mini-medical school my aching neck my aching...
TRANSCRIPT
MINI-MEDICAL SCHOOL
My Aching Neck ndash My Aching Back
Mario De Pinto MD Department of Anesthesiology and Perioperative Care
Pain Management Center
March 10 2016
NO DISCLOSURES
OBJECTIVES
Epidemiology ndash Risk Factors
Sources and Causes of Neck and Low Back Pain
Short and Long Term Management
DEFINITIONS
NECK PAIN (NP)
Pain in the neck withwithout pain referred into one or both upper extremities
In some cases pain may be associated with headaches
LOW BACK PAIN (LBP)
Pain on the posterior aspect of the body
from the lower margin of the 12th rib to the lower gluteal folds withwithout pain referred into one or both extremities
EPIDEMIOLOGY
NECK PAIN - PREVALENCE
Global point prevalence in 2010 - 49 Peaks at a young age - 45 years
Higher in females ndash 58 vs 40
LOW BACK PAIN
Global point prevalence in 2010 ndash 94 Higher in males 101 vs 87 Peaks at approx 80 years of age
Prevalence total number of
cases of a disease in a given
population at a specific time
MSK pain reported by 521 of persons aged 18 years and older in 2012
LBP most common (286) NP third most common (152)
(Knee pain second most common at 181)
Females report MSK pain more frequently than males (546 vs
495) The prevalence of LBP and NP highest
for persons age 45 to 64 years
MUSCULOSKELETAL (MSK) DISORDERS ndash US DATA
About half (496)of the total disability burden associated
with MSK disorders is from LBP
NP (201) also caused
substantial disability burden
Between 1998-2011 total direct and indirect costs of
musculoskeletal conditions rose from $3961 billion to $8738
billion ( 121)
Over the same period of time the US Gross Domestic Product
(GDP) has risen from $115 trillion to $152 trillion ( 32)
MUSCULOSKELETAL (MSK) DISORDERS - COST
RISK FACTORS
Gender Regardless of age MK pain more common among working women than working men
(Herin F et al Pain 2014 155 937-43)
Women seem to have sensitivity to pain (Leville SG et al Pain 2005 116 332-8)
Age Highest incidence of NP and LBP in the 3rd-
4th decade and overall prevalence increasing until age 60-65
(Hoy D et al Best Pract Res Clin Rheumatol 2010 24 769-81)
Occupational factors
Repetitive work awkward postures vibrations
(Neupane S et al Int Arch Occup Environ Health 2013 86 581-9)
(Herin F et al Pain 2014 155 937-43)
Psychosocial Factors
High level of emotional distress anxiety depression fear of
movement with avoidance behaviors (resting and limping)
correlated with high level of NPsup1 and LBPsup2 disability
(Johansen JB et al Clin J Pain 2013 29 1029-1035sup1)
(Grotle M et al Pain 2004 112 343-352sup2)
Job dissatisfaction work requiring repetitive tasks
limited autonomy and opportunities for learning and growing
professionally (van Tulder M et al Clin Rheum 2002 16(5) 761-75
risk of MSK pain in women
(Herin F et al Pain 2014 155 937-43)
Lower levels of education - strong predictor of more prolonged episode duration and poorer
outcome (Chou R et al Ann Int Med 2007 147(7) 478-91)
(Deyo RA et al Spine 2006 31 2724-7)
Psychosocial Factors
Problems with sleep
Sometimes - Risk of developing chronic NP LBP - 22-32
OftenAlways - 51-66 (PJ Moork et al Eur J of Pub Health 2013
24(6) 924-29)
Lack of sleep induces a state of low-level systemic inflammation that sensitizes the
nociceptive system (Haack M et al Sleep 2007 30 1145-52) (Wang H et al Clin J Pain 2008 24 273-8)
FROM THE MOVIE ldquoInsomniardquo
Lack of exercise - Increased body weight
Lack of sleep ndash Lack of physical exercise ndash Increased body weight ndash bad combination
(PJ Moork et al Eur J of Pub Health 2013 24(6) 924-29)
Lack of physical activityIncreased BMI
low-grade systemic inflammation that the susceptibility to chronic pain (Roytblat L et al Obesity 2000 8 673-5)
(Petersen AMW et al J Appl Physiol 2005 98 1154-62)
SOURCES OF NECK AND LOW BACK PAIN
a Large disk herniation at the C5-6 disk level
b Right sided disk herniation with nerve root compromise
Patient likely to complain of NP radiated to right upper extremity shooting stabbing
electrical shock-like with paresthesiae
CERVICAL-LUMBAR INTERVERTEBRAL DISK
MECHANISM Inflammation of the nerve roots
When a disk ruptures inflammatory
mediators are released from the nucleus polposus (the inner part of the disk)
around the nerve root leading to chemical neuroradiculitis
CERVICAL-LUMBAR INTERVERTEBRAL DISK
True synovial joints
between the C2-C7 vertebrae located behind the plane of the intervertebral foramina
and the spinal nerves contained therein
Arthritic changes may cause axial neck pain withwithout upper extremity pain
CERVICAL FACET JOINTS
CERVICAL FACET JOINTS
C2-3 C5-6 C6-7
most frequent
facetogenic pain
generators in the cervical
spine
CERVICAL FACET JOINTS
C2-3 joint Pain in the sub-occipital region
radiating to occiput auricular region vertex of the head forehead and orbit
C5-6 joint
Pain radiates over the deltoid region and into the arm
C6-7 joint Pain radiates over
over the medial scapula
ATLANTO-AXIAL JOINT (C1-2)
Pain from C1-2 occurs higher than pain from C2-3
vertex rather than forehead and temple
ATLANTO-OCCIPITAL JOINT (C 0-1)
Pain from C 0-1 almost superimposes pain stemming
from C1-2
Unusual source of neck pain
Note the close anatomic relationship between C0-
1 joint and C1 nerve
between C1-2 joint and C2 ganglia and nerve
and between these joints and the vertebral artery
OTHER SOURCES OF NECK PAIN
Posterior neck muscles
Cervical dura mater
Atlanto-axial joint ligaments
Vertebral artery
Cervical vertebral bodies
True synovial joints with a space a synovial membrane hyaline cartilage surfaces and a
fibrous capsule located in front of the plane of the foramina and the nerve root therein
Arthritic changes may cause axial low back pain withwithout lower extremity pain
LUMBAR FACET JOINTS
LUMBAR FACET JOINTS PAIN CHARACTERISTICS
More common in patients 65
yearolder
Axial low back pain
withwithout radiation to the
lower extremities
Morning stiffness Pain when
starting to move relieved by
the recumbent position
Worsening as day goes by
LUMBAR FACET JOINTS PAIN PATTERNS
L4-5 L5-S1
most frequent facetogenic
pain generators in the lumbar
spine
Pain does not extend down
beyond the level of the knee
Largest axial joint in the
body
Only the anterior third is a
true synovial joint
Complex innervation
including sensory fibers
from L5 through S4 spinal
nerves
SACRO-ILIAC JOINT
A B
No difference in gender
Mean age 40-50
Prevalence 13-30 of
patients with ho low back
pain
Most commonly causing
unilateral symptoms
SACRO-ILIAC JOINT
Pain is always maximal below L5
May radiate to hips groin buttocks
posterior thighs
Patterns of referred pain somewhat
similar to those due to disk and orfacet
joint mediated pain
SACRO-ILIAC JOINT PAIN PATTERN
PIRIFORMIS MUSCLE
Located in the gluteal region is one of the muscles of the lateral
rotator group
It is situated within the posterior wall of the pelvis partly at the
back of the hip joint
Passes out of the pelvis through the greater sciatic foramen
Sciatic nerve
PIRIFORMIS MUSCLE
Sport activities andor certain movements (running lunging) can
stress the piriformis muscle
The subsequent muscle spasm may manifest as MSK low back pain
radiating to the buttock and along the sciatic nerve
Prolonged sitting stretching climbing stairs or walking on inclines squatting
worsen the pain
REALLY A PAIN THE BUTT
OTHER SOURCES OF LOW BACK PAIN
Posterior lumbo-sacral paraspinal pelvic girdle muscles
Lumbar spine ligaments tendons
Vertebral bodies
CAUSES OF NECK AND LOW BACK PAIN
TUMORS
INFECTIONS Discitis Osteomyelitis Septic arthritis Meningitis
VASCULAR DISORDERS (egCarotid artery dissection)
AUTOIMMUNE DISORDERS Rheumatoid arthritis Ankylosing spondylitis Polymyalgia rheumatica
TRAUMA (FracturesDislocations)
MSK DISORDERS Soft tissue injuries Whiplash CervicalLumbosacral
strain Myofascial disorders Fibromyalgia
JOINT DISORDERS Spondylosis and Osteoarthritis
MANAGEMENT
Self limited condition
Symptoms and disability improve rapidly
Most patients return to work and normal activities in 4-6 weeks
(Pengel LH et al BMJ 2003 327 323)
NATURAL HISTORY
1 in 3 patients
Persistent moderate pain 1 year after an acute episode
1 in 5 patients report substantial limitations in activity (von Korff al et al Spine 1996 21 2833-7 ndash discussion 2838-9)
NATURAL HISTORY
History and Physical Exam
Blood work to rule out the
presence of a malignancy andor an infection
Plain radiographs of
cervicallumbar spine CTMRI in patients with neurologic
complaints or with pain not improving
DIAGNOSIS
MAIN GOAL
Achieve adequate pain control (NSAIDs Tylenol Muscle
Relaxants Gabapentinoids short acting opioids)
Relative rest
Activity modifications
INITIAL MANAGEMENT
Epidural steroid injections are an
option in patients with disk herniation back and leg pain
INITIAL MANAGEMENT
Anesth Analg 2016 Mar122(3)857-70 Bhatia A1 Flamer D Shah PS Cohen SP
CONCLUSIONS Epidural steroids injections provide
some analgesic benefit at 3 months in patients with lumbosacral radicular pain
due to herniated intervertebral disks but they have no impact on physical
disability or incidence of surgery
Epidural steroid injections are an option in
patients with spinal stenosis
INITIAL MANAGEMENT
Spinal stenosis causes mechanical compression of the nerve roots swelling
(microvascular injury) producing pain (Olmarker K et al Spine 1989 14 569-573)
L3-4 Spinal Stenosis
INITIAL MANAGEMENT
STEROIDS
inhibit swelling (edema) around the nerve root
(Rydevik B et al Spine 1984 9 7-15)
improve blood flow to neural elements decreasing ischemic neuritis
(Fukusaki M et al Clin J Pain 1998 14 148-51)
block conduction in nociceptive nerve fibers (Johansson A et al Acta Anesthesiol Scand
1990 34 335-38) L4-5 Severe Spinal Stenosis
INITIAL MANAGEMENT
Usually spinal stenosis occurs in pts of senior age
Some of these patients may significant comorbidities and higher sensitivity to
pain medications
Multilevel Cervical Spinal Stenosis
INITIAL MANAGEMENT
Intra-articular facet joint injections are appropriate when a clinical
diagnosis of facet joint ldquosyndromerdquo is confirmed
Axial back pain withwithout radiation
to the extremities
Morning neckback stiffness Pain when starting to move worse on necklumbar
spine extension relieved by the recumbent position
Intra-articular C3-4 facet joint injection
Intra-articular L5-S1 facet joint injection
INITIAL MANAGEMENT
Injections helpful in diagnosis and management of LBP secondary
to SI Joint ldquoSyndromerdquo
Pain is always maximal below L5
May radiate to hips groin buttocks posterior thighs
Patterns of referred pain somewhat similar to those due to disk and orfacet joint mediated
pain
Intra-articular SI Joint Injection
INITIAL MANAGEMENT
Injections helpful in diagnosis and management of LBP due to Piriformis Muscle Syndrome
A REAL PAIN THE BUTT
INITIAL MANAGEMENT ACUPUNCTURE
Some evidence that acupuncture and variations
thereof (acupressure cupping) potentially helpful in the acutesubacute period in
patients with NP and LBP
(Yuan QI et al PloS One 2015 Febr 1-37)
NEXT STEP
Rehabilitation and regaining of function
Physical Therapy very important component of the
rehabilitation
A symbiotic relationship between patient and
therapist key of a successful physical rehabilitation
program
The role of YOGA
Better pain control at rest and with
activities with yoga (9-week program with weekly 90-minute classes) when
compared to a self care exercise program in patients with neck pain
Significant treatment effects of yoga found for pain-related apprehension
disability quality of life and psychological outcomes (depression
fatigue anger)
(Michalsen A et al the J Pain 2012 13(11) 1122-30)
THE IMPORTANCE OF REMAINING ACTIVE
Increasing the amount of steps
walkedday by 1000 over the course of a year reduced the risk of neck pain by
14 in a group of people (men and women age 20-45) with sedentary jobs
(Sitthipornvorakul EA et al Eur Spine J
2015 24 417-24)
SPINAL MANIPULATION No Thank you
Systematic review of spinal
manipulation in patients with a variety of pain conditions including NP
and LBP
Failed to demonstrate that spinal manipulation is an effective
intervention for pain management
(Posadzki P Pain Med 2012 13 754-61)
CONCLUSIONS
Neck and Low Back pain syndromes are usually self limited conditions that can convert in chronic pain conditions causing
prolonged disability
The prevalence and cost of these conditions has significantly increased over the course of the last 15-20 years
Aggressive management of pain during the acute phase is
important because adequate pain control shortens the time and level of disability and facilitates the rehabilitation process
CONCLUSIONS
A variety of treatment modalities including medications acupuncture injections PT Yoga are utilized to manage pain and facilitate the
recovery process
Reducing stress and activities associated with the generation of pain maintaining an appropriate physical exercise regimen and a body weight
as close as possible to the ideal body weight will likely result in a decreased incidenceprevalence of short and long term NP and LBP
THANK YOU
QUESTIONS
NO DISCLOSURES
OBJECTIVES
Epidemiology ndash Risk Factors
Sources and Causes of Neck and Low Back Pain
Short and Long Term Management
DEFINITIONS
NECK PAIN (NP)
Pain in the neck withwithout pain referred into one or both upper extremities
In some cases pain may be associated with headaches
LOW BACK PAIN (LBP)
Pain on the posterior aspect of the body
from the lower margin of the 12th rib to the lower gluteal folds withwithout pain referred into one or both extremities
EPIDEMIOLOGY
NECK PAIN - PREVALENCE
Global point prevalence in 2010 - 49 Peaks at a young age - 45 years
Higher in females ndash 58 vs 40
LOW BACK PAIN
Global point prevalence in 2010 ndash 94 Higher in males 101 vs 87 Peaks at approx 80 years of age
Prevalence total number of
cases of a disease in a given
population at a specific time
MSK pain reported by 521 of persons aged 18 years and older in 2012
LBP most common (286) NP third most common (152)
(Knee pain second most common at 181)
Females report MSK pain more frequently than males (546 vs
495) The prevalence of LBP and NP highest
for persons age 45 to 64 years
MUSCULOSKELETAL (MSK) DISORDERS ndash US DATA
About half (496)of the total disability burden associated
with MSK disorders is from LBP
NP (201) also caused
substantial disability burden
Between 1998-2011 total direct and indirect costs of
musculoskeletal conditions rose from $3961 billion to $8738
billion ( 121)
Over the same period of time the US Gross Domestic Product
(GDP) has risen from $115 trillion to $152 trillion ( 32)
MUSCULOSKELETAL (MSK) DISORDERS - COST
RISK FACTORS
Gender Regardless of age MK pain more common among working women than working men
(Herin F et al Pain 2014 155 937-43)
Women seem to have sensitivity to pain (Leville SG et al Pain 2005 116 332-8)
Age Highest incidence of NP and LBP in the 3rd-
4th decade and overall prevalence increasing until age 60-65
(Hoy D et al Best Pract Res Clin Rheumatol 2010 24 769-81)
Occupational factors
Repetitive work awkward postures vibrations
(Neupane S et al Int Arch Occup Environ Health 2013 86 581-9)
(Herin F et al Pain 2014 155 937-43)
Psychosocial Factors
High level of emotional distress anxiety depression fear of
movement with avoidance behaviors (resting and limping)
correlated with high level of NPsup1 and LBPsup2 disability
(Johansen JB et al Clin J Pain 2013 29 1029-1035sup1)
(Grotle M et al Pain 2004 112 343-352sup2)
Job dissatisfaction work requiring repetitive tasks
limited autonomy and opportunities for learning and growing
professionally (van Tulder M et al Clin Rheum 2002 16(5) 761-75
risk of MSK pain in women
(Herin F et al Pain 2014 155 937-43)
Lower levels of education - strong predictor of more prolonged episode duration and poorer
outcome (Chou R et al Ann Int Med 2007 147(7) 478-91)
(Deyo RA et al Spine 2006 31 2724-7)
Psychosocial Factors
Problems with sleep
Sometimes - Risk of developing chronic NP LBP - 22-32
OftenAlways - 51-66 (PJ Moork et al Eur J of Pub Health 2013
24(6) 924-29)
Lack of sleep induces a state of low-level systemic inflammation that sensitizes the
nociceptive system (Haack M et al Sleep 2007 30 1145-52) (Wang H et al Clin J Pain 2008 24 273-8)
FROM THE MOVIE ldquoInsomniardquo
Lack of exercise - Increased body weight
Lack of sleep ndash Lack of physical exercise ndash Increased body weight ndash bad combination
(PJ Moork et al Eur J of Pub Health 2013 24(6) 924-29)
Lack of physical activityIncreased BMI
low-grade systemic inflammation that the susceptibility to chronic pain (Roytblat L et al Obesity 2000 8 673-5)
(Petersen AMW et al J Appl Physiol 2005 98 1154-62)
SOURCES OF NECK AND LOW BACK PAIN
a Large disk herniation at the C5-6 disk level
b Right sided disk herniation with nerve root compromise
Patient likely to complain of NP radiated to right upper extremity shooting stabbing
electrical shock-like with paresthesiae
CERVICAL-LUMBAR INTERVERTEBRAL DISK
MECHANISM Inflammation of the nerve roots
When a disk ruptures inflammatory
mediators are released from the nucleus polposus (the inner part of the disk)
around the nerve root leading to chemical neuroradiculitis
CERVICAL-LUMBAR INTERVERTEBRAL DISK
True synovial joints
between the C2-C7 vertebrae located behind the plane of the intervertebral foramina
and the spinal nerves contained therein
Arthritic changes may cause axial neck pain withwithout upper extremity pain
CERVICAL FACET JOINTS
CERVICAL FACET JOINTS
C2-3 C5-6 C6-7
most frequent
facetogenic pain
generators in the cervical
spine
CERVICAL FACET JOINTS
C2-3 joint Pain in the sub-occipital region
radiating to occiput auricular region vertex of the head forehead and orbit
C5-6 joint
Pain radiates over the deltoid region and into the arm
C6-7 joint Pain radiates over
over the medial scapula
ATLANTO-AXIAL JOINT (C1-2)
Pain from C1-2 occurs higher than pain from C2-3
vertex rather than forehead and temple
ATLANTO-OCCIPITAL JOINT (C 0-1)
Pain from C 0-1 almost superimposes pain stemming
from C1-2
Unusual source of neck pain
Note the close anatomic relationship between C0-
1 joint and C1 nerve
between C1-2 joint and C2 ganglia and nerve
and between these joints and the vertebral artery
OTHER SOURCES OF NECK PAIN
Posterior neck muscles
Cervical dura mater
Atlanto-axial joint ligaments
Vertebral artery
Cervical vertebral bodies
True synovial joints with a space a synovial membrane hyaline cartilage surfaces and a
fibrous capsule located in front of the plane of the foramina and the nerve root therein
Arthritic changes may cause axial low back pain withwithout lower extremity pain
LUMBAR FACET JOINTS
LUMBAR FACET JOINTS PAIN CHARACTERISTICS
More common in patients 65
yearolder
Axial low back pain
withwithout radiation to the
lower extremities
Morning stiffness Pain when
starting to move relieved by
the recumbent position
Worsening as day goes by
LUMBAR FACET JOINTS PAIN PATTERNS
L4-5 L5-S1
most frequent facetogenic
pain generators in the lumbar
spine
Pain does not extend down
beyond the level of the knee
Largest axial joint in the
body
Only the anterior third is a
true synovial joint
Complex innervation
including sensory fibers
from L5 through S4 spinal
nerves
SACRO-ILIAC JOINT
A B
No difference in gender
Mean age 40-50
Prevalence 13-30 of
patients with ho low back
pain
Most commonly causing
unilateral symptoms
SACRO-ILIAC JOINT
Pain is always maximal below L5
May radiate to hips groin buttocks
posterior thighs
Patterns of referred pain somewhat
similar to those due to disk and orfacet
joint mediated pain
SACRO-ILIAC JOINT PAIN PATTERN
PIRIFORMIS MUSCLE
Located in the gluteal region is one of the muscles of the lateral
rotator group
It is situated within the posterior wall of the pelvis partly at the
back of the hip joint
Passes out of the pelvis through the greater sciatic foramen
Sciatic nerve
PIRIFORMIS MUSCLE
Sport activities andor certain movements (running lunging) can
stress the piriformis muscle
The subsequent muscle spasm may manifest as MSK low back pain
radiating to the buttock and along the sciatic nerve
Prolonged sitting stretching climbing stairs or walking on inclines squatting
worsen the pain
REALLY A PAIN THE BUTT
OTHER SOURCES OF LOW BACK PAIN
Posterior lumbo-sacral paraspinal pelvic girdle muscles
Lumbar spine ligaments tendons
Vertebral bodies
CAUSES OF NECK AND LOW BACK PAIN
TUMORS
INFECTIONS Discitis Osteomyelitis Septic arthritis Meningitis
VASCULAR DISORDERS (egCarotid artery dissection)
AUTOIMMUNE DISORDERS Rheumatoid arthritis Ankylosing spondylitis Polymyalgia rheumatica
TRAUMA (FracturesDislocations)
MSK DISORDERS Soft tissue injuries Whiplash CervicalLumbosacral
strain Myofascial disorders Fibromyalgia
JOINT DISORDERS Spondylosis and Osteoarthritis
MANAGEMENT
Self limited condition
Symptoms and disability improve rapidly
Most patients return to work and normal activities in 4-6 weeks
(Pengel LH et al BMJ 2003 327 323)
NATURAL HISTORY
1 in 3 patients
Persistent moderate pain 1 year after an acute episode
1 in 5 patients report substantial limitations in activity (von Korff al et al Spine 1996 21 2833-7 ndash discussion 2838-9)
NATURAL HISTORY
History and Physical Exam
Blood work to rule out the
presence of a malignancy andor an infection
Plain radiographs of
cervicallumbar spine CTMRI in patients with neurologic
complaints or with pain not improving
DIAGNOSIS
MAIN GOAL
Achieve adequate pain control (NSAIDs Tylenol Muscle
Relaxants Gabapentinoids short acting opioids)
Relative rest
Activity modifications
INITIAL MANAGEMENT
Epidural steroid injections are an
option in patients with disk herniation back and leg pain
INITIAL MANAGEMENT
Anesth Analg 2016 Mar122(3)857-70 Bhatia A1 Flamer D Shah PS Cohen SP
CONCLUSIONS Epidural steroids injections provide
some analgesic benefit at 3 months in patients with lumbosacral radicular pain
due to herniated intervertebral disks but they have no impact on physical
disability or incidence of surgery
Epidural steroid injections are an option in
patients with spinal stenosis
INITIAL MANAGEMENT
Spinal stenosis causes mechanical compression of the nerve roots swelling
(microvascular injury) producing pain (Olmarker K et al Spine 1989 14 569-573)
L3-4 Spinal Stenosis
INITIAL MANAGEMENT
STEROIDS
inhibit swelling (edema) around the nerve root
(Rydevik B et al Spine 1984 9 7-15)
improve blood flow to neural elements decreasing ischemic neuritis
(Fukusaki M et al Clin J Pain 1998 14 148-51)
block conduction in nociceptive nerve fibers (Johansson A et al Acta Anesthesiol Scand
1990 34 335-38) L4-5 Severe Spinal Stenosis
INITIAL MANAGEMENT
Usually spinal stenosis occurs in pts of senior age
Some of these patients may significant comorbidities and higher sensitivity to
pain medications
Multilevel Cervical Spinal Stenosis
INITIAL MANAGEMENT
Intra-articular facet joint injections are appropriate when a clinical
diagnosis of facet joint ldquosyndromerdquo is confirmed
Axial back pain withwithout radiation
to the extremities
Morning neckback stiffness Pain when starting to move worse on necklumbar
spine extension relieved by the recumbent position
Intra-articular C3-4 facet joint injection
Intra-articular L5-S1 facet joint injection
INITIAL MANAGEMENT
Injections helpful in diagnosis and management of LBP secondary
to SI Joint ldquoSyndromerdquo
Pain is always maximal below L5
May radiate to hips groin buttocks posterior thighs
Patterns of referred pain somewhat similar to those due to disk and orfacet joint mediated
pain
Intra-articular SI Joint Injection
INITIAL MANAGEMENT
Injections helpful in diagnosis and management of LBP due to Piriformis Muscle Syndrome
A REAL PAIN THE BUTT
INITIAL MANAGEMENT ACUPUNCTURE
Some evidence that acupuncture and variations
thereof (acupressure cupping) potentially helpful in the acutesubacute period in
patients with NP and LBP
