Elevated Substance P in
CSF• Characteristic Tender Points
(18) • Suggestion of involment of
nerves and sensitization of nerves as well deconditioning
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Fibromyalgia II
• Low dose tricyclic• Sedative/ hypnotic• Analgesic doses of
NSAIDS• Controversial role of
narcotics
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Other Causes of Low Back Pain
• Infection• Tumor• Failed back surgery syndrome
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Diagnosis of LBP
• History and Physical Examination• Imaging studies• Laboratory tests• Diagnostic injections
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Diagnosis of LBP: X-ray
• X-Ray – good for detail of the bone structures in the spine
• Used to check for instability (spondylolisthesis), tumor and fractures
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Diagnosis of LBP: CT Scan
• Superior bony detail c/w MRI
• Good for soft tissues (discs, nerve)
• Also used for s/p discography
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Diagnosis of LBP: MRI
• Excellent for soft tissues such as nervous tissue, discs
• Best tissue contrast resolution
• Inability for some patients with implantables
• Limitations include bony detail/cost and time
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Diagnosis of LBP Bone Scan
• Usually Technetium 99
• Extremely sensitive but non-specific
• Inexpensive• Accumulate in
metabolically active areas
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Treatment of Low Back Pain
• Medical Management• Injection therapy• Physical Therapy and modalities• Biofeedback and relaxation therapies• Surgery
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Treatment Modalities Conservative Management
• Apply cold then heat• Ice 20 min periods
several times• Then apply heat for 20
min periods• Meds (NSAIDS for
inflammation and tylenol for pain, muscle relaxant)
• Physical Therapy
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Treatment Modalities
• Less aggressive to more aggressive• Epidural injections• Nerve root block• Facet Injections• Radiofrequency ablation of nerves
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Treatment Modalities Moderate
• Laser endoscopic spinal endoscopy
• For contained disc herniations
• Laser/illumination/imagin g/irrigation and aspiration on handheld catheter
• YAG laser – energy absorbed in 0.5 mm of tissue
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Treatment Modalities Moderate
• Nucleoplasty• “Coblation”• Combines ablation of
disc tissue and coagulation of surrounding tissue for disc decompression
• Percutaneous diskectomy
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Treatment Modalities Moderate
• IDET• Alternative for spinal
fusion in a group of young patients
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Treatment Modalities Moderate
• Vertebroplasty and Kyphoplasty
• Painful vertebral body fracture secondary to osteoprosis
• Reduces pain, stablizes fracture and helps in return to previous level of functioning
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Treatment Modalities Surgical Options
• Spinal decompression• Laminectomy• Discectomy• Spinal fusion• Artificial disks
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Prevention of LBP• Proper lifting techniques• Regular exercise• Maintaining proper body
weight• Avoidance of smoking• Maintaining proper
posture when standing and sitting
• Abdominal musculature