(Yuan QI et al PloS One 2015 Febr 1-37)
NEXT STEP
Rehabilitation and regaining of function
Physical Therapy very important component of the
rehabilitation
A symbiotic relationship between patient and
therapist key of a successful physical rehabilitation
program
The role of YOGA
Better pain control at rest and with
activities with yoga (9-week program with weekly 90-minute classes) when
compared to a self care exercise program in patients with neck pain
Significant treatment effects of yoga found for pain-related apprehension
disability quality of life and psychological outcomes (depression
fatigue anger)
(Michalsen A et al the J Pain 2012 13(11) 1122-30)
THE IMPORTANCE OF REMAINING ACTIVE
Increasing the amount of steps
walkedday by 1000 over the course of a year reduced the risk of neck pain by
14 in a group of people (men and women age 20-45) with sedentary jobs
(Sitthipornvorakul EA et al Eur Spine J
2015 24 417-24)
SPINAL MANIPULATION No Thank you
Systematic review of spinal
manipulation in patients with a variety of pain conditions including NP
and LBP
Failed to demonstrate that spinal manipulation is an effective
intervention for pain management
(Posadzki P Pain Med 2012 13 754-61)
CONCLUSIONS
Neck and Low Back pain syndromes are usually self limited conditions that can convert in chronic pain conditions causing
prolonged disability
The prevalence and cost of these conditions has significantly increased over the course of the last 15-20 years
Aggressive management of pain during the acute phase is
important because adequate pain control shortens the time and level of disability and facilitates the rehabilitation process
CONCLUSIONS
A variety of treatment modalities including medications acupuncture injections PT Yoga are utilized to manage pain and facilitate the
recovery process
Reducing stress and activities associated with the generation of pain maintaining an appropriate physical exercise regimen and a body weight
as close as possible to the ideal body weight will likely result in a decreased incidenceprevalence of short and long term NP and LBP
THANK YOU
QUESTIONS
OBJECTIVES
Epidemiology ndash Risk Factors
Sources and Causes of Neck and Low Back Pain
Short and Long Term Management
DEFINITIONS
NECK PAIN (NP)
Pain in the neck withwithout pain referred into one or both upper extremities
In some cases pain may be associated with headaches
LOW BACK PAIN (LBP)
Pain on the posterior aspect of the body
from the lower margin of the 12th rib to the lower gluteal folds withwithout pain referred into one or both extremities
EPIDEMIOLOGY
NECK PAIN - PREVALENCE
Global point prevalence in 2010 - 49 Peaks at a young age - 45 years
Higher in females ndash 58 vs 40
LOW BACK PAIN
Global point prevalence in 2010 ndash 94 Higher in males 101 vs 87 Peaks at approx 80 years of age
Prevalence total number of
cases of a disease in a given
population at a specific time
MSK pain reported by 521 of persons aged 18 years and older in 2012
LBP most common (286) NP third most common (152)
(Knee pain second most common at 181)
Females report MSK pain more frequently than males (546 vs
495) The prevalence of LBP and NP highest
for persons age 45 to 64 years
MUSCULOSKELETAL (MSK) DISORDERS ndash US DATA
About half (496)of the total disability burden associated
with MSK disorders is from LBP
NP (201) also caused
substantial disability burden
Between 1998-2011 total direct and indirect costs of
musculoskeletal conditions rose from $3961 billion to $8738
billion ( 121)
Over the same period of time the US Gross Domestic Product
(GDP) has risen from $115 trillion to $152 trillion ( 32)
MUSCULOSKELETAL (MSK) DISORDERS - COST
RISK FACTORS
Gender Regardless of age MK pain more common among working women than working men
(Herin F et al Pain 2014 155 937-43)
Women seem to have sensitivity to pain (Leville SG et al Pain 2005 116 332-8)
Age Highest incidence of NP and LBP in the 3rd-
4th decade and overall prevalence increasing until age 60-65
(Hoy D et al Best Pract Res Clin Rheumatol 2010 24 769-81)
Occupational factors
Repetitive work awkward postures vibrations
(Neupane S et al Int Arch Occup Environ Health 2013 86 581-9)
(Herin F et al Pain 2014 155 937-43)
Psychosocial Factors
High level of emotional distress anxiety depression fear of
movement with avoidance behaviors (resting and limping)
correlated with high level of NPsup1 and LBPsup2 disability
(Johansen JB et al Clin J Pain 2013 29 1029-1035sup1)
(Grotle M et al Pain 2004 112 343-352sup2)
Job dissatisfaction work requiring repetitive tasks
limited autonomy and opportunities for learning and growing
professionally (van Tulder M et al Clin Rheum 2002 16(5) 761-75
risk of MSK pain in women
(Herin F et al Pain 2014 155 937-43)
Lower levels of education - strong predictor of more prolonged episode duration and poorer
outcome (Chou R et al Ann Int Med 2007 147(7) 478-91)
(Deyo RA et al Spine 2006 31 2724-7)
Psychosocial Factors
Problems with sleep
Sometimes - Risk of developing chronic NP LBP - 22-32
OftenAlways - 51-66 (PJ Moork et al Eur J of Pub Health 2013
24(6) 924-29)
Lack of sleep induces a state of low-level systemic inflammation that sensitizes the
nociceptive system (Haack M et al Sleep 2007 30 1145-52) (Wang H et al Clin J Pain 2008 24 273-8)
FROM THE MOVIE ldquoInsomniardquo
Lack of exercise - Increased body weight
Lack of sleep ndash Lack of physical exercise ndash Increased body weight ndash bad combination
(PJ Moork et al Eur J of Pub Health 2013 24(6) 924-29)
Lack of physical activityIncreased BMI
low-grade systemic inflammation that the susceptibility to chronic pain (Roytblat L et al Obesity 2000 8 673-5)
(Petersen AMW et al J Appl Physiol 2005 98 1154-62)
SOURCES OF NECK AND LOW BACK PAIN
a Large disk herniation at the C5-6 disk level
b Right sided disk herniation with nerve root compromise
Patient likely to complain of NP radiated to right upper extremity shooting stabbing
electrical shock-like with paresthesiae
CERVICAL-LUMBAR INTERVERTEBRAL DISK
MECHANISM Inflammation of the nerve roots
When a disk ruptures inflammatory
mediators are released from the nucleus polposus (the inner part of the disk)
around the nerve root leading to chemical neuroradiculitis
CERVICAL-LUMBAR INTERVERTEBRAL DISK
True synovial joints
between the C2-C7 vertebrae located behind the plane of the intervertebral foramina
and the spinal nerves contained therein
Arthritic changes may cause axial neck pain withwithout upper extremity pain
CERVICAL FACET JOINTS
CERVICAL FACET JOINTS
C2-3 C5-6 C6-7
most frequent
facetogenic pain
generators in the cervical
spine
CERVICAL FACET JOINTS
C2-3 joint Pain in the sub-occipital region
radiating to occiput auricular region vertex of the head forehead and orbit
C5-6 joint
Pain radiates over the deltoid region and into the arm
C6-7 joint Pain radiates over
over the medial scapula
ATLANTO-AXIAL JOINT (C1-2)
Pain from C1-2 occurs higher than pain from C2-3
vertex rather than forehead and temple
ATLANTO-OCCIPITAL JOINT (C 0-1)
Pain from C 0-1 almost superimposes pain stemming
from C1-2
Unusual source of neck pain
Note the close anatomic relationship between C0-
1 joint and C1 nerve
between C1-2 joint and C2 ganglia and nerve
and between these joints and the vertebral artery
OTHER SOURCES OF NECK PAIN
Posterior neck muscles
Cervical dura mater
Atlanto-axial joint ligaments
Vertebral artery
Cervical vertebral bodies
True synovial joints with a space a synovial membrane hyaline cartilage surfaces and a
fibrous capsule located in front of the plane of the foramina and the nerve root therein
Arthritic changes may cause axial low back pain withwithout lower extremity pain
LUMBAR FACET JOINTS
LUMBAR FACET JOINTS PAIN CHARACTERISTICS
More common in patients 65
yearolder
Axial low back pain
withwithout radiation to the
lower extremities
Morning stiffness Pain when
starting to move relieved by
the recumbent position
Worsening as day goes by
LUMBAR FACET JOINTS PAIN PATTERNS
L4-5 L5-S1
most frequent facetogenic
pain generators in the lumbar
spine
Pain does not extend down
beyond the level of the knee
Largest axial joint in the
body
Only the anterior third is a
true synovial joint
Complex innervation
including sensory fibers
from L5 through S4 spinal
nerves
SACRO-ILIAC JOINT
A B
No difference in gender
Mean age 40-50
Prevalence 13-30 of
patients with ho low back
pain
Most commonly causing
unilateral symptoms
SACRO-ILIAC JOINT
Pain is always maximal below L5
May radiate to hips groin buttocks
posterior thighs
Patterns of referred pain somewhat
similar to those due to disk and orfacet
joint mediated pain
SACRO-ILIAC JOINT PAIN PATTERN
PIRIFORMIS MUSCLE
Located in the gluteal region is one of the muscles of the lateral
rotator group
It is situated within the posterior wall of the pelvis partly at the
back of the hip joint
Passes out of the pelvis through the greater sciatic foramen
Sciatic nerve
PIRIFORMIS MUSCLE
Sport activities andor certain movements (running lunging) can
stress the piriformis muscle
The subsequent muscle spasm may manifest as MSK low back pain
radiating to the buttock and along the sciatic nerve
Prolonged sitting stretching climbing stairs or walking on inclines squatting
worsen the pain
REALLY A PAIN THE BUTT
OTHER SOURCES OF LOW BACK PAIN
Posterior lumbo-sacral paraspinal pelvic girdle muscles
Lumbar spine ligaments tendons
Vertebral bodies
CAUSES OF NECK AND LOW BACK PAIN
TUMORS
INFECTIONS Discitis Osteomyelitis Septic arthritis Meningitis
VASCULAR DISORDERS (egCarotid artery dissection)
AUTOIMMUNE DISORDERS Rheumatoid arthritis Ankylosing spondylitis Polymyalgia rheumatica
TRAUMA (FracturesDislocations)
MSK DISORDERS Soft tissue injuries Whiplash CervicalLumbosacral
strain Myofascial disorders Fibromyalgia
JOINT DISORDERS Spondylosis and Osteoarthritis
MANAGEMENT
Self limited condition
Symptoms and disability improve rapidly
Most patients return to work and normal activities in 4-6 weeks
(Pengel LH et al BMJ 2003 327 323)
NATURAL HISTORY
1 in 3 patients
Persistent moderate pain 1 year after an acute episode
1 in 5 patients report substantial limitations in activity (von Korff al et al Spine 1996 21 2833-7 ndash discussion 2838-9)
NATURAL HISTORY
History and Physical Exam
Blood work to rule out the
presence of a malignancy andor an infection
Plain radiographs of
cervicallumbar spine CTMRI in patients with neurologic
complaints or with pain not improving
DIAGNOSIS
MAIN GOAL
Achieve adequate pain control (NSAIDs Tylenol Muscle
Relaxants Gabapentinoids short acting opioids)
Relative rest
Activity modifications
INITIAL MANAGEMENT
Epidural steroid injections are an
option in patients with disk herniation back and leg pain
INITIAL MANAGEMENT
Anesth Analg 2016 Mar122(3)857-70 Bhatia A1 Flamer D Shah PS Cohen SP
CONCLUSIONS Epidural steroids injections provide
some analgesic benefit at 3 months in patients with lumbosacral radicular pain
due to herniated intervertebral disks but they have no impact on physical
disability or incidence of surgery
Epidural steroid injections are an option in
patients with spinal stenosis
INITIAL MANAGEMENT
Spinal stenosis causes mechanical compression of the nerve roots swelling
(microvascular injury) producing pain (Olmarker K et al Spine 1989 14 569-573)
L3-4 Spinal Stenosis
INITIAL MANAGEMENT
STEROIDS
inhibit swelling (edema) around the nerve root
(Rydevik B et al Spine 1984 9 7-15)
improve blood flow to neural elements decreasing ischemic neuritis
(Fukusaki M et al Clin J Pain 1998 14 148-51)
block conduction in nociceptive nerve fibers (Johansson A et al Acta Anesthesiol Scand
1990 34 335-38) L4-5 Severe Spinal Stenosis
INITIAL MANAGEMENT
Usually spinal stenosis occurs in pts of senior age
Some of these patients may significant comorbidities and higher sensitivity to
pain medications
Multilevel Cervical Spinal Stenosis
INITIAL MANAGEMENT
Intra-articular facet joint injections are appropriate when a clinical
diagnosis of facet joint ldquosyndromerdquo is confirmed
Axial back pain withwithout radiation
to the extremities
Morning neckback stiffness Pain when starting to move worse on necklumbar
spine extension relieved by the recumbent position
Intra-articular C3-4 facet joint injection
Intra-articular L5-S1 facet joint injection
INITIAL MANAGEMENT
Injections helpful in diagnosis and management of LBP secondary
to SI Joint ldquoSyndromerdquo
Pain is always maximal below L5
May radiate to hips groin buttocks posterior thighs
Patterns of referred pain somewhat similar to those due to disk and orfacet joint mediated
pain
Intra-articular SI Joint Injection
INITIAL MANAGEMENT
Injections helpful in diagnosis and management of LBP due to Piriformis Muscle Syndrome
A REAL PAIN THE BUTT
INITIAL MANAGEMENT ACUPUNCTURE
Some evidence that acupuncture and variations
thereof (acupressure cupping) potentially helpful in the acutesubacute period in
patients with NP and LBP
(Yuan QI et al PloS One 2015 Febr 1-37)
NEXT STEP
Rehabilitation and regaining of function
Physical Therapy very important component of the
rehabilitation
A symbiotic relationship between patient and
therapist key of a successful physical rehabilitation
program
The role of YOGA
Better pain control at rest and with
activities with yoga (9-week program with weekly 90-minute classes) when
compared to a self care exercise program in patients with neck pain
Significant treatment effects of yoga found for pain-related apprehension
disability quality of life and psychological outcomes (depression
fatigue anger)
(Michalsen A et al the J Pain 2012 13(11) 1122-30)
THE IMPORTANCE OF REMAINING ACTIVE
Increasing the amount of steps
walkedday by 1000 over the course of a year reduced the risk of neck pain by
14 in a group of people (men and women age 20-45) with sedentary jobs
(Sitthipornvorakul EA et al Eur Spine J
2015 24 417-24)
SPINAL MANIPULATION No Thank you
Systematic review of spinal
manipulation in patients with a variety of pain conditions including NP
and LBP
Failed to demonstrate that spinal manipulation is an effective
intervention for pain management
(Posadzki P Pain Med 2012 13 754-61)
CONCLUSIONS
Neck and Low Back pain syndromes are usually self limited conditions that can convert in chronic pain conditions causing
prolonged disability
The prevalence and cost of these conditions has significantly increased over the course of the last 15-20 years
Aggressive management of pain during the acute phase is
important because adequate pain control shortens the time and level of disability and facilitates the rehabilitation process
CONCLUSIONS
A variety of treatment modalities including medications acupuncture injections PT Yoga are utilized to manage pain and facilitate the
recovery process
Reducing stress and activities associated with the generation of pain maintaining an appropriate physical exercise regimen and a body weight
as close as possible to the ideal body weight will likely result in a decreased incidenceprevalence of short and long term NP and LBP
THANK YOU
QUESTIONS
DEFINITIONS
NECK PAIN (NP)
Pain in the neck withwithout pain referred into one or both upper extremities
In some cases pain may be associated with headaches
LOW BACK PAIN (LBP)
Pain on the posterior aspect of the body
from the lower margin of the 12th rib to the lower gluteal folds withwithout pain referred into one or both extremities
EPIDEMIOLOGY
NECK PAIN - PREVALENCE
Global point prevalence in 2010 - 49 Peaks at a young age - 45 years
Higher in females ndash 58 vs 40
LOW BACK PAIN
Global point prevalence in 2010 ndash 94 Higher in males 101 vs 87 Peaks at approx 80 years of age
Prevalence total number of
cases of a disease in a given
population at a specific time
MSK pain reported by 521 of persons aged 18 years and older in 2012
LBP most common (286) NP third most common (152)
(Knee pain second most common at 181)
Females report MSK pain more frequently than males (546 vs
495) The prevalence of LBP and NP highest
for persons age 45 to 64 years
MUSCULOSKELETAL (MSK) DISORDERS ndash US DATA
About half (496)of the total disability burden associated
with MSK disorders is from LBP
NP (201) also caused
substantial disability burden
Between 1998-2011 total direct and indirect costs of
musculoskeletal conditions rose from $3961 billion to $8738
billion ( 121)
Over the same period of time the US Gross Domestic Product
(GDP) has risen from $115 trillion to $152 trillion ( 32)
MUSCULOSKELETAL (MSK) DISORDERS - COST
RISK FACTORS
Gender Regardless of age MK pain more common among working women than working men
(Herin F et al Pain 2014 155 937-43)
Women seem to have sensitivity to pain (Leville SG et al Pain 2005 116 332-8)
Age Highest incidence of NP and LBP in the 3rd-
4th decade and overall prevalence increasing until age 60-65
(Hoy D et al Best Pract Res Clin Rheumatol 2010 24 769-81)
Occupational factors
Repetitive work awkward postures vibrations
(Neupane S et al Int Arch Occup Environ Health 2013 86 581-9)
(Herin F et al Pain 2014 155 937-43)
Psychosocial Factors
High level of emotional distress anxiety depression fear of
movement with avoidance behaviors (resting and limping)
correlated with high level of NPsup1 and LBPsup2 disability
(Johansen JB et al Clin J Pain 2013 29 1029-1035sup1)
(Grotle M et al Pain 2004 112 343-352sup2)
Job dissatisfaction work requiring repetitive tasks
limited autonomy and opportunities for learning and growing
professionally (van Tulder M et al Clin Rheum 2002 16(5) 761-75
risk of MSK pain in women
(Herin F et al Pain 2014 155 937-43)
Lower levels of education - strong predictor of more prolonged episode duration and poorer
outcome (Chou R et al Ann Int Med 2007 147(7) 478-91)
(Deyo RA et al Spine 2006 31 2724-7)
Psychosocial Factors
Problems with sleep
Sometimes - Risk of developing chronic NP LBP - 22-32
OftenAlways - 51-66 (PJ Moork et al Eur J of Pub Health 2013
24(6) 924-29)
Lack of sleep induces a state of low-level systemic inflammation that sensitizes the
nociceptive system (Haack M et al Sleep 2007 30 1145-52) (Wang H et al Clin J Pain 2008 24 273-8)
FROM THE MOVIE ldquoInsomniardquo
Lack of exercise - Increased body weight
Lack of sleep ndash Lack of physical exercise ndash Increased body weight ndash bad combination
(PJ Moork et al Eur J of Pub Health 2013 24(6) 924-29)
Lack of physical activityIncreased BMI
low-grade systemic inflammation that the susceptibility to chronic pain (Roytblat L et al Obesity 2000 8 673-5)
(Petersen AMW et al J Appl Physiol 2005 98 1154-62)
SOURCES OF NECK AND LOW BACK PAIN
a Large disk herniation at the C5-6 disk level
b Right sided disk herniation with nerve root compromise
Patient likely to complain of NP radiated to right upper extremity shooting stabbing
electrical shock-like with paresthesiae
CERVICAL-LUMBAR INTERVERTEBRAL DISK
MECHANISM Inflammation of the nerve roots
When a disk ruptures inflammatory
mediators are released from the nucleus polposus (the inner part of the disk)
around the nerve root leading to chemical neuroradiculitis
CERVICAL-LUMBAR INTERVERTEBRAL DISK
True synovial joints
between the C2-C7 vertebrae located behind the plane of the intervertebral foramina
and the spinal nerves contained therein
Arthritic changes may cause axial neck pain withwithout upper extremity pain
CERVICAL FACET JOINTS
CERVICAL FACET JOINTS
C2-3 C5-6 C6-7
most frequent
facetogenic pain
generators in the cervical
spine
CERVICAL FACET JOINTS
C2-3 joint Pain in the sub-occipital region
radiating to occiput auricular region vertex of the head forehead and orbit
C5-6 joint
Pain radiates over the deltoid region and into the arm
C6-7 joint Pain radiates over
over the medial scapula
ATLANTO-AXIAL JOINT (C1-2)
Pain from C1-2 occurs higher than pain from C2-3
vertex rather than forehead and temple
ATLANTO-OCCIPITAL JOINT (C 0-1)
Pain from C 0-1 almost superimposes pain stemming
from C1-2
Unusual source of neck pain
Note the close anatomic relationship between C0-
1 joint and C1 nerve
between C1-2 joint and C2 ganglia and nerve
and between these joints and the vertebral artery
OTHER SOURCES OF NECK PAIN
Posterior neck muscles
Cervical dura mater
Atlanto-axial joint ligaments
Vertebral artery
Cervical vertebral bodies
True synovial joints with a space a synovial membrane hyaline cartilage surfaces and a
fibrous capsule located in front of the plane of the foramina and the nerve root therein
Arthritic changes may cause axial low back pain withwithout lower extremity pain
LUMBAR FACET JOINTS
LUMBAR FACET JOINTS PAIN CHARACTERISTICS
More common in patients 65
yearolder
Axial low back pain
withwithout radiation to the
lower extremities
Morning stiffness Pain when
starting to move relieved by
the recumbent position
Worsening as day goes by
LUMBAR FACET JOINTS PAIN PATTERNS
L4-5 L5-S1
most frequent facetogenic
pain generators in the lumbar
spine
Pain does not extend down
beyond the level of the knee
Largest axial joint in the
body
Only the anterior third is a
true synovial joint
Complex innervation
including sensory fibers
from L5 through S4 spinal
nerves
SACRO-ILIAC JOINT
A B
No difference in gender
Mean age 40-50
Prevalence 13-30 of
patients with ho low back
pain
Most commonly causing
unilateral symptoms
SACRO-ILIAC JOINT
Pain is always maximal below L5
May radiate to hips groin buttocks
posterior thighs
Patterns of referred pain somewhat
similar to those due to disk and orfacet
joint mediated pain
SACRO-ILIAC JOINT PAIN PATTERN
PIRIFORMIS MUSCLE
Located in the gluteal region is one of the muscles of the lateral
rotator group
It is situated within the posterior wall of the pelvis partly at the
back of the hip joint
Passes out of the pelvis through the greater sciatic foramen
Sciatic nerve
PIRIFORMIS MUSCLE
Sport activities andor certain movements (running lunging) can
stress the piriformis muscle
The subsequent muscle spasm may manifest as MSK low back pain
radiating to the buttock and along the sciatic nerve
Prolonged sitting stretching climbing stairs or walking on inclines squatting
worsen the pain
REALLY A PAIN THE BUTT
OTHER SOURCES OF LOW BACK PAIN
Posterior lumbo-sacral paraspinal pelvic girdle muscles
Lumbar spine ligaments tendons
Vertebral bodies
CAUSES OF NECK AND LOW BACK PAIN
TUMORS
INFECTIONS Discitis Osteomyelitis Septic arthritis Meningitis
VASCULAR DISORDERS (egCarotid artery dissection)
AUTOIMMUNE DISORDERS Rheumatoid arthritis Ankylosing spondylitis Polymyalgia rheumatica
TRAUMA (FracturesDislocations)
MSK DISORDERS Soft tissue injuries Whiplash CervicalLumbosacral
strain Myofascial disorders Fibromyalgia
JOINT DISORDERS Spondylosis and Osteoarthritis
MANAGEMENT
Self limited condition
Symptoms and disability improve rapidly
Most patients return to work and normal activities in 4-6 weeks
(Pengel LH et al BMJ 2003 327 323)
NATURAL HISTORY
1 in 3 patients
Persistent moderate pain 1 year after an acute episode
1 in 5 patients report substantial limitations in activity (von Korff al et al Spine 1996 21 2833-7 ndash discussion 2838-9)
NATURAL HISTORY
History and Physical Exam
Blood work to rule out the
presence of a malignancy andor an infection
Plain radiographs of
cervicallumbar spine CTMRI in patients with neurologic
complaints or with pain not improving
DIAGNOSIS
MAIN GOAL
Achieve adequate pain control (NSAIDs Tylenol Muscle
Relaxants Gabapentinoids short acting opioids)
Relative rest
Activity modifications
INITIAL MANAGEMENT
Epidural steroid injections are an
option in patients with disk herniation back and leg pain
INITIAL MANAGEMENT
Anesth Analg 2016 Mar122(3)857-70 Bhatia A1 Flamer D Shah PS Cohen SP
CONCLUSIONS Epidural steroids injections provide
some analgesic benefit at 3 months in patients with lumbosacral radicular pain
due to herniated intervertebral disks but they have no impact on physical
disability or incidence of surgery
Epidural steroid injections are an option in
patients with spinal stenosis
INITIAL MANAGEMENT
Spinal stenosis causes mechanical compression of the nerve roots swelling
(microvascular injury) producing pain (Olmarker K et al Spine 1989 14 569-573)
L3-4 Spinal Stenosis
INITIAL MANAGEMENT
STEROIDS
inhibit swelling (edema) around the nerve root
(Rydevik B et al Spine 1984 9 7-15)
improve blood flow to neural elements decreasing ischemic neuritis
(Fukusaki M et al Clin J Pain 1998 14 148-51)
block conduction in nociceptive nerve fibers (Johansson A et al Acta Anesthesiol Scand
1990 34 335-38) L4-5 Severe Spinal Stenosis
INITIAL MANAGEMENT
Usually spinal stenosis occurs in pts of senior age
Some of these patients may significant comorbidities and higher sensitivity to
pain medications
Multilevel Cervical Spinal Stenosis
INITIAL MANAGEMENT
Intra-articular facet joint injections are appropriate when a clinical
diagnosis of facet joint ldquosyndromerdquo is confirmed
Axial back pain withwithout radiation
to the extremities
Morning neckback stiffness Pain when starting to move worse on necklumbar
spine extension relieved by the recumbent position
Intra-articular C3-4 facet joint injection
Intra-articular L5-S1 facet joint injection
INITIAL MANAGEMENT
Injections helpful in diagnosis and management of LBP secondary
to SI Joint ldquoSyndromerdquo
Pain is always maximal below L5
May radiate to hips groin buttocks posterior thighs
Patterns of referred pain somewhat similar to those due to disk and orfacet joint mediated
pain
Intra-articular SI Joint Injection
INITIAL MANAGEMENT
Injections helpful in diagnosis and management of LBP due to Piriformis Muscle Syndrome
A REAL PAIN THE BUTT
INITIAL MANAGEMENT ACUPUNCTURE
Some evidence that acupuncture and variations
thereof (acupressure cupping) potentially helpful in the acutesubacute period in
patients with NP and LBP
(Yuan QI et al PloS One 2015 Febr 1-37)
NEXT STEP
Rehabilitation and regaining of function
Physical Therapy very important component of the
rehabilitation
A symbiotic relationship between patient and
therapist key of a successful physical rehabilitation
program
The role of YOGA
Better pain control at rest and with
activities with yoga (9-week program with weekly 90-minute classes) when
compared to a self care exercise program in patients with neck pain
Significant treatment effects of yoga found for pain-related apprehension
disability quality of life and psychological outcomes (depression
fatigue anger)
(Michalsen A et al the J Pain 2012 13(11) 1122-30)
THE IMPORTANCE OF REMAINING ACTIVE
Increasing the amount of steps
walkedday by 1000 over the course of a year reduced the risk of neck pain by
14 in a group of people (men and women age 20-45) with sedentary jobs
(Sitthipornvorakul EA et al Eur Spine J
2015 24 417-24)
SPINAL MANIPULATION No Thank you
Systematic review of spinal
manipulation in patients with a variety of pain conditions including NP
and LBP
Failed to demonstrate that spinal manipulation is an effective
intervention for pain management
(Posadzki P Pain Med 2012 13 754-61)
CONCLUSIONS
Neck and Low Back pain syndromes are usually self limited conditions that can convert in chronic pain conditions causing
prolonged disability
The prevalence and cost of these conditions has significantly increased over the course of the last 15-20 years
Aggressive management of pain during the acute phase is
important because adequate pain control shortens the time and level of disability and facilitates the rehabilitation process
CONCLUSIONS
A variety of treatment modalities including medications acupuncture injections PT Yoga are utilized to manage pain and facilitate the
recovery process
Reducing stress and activities associated with the generation of pain maintaining an appropriate physical exercise regimen and a body weight
as close as possible to the ideal body weight will likely result in a decreased incidenceprevalence of short and long term NP and LBP
THANK YOU
QUESTIONS
NECK PAIN (NP)
Pain in the neck withwithout pain referred into one or both upper extremities
In some cases pain may be associated with headaches
LOW BACK PAIN (LBP)
Pain on the posterior aspect of the body
from the lower margin of the 12th rib to the lower gluteal folds withwithout pain referred into one or both extremities
EPIDEMIOLOGY
NECK PAIN - PREVALENCE
Global point prevalence in 2010 - 49 Peaks at a young age - 45 years
Higher in females ndash 58 vs 40
LOW BACK PAIN
Global point prevalence in 2010 ndash 94 Higher in males 101 vs 87 Peaks at approx 80 years of age
Prevalence total number of
cases of a disease in a given
population at a specific time
MSK pain reported by 521 of persons aged 18 years and older in 2012
LBP most common (286) NP third most common (152)
(Knee pain second most common at 181)
Females report MSK pain more frequently than males (546 vs
495) The prevalence of LBP and NP highest
for persons age 45 to 64 years
MUSCULOSKELETAL (MSK) DISORDERS ndash US DATA
About half (496)of the total disability burden associated
with MSK disorders is from LBP
NP (201) also caused
substantial disability burden
Between 1998-2011 total direct and indirect costs of
musculoskeletal conditions rose from $3961 billion to $8738
billion ( 121)
Over the same period of time the US Gross Domestic Product
(GDP) has risen from $115 trillion to $152 trillion ( 32)
MUSCULOSKELETAL (MSK) DISORDERS - COST
RISK FACTORS
Gender Regardless of age MK pain more common among working women than working men
(Herin F et al Pain 2014 155 937-43)
Women seem to have sensitivity to pain (Leville SG et al Pain 2005 116 332-8)
Age Highest incidence of NP and LBP in the 3rd-
4th decade and overall prevalence increasing until age 60-65
(Hoy D et al Best Pract Res Clin Rheumatol 2010 24 769-81)
Occupational factors
Repetitive work awkward postures vibrations
(Neupane S et al Int Arch Occup Environ Health 2013 86 581-9)
(Herin F et al Pain 2014 155 937-43)
Psychosocial Factors
High level of emotional distress anxiety depression fear of
movement with avoidance behaviors (resting and limping)
correlated with high level of NPsup1 and LBPsup2 disability
(Johansen JB et al Clin J Pain 2013 29 1029-1035sup1)
(Grotle M et al Pain 2004 112 343-352sup2)
Job dissatisfaction work requiring repetitive tasks
limited autonomy and opportunities for learning and growing
professionally (van Tulder M et al Clin Rheum 2002 16(5) 761-75
risk of MSK pain in women
(Herin F et al Pain 2014 155 937-43)
Lower levels of education - strong predictor of more prolonged episode duration and poorer
outcome (Chou R et al Ann Int Med 2007 147(7) 478-91)
(Deyo RA et al Spine 2006 31 2724-7)
Psychosocial Factors
Problems with sleep
Sometimes - Risk of developing chronic NP LBP - 22-32
OftenAlways - 51-66 (PJ Moork et al Eur J of Pub Health 2013
24(6) 924-29)
Lack of sleep induces a state of low-level systemic inflammation that sensitizes the
nociceptive system (Haack M et al Sleep 2007 30 1145-52) (Wang H et al Clin J Pain 2008 24 273-8)
FROM THE MOVIE ldquoInsomniardquo
Lack of exercise - Increased body weight
Lack of sleep ndash Lack of physical exercise ndash Increased body weight ndash bad combination
(PJ Moork et al Eur J of Pub Health 2013 24(6) 924-29)
Lack of physical activityIncreased BMI
low-grade systemic inflammation that the susceptibility to chronic pain (Roytblat L et al Obesity 2000 8 673-5)
(Petersen AMW et al J Appl Physiol 2005 98 1154-62)
SOURCES OF NECK AND LOW BACK PAIN
a Large disk herniation at the C5-6 disk level
b Right sided disk herniation with nerve root compromise
Patient likely to complain of NP radiated to right upper extremity shooting stabbing
electrical shock-like with paresthesiae
CERVICAL-LUMBAR INTERVERTEBRAL DISK
MECHANISM Inflammation of the nerve roots
When a disk ruptures inflammatory
mediators are released from the nucleus polposus (the inner part of the disk)
around the nerve root leading to chemical neuroradiculitis
CERVICAL-LUMBAR INTERVERTEBRAL DISK
True synovial joints
between the C2-C7 vertebrae located behind the plane of the intervertebral foramina
and the spinal nerves contained therein
Arthritic changes may cause axial neck pain withwithout upper extremity pain
CERVICAL FACET JOINTS
CERVICAL FACET JOINTS
C2-3 C5-6 C6-7
most frequent
facetogenic pain
generators in the cervical
spine
CERVICAL FACET JOINTS
C2-3 joint Pain in the sub-occipital region
radiating to occiput auricular region vertex of the head forehead and orbit
C5-6 joint
Pain radiates over the deltoid region and into the arm
C6-7 joint Pain radiates over
over the medial scapula
ATLANTO-AXIAL JOINT (C1-2)
Pain from C1-2 occurs higher than pain from C2-3
vertex rather than forehead and temple
ATLANTO-OCCIPITAL JOINT (C 0-1)
Pain from C 0-1 almost superimposes pain stemming
from C1-2
Unusual source of neck pain
Note the close anatomic relationship between C0-
1 joint and C1 nerve
between C1-2 joint and C2 ganglia and nerve
and between these joints and the vertebral artery
OTHER SOURCES OF NECK PAIN
Posterior neck muscles
Cervical dura mater
Atlanto-axial joint ligaments
Vertebral artery
Cervical vertebral bodies
True synovial joints with a space a synovial membrane hyaline cartilage surfaces and a
fibrous capsule located in front of the plane of the foramina and the nerve root therein
Arthritic changes may cause axial low back pain withwithout lower extremity pain
LUMBAR FACET JOINTS
LUMBAR FACET JOINTS PAIN CHARACTERISTICS
More common in patients 65
yearolder
Axial low back pain
withwithout radiation to the
lower extremities
Morning stiffness Pain when
starting to move relieved by
the recumbent position
Worsening as day goes by
LUMBAR FACET JOINTS PAIN PATTERNS
L4-5 L5-S1
most frequent facetogenic
pain generators in the lumbar
spine
Pain does not extend down
beyond the level of the knee
Largest axial joint in the
body
Only the anterior third is a
true synovial joint
Complex innervation
including sensory fibers
from L5 through S4 spinal
nerves
SACRO-ILIAC JOINT
A B
No difference in gender
Mean age 40-50
Prevalence 13-30 of
patients with ho low back
pain
Most commonly causing
unilateral symptoms
SACRO-ILIAC JOINT
Pain is always maximal below L5
May radiate to hips groin buttocks
posterior thighs
Patterns of referred pain somewhat
similar to those due to disk and orfacet
joint mediated pain
SACRO-ILIAC JOINT PAIN PATTERN
PIRIFORMIS MUSCLE
Located in the gluteal region is one of the muscles of the lateral
rotator group
It is situated within the posterior wall of the pelvis partly at the
back of the hip joint
Passes out of the pelvis through the greater sciatic foramen
Sciatic nerve
PIRIFORMIS MUSCLE
Sport activities andor certain movements (running lunging) can
stress the piriformis muscle
The subsequent muscle spasm may manifest as MSK low back pain
radiating to the buttock and along the sciatic nerve
Prolonged sitting stretching climbing stairs or walking on inclines squatting
worsen the pain
REALLY A PAIN THE BUTT
OTHER SOURCES OF LOW BACK PAIN
Posterior lumbo-sacral paraspinal pelvic girdle muscles
Lumbar spine ligaments tendons
Vertebral bodies
CAUSES OF NECK AND LOW BACK PAIN
TUMORS
INFECTIONS Discitis Osteomyelitis Septic arthritis Meningitis
VASCULAR DISORDERS (egCarotid artery dissection)
AUTOIMMUNE DISORDERS Rheumatoid arthritis Ankylosing spondylitis Polymyalgia rheumatica
TRAUMA (FracturesDislocations)
MSK DISORDERS Soft tissue injuries Whiplash CervicalLumbosacral
strain Myofascial disorders Fibromyalgia
JOINT DISORDERS Spondylosis and Osteoarthritis
MANAGEMENT
Self limited condition
Symptoms and disability improve rapidly
Most patients return to work and normal activities in 4-6 weeks
(Pengel LH et al BMJ 2003 327 323)
NATURAL HISTORY
1 in 3 patients
Persistent moderate pain 1 year after an acute episode
1 in 5 patients report substantial limitations in activity (von Korff al et al Spine 1996 21 2833-7 ndash discussion 2838-9)
NATURAL HISTORY
History and Physical Exam
Blood work to rule out the
presence of a malignancy andor an infection
Plain radiographs of
cervicallumbar spine CTMRI in patients with neurologic
complaints or with pain not improving
DIAGNOSIS
MAIN GOAL
Achieve adequate pain control (NSAIDs Tylenol Muscle
Relaxants Gabapentinoids short acting opioids)
Relative rest
Activity modifications
INITIAL MANAGEMENT
Epidural steroid injections are an
option in patients with disk herniation back and leg pain
INITIAL MANAGEMENT
Anesth Analg 2016 Mar122(3)857-70 Bhatia A1 Flamer D Shah PS Cohen SP
CONCLUSIONS Epidural steroids injections provide
some analgesic benefit at 3 months in patients with lumbosacral radicular pain
due to herniated intervertebral disks but they have no impact on physical
disability or incidence of surgery
Epidural steroid injections are an option in
patients with spinal stenosis
INITIAL MANAGEMENT
Spinal stenosis causes mechanical compression of the nerve roots swelling
(microvascular injury) producing pain (Olmarker K et al Spine 1989 14 569-573)
L3-4 Spinal Stenosis
INITIAL MANAGEMENT
STEROIDS
inhibit swelling (edema) around the nerve root
(Rydevik B et al Spine 1984 9 7-15)
improve blood flow to neural elements decreasing ischemic neuritis
(Fukusaki M et al Clin J Pain 1998 14 148-51)
block conduction in nociceptive nerve fibers (Johansson A et al Acta Anesthesiol Scand
1990 34 335-38) L4-5 Severe Spinal Stenosis
INITIAL MANAGEMENT
Usually spinal stenosis occurs in pts of senior age
Some of these patients may significant comorbidities and higher sensitivity to
pain medications
Multilevel Cervical Spinal Stenosis
INITIAL MANAGEMENT
Intra-articular facet joint injections are appropriate when a clinical
diagnosis of facet joint ldquosyndromerdquo is confirmed
Axial back pain withwithout radiation
to the extremities
Morning neckback stiffness Pain when starting to move worse on necklumbar
spine extension relieved by the recumbent position
Intra-articular C3-4 facet joint injection
Intra-articular L5-S1 facet joint injection
INITIAL MANAGEMENT
Injections helpful in diagnosis and management of LBP secondary
to SI Joint ldquoSyndromerdquo
Pain is always maximal below L5
May radiate to hips groin buttocks posterior thighs
Patterns of referred pain somewhat similar to those due to disk and orfacet joint mediated
pain
Intra-articular SI Joint Injection
INITIAL MANAGEMENT
Injections helpful in diagnosis and management of LBP due to Piriformis Muscle Syndrome
A REAL PAIN THE BUTT
INITIAL MANAGEMENT ACUPUNCTURE
Some evidence that acupuncture and variations
thereof (acupressure cupping) potentially helpful in the acutesubacute period in
patients with NP and LBP
(Yuan QI et al PloS One 2015 Febr 1-37)
NEXT STEP
Rehabilitation and regaining of function
Physical Therapy very important component of the
rehabilitation
A symbiotic relationship between patient and
therapist key of a successful physical rehabilitation
program
The role of YOGA
Better pain control at rest and with
activities with yoga (9-week program with weekly 90-minute classes) when
compared to a self care exercise program in patients with neck pain
Significant treatment effects of yoga found for pain-related apprehension
disability quality of life and psychological outcomes (depression
fatigue anger)
(Michalsen A et al the J Pain 2012 13(11) 1122-30)
THE IMPORTANCE OF REMAINING ACTIVE
Increasing the amount of steps
walkedday by 1000 over the course of a year reduced the risk of neck pain by
14 in a group of people (men and women age 20-45) with sedentary jobs
(Sitthipornvorakul EA et al Eur Spine J
2015 24 417-24)
SPINAL MANIPULATION No Thank you
Systematic review of spinal
manipulation in patients with a variety of pain conditions including NP
and LBP
Failed to demonstrate that spinal manipulation is an effective
intervention for pain management
(Posadzki P Pain Med 2012 13 754-61)
CONCLUSIONS
Neck and Low Back pain syndromes are usually self limited conditions that can convert in chronic pain conditions causing
prolonged disability
The prevalence and cost of these conditions has significantly increased over the course of the last 15-20 years
Aggressive management of pain during the acute phase is
important because adequate pain control shortens the time and level of disability and facilitates the rehabilitation process
CONCLUSIONS
A variety of treatment modalities including medications acupuncture injections PT Yoga are utilized to manage pain and facilitate the
recovery process
Reducing stress and activities associated with the generation of pain maintaining an appropriate physical exercise regimen and a body weight
as close as possible to the ideal body weight will likely result in a decreased incidenceprevalence of short and long term NP and LBP
THANK YOU
QUESTIONS
EPIDEMIOLOGY
NECK PAIN - PREVALENCE
Global point prevalence in 2010 - 49 Peaks at a young age - 45 years
Higher in females ndash 58 vs 40
LOW BACK PAIN
Global point prevalence in 2010 ndash 94 Higher in males 101 vs 87 Peaks at approx 80 years of age
Prevalence total number of
cases of a disease in a given
population at a specific time
MSK pain reported by 521 of persons aged 18 years and older in 2012
LBP most common (286) NP third most common (152)
(Knee pain second most common at 181)
Females report MSK pain more frequently than males (546 vs
495) The prevalence of LBP and NP highest
for persons age 45 to 64 years
MUSCULOSKELETAL (MSK) DISORDERS ndash US DATA
About half (496)of the total disability burden associated
with MSK disorders is from LBP
NP (201) also caused
substantial disability burden
Between 1998-2011 total direct and indirect costs of
musculoskeletal conditions rose from $3961 billion to $8738
billion ( 121)
Over the same period of time the US Gross Domestic Product
(GDP) has risen from $115 trillion to $152 trillion ( 32)
MUSCULOSKELETAL (MSK) DISORDERS - COST
RISK FACTORS
Gender Regardless of age MK pain more common among working women than working men
(Herin F et al Pain 2014 155 937-43)
Women seem to have sensitivity to pain (Leville SG et al Pain 2005 116 332-8)
Age Highest incidence of NP and LBP in the 3rd-
4th decade and overall prevalence increasing until age 60-65
(Hoy D et al Best Pract Res Clin Rheumatol 2010 24 769-81)
Occupational factors
Repetitive work awkward postures vibrations
(Neupane S et al Int Arch Occup Environ Health 2013 86 581-9)
(Herin F et al Pain 2014 155 937-43)
Psychosocial Factors
High level of emotional distress anxiety depression fear of
movement with avoidance behaviors (resting and limping)
correlated with high level of NPsup1 and LBPsup2 disability
(Johansen JB et al Clin J Pain 2013 29 1029-1035sup1)
(Grotle M et al Pain 2004 112 343-352sup2)
Job dissatisfaction work requiring repetitive tasks
limited autonomy and opportunities for learning and growing
professionally (van Tulder M et al Clin Rheum 2002 16(5) 761-75
risk of MSK pain in women
(Herin F et al Pain 2014 155 937-43)
Lower levels of education - strong predictor of more prolonged episode duration and poorer
outcome (Chou R et al Ann Int Med 2007 147(7) 478-91)
(Deyo RA et al Spine 2006 31 2724-7)
Psychosocial Factors
Problems with sleep
Sometimes - Risk of developing chronic NP LBP - 22-32
OftenAlways - 51-66 (PJ Moork et al Eur J of Pub Health 2013
24(6) 924-29)
Lack of sleep induces a state of low-level systemic inflammation that sensitizes the
nociceptive system (Haack M et al Sleep 2007 30 1145-52) (Wang H et al Clin J Pain 2008 24 273-8)
FROM THE MOVIE ldquoInsomniardquo
Lack of exercise - Increased body weight
Lack of sleep ndash Lack of physical exercise ndash Increased body weight ndash bad combination
(PJ Moork et al Eur J of Pub Health 2013 24(6) 924-29)
Lack of physical activityIncreased BMI
low-grade systemic inflammation that the susceptibility to chronic pain (Roytblat L et al Obesity 2000 8 673-5)
(Petersen AMW et al J Appl Physiol 2005 98 1154-62)
SOURCES OF NECK AND LOW BACK PAIN
a Large disk herniation at the C5-6 disk level
b Right sided disk herniation with nerve root compromise
Patient likely to complain of NP radiated to right upper extremity shooting stabbing
electrical shock-like with paresthesiae
CERVICAL-LUMBAR INTERVERTEBRAL DISK
MECHANISM Inflammation of the nerve roots
When a disk ruptures inflammatory
mediators are released from the nucleus polposus (the inner part of the disk)
around the nerve root leading to chemical neuroradiculitis
CERVICAL-LUMBAR INTERVERTEBRAL DISK
True synovial joints
between the C2-C7 vertebrae located behind the plane of the intervertebral foramina
and the spinal nerves contained therein
Arthritic changes may cause axial neck pain withwithout upper extremity pain
CERVICAL FACET JOINTS
CERVICAL FACET JOINTS
C2-3 C5-6 C6-7
most frequent
facetogenic pain
generators in the cervical
spine
CERVICAL FACET JOINTS
C2-3 joint Pain in the sub-occipital region
radiating to occiput auricular region vertex of the head forehead and orbit
C5-6 joint
Pain radiates over the deltoid region and into the arm
C6-7 joint Pain radiates over
over the medial scapula
ATLANTO-AXIAL JOINT (C1-2)
Pain from C1-2 occurs higher than pain from C2-3
vertex rather than forehead and temple
ATLANTO-OCCIPITAL JOINT (C 0-1)
Pain from C 0-1 almost superimposes pain stemming
from C1-2
Unusual source of neck pain
Note the close anatomic relationship between C0-
1 joint and C1 nerve
between C1-2 joint and C2 ganglia and nerve
and between these joints and the vertebral artery
OTHER SOURCES OF NECK PAIN
Posterior neck muscles
Cervical dura mater
Atlanto-axial joint ligaments
Vertebral artery
Cervical vertebral bodies
True synovial joints with a space a synovial membrane hyaline cartilage surfaces and a
fibrous capsule located in front of the plane of the foramina and the nerve root therein
Arthritic changes may cause axial low back pain withwithout lower extremity pain
LUMBAR FACET JOINTS
LUMBAR FACET JOINTS PAIN CHARACTERISTICS
More common in patients 65
yearolder
Axial low back pain
withwithout radiation to the
lower extremities
Morning stiffness Pain when
starting to move relieved by
the recumbent position
Worsening as day goes by
LUMBAR FACET JOINTS PAIN PATTERNS
L4-5 L5-S1
most frequent facetogenic
pain generators in the lumbar
spine
Pain does not extend down
beyond the level of the knee
Largest axial joint in the
body
Only the anterior third is a
true synovial joint
Complex innervation
including sensory fibers
from L5 through S4 spinal
nerves
SACRO-ILIAC JOINT
A B
No difference in gender
Mean age 40-50
Prevalence 13-30 of
patients with ho low back
pain
Most commonly causing
unilateral symptoms
SACRO-ILIAC JOINT
Pain is always maximal below L5
May radiate to hips groin buttocks
posterior thighs
Patterns of referred pain somewhat
similar to those due to disk and orfacet
joint mediated pain
SACRO-ILIAC JOINT PAIN PATTERN
PIRIFORMIS MUSCLE
Located in the gluteal region is one of the muscles of the lateral
rotator group
It is situated within the posterior wall of the pelvis partly at the
back of the hip joint
Passes out of the pelvis through the greater sciatic foramen
Sciatic nerve
PIRIFORMIS MUSCLE
Sport activities andor certain movements (running lunging) can
stress the piriformis muscle
The subsequent muscle spasm may manifest as MSK low back pain
radiating to the buttock and along the sciatic nerve
Prolonged sitting stretching climbing stairs or walking on inclines squatting
worsen the pain
REALLY A PAIN THE BUTT
OTHER SOURCES OF LOW BACK PAIN
Posterior lumbo-sacral paraspinal pelvic girdle muscles
Lumbar spine ligaments tendons
Vertebral bodies
CAUSES OF NECK AND LOW BACK PAIN
TUMORS
INFECTIONS Discitis Osteomyelitis Septic arthritis Meningitis
VASCULAR DISORDERS (egCarotid artery dissection)
AUTOIMMUNE DISORDERS Rheumatoid arthritis Ankylosing spondylitis Polymyalgia rheumatica
TRAUMA (FracturesDislocations)
MSK DISORDERS Soft tissue injuries Whiplash CervicalLumbosacral
strain Myofascial disorders Fibromyalgia
JOINT DISORDERS Spondylosis and Osteoarthritis
MANAGEMENT
Self limited condition
Symptoms and disability improve rapidly
Most patients return to work and normal activities in 4-6 weeks
(Pengel LH et al BMJ 2003 327 323)
NATURAL HISTORY
1 in 3 patients
Persistent moderate pain 1 year after an acute episode
1 in 5 patients report substantial limitations in activity (von Korff al et al Spine 1996 21 2833-7 ndash discussion 2838-9)
NATURAL HISTORY
History and Physical Exam
Blood work to rule out the
presence of a malignancy andor an infection
Plain radiographs of
cervicallumbar spine CTMRI in patients with neurologic
complaints or with pain not improving
DIAGNOSIS
MAIN GOAL
Achieve adequate pain control (NSAIDs Tylenol Muscle
Relaxants Gabapentinoids short acting opioids)
Relative rest
Activity modifications
INITIAL MANAGEMENT
Epidural steroid injections are an
option in patients with disk herniation back and leg pain
INITIAL MANAGEMENT
Anesth Analg 2016 Mar122(3)857-70 Bhatia A1 Flamer D Shah PS Cohen SP
CONCLUSIONS Epidural steroids injections provide
some analgesic benefit at 3 months in patients with lumbosacral radicular pain
due to herniated intervertebral disks but they have no impact on physical
disability or incidence of surgery
Epidural steroid injections are an option in
patients with spinal stenosis
INITIAL MANAGEMENT
Spinal stenosis causes mechanical compression of the nerve roots swelling
(microvascular injury) producing pain (Olmarker K et al Spine 1989 14 569-573)
L3-4 Spinal Stenosis
INITIAL MANAGEMENT
STEROIDS
inhibit swelling (edema) around the nerve root
(Rydevik B et al Spine 1984 9 7-15)
improve blood flow to neural elements decreasing ischemic neuritis
(Fukusaki M et al Clin J Pain 1998 14 148-51)
block conduction in nociceptive nerve fibers (Johansson A et al Acta Anesthesiol Scand
1990 34 335-38) L4-5 Severe Spinal Stenosis
INITIAL MANAGEMENT
Usually spinal stenosis occurs in pts of senior age
Some of these patients may significant comorbidities and higher sensitivity to
pain medications
Multilevel Cervical Spinal Stenosis
INITIAL MANAGEMENT
Intra-articular facet joint injections are appropriate when a clinical
diagnosis of facet joint ldquosyndromerdquo is confirmed
Axial back pain withwithout radiation
to the extremities
Morning neckback stiffness Pain when starting to move worse on necklumbar
spine extension relieved by the recumbent position
Intra-articular C3-4 facet joint injection
Intra-articular L5-S1 facet joint injection
INITIAL MANAGEMENT
Injections helpful in diagnosis and management of LBP secondary
to SI Joint ldquoSyndromerdquo
Pain is always maximal below L5
May radiate to hips groin buttocks posterior thighs
Patterns of referred pain somewhat similar to those due to disk and orfacet joint mediated
pain
Intra-articular SI Joint Injection
INITIAL MANAGEMENT
Injections helpful in diagnosis and management of LBP due to Piriformis Muscle Syndrome
A REAL PAIN THE BUTT
INITIAL MANAGEMENT ACUPUNCTURE
Some evidence that acupuncture and variations
thereof (acupressure cupping) potentially helpful in the acutesubacute period in
patients with NP and LBP
(Yuan QI et al PloS One 2015 Febr 1-37)
NEXT STEP
Rehabilitation and regaining of function
Physical Therapy very important component of the
rehabilitation
A symbiotic relationship between patient and
therapist key of a successful physical rehabilitation
program
The role of YOGA
Better pain control at rest and with
activities with yoga (9-week program with weekly 90-minute classes) when
compared to a self care exercise program in patients with neck pain
Significant treatment effects of yoga found for pain-related apprehension
disability quality of life and psychological outcomes (depression
fatigue anger)
(Michalsen A et al the J Pain 2012 13(11) 1122-30)
THE IMPORTANCE OF REMAINING ACTIVE
Increasing the amount of steps
walkedday by 1000 over the course of a year reduced the risk of neck pain by
14 in a group of people (men and women age 20-45) with sedentary jobs
(Sitthipornvorakul EA et al Eur Spine J
2015 24 417-24)
SPINAL MANIPULATION No Thank you
Systematic review of spinal
manipulation in patients with a variety of pain conditions including NP
and LBP
Failed to demonstrate that spinal manipulation is an effective
intervention for pain management
(Posadzki P Pain Med 2012 13 754-61)
CONCLUSIONS
Neck and Low Back pain syndromes are usually self limited conditions that can convert in chronic pain conditions causing
prolonged disability
The prevalence and cost of these conditions has significantly increased over the course of the last 15-20 years
Aggressive management of pain during the acute phase is
important because adequate pain control shortens the time and level of disability and facilitates the rehabilitation process
CONCLUSIONS
A variety of treatment modalities including medications acupuncture injections PT Yoga are utilized to manage pain and facilitate the
recovery process
Reducing stress and activities associated with the generation of pain maintaining an appropriate physical exercise regimen and a body weight
as close as possible to the ideal body weight will likely result in a decreased incidenceprevalence of short and long term NP and LBP
THANK YOU
QUESTIONS
NECK PAIN - PREVALENCE
Global point prevalence in 2010 - 49 Peaks at a young age - 45 years
Higher in females ndash 58 vs 40
LOW BACK PAIN
Global point prevalence in 2010 ndash 94 Higher in males 101 vs 87 Peaks at approx 80 years of age
Prevalence total number of
cases of a disease in a given
population at a specific time
MSK pain reported by 521 of persons aged 18 years and older in 2012
LBP most common (286) NP third most common (152)
(Knee pain second most common at 181)
Females report MSK pain more frequently than males (546 vs
495) The prevalence of LBP and NP highest
for persons age 45 to 64 years
MUSCULOSKELETAL (MSK) DISORDERS ndash US DATA
About half (496)of the total disability burden associated
with MSK disorders is from LBP
NP (201) also caused
substantial disability burden
Between 1998-2011 total direct and indirect costs of
musculoskeletal conditions rose from $3961 billion to $8738
billion ( 121)
Over the same period of time the US Gross Domestic Product
(GDP) has risen from $115 trillion to $152 trillion ( 32)
MUSCULOSKELETAL (MSK) DISORDERS - COST
RISK FACTORS
Gender Regardless of age MK pain more common among working women than working men
(Herin F et al Pain 2014 155 937-43)
Women seem to have sensitivity to pain (Leville SG et al Pain 2005 116 332-8)
Age Highest incidence of NP and LBP in the 3rd-
4th decade and overall prevalence increasing until age 60-65
(Hoy D et al Best Pract Res Clin Rheumatol 2010 24 769-81)
Occupational factors
Repetitive work awkward postures vibrations
(Neupane S et al Int Arch Occup Environ Health 2013 86 581-9)
(Herin F et al Pain 2014 155 937-43)
Psychosocial Factors
High level of emotional distress anxiety depression fear of
movement with avoidance behaviors (resting and limping)
correlated with high level of NPsup1 and LBPsup2 disability
(Johansen JB et al Clin J Pain 2013 29 1029-1035sup1)
(Grotle M et al Pain 2004 112 343-352sup2)
Job dissatisfaction work requiring repetitive tasks
limited autonomy and opportunities for learning and growing
professionally (van Tulder M et al Clin Rheum 2002 16(5) 761-75
risk of MSK pain in women
(Herin F et al Pain 2014 155 937-43)
Lower levels of education - strong predictor of more prolonged episode duration and poorer
outcome (Chou R et al Ann Int Med 2007 147(7) 478-91)
(Deyo RA et al Spine 2006 31 2724-7)
Psychosocial Factors
Problems with sleep
Sometimes - Risk of developing chronic NP LBP - 22-32
OftenAlways - 51-66 (PJ Moork et al Eur J of Pub Health 2013
24(6) 924-29)
Lack of sleep induces a state of low-level systemic inflammation that sensitizes the
nociceptive system (Haack M et al Sleep 2007 30 1145-52) (Wang H et al Clin J Pain 2008 24 273-8)
FROM THE MOVIE ldquoInsomniardquo
Lack of exercise - Increased body weight
Lack of sleep ndash Lack of physical exercise ndash Increased body weight ndash bad combination
(PJ Moork et al Eur J of Pub Health 2013 24(6) 924-29)
Lack of physical activityIncreased BMI
low-grade systemic inflammation that the susceptibility to chronic pain (Roytblat L et al Obesity 2000 8 673-5)
(Petersen AMW et al J Appl Physiol 2005 98 1154-62)
SOURCES OF NECK AND LOW BACK PAIN
a Large disk herniation at the C5-6 disk level
b Right sided disk herniation with nerve root compromise
Patient likely to complain of NP radiated to right upper extremity shooting stabbing
electrical shock-like with paresthesiae
CERVICAL-LUMBAR INTERVERTEBRAL DISK
MECHANISM Inflammation of the nerve roots
When a disk ruptures inflammatory
mediators are released from the nucleus polposus (the inner part of the disk)
around the nerve root leading to chemical neuroradiculitis
CERVICAL-LUMBAR INTERVERTEBRAL DISK
True synovial joints
between the C2-C7 vertebrae located behind the plane of the intervertebral foramina
and the spinal nerves contained therein
Arthritic changes may cause axial neck pain withwithout upper extremity pain
CERVICAL FACET JOINTS
CERVICAL FACET JOINTS
C2-3 C5-6 C6-7
most frequent
facetogenic pain
generators in the cervical
spine
CERVICAL FACET JOINTS
C2-3 joint Pain in the sub-occipital region
radiating to occiput auricular region vertex of the head forehead and orbit
C5-6 joint
Pain radiates over the deltoid region and into the arm
C6-7 joint Pain radiates over
over the medial scapula
ATLANTO-AXIAL JOINT (C1-2)
Pain from C1-2 occurs higher than pain from C2-3
vertex rather than forehead and temple
ATLANTO-OCCIPITAL JOINT (C 0-1)
Pain from C 0-1 almost superimposes pain stemming
from C1-2
Unusual source of neck pain
Note the close anatomic relationship between C0-
1 joint and C1 nerve
between C1-2 joint and C2 ganglia and nerve
and between these joints and the vertebral artery
OTHER SOURCES OF NECK PAIN
Posterior neck muscles
Cervical dura mater
Atlanto-axial joint ligaments
Vertebral artery
Cervical vertebral bodies
True synovial joints with a space a synovial membrane hyaline cartilage surfaces and a
fibrous capsule located in front of the plane of the foramina and the nerve root therein
Arthritic changes may cause axial low back pain withwithout lower extremity pain
LUMBAR FACET JOINTS
LUMBAR FACET JOINTS PAIN CHARACTERISTICS
More common in patients 65
yearolder
Axial low back pain
withwithout radiation to the
lower extremities
Morning stiffness Pain when
starting to move relieved by
the recumbent position
Worsening as day goes by
LUMBAR FACET JOINTS PAIN PATTERNS
L4-5 L5-S1
most frequent facetogenic
pain generators in the lumbar
spine
Pain does not extend down
beyond the level of the knee
Largest axial joint in the
body
Only the anterior third is a
true synovial joint
Complex innervation
including sensory fibers
from L5 through S4 spinal
nerves
SACRO-ILIAC JOINT
A B
No difference in gender
Mean age 40-50
Prevalence 13-30 of
patients with ho low back
pain
Most commonly causing
unilateral symptoms
SACRO-ILIAC JOINT
Pain is always maximal below L5
May radiate to hips groin buttocks
posterior thighs
Patterns of referred pain somewhat
similar to those due to disk and orfacet
joint mediated pain
SACRO-ILIAC JOINT PAIN PATTERN
PIRIFORMIS MUSCLE
Located in the gluteal region is one of the muscles of the lateral
rotator group
It is situated within the posterior wall of the pelvis partly at the
back of the hip joint
Passes out of the pelvis through the greater sciatic foramen
Sciatic nerve
PIRIFORMIS MUSCLE
Sport activities andor certain movements (running lunging) can
stress the piriformis muscle
The subsequent muscle spasm may manifest as MSK low back pain
radiating to the buttock and along the sciatic nerve
Prolonged sitting stretching climbing stairs or walking on inclines squatting
worsen the pain
REALLY A PAIN THE BUTT
OTHER SOURCES OF LOW BACK PAIN
Posterior lumbo-sacral paraspinal pelvic girdle muscles
Lumbar spine ligaments tendons
Vertebral bodies
CAUSES OF NECK AND LOW BACK PAIN
TUMORS
INFECTIONS Discitis Osteomyelitis Septic arthritis Meningitis
VASCULAR DISORDERS (egCarotid artery dissection)
AUTOIMMUNE DISORDERS Rheumatoid arthritis Ankylosing spondylitis Polymyalgia rheumatica
TRAUMA (FracturesDislocations)
MSK DISORDERS Soft tissue injuries Whiplash CervicalLumbosacral
strain Myofascial disorders Fibromyalgia
JOINT DISORDERS Spondylosis and Osteoarthritis
MANAGEMENT
Self limited condition
Symptoms and disability improve rapidly
Most patients return to work and normal activities in 4-6 weeks
(Pengel LH et al BMJ 2003 327 323)
NATURAL HISTORY
1 in 3 patients
Persistent moderate pain 1 year after an acute episode
1 in 5 patients report substantial limitations in activity (von Korff al et al Spine 1996 21 2833-7 ndash discussion 2838-9)
NATURAL HISTORY
History and Physical Exam
Blood work to rule out the
presence of a malignancy andor an infection
Plain radiographs of
cervicallumbar spine CTMRI in patients with neurologic
complaints or with pain not improving
DIAGNOSIS
MAIN GOAL
Achieve adequate pain control (NSAIDs Tylenol Muscle
Relaxants Gabapentinoids short acting opioids)
Relative rest
Activity modifications
INITIAL MANAGEMENT
Epidural steroid injections are an
option in patients with disk herniation back and leg pain
INITIAL MANAGEMENT
Anesth Analg 2016 Mar122(3)857-70 Bhatia A1 Flamer D Shah PS Cohen SP
CONCLUSIONS Epidural steroids injections provide
some analgesic benefit at 3 months in patients with lumbosacral radicular pain
due to herniated intervertebral disks but they have no impact on physical
disability or incidence of surgery
Epidural steroid injections are an option in
patients with spinal stenosis
INITIAL MANAGEMENT
Spinal stenosis causes mechanical compression of the nerve roots swelling
(microvascular injury) producing pain (Olmarker K et al Spine 1989 14 569-573)
L3-4 Spinal Stenosis
INITIAL MANAGEMENT
STEROIDS
inhibit swelling (edema) around the nerve root
(Rydevik B et al Spine 1984 9 7-15)
improve blood flow to neural elements decreasing ischemic neuritis
(Fukusaki M et al Clin J Pain 1998 14 148-51)
block conduction in nociceptive nerve fibers (Johansson A et al Acta Anesthesiol Scand
1990 34 335-38) L4-5 Severe Spinal Stenosis
INITIAL MANAGEMENT
Usually spinal stenosis occurs in pts of senior age
Some of these patients may significant comorbidities and higher sensitivity to
pain medications
Multilevel Cervical Spinal Stenosis
INITIAL MANAGEMENT
Intra-articular facet joint injections are appropriate when a clinical
diagnosis of facet joint ldquosyndromerdquo is confirmed
Axial back pain withwithout radiation
to the extremities
Morning neckback stiffness Pain when starting to move worse on necklumbar
spine extension relieved by the recumbent position
Intra-articular C3-4 facet joint injection
Intra-articular L5-S1 facet joint injection
INITIAL MANAGEMENT
Injections helpful in diagnosis and management of LBP secondary
to SI Joint ldquoSyndromerdquo
Pain is always maximal below L5
May radiate to hips groin buttocks posterior thighs
Patterns of referred pain somewhat similar to those due to disk and orfacet joint mediated
pain
Intra-articular SI Joint Injection
INITIAL MANAGEMENT
Injections helpful in diagnosis and management of LBP due to Piriformis Muscle Syndrome
A REAL PAIN THE BUTT
INITIAL MANAGEMENT ACUPUNCTURE
Some evidence that acupuncture and variations
thereof (acupressure cupping) potentially helpful in the acutesubacute period in
patients with NP and LBP
(Yuan QI et al PloS One 2015 Febr 1-37)
NEXT STEP
Rehabilitation and regaining of function
Physical Therapy very important component of the
rehabilitation
A symbiotic relationship between patient and
therapist key of a successful physical rehabilitation
program
The role of YOGA
Better pain control at rest and with
activities with yoga (9-week program with weekly 90-minute classes) when
compared to a self care exercise program in patients with neck pain
Significant treatment effects of yoga found for pain-related apprehension
disability quality of life and psychological outcomes (depression
fatigue anger)
(Michalsen A et al the J Pain 2012 13(11) 1122-30)
THE IMPORTANCE OF REMAINING ACTIVE
Increasing the amount of steps
walkedday by 1000 over the course of a year reduced the risk of neck pain by
14 in a group of people (men and women age 20-45) with sedentary jobs
(Sitthipornvorakul EA et al Eur Spine J
2015 24 417-24)
SPINAL MANIPULATION No Thank you
Systematic review of spinal
manipulation in patients with a variety of pain conditions including NP
and LBP
Failed to demonstrate that spinal manipulation is an effective
intervention for pain management
(Posadzki P Pain Med 2012 13 754-61)
CONCLUSIONS
Neck and Low Back pain syndromes are usually self limited conditions that can convert in chronic pain conditions causing
prolonged disability
The prevalence and cost of these conditions has significantly increased over the course of the last 15-20 years
Aggressive management of pain during the acute phase is
important because adequate pain control shortens the time and level of disability and facilitates the rehabilitation process
CONCLUSIONS
A variety of treatment modalities including medications acupuncture injections PT Yoga are utilized to manage pain and facilitate the
recovery process
Reducing stress and activities associated with the generation of pain maintaining an appropriate physical exercise regimen and a body weight
as close as possible to the ideal body weight will likely result in a decreased incidenceprevalence of short and long term NP and LBP
THANK YOU
QUESTIONS
MSK pain reported by 521 of persons aged 18 years and older in 2012
LBP most common (286) NP third most common (152)
(Knee pain second most common at 181)
Females report MSK pain more frequently than males (546 vs
495) The prevalence of LBP and NP highest
for persons age 45 to 64 years
MUSCULOSKELETAL (MSK) DISORDERS ndash US DATA
About half (496)of the total disability burden associated
with MSK disorders is from LBP
NP (201) also caused
substantial disability burden
Between 1998-2011 total direct and indirect costs of
musculoskeletal conditions rose from $3961 billion to $8738
billion ( 121)
Over the same period of time the US Gross Domestic Product
(GDP) has risen from $115 trillion to $152 trillion ( 32)
MUSCULOSKELETAL (MSK) DISORDERS - COST
RISK FACTORS
Gender Regardless of age MK pain more common among working women than working men
(Herin F et al Pain 2014 155 937-43)
Women seem to have sensitivity to pain (Leville SG et al Pain 2005 116 332-8)
Age Highest incidence of NP and LBP in the 3rd-
4th decade and overall prevalence increasing until age 60-65
(Hoy D et al Best Pract Res Clin Rheumatol 2010 24 769-81)
Occupational factors
Repetitive work awkward postures vibrations
(Neupane S et al Int Arch Occup Environ Health 2013 86 581-9)
(Herin F et al Pain 2014 155 937-43)
Psychosocial Factors
High level of emotional distress anxiety depression fear of
movement with avoidance behaviors (resting and limping)
correlated with high level of NPsup1 and LBPsup2 disability
(Johansen JB et al Clin J Pain 2013 29 1029-1035sup1)
(Grotle M et al Pain 2004 112 343-352sup2)
Job dissatisfaction work requiring repetitive tasks
limited autonomy and opportunities for learning and growing
professionally (van Tulder M et al Clin Rheum 2002 16(5) 761-75
risk of MSK pain in women
(Herin F et al Pain 2014 155 937-43)
Lower levels of education - strong predictor of more prolonged episode duration and poorer
outcome (Chou R et al Ann Int Med 2007 147(7) 478-91)
(Deyo RA et al Spine 2006 31 2724-7)
Psychosocial Factors
Problems with sleep
Sometimes - Risk of developing chronic NP LBP - 22-32
OftenAlways - 51-66 (PJ Moork et al Eur J of Pub Health 2013
24(6) 924-29)
Lack of sleep induces a state of low-level systemic inflammation that sensitizes the
nociceptive system (Haack M et al Sleep 2007 30 1145-52) (Wang H et al Clin J Pain 2008 24 273-8)
FROM THE MOVIE ldquoInsomniardquo
Lack of exercise - Increased body weight
Lack of sleep ndash Lack of physical exercise ndash Increased body weight ndash bad combination
(PJ Moork et al Eur J of Pub Health 2013 24(6) 924-29)
Lack of physical activityIncreased BMI
low-grade systemic inflammation that the susceptibility to chronic pain (Roytblat L et al Obesity 2000 8 673-5)
(Petersen AMW et al J Appl Physiol 2005 98 1154-62)
SOURCES OF NECK AND LOW BACK PAIN
a Large disk herniation at the C5-6 disk level
b Right sided disk herniation with nerve root compromise
Patient likely to complain of NP radiated to right upper extremity shooting stabbing
electrical shock-like with paresthesiae
CERVICAL-LUMBAR INTERVERTEBRAL DISK
MECHANISM Inflammation of the nerve roots
When a disk ruptures inflammatory
mediators are released from the nucleus polposus (the inner part of the disk)
around the nerve root leading to chemical neuroradiculitis
CERVICAL-LUMBAR INTERVERTEBRAL DISK
True synovial joints
between the C2-C7 vertebrae located behind the plane of the intervertebral foramina
and the spinal nerves contained therein
Arthritic changes may cause axial neck pain withwithout upper extremity pain
CERVICAL FACET JOINTS
CERVICAL FACET JOINTS
C2-3 C5-6 C6-7
most frequent
facetogenic pain
generators in the cervical
spine
CERVICAL FACET JOINTS
C2-3 joint Pain in the sub-occipital region
radiating to occiput auricular region vertex of the head forehead and orbit
C5-6 joint
Pain radiates over the deltoid region and into the arm
C6-7 joint Pain radiates over
over the medial scapula
ATLANTO-AXIAL JOINT (C1-2)
Pain from C1-2 occurs higher than pain from C2-3
vertex rather than forehead and temple
ATLANTO-OCCIPITAL JOINT (C 0-1)
Pain from C 0-1 almost superimposes pain stemming
from C1-2
Unusual source of neck pain
Note the close anatomic relationship between C0-
1 joint and C1 nerve
between C1-2 joint and C2 ganglia and nerve
and between these joints and the vertebral artery
OTHER SOURCES OF NECK PAIN
Posterior neck muscles
Cervical dura mater
Atlanto-axial joint ligaments
Vertebral artery
Cervical vertebral bodies
True synovial joints with a space a synovial membrane hyaline cartilage surfaces and a
fibrous capsule located in front of the plane of the foramina and the nerve root therein
Arthritic changes may cause axial low back pain withwithout lower extremity pain
LUMBAR FACET JOINTS
LUMBAR FACET JOINTS PAIN CHARACTERISTICS
More common in patients 65
yearolder
Axial low back pain
withwithout radiation to the
lower extremities
Morning stiffness Pain when
starting to move relieved by
the recumbent position
Worsening as day goes by
LUMBAR FACET JOINTS PAIN PATTERNS
L4-5 L5-S1
most frequent facetogenic
pain generators in the lumbar
spine
Pain does not extend down
beyond the level of the knee
Largest axial joint in the
body
Only the anterior third is a
true synovial joint
Complex innervation
including sensory fibers
from L5 through S4 spinal
nerves
SACRO-ILIAC JOINT
A B
No difference in gender
Mean age 40-50
Prevalence 13-30 of
patients with ho low back
pain
Most commonly causing
unilateral symptoms
SACRO-ILIAC JOINT
Pain is always maximal below L5
May radiate to hips groin buttocks
posterior thighs
Patterns of referred pain somewhat
similar to those due to disk and orfacet
joint mediated pain
SACRO-ILIAC JOINT PAIN PATTERN
PIRIFORMIS MUSCLE
Located in the gluteal region is one of the muscles of the lateral
rotator group
It is situated within the posterior wall of the pelvis partly at the
back of the hip joint
Passes out of the pelvis through the greater sciatic foramen
Sciatic nerve
PIRIFORMIS MUSCLE
Sport activities andor certain movements (running lunging) can
stress the piriformis muscle
The subsequent muscle spasm may manifest as MSK low back pain
radiating to the buttock and along the sciatic nerve
Prolonged sitting stretching climbing stairs or walking on inclines squatting
worsen the pain
REALLY A PAIN THE BUTT
OTHER SOURCES OF LOW BACK PAIN
Posterior lumbo-sacral paraspinal pelvic girdle muscles
Lumbar spine ligaments tendons
Vertebral bodies
CAUSES OF NECK AND LOW BACK PAIN
TUMORS
INFECTIONS Discitis Osteomyelitis Septic arthritis Meningitis
VASCULAR DISORDERS (egCarotid artery dissection)
AUTOIMMUNE DISORDERS Rheumatoid arthritis Ankylosing spondylitis Polymyalgia rheumatica
TRAUMA (FracturesDislocations)
MSK DISORDERS Soft tissue injuries Whiplash CervicalLumbosacral
strain Myofascial disorders Fibromyalgia
JOINT DISORDERS Spondylosis and Osteoarthritis
MANAGEMENT
Self limited condition
Symptoms and disability improve rapidly
Most patients return to work and normal activities in 4-6 weeks
(Pengel LH et al BMJ 2003 327 323)
NATURAL HISTORY
1 in 3 patients
Persistent moderate pain 1 year after an acute episode
1 in 5 patients report substantial limitations in activity (von Korff al et al Spine 1996 21 2833-7 ndash discussion 2838-9)
NATURAL HISTORY
History and Physical Exam
Blood work to rule out the
presence of a malignancy andor an infection
Plain radiographs of
cervicallumbar spine CTMRI in patients with neurologic
complaints or with pain not improving
DIAGNOSIS
MAIN GOAL
Achieve adequate pain control (NSAIDs Tylenol Muscle
Relaxants Gabapentinoids short acting opioids)
Relative rest
Activity modifications
INITIAL MANAGEMENT
Epidural steroid injections are an
option in patients with disk herniation back and leg pain
INITIAL MANAGEMENT
Anesth Analg 2016 Mar122(3)857-70 Bhatia A1 Flamer D Shah PS Cohen SP
CONCLUSIONS Epidural steroids injections provide
some analgesic benefit at 3 months in patients with lumbosacral radicular pain
due to herniated intervertebral disks but they have no impact on physical
disability or incidence of surgery
Epidural steroid injections are an option in
patients with spinal stenosis
INITIAL MANAGEMENT
Spinal stenosis causes mechanical compression of the nerve roots swelling
(microvascular injury) producing pain (Olmarker K et al Spine 1989 14 569-573)
L3-4 Spinal Stenosis
INITIAL MANAGEMENT
STEROIDS
inhibit swelling (edema) around the nerve root
(Rydevik B et al Spine 1984 9 7-15)
improve blood flow to neural elements decreasing ischemic neuritis
(Fukusaki M et al Clin J Pain 1998 14 148-51)
block conduction in nociceptive nerve fibers (Johansson A et al Acta Anesthesiol Scand
1990 34 335-38) L4-5 Severe Spinal Stenosis
INITIAL MANAGEMENT
Usually spinal stenosis occurs in pts of senior age
Some of these patients may significant comorbidities and higher sensitivity to
pain medications
Multilevel Cervical Spinal Stenosis
INITIAL MANAGEMENT
Intra-articular facet joint injections are appropriate when a clinical
diagnosis of facet joint ldquosyndromerdquo is confirmed
Axial back pain withwithout radiation
to the extremities
Morning neckback stiffness Pain when starting to move worse on necklumbar
spine extension relieved by the recumbent position
Intra-articular C3-4 facet joint injection
Intra-articular L5-S1 facet joint injection
INITIAL MANAGEMENT
Injections helpful in diagnosis and management of LBP secondary
to SI Joint ldquoSyndromerdquo
Pain is always maximal below L5
May radiate to hips groin buttocks posterior thighs
Patterns of referred pain somewhat similar to those due to disk and orfacet joint mediated
pain
Intra-articular SI Joint Injection
INITIAL MANAGEMENT
Injections helpful in diagnosis and management of LBP due to Piriformis Muscle Syndrome
A REAL PAIN THE BUTT
INITIAL MANAGEMENT ACUPUNCTURE
Some evidence that acupuncture and variations
thereof (acupressure cupping) potentially helpful in the acutesubacute period in
patients with NP and LBP
(Yuan QI et al PloS One 2015 Febr 1-37)
NEXT STEP
Rehabilitation and regaining of function
Physical Therapy very important component of the
rehabilitation
A symbiotic relationship between patient and
therapist key of a successful physical rehabilitation
program
The role of YOGA
Better pain control at rest and with
activities with yoga (9-week program with weekly 90-minute classes) when
compared to a self care exercise program in patients with neck pain
Significant treatment effects of yoga found for pain-related apprehension
disability quality of life and psychological outcomes (depression
fatigue anger)
(Michalsen A et al the J Pain 2012 13(11) 1122-30)
THE IMPORTANCE OF REMAINING ACTIVE
Increasing the amount of steps
walkedday by 1000 over the course of a year reduced the risk of neck pain by
14 in a group of people (men and women age 20-45) with sedentary jobs
(Sitthipornvorakul EA et al Eur Spine J
2015 24 417-24)
SPINAL MANIPULATION No Thank you
Systematic review of spinal
manipulation in patients with a variety of pain conditions including NP
and LBP
Failed to demonstrate that spinal manipulation is an effective
intervention for pain management
(Posadzki P Pain Med 2012 13 754-61)
CONCLUSIONS
Neck and Low Back pain syndromes are usually self limited conditions that can convert in chronic pain conditions causing
prolonged disability
The prevalence and cost of these conditions has significantly increased over the course of the last 15-20 years
Aggressive management of pain during the acute phase is
important because adequate pain control shortens the time and level of disability and facilitates the rehabilitation process
CONCLUSIONS
A variety of treatment modalities including medications acupuncture injections PT Yoga are utilized to manage pain and facilitate the
recovery process
Reducing stress and activities associated with the generation of pain maintaining an appropriate physical exercise regimen and a body weight
as close as possible to the ideal body weight will likely result in a decreased incidenceprevalence of short and long term NP and LBP
THANK YOU
QUESTIONS
About half (496)of the total disability burden associated
with MSK disorders is from LBP
NP (201) also caused
substantial disability burden
Between 1998-2011 total direct and indirect costs of
musculoskeletal conditions rose from $3961 billion to $8738
billion ( 121)
Over the same period of time the US Gross Domestic Product
(GDP) has risen from $115 trillion to $152 trillion ( 32)
MUSCULOSKELETAL (MSK) DISORDERS - COST
RISK FACTORS
Gender Regardless of age MK pain more common among working women than working men
(Herin F et al Pain 2014 155 937-43)
Women seem to have sensitivity to pain (Leville SG et al Pain 2005 116 332-8)
Age Highest incidence of NP and LBP in the 3rd-
4th decade and overall prevalence increasing until age 60-65
(Hoy D et al Best Pract Res Clin Rheumatol 2010 24 769-81)
Occupational factors
Repetitive work awkward postures vibrations
(Neupane S et al Int Arch Occup Environ Health 2013 86 581-9)
(Herin F et al Pain 2014 155 937-43)
Psychosocial Factors
High level of emotional distress anxiety depression fear of
movement with avoidance behaviors (resting and limping)
correlated with high level of NPsup1 and LBPsup2 disability
(Johansen JB et al Clin J Pain 2013 29 1029-1035sup1)
(Grotle M et al Pain 2004 112 343-352sup2)
Job dissatisfaction work requiring repetitive tasks
limited autonomy and opportunities for learning and growing
professionally (van Tulder M et al Clin Rheum 2002 16(5) 761-75
risk of MSK pain in women
(Herin F et al Pain 2014 155 937-43)
Lower levels of education - strong predictor of more prolonged episode duration and poorer
outcome (Chou R et al Ann Int Med 2007 147(7) 478-91)
(Deyo RA et al Spine 2006 31 2724-7)
Psychosocial Factors
Problems with sleep
Sometimes - Risk of developing chronic NP LBP - 22-32
OftenAlways - 51-66 (PJ Moork et al Eur J of Pub Health 2013
24(6) 924-29)
Lack of sleep induces a state of low-level systemic inflammation that sensitizes the
nociceptive system (Haack M et al Sleep 2007 30 1145-52) (Wang H et al Clin J Pain 2008 24 273-8)
FROM THE MOVIE ldquoInsomniardquo
Lack of exercise - Increased body weight
Lack of sleep ndash Lack of physical exercise ndash Increased body weight ndash bad combination
(PJ Moork et al Eur J of Pub Health 2013 24(6) 924-29)
Lack of physical activityIncreased BMI
low-grade systemic inflammation that the susceptibility to chronic pain (Roytblat L et al Obesity 2000 8 673-5)
(Petersen AMW et al J Appl Physiol 2005 98 1154-62)
SOURCES OF NECK AND LOW BACK PAIN
a Large disk herniation at the C5-6 disk level
b Right sided disk herniation with nerve root compromise
Patient likely to complain of NP radiated to right upper extremity shooting stabbing
electrical shock-like with paresthesiae
CERVICAL-LUMBAR INTERVERTEBRAL DISK
MECHANISM Inflammation of the nerve roots
When a disk ruptures inflammatory
mediators are released from the nucleus polposus (the inner part of the disk)
around the nerve root leading to chemical neuroradiculitis
CERVICAL-LUMBAR INTERVERTEBRAL DISK
True synovial joints
between the C2-C7 vertebrae located behind the plane of the intervertebral foramina
and the spinal nerves contained therein
Arthritic changes may cause axial neck pain withwithout upper extremity pain
CERVICAL FACET JOINTS
CERVICAL FACET JOINTS
C2-3 C5-6 C6-7
most frequent
facetogenic pain
generators in the cervical
spine
CERVICAL FACET JOINTS
C2-3 joint Pain in the sub-occipital region
radiating to occiput auricular region vertex of the head forehead and orbit
C5-6 joint
Pain radiates over the deltoid region and into the arm
C6-7 joint Pain radiates over
over the medial scapula
ATLANTO-AXIAL JOINT (C1-2)
Pain from C1-2 occurs higher than pain from C2-3
vertex rather than forehead and temple
ATLANTO-OCCIPITAL JOINT (C 0-1)
Pain from C 0-1 almost superimposes pain stemming
from C1-2
Unusual source of neck pain
Note the close anatomic relationship between C0-
1 joint and C1 nerve
between C1-2 joint and C2 ganglia and nerve
and between these joints and the vertebral artery
OTHER SOURCES OF NECK PAIN
Posterior neck muscles
Cervical dura mater
Atlanto-axial joint ligaments
Vertebral artery
Cervical vertebral bodies
True synovial joints with a space a synovial membrane hyaline cartilage surfaces and a
fibrous capsule located in front of the plane of the foramina and the nerve root therein
Arthritic changes may cause axial low back pain withwithout lower extremity pain
LUMBAR FACET JOINTS
LUMBAR FACET JOINTS PAIN CHARACTERISTICS
More common in patients 65
yearolder
Axial low back pain
withwithout radiation to the
lower extremities
Morning stiffness Pain when
starting to move relieved by
the recumbent position
Worsening as day goes by
LUMBAR FACET JOINTS PAIN PATTERNS
L4-5 L5-S1
most frequent facetogenic
pain generators in the lumbar
spine
Pain does not extend down
beyond the level of the knee
Largest axial joint in the
body
Only the anterior third is a
true synovial joint
Complex innervation
including sensory fibers
from L5 through S4 spinal
nerves
SACRO-ILIAC JOINT
A B
No difference in gender
Mean age 40-50
Prevalence 13-30 of
patients with ho low back
pain
Most commonly causing
unilateral symptoms
SACRO-ILIAC JOINT
Pain is always maximal below L5
May radiate to hips groin buttocks
posterior thighs
Patterns of referred pain somewhat
similar to those due to disk and orfacet
joint mediated pain
SACRO-ILIAC JOINT PAIN PATTERN
PIRIFORMIS MUSCLE
Located in the gluteal region is one of the muscles of the lateral
rotator group
It is situated within the posterior wall of the pelvis partly at the
back of the hip joint
Passes out of the pelvis through the greater sciatic foramen
Sciatic nerve
PIRIFORMIS MUSCLE
Sport activities andor certain movements (running lunging) can
stress the piriformis muscle
The subsequent muscle spasm may manifest as MSK low back pain
radiating to the buttock and along the sciatic nerve
Prolonged sitting stretching climbing stairs or walking on inclines squatting
worsen the pain
REALLY A PAIN THE BUTT
OTHER SOURCES OF LOW BACK PAIN
Posterior lumbo-sacral paraspinal pelvic girdle muscles
Lumbar spine ligaments tendons
Vertebral bodies
CAUSES OF NECK AND LOW BACK PAIN
TUMORS
INFECTIONS Discitis Osteomyelitis Septic arthritis Meningitis
VASCULAR DISORDERS (egCarotid artery dissection)
AUTOIMMUNE DISORDERS Rheumatoid arthritis Ankylosing spondylitis Polymyalgia rheumatica
TRAUMA (FracturesDislocations)
MSK DISORDERS Soft tissue injuries Whiplash CervicalLumbosacral
strain Myofascial disorders Fibromyalgia
JOINT DISORDERS Spondylosis and Osteoarthritis
MANAGEMENT
Self limited condition
Symptoms and disability improve rapidly
Most patients return to work and normal activities in 4-6 weeks
(Pengel LH et al BMJ 2003 327 323)
NATURAL HISTORY
1 in 3 patients
Persistent moderate pain 1 year after an acute episode
1 in 5 patients report substantial limitations in activity (von Korff al et al Spine 1996 21 2833-7 ndash discussion 2838-9)
NATURAL HISTORY
History and Physical Exam
Blood work to rule out the
presence of a malignancy andor an infection
Plain radiographs of
cervicallumbar spine CTMRI in patients with neurologic
complaints or with pain not improving
DIAGNOSIS
MAIN GOAL
Achieve adequate pain control (NSAIDs Tylenol Muscle
Relaxants Gabapentinoids short acting opioids)
Relative rest
Activity modifications
INITIAL MANAGEMENT
Epidural steroid injections are an
option in patients with disk herniation back and leg pain
INITIAL MANAGEMENT
Anesth Analg 2016 Mar122(3)857-70 Bhatia A1 Flamer D Shah PS Cohen SP
CONCLUSIONS Epidural steroids injections provide
some analgesic benefit at 3 months in patients with lumbosacral radicular pain
due to herniated intervertebral disks but they have no impact on physical
disability or incidence of surgery
Epidural steroid injections are an option in
patients with spinal stenosis
INITIAL MANAGEMENT
Spinal stenosis causes mechanical compression of the nerve roots swelling
(microvascular injury) producing pain (Olmarker K et al Spine 1989 14 569-573)
L3-4 Spinal Stenosis
INITIAL MANAGEMENT
STEROIDS
inhibit swelling (edema) around the nerve root
(Rydevik B et al Spine 1984 9 7-15)
improve blood flow to neural elements decreasing ischemic neuritis
(Fukusaki M et al Clin J Pain 1998 14 148-51)
block conduction in nociceptive nerve fibers (Johansson A et al Acta Anesthesiol Scand
1990 34 335-38) L4-5 Severe Spinal Stenosis
INITIAL MANAGEMENT
Usually spinal stenosis occurs in pts of senior age
Some of these patients may significant comorbidities and higher sensitivity to
pain medications
Multilevel Cervical Spinal Stenosis
INITIAL MANAGEMENT
Intra-articular facet joint injections are appropriate when a clinical
diagnosis of facet joint ldquosyndromerdquo is confirmed
Axial back pain withwithout radiation
to the extremities
Morning neckback stiffness Pain when starting to move worse on necklumbar
spine extension relieved by the recumbent position
Intra-articular C3-4 facet joint injection
Intra-articular L5-S1 facet joint injection
INITIAL MANAGEMENT
Injections helpful in diagnosis and management of LBP secondary
to SI Joint ldquoSyndromerdquo
Pain is always maximal below L5
May radiate to hips groin buttocks posterior thighs
Patterns of referred pain somewhat similar to those due to disk and orfacet joint mediated
pain
Intra-articular SI Joint Injection
INITIAL MANAGEMENT
Injections helpful in diagnosis and management of LBP due to Piriformis Muscle Syndrome
A REAL PAIN THE BUTT
INITIAL MANAGEMENT ACUPUNCTURE
Some evidence that acupuncture and variations
thereof (acupressure cupping) potentially helpful in the acutesubacute period in
patients with NP and LBP
(Yuan QI et al PloS One 2015 Febr 1-37)
NEXT STEP
Rehabilitation and regaining of function
Physical Therapy very important component of the
rehabilitation
A symbiotic relationship between patient and
therapist key of a successful physical rehabilitation
program
The role of YOGA
Better pain control at rest and with
activities with yoga (9-week program with weekly 90-minute classes) when
compared to a self care exercise program in patients with neck pain
Significant treatment effects of yoga found for pain-related apprehension
disability quality of life and psychological outcomes (depression
fatigue anger)
(Michalsen A et al the J Pain 2012 13(11) 1122-30)
THE IMPORTANCE OF REMAINING ACTIVE
Increasing the amount of steps
walkedday by 1000 over the course of a year reduced the risk of neck pain by
14 in a group of people (men and women age 20-45) with sedentary jobs
(Sitthipornvorakul EA et al Eur Spine J
2015 24 417-24)
SPINAL MANIPULATION No Thank you
Systematic review of spinal
manipulation in patients with a variety of pain conditions including NP
and LBP
Failed to demonstrate that spinal manipulation is an effective
intervention for pain management
(Posadzki P Pain Med 2012 13 754-61)
CONCLUSIONS
Neck and Low Back pain syndromes are usually self limited conditions that can convert in chronic pain conditions causing
prolonged disability
The prevalence and cost of these conditions has significantly increased over the course of the last 15-20 years
Aggressive management of pain during the acute phase is
important because adequate pain control shortens the time and level of disability and facilitates the rehabilitation process
CONCLUSIONS
A variety of treatment modalities including medications acupuncture injections PT Yoga are utilized to manage pain and facilitate the
recovery process
Reducing stress and activities associated with the generation of pain maintaining an appropriate physical exercise regimen and a body weight
as close as possible to the ideal body weight will likely result in a decreased incidenceprevalence of short and long term NP and LBP
THANK YOU
QUESTIONS
Between 1998-2011 total direct and indirect costs of
musculoskeletal conditions rose from $3961 billion to $8738
billion ( 121)
Over the same period of time the US Gross Domestic Product
(GDP) has risen from $115 trillion to $152 trillion ( 32)
MUSCULOSKELETAL (MSK) DISORDERS - COST
RISK FACTORS
Gender Regardless of age MK pain more common among working women than working men
(Herin F et al Pain 2014 155 937-43)
Women seem to have sensitivity to pain (Leville SG et al Pain 2005 116 332-8)
Age Highest incidence of NP and LBP in the 3rd-
4th decade and overall prevalence increasing until age 60-65
(Hoy D et al Best Pract Res Clin Rheumatol 2010 24 769-81)
Occupational factors
Repetitive work awkward postures vibrations
(Neupane S et al Int Arch Occup Environ Health 2013 86 581-9)
(Herin F et al Pain 2014 155 937-43)
Psychosocial Factors
High level of emotional distress anxiety depression fear of
movement with avoidance behaviors (resting and limping)
correlated with high level of NPsup1 and LBPsup2 disability
(Johansen JB et al Clin J Pain 2013 29 1029-1035sup1)
(Grotle M et al Pain 2004 112 343-352sup2)
Job dissatisfaction work requiring repetitive tasks
limited autonomy and opportunities for learning and growing
professionally (van Tulder M et al Clin Rheum 2002 16(5) 761-75
risk of MSK pain in women
(Herin F et al Pain 2014 155 937-43)
Lower levels of education - strong predictor of more prolonged episode duration and poorer
outcome (Chou R et al Ann Int Med 2007 147(7) 478-91)
(Deyo RA et al Spine 2006 31 2724-7)
Psychosocial Factors
Problems with sleep
Sometimes - Risk of developing chronic NP LBP - 22-32
OftenAlways - 51-66 (PJ Moork et al Eur J of Pub Health 2013
24(6) 924-29)
Lack of sleep induces a state of low-level systemic inflammation that sensitizes the
nociceptive system (Haack M et al Sleep 2007 30 1145-52) (Wang H et al Clin J Pain 2008 24 273-8)
FROM THE MOVIE ldquoInsomniardquo
Lack of exercise - Increased body weight
Lack of sleep ndash Lack of physical exercise ndash Increased body weight ndash bad combination
(PJ Moork et al Eur J of Pub Health 2013 24(6) 924-29)
Lack of physical activityIncreased BMI
low-grade systemic inflammation that the susceptibility to chronic pain (Roytblat L et al Obesity 2000 8 673-5)
(Petersen AMW et al J Appl Physiol 2005 98 1154-62)
SOURCES OF NECK AND LOW BACK PAIN
a Large disk herniation at the C5-6 disk level
b Right sided disk herniation with nerve root compromise
Patient likely to complain of NP radiated to right upper extremity shooting stabbing
electrical shock-like with paresthesiae
CERVICAL-LUMBAR INTERVERTEBRAL DISK
MECHANISM Inflammation of the nerve roots
When a disk ruptures inflammatory
mediators are released from the nucleus polposus (the inner part of the disk)
around the nerve root leading to chemical neuroradiculitis
CERVICAL-LUMBAR INTERVERTEBRAL DISK
True synovial joints
between the C2-C7 vertebrae located behind the plane of the intervertebral foramina
and the spinal nerves contained therein
Arthritic changes may cause axial neck pain withwithout upper extremity pain
CERVICAL FACET JOINTS
CERVICAL FACET JOINTS
C2-3 C5-6 C6-7
most frequent
facetogenic pain
generators in the cervical
spine
CERVICAL FACET JOINTS
C2-3 joint Pain in the sub-occipital region
radiating to occiput auricular region vertex of the head forehead and orbit
C5-6 joint
Pain radiates over the deltoid region and into the arm
C6-7 joint Pain radiates over
over the medial scapula
ATLANTO-AXIAL JOINT (C1-2)
Pain from C1-2 occurs higher than pain from C2-3
vertex rather than forehead and temple
ATLANTO-OCCIPITAL JOINT (C 0-1)
Pain from C 0-1 almost superimposes pain stemming
from C1-2
Unusual source of neck pain
Note the close anatomic relationship between C0-
1 joint and C1 nerve
between C1-2 joint and C2 ganglia and nerve
and between these joints and the vertebral artery
OTHER SOURCES OF NECK PAIN
Posterior neck muscles
Cervical dura mater
Atlanto-axial joint ligaments
Vertebral artery
Cervical vertebral bodies
True synovial joints with a space a synovial membrane hyaline cartilage surfaces and a
fibrous capsule located in front of the plane of the foramina and the nerve root therein
Arthritic changes may cause axial low back pain withwithout lower extremity pain
LUMBAR FACET JOINTS
LUMBAR FACET JOINTS PAIN CHARACTERISTICS
More common in patients 65
yearolder
Axial low back pain
withwithout radiation to the
lower extremities
Morning stiffness Pain when
starting to move relieved by
the recumbent position
Worsening as day goes by
LUMBAR FACET JOINTS PAIN PATTERNS
L4-5 L5-S1
most frequent facetogenic
pain generators in the lumbar
spine
Pain does not extend down
beyond the level of the knee
Largest axial joint in the
body
Only the anterior third is a
true synovial joint
Complex innervation
including sensory fibers
from L5 through S4 spinal
nerves
SACRO-ILIAC JOINT
A B
No difference in gender
Mean age 40-50
Prevalence 13-30 of
patients with ho low back
pain
Most commonly causing
unilateral symptoms
SACRO-ILIAC JOINT
Pain is always maximal below L5
May radiate to hips groin buttocks
posterior thighs
Patterns of referred pain somewhat
similar to those due to disk and orfacet
joint mediated pain
SACRO-ILIAC JOINT PAIN PATTERN
PIRIFORMIS MUSCLE
Located in the gluteal region is one of the muscles of the lateral
rotator group
It is situated within the posterior wall of the pelvis partly at the
back of the hip joint
Passes out of the pelvis through the greater sciatic foramen
Sciatic nerve
PIRIFORMIS MUSCLE
Sport activities andor certain movements (running lunging) can
stress the piriformis muscle
The subsequent muscle spasm may manifest as MSK low back pain
radiating to the buttock and along the sciatic nerve
Prolonged sitting stretching climbing stairs or walking on inclines squatting
worsen the pain
REALLY A PAIN THE BUTT
OTHER SOURCES OF LOW BACK PAIN
Posterior lumbo-sacral paraspinal pelvic girdle muscles
Lumbar spine ligaments tendons
Vertebral bodies
CAUSES OF NECK AND LOW BACK PAIN
TUMORS
INFECTIONS Discitis Osteomyelitis Septic arthritis Meningitis
VASCULAR DISORDERS (egCarotid artery dissection)
AUTOIMMUNE DISORDERS Rheumatoid arthritis Ankylosing spondylitis Polymyalgia rheumatica
TRAUMA (FracturesDislocations)
MSK DISORDERS Soft tissue injuries Whiplash CervicalLumbosacral
strain Myofascial disorders Fibromyalgia
JOINT DISORDERS Spondylosis and Osteoarthritis
MANAGEMENT
Self limited condition
Symptoms and disability improve rapidly
Most patients return to work and normal activities in 4-6 weeks
(Pengel LH et al BMJ 2003 327 323)
NATURAL HISTORY
1 in 3 patients
Persistent moderate pain 1 year after an acute episode
1 in 5 patients report substantial limitations in activity (von Korff al et al Spine 1996 21 2833-7 ndash discussion 2838-9)
NATURAL HISTORY
History and Physical Exam
Blood work to rule out the
presence of a malignancy andor an infection
Plain radiographs of
cervicallumbar spine CTMRI in patients with neurologic
complaints or with pain not improving
DIAGNOSIS
MAIN GOAL
Achieve adequate pain control (NSAIDs Tylenol Muscle
Relaxants Gabapentinoids short acting opioids)
Relative rest
Activity modifications
INITIAL MANAGEMENT
Epidural steroid injections are an
option in patients with disk herniation back and leg pain
INITIAL MANAGEMENT
Anesth Analg 2016 Mar122(3)857-70 Bhatia A1 Flamer D Shah PS Cohen SP
CONCLUSIONS Epidural steroids injections provide
some analgesic benefit at 3 months in patients with lumbosacral radicular pain
due to herniated intervertebral disks but they have no impact on physical
disability or incidence of surgery
Epidural steroid injections are an option in
patients with spinal stenosis
INITIAL MANAGEMENT
Spinal stenosis causes mechanical compression of the nerve roots swelling
(microvascular injury) producing pain (Olmarker K et al Spine 1989 14 569-573)
L3-4 Spinal Stenosis
INITIAL MANAGEMENT
STEROIDS
inhibit swelling (edema) around the nerve root
(Rydevik B et al Spine 1984 9 7-15)
improve blood flow to neural elements decreasing ischemic neuritis
(Fukusaki M et al Clin J Pain 1998 14 148-51)
block conduction in nociceptive nerve fibers (Johansson A et al Acta Anesthesiol Scand
1990 34 335-38) L4-5 Severe Spinal Stenosis
INITIAL MANAGEMENT
Usually spinal stenosis occurs in pts of senior age
Some of these patients may significant comorbidities and higher sensitivity to
pain medications
Multilevel Cervical Spinal Stenosis
INITIAL MANAGEMENT
Intra-articular facet joint injections are appropriate when a clinical
diagnosis of facet joint ldquosyndromerdquo is confirmed
Axial back pain withwithout radiation
to the extremities
Morning neckback stiffness Pain when starting to move worse on necklumbar
spine extension relieved by the recumbent position
Intra-articular C3-4 facet joint injection
Intra-articular L5-S1 facet joint injection
INITIAL MANAGEMENT
Injections helpful in diagnosis and management of LBP secondary
to SI Joint ldquoSyndromerdquo
Pain is always maximal below L5
May radiate to hips groin buttocks posterior thighs
Patterns of referred pain somewhat similar to those due to disk and orfacet joint mediated
pain
Intra-articular SI Joint Injection
INITIAL MANAGEMENT
Injections helpful in diagnosis and management of LBP due to Piriformis Muscle Syndrome
A REAL PAIN THE BUTT
INITIAL MANAGEMENT ACUPUNCTURE
Some evidence that acupuncture and variations
thereof (acupressure cupping) potentially helpful in the acutesubacute period in
patients with NP and LBP
(Yuan QI et al PloS One 2015 Febr 1-37)
NEXT STEP
Rehabilitation and regaining of function
Physical Therapy very important component of the
rehabilitation
A symbiotic relationship between patient and
therapist key of a successful physical rehabilitation
program
The role of YOGA
Better pain control at rest and with
activities with yoga (9-week program with weekly 90-minute classes) when
compared to a self care exercise program in patients with neck pain
Significant treatment effects of yoga found for pain-related apprehension
disability quality of life and psychological outcomes (depression
fatigue anger)
(Michalsen A et al the J Pain 2012 13(11) 1122-30)
THE IMPORTANCE OF REMAINING ACTIVE
Increasing the amount of steps
walkedday by 1000 over the course of a year reduced the risk of neck pain by
14 in a group of people (men and women age 20-45) with sedentary jobs
(Sitthipornvorakul EA et al Eur Spine J
2015 24 417-24)
SPINAL MANIPULATION No Thank you
Systematic review of spinal
manipulation in patients with a variety of pain conditions including NP
and LBP
Failed to demonstrate that spinal manipulation is an effective
intervention for pain management
(Posadzki P Pain Med 2012 13 754-61)
CONCLUSIONS
Neck and Low Back pain syndromes are usually self limited conditions that can convert in chronic pain conditions causing
prolonged disability
The prevalence and cost of these conditions has significantly increased over the course of the last 15-20 years
Aggressive management of pain during the acute phase is
important because adequate pain control shortens the time and level of disability and facilitates the rehabilitation process
CONCLUSIONS
A variety of treatment modalities including medications acupuncture injections PT Yoga are utilized to manage pain and facilitate the
recovery process
Reducing stress and activities associated with the generation of pain maintaining an appropriate physical exercise regimen and a body weight
as close as possible to the ideal body weight will likely result in a decreased incidenceprevalence of short and long term NP and LBP
THANK YOU
QUESTIONS
RISK FACTORS
Gender Regardless of age MK pain more common among working women than working men
(Herin F et al Pain 2014 155 937-43)
Women seem to have sensitivity to pain (Leville SG et al Pain 2005 116 332-8)
Age Highest incidence of NP and LBP in the 3rd-
4th decade and overall prevalence increasing until age 60-65
(Hoy D et al Best Pract Res Clin Rheumatol 2010 24 769-81)
Occupational factors
Repetitive work awkward postures vibrations
(Neupane S et al Int Arch Occup Environ Health 2013 86 581-9)
(Herin F et al Pain 2014 155 937-43)
Psychosocial Factors
High level of emotional distress anxiety depression fear of
movement with avoidance behaviors (resting and limping)
correlated with high level of NPsup1 and LBPsup2 disability
(Johansen JB et al Clin J Pain 2013 29 1029-1035sup1)
(Grotle M et al Pain 2004 112 343-352sup2)
Job dissatisfaction work requiring repetitive tasks
limited autonomy and opportunities for learning and growing
professionally (van Tulder M et al Clin Rheum 2002 16(5) 761-75
risk of MSK pain in women
(Herin F et al Pain 2014 155 937-43)
Lower levels of education - strong predictor of more prolonged episode duration and poorer
outcome (Chou R et al Ann Int Med 2007 147(7) 478-91)
(Deyo RA et al Spine 2006 31 2724-7)
Psychosocial Factors
Problems with sleep
Sometimes - Risk of developing chronic NP LBP - 22-32
OftenAlways - 51-66 (PJ Moork et al Eur J of Pub Health 2013
24(6) 924-29)
Lack of sleep induces a state of low-level systemic inflammation that sensitizes the
nociceptive system (Haack M et al Sleep 2007 30 1145-52) (Wang H et al Clin J Pain 2008 24 273-8)
FROM THE MOVIE ldquoInsomniardquo
Lack of exercise - Increased body weight
Lack of sleep ndash Lack of physical exercise ndash Increased body weight ndash bad combination
(PJ Moork et al Eur J of Pub Health 2013 24(6) 924-29)
Lack of physical activityIncreased BMI
low-grade systemic inflammation that the susceptibility to chronic pain (Roytblat L et al Obesity 2000 8 673-5)
(Petersen AMW et al J Appl Physiol 2005 98 1154-62)
SOURCES OF NECK AND LOW BACK PAIN
a Large disk herniation at the C5-6 disk level
b Right sided disk herniation with nerve root compromise
Patient likely to complain of NP radiated to right upper extremity shooting stabbing
electrical shock-like with paresthesiae
CERVICAL-LUMBAR INTERVERTEBRAL DISK
MECHANISM Inflammation of the nerve roots
When a disk ruptures inflammatory
mediators are released from the nucleus polposus (the inner part of the disk)
around the nerve root leading to chemical neuroradiculitis
CERVICAL-LUMBAR INTERVERTEBRAL DISK
True synovial joints
between the C2-C7 vertebrae located behind the plane of the intervertebral foramina
and the spinal nerves contained therein
Arthritic changes may cause axial neck pain withwithout upper extremity pain
CERVICAL FACET JOINTS
CERVICAL FACET JOINTS
C2-3 C5-6 C6-7
most frequent
facetogenic pain
generators in the cervical
spine
CERVICAL FACET JOINTS
C2-3 joint Pain in the sub-occipital region
radiating to occiput auricular region vertex of the head forehead and orbit
C5-6 joint
Pain radiates over the deltoid region and into the arm
C6-7 joint Pain radiates over
over the medial scapula
ATLANTO-AXIAL JOINT (C1-2)
Pain from C1-2 occurs higher than pain from C2-3
vertex rather than forehead and temple
ATLANTO-OCCIPITAL JOINT (C 0-1)
Pain from C 0-1 almost superimposes pain stemming
from C1-2
Unusual source of neck pain
Note the close anatomic relationship between C0-
1 joint and C1 nerve
between C1-2 joint and C2 ganglia and nerve
and between these joints and the vertebral artery
OTHER SOURCES OF NECK PAIN
Posterior neck muscles
Cervical dura mater
Atlanto-axial joint ligaments
Vertebral artery
Cervical vertebral bodies
True synovial joints with a space a synovial membrane hyaline cartilage surfaces and a
fibrous capsule located in front of the plane of the foramina and the nerve root therein
Arthritic changes may cause axial low back pain withwithout lower extremity pain
LUMBAR FACET JOINTS
LUMBAR FACET JOINTS PAIN CHARACTERISTICS
More common in patients 65
yearolder
Axial low back pain
withwithout radiation to the
lower extremities
Morning stiffness Pain when
starting to move relieved by
the recumbent position
Worsening as day goes by
LUMBAR FACET JOINTS PAIN PATTERNS
L4-5 L5-S1
most frequent facetogenic
pain generators in the lumbar
spine
Pain does not extend down
beyond the level of the knee
Largest axial joint in the
body
Only the anterior third is a
true synovial joint
Complex innervation
including sensory fibers
from L5 through S4 spinal
nerves
SACRO-ILIAC JOINT
A B
No difference in gender
Mean age 40-50
Prevalence 13-30 of
patients with ho low back
pain
Most commonly causing
unilateral symptoms
SACRO-ILIAC JOINT
Pain is always maximal below L5
May radiate to hips groin buttocks
posterior thighs
Patterns of referred pain somewhat
similar to those due to disk and orfacet
joint mediated pain
SACRO-ILIAC JOINT PAIN PATTERN
PIRIFORMIS MUSCLE
Located in the gluteal region is one of the muscles of the lateral
rotator group
It is situated within the posterior wall of the pelvis partly at the
back of the hip joint
Passes out of the pelvis through the greater sciatic foramen
Sciatic nerve
PIRIFORMIS MUSCLE
Sport activities andor certain movements (running lunging) can
stress the piriformis muscle
The subsequent muscle spasm may manifest as MSK low back pain
radiating to the buttock and along the sciatic nerve
Prolonged sitting stretching climbing stairs or walking on inclines squatting
worsen the pain
REALLY A PAIN THE BUTT
OTHER SOURCES OF LOW BACK PAIN
Posterior lumbo-sacral paraspinal pelvic girdle muscles
Lumbar spine ligaments tendons
Vertebral bodies
CAUSES OF NECK AND LOW BACK PAIN
TUMORS
INFECTIONS Discitis Osteomyelitis Septic arthritis Meningitis
VASCULAR DISORDERS (egCarotid artery dissection)
AUTOIMMUNE DISORDERS Rheumatoid arthritis Ankylosing spondylitis Polymyalgia rheumatica
TRAUMA (FracturesDislocations)
MSK DISORDERS Soft tissue injuries Whiplash CervicalLumbosacral
strain Myofascial disorders Fibromyalgia
JOINT DISORDERS Spondylosis and Osteoarthritis
MANAGEMENT
Self limited condition
Symptoms and disability improve rapidly
Most patients return to work and normal activities in 4-6 weeks
(Pengel LH et al BMJ 2003 327 323)
NATURAL HISTORY
1 in 3 patients
Persistent moderate pain 1 year after an acute episode
1 in 5 patients report substantial limitations in activity (von Korff al et al Spine 1996 21 2833-7 ndash discussion 2838-9)
NATURAL HISTORY
History and Physical Exam
Blood work to rule out the
presence of a malignancy andor an infection
Plain radiographs of
cervicallumbar spine CTMRI in patients with neurologic
complaints or with pain not improving
DIAGNOSIS
MAIN GOAL
Achieve adequate pain control (NSAIDs Tylenol Muscle
Relaxants Gabapentinoids short acting opioids)
Relative rest
Activity modifications
INITIAL MANAGEMENT
Epidural steroid injections are an
option in patients with disk herniation back and leg pain
INITIAL MANAGEMENT
Anesth Analg 2016 Mar122(3)857-70 Bhatia A1 Flamer D Shah PS Cohen SP
CONCLUSIONS Epidural steroids injections provide
some analgesic benefit at 3 months in patients with lumbosacral radicular pain
due to herniated intervertebral disks but they have no impact on physical
disability or incidence of surgery
Epidural steroid injections are an option in
patients with spinal stenosis
INITIAL MANAGEMENT
Spinal stenosis causes mechanical compression of the nerve roots swelling
(microvascular injury) producing pain (Olmarker K et al Spine 1989 14 569-573)
L3-4 Spinal Stenosis
INITIAL MANAGEMENT
STEROIDS
inhibit swelling (edema) around the nerve root
(Rydevik B et al Spine 1984 9 7-15)
improve blood flow to neural elements decreasing ischemic neuritis
(Fukusaki M et al Clin J Pain 1998 14 148-51)
block conduction in nociceptive nerve fibers (Johansson A et al Acta Anesthesiol Scand
1990 34 335-38) L4-5 Severe Spinal Stenosis
INITIAL MANAGEMENT
Usually spinal stenosis occurs in pts of senior age
Some of these patients may significant comorbidities and higher sensitivity to
pain medications
Multilevel Cervical Spinal Stenosis
INITIAL MANAGEMENT
Intra-articular facet joint injections are appropriate when a clinical
diagnosis of facet joint ldquosyndromerdquo is confirmed
Axial back pain withwithout radiation
to the extremities
Morning neckback stiffness Pain when starting to move worse on necklumbar
spine extension relieved by the recumbent position
Intra-articular C3-4 facet joint injection
Intra-articular L5-S1 facet joint injection
INITIAL MANAGEMENT
Injections helpful in diagnosis and management of LBP secondary
to SI Joint ldquoSyndromerdquo
Pain is always maximal below L5
May radiate to hips groin buttocks posterior thighs
Patterns of referred pain somewhat similar to those due to disk and orfacet joint mediated
pain
Intra-articular SI Joint Injection
INITIAL MANAGEMENT
Injections helpful in diagnosis and management of LBP due to Piriformis Muscle Syndrome
A REAL PAIN THE BUTT
INITIAL MANAGEMENT ACUPUNCTURE
Some evidence that acupuncture and variations
thereof (acupressure cupping) potentially helpful in the acutesubacute period in
patients with NP and LBP
(Yuan QI et al PloS One 2015 Febr 1-37)
NEXT STEP
Rehabilitation and regaining of function
Physical Therapy very important component of the
rehabilitation
A symbiotic relationship between patient and
therapist key of a successful physical rehabilitation
program
The role of YOGA
Better pain control at rest and with
activities with yoga (9-week program with weekly 90-minute classes) when
compared to a self care exercise program in patients with neck pain
Significant treatment effects of yoga found for pain-related apprehension
disability quality of life and psychological outcomes (depression
fatigue anger)
(Michalsen A et al the J Pain 2012 13(11) 1122-30)
THE IMPORTANCE OF REMAINING ACTIVE
Increasing the amount of steps
walkedday by 1000 over the course of a year reduced the risk of neck pain by
14 in a group of people (men and women age 20-45) with sedentary jobs
(Sitthipornvorakul EA et al Eur Spine J
2015 24 417-24)
SPINAL MANIPULATION No Thank you
Systematic review of spinal
manipulation in patients with a variety of pain conditions including NP
and LBP
Failed to demonstrate that spinal manipulation is an effective
intervention for pain management
(Posadzki P Pain Med 2012 13 754-61)
CONCLUSIONS
Neck and Low Back pain syndromes are usually self limited conditions that can convert in chronic pain conditions causing
prolonged disability
The prevalence and cost of these conditions has significantly increased over the course of the last 15-20 years
Aggressive management of pain during the acute phase is
important because adequate pain control shortens the time and level of disability and facilitates the rehabilitation process
CONCLUSIONS
A variety of treatment modalities including medications acupuncture injections PT Yoga are utilized to manage pain and facilitate the
recovery process
Reducing stress and activities associated with the generation of pain maintaining an appropriate physical exercise regimen and a body weight
as close as possible to the ideal body weight will likely result in a decreased incidenceprevalence of short and long term NP and LBP
THANK YOU
QUESTIONS
Gender Regardless of age MK pain more common among working women than working men
(Herin F et al Pain 2014 155 937-43)
Women seem to have sensitivity to pain (Leville SG et al Pain 2005 116 332-8)
Age Highest incidence of NP and LBP in the 3rd-
4th decade and overall prevalence increasing until age 60-65
(Hoy D et al Best Pract Res Clin Rheumatol 2010 24 769-81)
Occupational factors
Repetitive work awkward postures vibrations
(Neupane S et al Int Arch Occup Environ Health 2013 86 581-9)
(Herin F et al Pain 2014 155 937-43)
Psychosocial Factors
High level of emotional distress anxiety depression fear of
movement with avoidance behaviors (resting and limping)
correlated with high level of NPsup1 and LBPsup2 disability
(Johansen JB et al Clin J Pain 2013 29 1029-1035sup1)
(Grotle M et al Pain 2004 112 343-352sup2)
Job dissatisfaction work requiring repetitive tasks
limited autonomy and opportunities for learning and growing
professionally (van Tulder M et al Clin Rheum 2002 16(5) 761-75
risk of MSK pain in women
(Herin F et al Pain 2014 155 937-43)
Lower levels of education - strong predictor of more prolonged episode duration and poorer
outcome (Chou R et al Ann Int Med 2007 147(7) 478-91)
(Deyo RA et al Spine 2006 31 2724-7)
Psychosocial Factors
Problems with sleep
Sometimes - Risk of developing chronic NP LBP - 22-32
OftenAlways - 51-66 (PJ Moork et al Eur J of Pub Health 2013
24(6) 924-29)
Lack of sleep induces a state of low-level systemic inflammation that sensitizes the
nociceptive system (Haack M et al Sleep 2007 30 1145-52) (Wang H et al Clin J Pain 2008 24 273-8)
FROM THE MOVIE ldquoInsomniardquo
Lack of exercise - Increased body weight
Lack of sleep ndash Lack of physical exercise ndash Increased body weight ndash bad combination
(PJ Moork et al Eur J of Pub Health 2013 24(6) 924-29)
Lack of physical activityIncreased BMI
low-grade systemic inflammation that the susceptibility to chronic pain (Roytblat L et al Obesity 2000 8 673-5)
(Petersen AMW et al J Appl Physiol 2005 98 1154-62)
SOURCES OF NECK AND LOW BACK PAIN
a Large disk herniation at the C5-6 disk level
b Right sided disk herniation with nerve root compromise
Patient likely to complain of NP radiated to right upper extremity shooting stabbing
electrical shock-like with paresthesiae
CERVICAL-LUMBAR INTERVERTEBRAL DISK
MECHANISM Inflammation of the nerve roots
When a disk ruptures inflammatory
mediators are released from the nucleus polposus (the inner part of the disk)
around the nerve root leading to chemical neuroradiculitis
CERVICAL-LUMBAR INTERVERTEBRAL DISK
True synovial joints
between the C2-C7 vertebrae located behind the plane of the intervertebral foramina
and the spinal nerves contained therein
Arthritic changes may cause axial neck pain withwithout upper extremity pain
CERVICAL FACET JOINTS
CERVICAL FACET JOINTS
C2-3 C5-6 C6-7
most frequent
facetogenic pain
generators in the cervical
spine
CERVICAL FACET JOINTS
C2-3 joint Pain in the sub-occipital region
radiating to occiput auricular region vertex of the head forehead and orbit
C5-6 joint
Pain radiates over the deltoid region and into the arm
C6-7 joint Pain radiates over
over the medial scapula
ATLANTO-AXIAL JOINT (C1-2)
Pain from C1-2 occurs higher than pain from C2-3
vertex rather than forehead and temple
ATLANTO-OCCIPITAL JOINT (C 0-1)
Pain from C 0-1 almost superimposes pain stemming
from C1-2
Unusual source of neck pain
Note the close anatomic relationship between C0-
1 joint and C1 nerve
between C1-2 joint and C2 ganglia and nerve
and between these joints and the vertebral artery
OTHER SOURCES OF NECK PAIN
Posterior neck muscles
Cervical dura mater
Atlanto-axial joint ligaments
Vertebral artery
Cervical vertebral bodies
True synovial joints with a space a synovial membrane hyaline cartilage surfaces and a
fibrous capsule located in front of the plane of the foramina and the nerve root therein
Arthritic changes may cause axial low back pain withwithout lower extremity pain
LUMBAR FACET JOINTS
LUMBAR FACET JOINTS PAIN CHARACTERISTICS
More common in patients 65
yearolder
Axial low back pain
withwithout radiation to the
lower extremities
Morning stiffness Pain when
starting to move relieved by
the recumbent position
Worsening as day goes by
LUMBAR FACET JOINTS PAIN PATTERNS
L4-5 L5-S1
most frequent facetogenic
pain generators in the lumbar
spine
Pain does not extend down
beyond the level of the knee
Largest axial joint in the
body
Only the anterior third is a
true synovial joint
Complex innervation
including sensory fibers
from L5 through S4 spinal
nerves
SACRO-ILIAC JOINT
A B
No difference in gender
Mean age 40-50
Prevalence 13-30 of
patients with ho low back
pain
Most commonly causing
unilateral symptoms
SACRO-ILIAC JOINT
Pain is always maximal below L5
May radiate to hips groin buttocks
posterior thighs
Patterns of referred pain somewhat
similar to those due to disk and orfacet
joint mediated pain
SACRO-ILIAC JOINT PAIN PATTERN
PIRIFORMIS MUSCLE
Located in the gluteal region is one of the muscles of the lateral
rotator group
It is situated within the posterior wall of the pelvis partly at the
back of the hip joint
Passes out of the pelvis through the greater sciatic foramen
Sciatic nerve
PIRIFORMIS MUSCLE
Sport activities andor certain movements (running lunging) can
stress the piriformis muscle
The subsequent muscle spasm may manifest as MSK low back pain
radiating to the buttock and along the sciatic nerve
Prolonged sitting stretching climbing stairs or walking on inclines squatting
worsen the pain
REALLY A PAIN THE BUTT
OTHER SOURCES OF LOW BACK PAIN
Posterior lumbo-sacral paraspinal pelvic girdle muscles
Lumbar spine ligaments tendons
Vertebral bodies
CAUSES OF NECK AND LOW BACK PAIN
TUMORS
INFECTIONS Discitis Osteomyelitis Septic arthritis Meningitis
VASCULAR DISORDERS (egCarotid artery dissection)
AUTOIMMUNE DISORDERS Rheumatoid arthritis Ankylosing spondylitis Polymyalgia rheumatica
TRAUMA (FracturesDislocations)
MSK DISORDERS Soft tissue injuries Whiplash CervicalLumbosacral
strain Myofascial disorders Fibromyalgia
JOINT DISORDERS Spondylosis and Osteoarthritis
MANAGEMENT
Self limited condition
Symptoms and disability improve rapidly
Most patients return to work and normal activities in 4-6 weeks
(Pengel LH et al BMJ 2003 327 323)
NATURAL HISTORY
1 in 3 patients
Persistent moderate pain 1 year after an acute episode
1 in 5 patients report substantial limitations in activity (von Korff al et al Spine 1996 21 2833-7 ndash discussion 2838-9)
NATURAL HISTORY
History and Physical Exam
Blood work to rule out the
presence of a malignancy andor an infection
Plain radiographs of
cervicallumbar spine CTMRI in patients with neurologic
complaints or with pain not improving
DIAGNOSIS
MAIN GOAL
Achieve adequate pain control (NSAIDs Tylenol Muscle
Relaxants Gabapentinoids short acting opioids)
Relative rest
Activity modifications
INITIAL MANAGEMENT
Epidural steroid injections are an
option in patients with disk herniation back and leg pain
INITIAL MANAGEMENT
Anesth Analg 2016 Mar122(3)857-70 Bhatia A1 Flamer D Shah PS Cohen SP
CONCLUSIONS Epidural steroids injections provide
some analgesic benefit at 3 months in patients with lumbosacral radicular pain
due to herniated intervertebral disks but they have no impact on physical
disability or incidence of surgery
Epidural steroid injections are an option in
patients with spinal stenosis
INITIAL MANAGEMENT
Spinal stenosis causes mechanical compression of the nerve roots swelling
(microvascular injury) producing pain (Olmarker K et al Spine 1989 14 569-573)
L3-4 Spinal Stenosis
INITIAL MANAGEMENT
STEROIDS
inhibit swelling (edema) around the nerve root
(Rydevik B et al Spine 1984 9 7-15)
improve blood flow to neural elements decreasing ischemic neuritis
(Fukusaki M et al Clin J Pain 1998 14 148-51)
block conduction in nociceptive nerve fibers (Johansson A et al Acta Anesthesiol Scand
1990 34 335-38) L4-5 Severe Spinal Stenosis
INITIAL MANAGEMENT
Usually spinal stenosis occurs in pts of senior age
Some of these patients may significant comorbidities and higher sensitivity to
pain medications
Multilevel Cervical Spinal Stenosis
INITIAL MANAGEMENT
Intra-articular facet joint injections are appropriate when a clinical
diagnosis of facet joint ldquosyndromerdquo is confirmed
Axial back pain withwithout radiation
to the extremities
Morning neckback stiffness Pain when starting to move worse on necklumbar
spine extension relieved by the recumbent position
Intra-articular C3-4 facet joint injection
Intra-articular L5-S1 facet joint injection
INITIAL MANAGEMENT
Injections helpful in diagnosis and management of LBP secondary
to SI Joint ldquoSyndromerdquo
Pain is always maximal below L5
May radiate to hips groin buttocks posterior thighs
Patterns of referred pain somewhat similar to those due to disk and orfacet joint mediated
pain
Intra-articular SI Joint Injection
INITIAL MANAGEMENT
Injections helpful in diagnosis and management of LBP due to Piriformis Muscle Syndrome
A REAL PAIN THE BUTT
INITIAL MANAGEMENT ACUPUNCTURE
Some evidence that acupuncture and variations
thereof (acupressure cupping) potentially helpful in the acutesubacute period in
patients with NP and LBP
(Yuan QI et al PloS One 2015 Febr 1-37)
NEXT STEP
Rehabilitation and regaining of function
Physical Therapy very important component of the
rehabilitation
A symbiotic relationship between patient and
therapist key of a successful physical rehabilitation
program
The role of YOGA
Better pain control at rest and with
activities with yoga (9-week program with weekly 90-minute classes) when
compared to a self care exercise program in patients with neck pain
Significant treatment effects of yoga found for pain-related apprehension
disability quality of life and psychological outcomes (depression
fatigue anger)
(Michalsen A et al the J Pain 2012 13(11) 1122-30)
THE IMPORTANCE OF REMAINING ACTIVE
Increasing the amount of steps
walkedday by 1000 over the course of a year reduced the risk of neck pain by
14 in a group of people (men and women age 20-45) with sedentary jobs
(Sitthipornvorakul EA et al Eur Spine J
2015 24 417-24)
SPINAL MANIPULATION No Thank you
Systematic review of spinal
manipulation in patients with a variety of pain conditions including NP
and LBP
Failed to demonstrate that spinal manipulation is an effective
intervention for pain management
(Posadzki P Pain Med 2012 13 754-61)
CONCLUSIONS
Neck and Low Back pain syndromes are usually self limited conditions that can convert in chronic pain conditions causing
prolonged disability
The prevalence and cost of these conditions has significantly increased over the course of the last 15-20 years
Aggressive management of pain during the acute phase is
important because adequate pain control shortens the time and level of disability and facilitates the rehabilitation process
CONCLUSIONS
A variety of treatment modalities including medications acupuncture injections PT Yoga are utilized to manage pain and facilitate the
recovery process
Reducing stress and activities associated with the generation of pain maintaining an appropriate physical exercise regimen and a body weight
as close as possible to the ideal body weight will likely result in a decreased incidenceprevalence of short and long term NP and LBP
THANK YOU
QUESTIONS
Occupational factors
Repetitive work awkward postures vibrations
(Neupane S et al Int Arch Occup Environ Health 2013 86 581-9)
(Herin F et al Pain 2014 155 937-43)
Psychosocial Factors
High level of emotional distress anxiety depression fear of
movement with avoidance behaviors (resting and limping)
correlated with high level of NPsup1 and LBPsup2 disability
(Johansen JB et al Clin J Pain 2013 29 1029-1035sup1)
(Grotle M et al Pain 2004 112 343-352sup2)
Job dissatisfaction work requiring repetitive tasks
limited autonomy and opportunities for learning and growing
professionally (van Tulder M et al Clin Rheum 2002 16(5) 761-75
risk of MSK pain in women
(Herin F et al Pain 2014 155 937-43)
Lower levels of education - strong predictor of more prolonged episode duration and poorer
outcome (Chou R et al Ann Int Med 2007 147(7) 478-91)
(Deyo RA et al Spine 2006 31 2724-7)
Psychosocial Factors
Problems with sleep
Sometimes - Risk of developing chronic NP LBP - 22-32
OftenAlways - 51-66 (PJ Moork et al Eur J of Pub Health 2013
24(6) 924-29)
Lack of sleep induces a state of low-level systemic inflammation that sensitizes the
nociceptive system (Haack M et al Sleep 2007 30 1145-52) (Wang H et al Clin J Pain 2008 24 273-8)
FROM THE MOVIE ldquoInsomniardquo
Lack of exercise - Increased body weight
Lack of sleep ndash Lack of physical exercise ndash Increased body weight ndash bad combination
(PJ Moork et al Eur J of Pub Health 2013 24(6) 924-29)
Lack of physical activityIncreased BMI
low-grade systemic inflammation that the susceptibility to chronic pain (Roytblat L et al Obesity 2000 8 673-5)
(Petersen AMW et al J Appl Physiol 2005 98 1154-62)
SOURCES OF NECK AND LOW BACK PAIN
a Large disk herniation at the C5-6 disk level
b Right sided disk herniation with nerve root compromise
Patient likely to complain of NP radiated to right upper extremity shooting stabbing
electrical shock-like with paresthesiae
CERVICAL-LUMBAR INTERVERTEBRAL DISK
MECHANISM Inflammation of the nerve roots
When a disk ruptures inflammatory
mediators are released from the nucleus polposus (the inner part of the disk)
around the nerve root leading to chemical neuroradiculitis
CERVICAL-LUMBAR INTERVERTEBRAL DISK
True synovial joints
between the C2-C7 vertebrae located behind the plane of the intervertebral foramina
and the spinal nerves contained therein
Arthritic changes may cause axial neck pain withwithout upper extremity pain
CERVICAL FACET JOINTS
CERVICAL FACET JOINTS
C2-3 C5-6 C6-7
most frequent
facetogenic pain
generators in the cervical
spine
CERVICAL FACET JOINTS
C2-3 joint Pain in the sub-occipital region
radiating to occiput auricular region vertex of the head forehead and orbit
C5-6 joint
Pain radiates over the deltoid region and into the arm
C6-7 joint Pain radiates over
over the medial scapula
ATLANTO-AXIAL JOINT (C1-2)
Pain from C1-2 occurs higher than pain from C2-3
vertex rather than forehead and temple
ATLANTO-OCCIPITAL JOINT (C 0-1)
Pain from C 0-1 almost superimposes pain stemming
from C1-2
Unusual source of neck pain
Note the close anatomic relationship between C0-
1 joint and C1 nerve
between C1-2 joint and C2 ganglia and nerve
and between these joints and the vertebral artery
OTHER SOURCES OF NECK PAIN
Posterior neck muscles
Cervical dura mater
Atlanto-axial joint ligaments
Vertebral artery
Cervical vertebral bodies
True synovial joints with a space a synovial membrane hyaline cartilage surfaces and a
fibrous capsule located in front of the plane of the foramina and the nerve root therein
Arthritic changes may cause axial low back pain withwithout lower extremity pain
LUMBAR FACET JOINTS
LUMBAR FACET JOINTS PAIN CHARACTERISTICS
More common in patients 65
yearolder
Axial low back pain
withwithout radiation to the
lower extremities
Morning stiffness Pain when
starting to move relieved by
the recumbent position
Worsening as day goes by
LUMBAR FACET JOINTS PAIN PATTERNS
L4-5 L5-S1
most frequent facetogenic
pain generators in the lumbar
spine
Pain does not extend down
beyond the level of the knee
Largest axial joint in the
body
Only the anterior third is a
true synovial joint
Complex innervation
including sensory fibers
from L5 through S4 spinal
nerves
SACRO-ILIAC JOINT
A B
No difference in gender
Mean age 40-50
Prevalence 13-30 of
patients with ho low back
pain
Most commonly causing
unilateral symptoms
SACRO-ILIAC JOINT
Pain is always maximal below L5
May radiate to hips groin buttocks
posterior thighs
Patterns of referred pain somewhat
similar to those due to disk and orfacet
joint mediated pain
SACRO-ILIAC JOINT PAIN PATTERN
PIRIFORMIS MUSCLE
Located in the gluteal region is one of the muscles of the lateral
rotator group
It is situated within the posterior wall of the pelvis partly at the
back of the hip joint
Passes out of the pelvis through the greater sciatic foramen
Sciatic nerve
PIRIFORMIS MUSCLE
Sport activities andor certain movements (running lunging) can
stress the piriformis muscle
The subsequent muscle spasm may manifest as MSK low back pain
radiating to the buttock and along the sciatic nerve
Prolonged sitting stretching climbing stairs or walking on inclines squatting
worsen the pain
REALLY A PAIN THE BUTT
OTHER SOURCES OF LOW BACK PAIN
Posterior lumbo-sacral paraspinal pelvic girdle muscles
Lumbar spine ligaments tendons
Vertebral bodies
CAUSES OF NECK AND LOW BACK PAIN
TUMORS
INFECTIONS Discitis Osteomyelitis Septic arthritis Meningitis
VASCULAR DISORDERS (egCarotid artery dissection)
AUTOIMMUNE DISORDERS Rheumatoid arthritis Ankylosing spondylitis Polymyalgia rheumatica
TRAUMA (FracturesDislocations)
MSK DISORDERS Soft tissue injuries Whiplash CervicalLumbosacral
strain Myofascial disorders Fibromyalgia
JOINT DISORDERS Spondylosis and Osteoarthritis
MANAGEMENT
Self limited condition
Symptoms and disability improve rapidly
Most patients return to work and normal activities in 4-6 weeks
(Pengel LH et al BMJ 2003 327 323)
NATURAL HISTORY
1 in 3 patients
Persistent moderate pain 1 year after an acute episode
1 in 5 patients report substantial limitations in activity (von Korff al et al Spine 1996 21 2833-7 ndash discussion 2838-9)
NATURAL HISTORY
History and Physical Exam
Blood work to rule out the
presence of a malignancy andor an infection
Plain radiographs of
cervicallumbar spine CTMRI in patients with neurologic
complaints or with pain not improving
DIAGNOSIS
MAIN GOAL
Achieve adequate pain control (NSAIDs Tylenol Muscle
Relaxants Gabapentinoids short acting opioids)
Relative rest
Activity modifications
INITIAL MANAGEMENT
Epidural steroid injections are an
option in patients with disk herniation back and leg pain
INITIAL MANAGEMENT
Anesth Analg 2016 Mar122(3)857-70 Bhatia A1 Flamer D Shah PS Cohen SP
CONCLUSIONS Epidural steroids injections provide
some analgesic benefit at 3 months in patients with lumbosacral radicular pain
due to herniated intervertebral disks but they have no impact on physical
disability or incidence of surgery
Epidural steroid injections are an option in
patients with spinal stenosis
INITIAL MANAGEMENT
Spinal stenosis causes mechanical compression of the nerve roots swelling
(microvascular injury) producing pain (Olmarker K et al Spine 1989 14 569-573)
L3-4 Spinal Stenosis
INITIAL MANAGEMENT
STEROIDS
inhibit swelling (edema) around the nerve root
(Rydevik B et al Spine 1984 9 7-15)
improve blood flow to neural elements decreasing ischemic neuritis
(Fukusaki M et al Clin J Pain 1998 14 148-51)
block conduction in nociceptive nerve fibers (Johansson A et al Acta Anesthesiol Scand
1990 34 335-38) L4-5 Severe Spinal Stenosis
INITIAL MANAGEMENT
Usually spinal stenosis occurs in pts of senior age
Some of these patients may significant comorbidities and higher sensitivity to
pain medications
Multilevel Cervical Spinal Stenosis
INITIAL MANAGEMENT
Intra-articular facet joint injections are appropriate when a clinical
diagnosis of facet joint ldquosyndromerdquo is confirmed
Axial back pain withwithout radiation
to the extremities
Morning neckback stiffness Pain when starting to move worse on necklumbar
spine extension relieved by the recumbent position
Intra-articular C3-4 facet joint injection
Intra-articular L5-S1 facet joint injection
INITIAL MANAGEMENT
Injections helpful in diagnosis and management of LBP secondary
to SI Joint ldquoSyndromerdquo
Pain is always maximal below L5
May radiate to hips groin buttocks posterior thighs
Patterns of referred pain somewhat similar to those due to disk and orfacet joint mediated
pain
Intra-articular SI Joint Injection
INITIAL MANAGEMENT
Injections helpful in diagnosis and management of LBP due to Piriformis Muscle Syndrome
A REAL PAIN THE BUTT
INITIAL MANAGEMENT ACUPUNCTURE
Some evidence that acupuncture and variations
thereof (acupressure cupping) potentially helpful in the acutesubacute period in
patients with NP and LBP
(Yuan QI et al PloS One 2015 Febr 1-37)
NEXT STEP
Rehabilitation and regaining of function
Physical Therapy very important component of the
rehabilitation
A symbiotic relationship between patient and
therapist key of a successful physical rehabilitation
program
The role of YOGA
Better pain control at rest and with
activities with yoga (9-week program with weekly 90-minute classes) when
compared to a self care exercise program in patients with neck pain
Significant treatment effects of yoga found for pain-related apprehension
disability quality of life and psychological outcomes (depression
fatigue anger)
(Michalsen A et al the J Pain 2012 13(11) 1122-30)
THE IMPORTANCE OF REMAINING ACTIVE
Increasing the amount of steps
walkedday by 1000 over the course of a year reduced the risk of neck pain by
14 in a group of people (men and women age 20-45) with sedentary jobs
(Sitthipornvorakul EA et al Eur Spine J
2015 24 417-24)
SPINAL MANIPULATION No Thank you
Systematic review of spinal
manipulation in patients with a variety of pain conditions including NP
and LBP
Failed to demonstrate that spinal manipulation is an effective
intervention for pain management
(Posadzki P Pain Med 2012 13 754-61)
CONCLUSIONS
Neck and Low Back pain syndromes are usually self limited conditions that can convert in chronic pain conditions causing
prolonged disability
The prevalence and cost of these conditions has significantly increased over the course of the last 15-20 years
Aggressive management of pain during the acute phase is
important because adequate pain control shortens the time and level of disability and facilitates the rehabilitation process
CONCLUSIONS
A variety of treatment modalities including medications acupuncture injections PT Yoga are utilized to manage pain and facilitate the
recovery process
Reducing stress and activities associated with the generation of pain maintaining an appropriate physical exercise regimen and a body weight
as close as possible to the ideal body weight will likely result in a decreased incidenceprevalence of short and long term NP and LBP
THANK YOU
QUESTIONS
Psychosocial Factors
High level of emotional distress anxiety depression fear of
movement with avoidance behaviors (resting and limping)
correlated with high level of NPsup1 and LBPsup2 disability
(Johansen JB et al Clin J Pain 2013 29 1029-1035sup1)
(Grotle M et al Pain 2004 112 343-352sup2)
Job dissatisfaction work requiring repetitive tasks
limited autonomy and opportunities for learning and growing
professionally (van Tulder M et al Clin Rheum 2002 16(5) 761-75
risk of MSK pain in women
(Herin F et al Pain 2014 155 937-43)
Lower levels of education - strong predictor of more prolonged episode duration and poorer
outcome (Chou R et al Ann Int Med 2007 147(7) 478-91)
(Deyo RA et al Spine 2006 31 2724-7)
Psychosocial Factors
Problems with sleep
Sometimes - Risk of developing chronic NP LBP - 22-32
OftenAlways - 51-66 (PJ Moork et al Eur J of Pub Health 2013
24(6) 924-29)
Lack of sleep induces a state of low-level systemic inflammation that sensitizes the
nociceptive system (Haack M et al Sleep 2007 30 1145-52) (Wang H et al Clin J Pain 2008 24 273-8)
FROM THE MOVIE ldquoInsomniardquo
Lack of exercise - Increased body weight
Lack of sleep ndash Lack of physical exercise ndash Increased body weight ndash bad combination
(PJ Moork et al Eur J of Pub Health 2013 24(6) 924-29)
Lack of physical activityIncreased BMI
low-grade systemic inflammation that the susceptibility to chronic pain (Roytblat L et al Obesity 2000 8 673-5)
(Petersen AMW et al J Appl Physiol 2005 98 1154-62)
SOURCES OF NECK AND LOW BACK PAIN
a Large disk herniation at the C5-6 disk level
b Right sided disk herniation with nerve root compromise
Patient likely to complain of NP radiated to right upper extremity shooting stabbing
electrical shock-like with paresthesiae
CERVICAL-LUMBAR INTERVERTEBRAL DISK
MECHANISM Inflammation of the nerve roots
When a disk ruptures inflammatory
mediators are released from the nucleus polposus (the inner part of the disk)
around the nerve root leading to chemical neuroradiculitis
CERVICAL-LUMBAR INTERVERTEBRAL DISK
True synovial joints
between the C2-C7 vertebrae located behind the plane of the intervertebral foramina
and the spinal nerves contained therein
Arthritic changes may cause axial neck pain withwithout upper extremity pain
CERVICAL FACET JOINTS
CERVICAL FACET JOINTS
C2-3 C5-6 C6-7
most frequent
facetogenic pain
generators in the cervical
spine
CERVICAL FACET JOINTS
C2-3 joint Pain in the sub-occipital region
radiating to occiput auricular region vertex of the head forehead and orbit
C5-6 joint
Pain radiates over the deltoid region and into the arm
C6-7 joint Pain radiates over
over the medial scapula
ATLANTO-AXIAL JOINT (C1-2)
Pain from C1-2 occurs higher than pain from C2-3
vertex rather than forehead and temple
ATLANTO-OCCIPITAL JOINT (C 0-1)
Pain from C 0-1 almost superimposes pain stemming
from C1-2
Unusual source of neck pain
Note the close anatomic relationship between C0-
1 joint and C1 nerve
between C1-2 joint and C2 ganglia and nerve
and between these joints and the vertebral artery
OTHER SOURCES OF NECK PAIN
Posterior neck muscles
Cervical dura mater
Atlanto-axial joint ligaments
Vertebral artery
Cervical vertebral bodies
True synovial joints with a space a synovial membrane hyaline cartilage surfaces and a
fibrous capsule located in front of the plane of the foramina and the nerve root therein
Arthritic changes may cause axial low back pain withwithout lower extremity pain
LUMBAR FACET JOINTS
LUMBAR FACET JOINTS PAIN CHARACTERISTICS
More common in patients 65
yearolder
Axial low back pain
withwithout radiation to the
lower extremities
Morning stiffness Pain when
starting to move relieved by
the recumbent position
Worsening as day goes by
LUMBAR FACET JOINTS PAIN PATTERNS
L4-5 L5-S1
most frequent facetogenic
pain generators in the lumbar
spine
Pain does not extend down
beyond the level of the knee
Largest axial joint in the
body
Only the anterior third is a
true synovial joint
Complex innervation
including sensory fibers
from L5 through S4 spinal
nerves
SACRO-ILIAC JOINT
A B
No difference in gender
Mean age 40-50
Prevalence 13-30 of
patients with ho low back
pain
Most commonly causing
unilateral symptoms
SACRO-ILIAC JOINT
Pain is always maximal below L5
May radiate to hips groin buttocks
posterior thighs
Patterns of referred pain somewhat
similar to those due to disk and orfacet
joint mediated pain
SACRO-ILIAC JOINT PAIN PATTERN
PIRIFORMIS MUSCLE
Located in the gluteal region is one of the muscles of the lateral
rotator group
It is situated within the posterior wall of the pelvis partly at the
back of the hip joint
Passes out of the pelvis through the greater sciatic foramen
Sciatic nerve
PIRIFORMIS MUSCLE
Sport activities andor certain movements (running lunging) can
stress the piriformis muscle
The subsequent muscle spasm may manifest as MSK low back pain
radiating to the buttock and along the sciatic nerve
Prolonged sitting stretching climbing stairs or walking on inclines squatting
worsen the pain
REALLY A PAIN THE BUTT
OTHER SOURCES OF LOW BACK PAIN
Posterior lumbo-sacral paraspinal pelvic girdle muscles
Lumbar spine ligaments tendons
Vertebral bodies
CAUSES OF NECK AND LOW BACK PAIN
TUMORS
INFECTIONS Discitis Osteomyelitis Septic arthritis Meningitis
VASCULAR DISORDERS (egCarotid artery dissection)
AUTOIMMUNE DISORDERS Rheumatoid arthritis Ankylosing spondylitis Polymyalgia rheumatica
TRAUMA (FracturesDislocations)
MSK DISORDERS Soft tissue injuries Whiplash CervicalLumbosacral
strain Myofascial disorders Fibromyalgia
JOINT DISORDERS Spondylosis and Osteoarthritis
MANAGEMENT
Self limited condition
Symptoms and disability improve rapidly
Most patients return to work and normal activities in 4-6 weeks
(Pengel LH et al BMJ 2003 327 323)
NATURAL HISTORY
1 in 3 patients
Persistent moderate pain 1 year after an acute episode
1 in 5 patients report substantial limitations in activity (von Korff al et al Spine 1996 21 2833-7 ndash discussion 2838-9)
NATURAL HISTORY
History and Physical Exam
Blood work to rule out the
presence of a malignancy andor an infection
Plain radiographs of
cervicallumbar spine CTMRI in patients with neurologic
complaints or with pain not improving
DIAGNOSIS
MAIN GOAL
Achieve adequate pain control (NSAIDs Tylenol Muscle
Relaxants Gabapentinoids short acting opioids)
Relative rest
Activity modifications
INITIAL MANAGEMENT
Epidural steroid injections are an
option in patients with disk herniation back and leg pain
INITIAL MANAGEMENT
Anesth Analg 2016 Mar122(3)857-70 Bhatia A1 Flamer D Shah PS Cohen SP
CONCLUSIONS Epidural steroids injections provide
some analgesic benefit at 3 months in patients with lumbosacral radicular pain
due to herniated intervertebral disks but they have no impact on physical
disability or incidence of surgery
Epidural steroid injections are an option in
patients with spinal stenosis
INITIAL MANAGEMENT
Spinal stenosis causes mechanical compression of the nerve roots swelling
(microvascular injury) producing pain (Olmarker K et al Spine 1989 14 569-573)
L3-4 Spinal Stenosis
INITIAL MANAGEMENT
STEROIDS
inhibit swelling (edema) around the nerve root
(Rydevik B et al Spine 1984 9 7-15)
improve blood flow to neural elements decreasing ischemic neuritis
(Fukusaki M et al Clin J Pain 1998 14 148-51)
block conduction in nociceptive nerve fibers (Johansson A et al Acta Anesthesiol Scand
1990 34 335-38) L4-5 Severe Spinal Stenosis
INITIAL MANAGEMENT
Usually spinal stenosis occurs in pts of senior age
Some of these patients may significant comorbidities and higher sensitivity to
pain medications
Multilevel Cervical Spinal Stenosis
INITIAL MANAGEMENT
Intra-articular facet joint injections are appropriate when a clinical
diagnosis of facet joint ldquosyndromerdquo is confirmed
Axial back pain withwithout radiation
to the extremities
Morning neckback stiffness Pain when starting to move worse on necklumbar
spine extension relieved by the recumbent position
Intra-articular C3-4 facet joint injection
Intra-articular L5-S1 facet joint injection
INITIAL MANAGEMENT
Injections helpful in diagnosis and management of LBP secondary
to SI Joint ldquoSyndromerdquo
Pain is always maximal below L5
May radiate to hips groin buttocks posterior thighs
Patterns of referred pain somewhat similar to those due to disk and orfacet joint mediated
pain
Intra-articular SI Joint Injection
INITIAL MANAGEMENT
Injections helpful in diagnosis and management of LBP due to Piriformis Muscle Syndrome
A REAL PAIN THE BUTT
INITIAL MANAGEMENT ACUPUNCTURE
Some evidence that acupuncture and variations
thereof (acupressure cupping) potentially helpful in the acutesubacute period in
patients with NP and LBP
(Yuan QI et al PloS One 2015 Febr 1-37)
NEXT STEP
Rehabilitation and regaining of function
Physical Therapy very important component of the
rehabilitation
A symbiotic relationship between patient and
therapist key of a successful physical rehabilitation
program
The role of YOGA
Better pain control at rest and with
activities with yoga (9-week program with weekly 90-minute classes) when
compared to a self care exercise program in patients with neck pain
Significant treatment effects of yoga found for pain-related apprehension
disability quality of life and psychological outcomes (depression
fatigue anger)
(Michalsen A et al the J Pain 2012 13(11) 1122-30)
THE IMPORTANCE OF REMAINING ACTIVE
Increasing the amount of steps
walkedday by 1000 over the course of a year reduced the risk of neck pain by
14 in a group of people (men and women age 20-45) with sedentary jobs
(Sitthipornvorakul EA et al Eur Spine J
2015 24 417-24)
SPINAL MANIPULATION No Thank you
Systematic review of spinal
manipulation in patients with a variety of pain conditions including NP
and LBP
Failed to demonstrate that spinal manipulation is an effective
intervention for pain management
(Posadzki P Pain Med 2012 13 754-61)
CONCLUSIONS
Neck and Low Back pain syndromes are usually self limited conditions that can convert in chronic pain conditions causing
prolonged disability
The prevalence and cost of these conditions has significantly increased over the course of the last 15-20 years
Aggressive management of pain during the acute phase is
important because adequate pain control shortens the time and level of disability and facilitates the rehabilitation process
CONCLUSIONS
A variety of treatment modalities including medications acupuncture injections PT Yoga are utilized to manage pain and facilitate the
recovery process
Reducing stress and activities associated with the generation of pain maintaining an appropriate physical exercise regimen and a body weight
as close as possible to the ideal body weight will likely result in a decreased incidenceprevalence of short and long term NP and LBP
THANK YOU
QUESTIONS
Job dissatisfaction work requiring repetitive tasks
limited autonomy and opportunities for learning and growing
professionally (van Tulder M et al Clin Rheum 2002 16(5) 761-75
risk of MSK pain in women
(Herin F et al Pain 2014 155 937-43)
Lower levels of education - strong predictor of more prolonged episode duration and poorer
outcome (Chou R et al Ann Int Med 2007 147(7) 478-91)
(Deyo RA et al Spine 2006 31 2724-7)
Psychosocial Factors
Problems with sleep
Sometimes - Risk of developing chronic NP LBP - 22-32
OftenAlways - 51-66 (PJ Moork et al Eur J of Pub Health 2013
24(6) 924-29)
Lack of sleep induces a state of low-level systemic inflammation that sensitizes the
nociceptive system (Haack M et al Sleep 2007 30 1145-52) (Wang H et al Clin J Pain 2008 24 273-8)
FROM THE MOVIE ldquoInsomniardquo
Lack of exercise - Increased body weight
Lack of sleep ndash Lack of physical exercise ndash Increased body weight ndash bad combination
(PJ Moork et al Eur J of Pub Health 2013 24(6) 924-29)
Lack of physical activityIncreased BMI
low-grade systemic inflammation that the susceptibility to chronic pain (Roytblat L et al Obesity 2000 8 673-5)
(Petersen AMW et al J Appl Physiol 2005 98 1154-62)
SOURCES OF NECK AND LOW BACK PAIN
a Large disk herniation at the C5-6 disk level
b Right sided disk herniation with nerve root compromise
Patient likely to complain of NP radiated to right upper extremity shooting stabbing
electrical shock-like with paresthesiae
CERVICAL-LUMBAR INTERVERTEBRAL DISK
MECHANISM Inflammation of the nerve roots
When a disk ruptures inflammatory
mediators are released from the nucleus polposus (the inner part of the disk)
around the nerve root leading to chemical neuroradiculitis
CERVICAL-LUMBAR INTERVERTEBRAL DISK
True synovial joints
between the C2-C7 vertebrae located behind the plane of the intervertebral foramina
and the spinal nerves contained therein
Arthritic changes may cause axial neck pain withwithout upper extremity pain
CERVICAL FACET JOINTS
CERVICAL FACET JOINTS
C2-3 C5-6 C6-7
most frequent
facetogenic pain
generators in the cervical
spine
CERVICAL FACET JOINTS
C2-3 joint Pain in the sub-occipital region
radiating to occiput auricular region vertex of the head forehead and orbit
C5-6 joint
Pain radiates over the deltoid region and into the arm
C6-7 joint Pain radiates over
over the medial scapula
ATLANTO-AXIAL JOINT (C1-2)
Pain from C1-2 occurs higher than pain from C2-3
vertex rather than forehead and temple
ATLANTO-OCCIPITAL JOINT (C 0-1)
Pain from C 0-1 almost superimposes pain stemming
from C1-2
Unusual source of neck pain
Note the close anatomic relationship between C0-
1 joint and C1 nerve
between C1-2 joint and C2 ganglia and nerve
and between these joints and the vertebral artery
OTHER SOURCES OF NECK PAIN
Posterior neck muscles
Cervical dura mater
Atlanto-axial joint ligaments
Vertebral artery
Cervical vertebral bodies
True synovial joints with a space a synovial membrane hyaline cartilage surfaces and a
fibrous capsule located in front of the plane of the foramina and the nerve root therein
Arthritic changes may cause axial low back pain withwithout lower extremity pain
LUMBAR FACET JOINTS
LUMBAR FACET JOINTS PAIN CHARACTERISTICS
More common in patients 65
yearolder
Axial low back pain
withwithout radiation to the
lower extremities
Morning stiffness Pain when
starting to move relieved by
the recumbent position
Worsening as day goes by
LUMBAR FACET JOINTS PAIN PATTERNS
L4-5 L5-S1
most frequent facetogenic
pain generators in the lumbar
spine
Pain does not extend down
beyond the level of the knee
Largest axial joint in the
body
Only the anterior third is a
true synovial joint
Complex innervation
including sensory fibers
from L5 through S4 spinal
nerves
SACRO-ILIAC JOINT
A B
No difference in gender
Mean age 40-50
Prevalence 13-30 of
patients with ho low back
pain
Most commonly causing
unilateral symptoms
SACRO-ILIAC JOINT
Pain is always maximal below L5
May radiate to hips groin buttocks
posterior thighs
Patterns of referred pain somewhat
similar to those due to disk and orfacet
joint mediated pain
SACRO-ILIAC JOINT PAIN PATTERN
PIRIFORMIS MUSCLE
Located in the gluteal region is one of the muscles of the lateral
rotator group
It is situated within the posterior wall of the pelvis partly at the
back of the hip joint
Passes out of the pelvis through the greater sciatic foramen
Sciatic nerve
PIRIFORMIS MUSCLE
Sport activities andor certain movements (running lunging) can
stress the piriformis muscle
The subsequent muscle spasm may manifest as MSK low back pain
radiating to the buttock and along the sciatic nerve
Prolonged sitting stretching climbing stairs or walking on inclines squatting
worsen the pain
REALLY A PAIN THE BUTT
OTHER SOURCES OF LOW BACK PAIN
Posterior lumbo-sacral paraspinal pelvic girdle muscles
Lumbar spine ligaments tendons
Vertebral bodies
CAUSES OF NECK AND LOW BACK PAIN
TUMORS
INFECTIONS Discitis Osteomyelitis Septic arthritis Meningitis
VASCULAR DISORDERS (egCarotid artery dissection)
AUTOIMMUNE DISORDERS Rheumatoid arthritis Ankylosing spondylitis Polymyalgia rheumatica
TRAUMA (FracturesDislocations)
MSK DISORDERS Soft tissue injuries Whiplash CervicalLumbosacral
strain Myofascial disorders Fibromyalgia
JOINT DISORDERS Spondylosis and Osteoarthritis
MANAGEMENT
Self limited condition
Symptoms and disability improve rapidly
Most patients return to work and normal activities in 4-6 weeks
(Pengel LH et al BMJ 2003 327 323)
NATURAL HISTORY
1 in 3 patients
Persistent moderate pain 1 year after an acute episode
1 in 5 patients report substantial limitations in activity (von Korff al et al Spine 1996 21 2833-7 ndash discussion 2838-9)
NATURAL HISTORY
History and Physical Exam
Blood work to rule out the
presence of a malignancy andor an infection
Plain radiographs of
cervicallumbar spine CTMRI in patients with neurologic
complaints or with pain not improving
DIAGNOSIS
MAIN GOAL
Achieve adequate pain control (NSAIDs Tylenol Muscle
Relaxants Gabapentinoids short acting opioids)
Relative rest
Activity modifications
INITIAL MANAGEMENT
Epidural steroid injections are an
option in patients with disk herniation back and leg pain
INITIAL MANAGEMENT
Anesth Analg 2016 Mar122(3)857-70 Bhatia A1 Flamer D Shah PS Cohen SP
CONCLUSIONS Epidural steroids injections provide
some analgesic benefit at 3 months in patients with lumbosacral radicular pain
due to herniated intervertebral disks but they have no impact on physical
disability or incidence of surgery
Epidural steroid injections are an option in
patients with spinal stenosis
INITIAL MANAGEMENT
Spinal stenosis causes mechanical compression of the nerve roots swelling
(microvascular injury) producing pain (Olmarker K et al Spine 1989 14 569-573)
L3-4 Spinal Stenosis
INITIAL MANAGEMENT
STEROIDS
inhibit swelling (edema) around the nerve root
(Rydevik B et al Spine 1984 9 7-15)
improve blood flow to neural elements decreasing ischemic neuritis
(Fukusaki M et al Clin J Pain 1998 14 148-51)
block conduction in nociceptive nerve fibers (Johansson A et al Acta Anesthesiol Scand
1990 34 335-38) L4-5 Severe Spinal Stenosis
INITIAL MANAGEMENT
Usually spinal stenosis occurs in pts of senior age
Some of these patients may significant comorbidities and higher sensitivity to
pain medications
Multilevel Cervical Spinal Stenosis
INITIAL MANAGEMENT
Intra-articular facet joint injections are appropriate when a clinical
diagnosis of facet joint ldquosyndromerdquo is confirmed
Axial back pain withwithout radiation
to the extremities
Morning neckback stiffness Pain when starting to move worse on necklumbar
spine extension relieved by the recumbent position
Intra-articular C3-4 facet joint injection
Intra-articular L5-S1 facet joint injection
INITIAL MANAGEMENT
Injections helpful in diagnosis and management of LBP secondary
to SI Joint ldquoSyndromerdquo
Pain is always maximal below L5
May radiate to hips groin buttocks posterior thighs
Patterns of referred pain somewhat similar to those due to disk and orfacet joint mediated
pain
Intra-articular SI Joint Injection
INITIAL MANAGEMENT
Injections helpful in diagnosis and management of LBP due to Piriformis Muscle Syndrome
A REAL PAIN THE BUTT
INITIAL MANAGEMENT ACUPUNCTURE
Some evidence that acupuncture and variations
thereof (acupressure cupping) potentially helpful in the acutesubacute period in
patients with NP and LBP
(Yuan QI et al PloS One 2015 Febr 1-37)
NEXT STEP
Rehabilitation and regaining of function
Physical Therapy very important component of the
rehabilitation
A symbiotic relationship between patient and
therapist key of a successful physical rehabilitation
program
The role of YOGA
Better pain control at rest and with
activities with yoga (9-week program with weekly 90-minute classes) when
compared to a self care exercise program in patients with neck pain
Significant treatment effects of yoga found for pain-related apprehension
disability quality of life and psychological outcomes (depression
fatigue anger)
(Michalsen A et al the J Pain 2012 13(11) 1122-30)
THE IMPORTANCE OF REMAINING ACTIVE
Increasing the amount of steps
walkedday by 1000 over the course of a year reduced the risk of neck pain by
14 in a group of people (men and women age 20-45) with sedentary jobs
(Sitthipornvorakul EA et al Eur Spine J
2015 24 417-24)
SPINAL MANIPULATION No Thank you
Systematic review of spinal
manipulation in patients with a variety of pain conditions including NP
and LBP
Failed to demonstrate that spinal manipulation is an effective
intervention for pain management
(Posadzki P Pain Med 2012 13 754-61)
CONCLUSIONS
Neck and Low Back pain syndromes are usually self limited conditions that can convert in chronic pain conditions causing
prolonged disability
The prevalence and cost of these conditions has significantly increased over the course of the last 15-20 years
Aggressive management of pain during the acute phase is
important because adequate pain control shortens the time and level of disability and facilitates the rehabilitation process
CONCLUSIONS
A variety of treatment modalities including medications acupuncture injections PT Yoga are utilized to manage pain and facilitate the
recovery process
Reducing stress and activities associated with the generation of pain maintaining an appropriate physical exercise regimen and a body weight
as close as possible to the ideal body weight will likely result in a decreased incidenceprevalence of short and long term NP and LBP
THANK YOU
QUESTIONS
Problems with sleep
Sometimes - Risk of developing chronic NP LBP - 22-32
OftenAlways - 51-66 (PJ Moork et al Eur J of Pub Health 2013
24(6) 924-29)
Lack of sleep induces a state of low-level systemic inflammation that sensitizes the
nociceptive system (Haack M et al Sleep 2007 30 1145-52) (Wang H et al Clin J Pain 2008 24 273-8)
FROM THE MOVIE ldquoInsomniardquo
Lack of exercise - Increased body weight
Lack of sleep ndash Lack of physical exercise ndash Increased body weight ndash bad combination
(PJ Moork et al Eur J of Pub Health 2013 24(6) 924-29)
Lack of physical activityIncreased BMI
low-grade systemic inflammation that the susceptibility to chronic pain (Roytblat L et al Obesity 2000 8 673-5)
(Petersen AMW et al J Appl Physiol 2005 98 1154-62)
SOURCES OF NECK AND LOW BACK PAIN
a Large disk herniation at the C5-6 disk level
b Right sided disk herniation with nerve root compromise
Patient likely to complain of NP radiated to right upper extremity shooting stabbing
electrical shock-like with paresthesiae
CERVICAL-LUMBAR INTERVERTEBRAL DISK
MECHANISM Inflammation of the nerve roots
When a disk ruptures inflammatory
mediators are released from the nucleus polposus (the inner part of the disk)
around the nerve root leading to chemical neuroradiculitis
CERVICAL-LUMBAR INTERVERTEBRAL DISK
True synovial joints
between the C2-C7 vertebrae located behind the plane of the intervertebral foramina
and the spinal nerves contained therein
Arthritic changes may cause axial neck pain withwithout upper extremity pain
CERVICAL FACET JOINTS
CERVICAL FACET JOINTS
C2-3 C5-6 C6-7
most frequent
facetogenic pain
generators in the cervical
spine
CERVICAL FACET JOINTS
C2-3 joint Pain in the sub-occipital region
radiating to occiput auricular region vertex of the head forehead and orbit
C5-6 joint
Pain radiates over the deltoid region and into the arm
C6-7 joint Pain radiates over
over the medial scapula
ATLANTO-AXIAL JOINT (C1-2)
Pain from C1-2 occurs higher than pain from C2-3
vertex rather than forehead and temple
ATLANTO-OCCIPITAL JOINT (C 0-1)
Pain from C 0-1 almost superimposes pain stemming
from C1-2
Unusual source of neck pain
Note the close anatomic relationship between C0-
1 joint and C1 nerve
between C1-2 joint and C2 ganglia and nerve
and between these joints and the vertebral artery
OTHER SOURCES OF NECK PAIN
Posterior neck muscles
Cervical dura mater
Atlanto-axial joint ligaments
Vertebral artery
Cervical vertebral bodies
True synovial joints with a space a synovial membrane hyaline cartilage surfaces and a
fibrous capsule located in front of the plane of the foramina and the nerve root therein
Arthritic changes may cause axial low back pain withwithout lower extremity pain
LUMBAR FACET JOINTS
LUMBAR FACET JOINTS PAIN CHARACTERISTICS
More common in patients 65
yearolder
Axial low back pain
withwithout radiation to the
lower extremities
Morning stiffness Pain when
starting to move relieved by
the recumbent position
Worsening as day goes by
LUMBAR FACET JOINTS PAIN PATTERNS
L4-5 L5-S1
most frequent facetogenic
pain generators in the lumbar
spine
Pain does not extend down
beyond the level of the knee
Largest axial joint in the
body
Only the anterior third is a
true synovial joint
Complex innervation
including sensory fibers
from L5 through S4 spinal
nerves
SACRO-ILIAC JOINT
A B
No difference in gender
Mean age 40-50
Prevalence 13-30 of
patients with ho low back
pain
Most commonly causing
unilateral symptoms
SACRO-ILIAC JOINT
Pain is always maximal below L5
May radiate to hips groin buttocks
posterior thighs
Patterns of referred pain somewhat
similar to those due to disk and orfacet
joint mediated pain
SACRO-ILIAC JOINT PAIN PATTERN
PIRIFORMIS MUSCLE
Located in the gluteal region is one of the muscles of the lateral
rotator group
It is situated within the posterior wall of the pelvis partly at the
back of the hip joint
Passes out of the pelvis through the greater sciatic foramen
Sciatic nerve
PIRIFORMIS MUSCLE
Sport activities andor certain movements (running lunging) can
stress the piriformis muscle
The subsequent muscle spasm may manifest as MSK low back pain
radiating to the buttock and along the sciatic nerve
Prolonged sitting stretching climbing stairs or walking on inclines squatting
worsen the pain
REALLY A PAIN THE BUTT
OTHER SOURCES OF LOW BACK PAIN
Posterior lumbo-sacral paraspinal pelvic girdle muscles
Lumbar spine ligaments tendons
Vertebral bodies
CAUSES OF NECK AND LOW BACK PAIN
TUMORS
INFECTIONS Discitis Osteomyelitis Septic arthritis Meningitis
VASCULAR DISORDERS (egCarotid artery dissection)
AUTOIMMUNE DISORDERS Rheumatoid arthritis Ankylosing spondylitis Polymyalgia rheumatica
TRAUMA (FracturesDislocations)
MSK DISORDERS Soft tissue injuries Whiplash CervicalLumbosacral
strain Myofascial disorders Fibromyalgia
JOINT DISORDERS Spondylosis and Osteoarthritis
MANAGEMENT
Self limited condition
Symptoms and disability improve rapidly
Most patients return to work and normal activities in 4-6 weeks
(Pengel LH et al BMJ 2003 327 323)
NATURAL HISTORY
1 in 3 patients
Persistent moderate pain 1 year after an acute episode
1 in 5 patients report substantial limitations in activity (von Korff al et al Spine 1996 21 2833-7 ndash discussion 2838-9)
NATURAL HISTORY
History and Physical Exam
Blood work to rule out the
presence of a malignancy andor an infection
Plain radiographs of
cervicallumbar spine CTMRI in patients with neurologic
complaints or with pain not improving
DIAGNOSIS
MAIN GOAL
Achieve adequate pain control (NSAIDs Tylenol Muscle
Relaxants Gabapentinoids short acting opioids)
Relative rest
Activity modifications
INITIAL MANAGEMENT
Epidural steroid injections are an
option in patients with disk herniation back and leg pain
INITIAL MANAGEMENT
Anesth Analg 2016 Mar122(3)857-70 Bhatia A1 Flamer D Shah PS Cohen SP
CONCLUSIONS Epidural steroids injections provide
some analgesic benefit at 3 months in patients with lumbosacral radicular pain
due to herniated intervertebral disks but they have no impact on physical
disability or incidence of surgery
Epidural steroid injections are an option in
patients with spinal stenosis
INITIAL MANAGEMENT
Spinal stenosis causes mechanical compression of the nerve roots swelling
(microvascular injury) producing pain (Olmarker K et al Spine 1989 14 569-573)
L3-4 Spinal Stenosis
INITIAL MANAGEMENT
STEROIDS
inhibit swelling (edema) around the nerve root
(Rydevik B et al Spine 1984 9 7-15)
improve blood flow to neural elements decreasing ischemic neuritis
(Fukusaki M et al Clin J Pain 1998 14 148-51)
block conduction in nociceptive nerve fibers (Johansson A et al Acta Anesthesiol Scand
1990 34 335-38) L4-5 Severe Spinal Stenosis
INITIAL MANAGEMENT
Usually spinal stenosis occurs in pts of senior age
Some of these patients may significant comorbidities and higher sensitivity to
pain medications
Multilevel Cervical Spinal Stenosis
INITIAL MANAGEMENT
Intra-articular facet joint injections are appropriate when a clinical
diagnosis of facet joint ldquosyndromerdquo is confirmed
Axial back pain withwithout radiation
to the extremities
Morning neckback stiffness Pain when starting to move worse on necklumbar
spine extension relieved by the recumbent position
Intra-articular C3-4 facet joint injection
Intra-articular L5-S1 facet joint injection
INITIAL MANAGEMENT
Injections helpful in diagnosis and management of LBP secondary
to SI Joint ldquoSyndromerdquo
Pain is always maximal below L5
May radiate to hips groin buttocks posterior thighs
Patterns of referred pain somewhat similar to those due to disk and orfacet joint mediated
pain
Intra-articular SI Joint Injection
INITIAL MANAGEMENT
Injections helpful in diagnosis and management of LBP due to Piriformis Muscle Syndrome
A REAL PAIN THE BUTT
INITIAL MANAGEMENT ACUPUNCTURE
Some evidence that acupuncture and variations
thereof (acupressure cupping) potentially helpful in the acutesubacute period in
patients with NP and LBP
(Yuan QI et al PloS One 2015 Febr 1-37)
NEXT STEP
Rehabilitation and regaining of function
Physical Therapy very important component of the
rehabilitation
A symbiotic relationship between patient and
therapist key of a successful physical rehabilitation
program
The role of YOGA
Better pain control at rest and with
activities with yoga (9-week program with weekly 90-minute classes) when
compared to a self care exercise program in patients with neck pain
Significant treatment effects of yoga found for pain-related apprehension
disability quality of life and psychological outcomes (depression
fatigue anger)
(Michalsen A et al the J Pain 2012 13(11) 1122-30)
THE IMPORTANCE OF REMAINING ACTIVE
Increasing the amount of steps
walkedday by 1000 over the course of a year reduced the risk of neck pain by
14 in a group of people (men and women age 20-45) with sedentary jobs
(Sitthipornvorakul EA et al Eur Spine J
2015 24 417-24)
SPINAL MANIPULATION No Thank you
Systematic review of spinal
manipulation in patients with a variety of pain conditions including NP
and LBP
Failed to demonstrate that spinal manipulation is an effective
intervention for pain management
(Posadzki P Pain Med 2012 13 754-61)
CONCLUSIONS
Neck and Low Back pain syndromes are usually self limited conditions that can convert in chronic pain conditions causing
prolonged disability
The prevalence and cost of these conditions has significantly increased over the course of the last 15-20 years
Aggressive management of pain during the acute phase is
important because adequate pain control shortens the time and level of disability and facilitates the rehabilitation process
CONCLUSIONS
A variety of treatment modalities including medications acupuncture injections PT Yoga are utilized to manage pain and facilitate the
recovery process
Reducing stress and activities associated with the generation of pain maintaining an appropriate physical exercise regimen and a body weight
as close as possible to the ideal body weight will likely result in a decreased incidenceprevalence of short and long term NP and LBP
THANK YOU
QUESTIONS
Lack of exercise - Increased body weight
Lack of sleep ndash Lack of physical exercise ndash Increased body weight ndash bad combination
(PJ Moork et al Eur J of Pub Health 2013 24(6) 924-29)
Lack of physical activityIncreased BMI
low-grade systemic inflammation that the susceptibility to chronic pain (Roytblat L et al Obesity 2000 8 673-5)
(Petersen AMW et al J Appl Physiol 2005 98 1154-62)
SOURCES OF NECK AND LOW BACK PAIN
a Large disk herniation at the C5-6 disk level
b Right sided disk herniation with nerve root compromise
Patient likely to complain of NP radiated to right upper extremity shooting stabbing
electrical shock-like with paresthesiae
CERVICAL-LUMBAR INTERVERTEBRAL DISK
MECHANISM Inflammation of the nerve roots
When a disk ruptures inflammatory
mediators are released from the nucleus polposus (the inner part of the disk)
around the nerve root leading to chemical neuroradiculitis
CERVICAL-LUMBAR INTERVERTEBRAL DISK
True synovial joints
between the C2-C7 vertebrae located behind the plane of the intervertebral foramina
and the spinal nerves contained therein
Arthritic changes may cause axial neck pain withwithout upper extremity pain
CERVICAL FACET JOINTS
CERVICAL FACET JOINTS
C2-3 C5-6 C6-7
most frequent
facetogenic pain
generators in the cervical
spine
CERVICAL FACET JOINTS
C2-3 joint Pain in the sub-occipital region
radiating to occiput auricular region vertex of the head forehead and orbit
C5-6 joint
Pain radiates over the deltoid region and into the arm
C6-7 joint Pain radiates over
over the medial scapula
ATLANTO-AXIAL JOINT (C1-2)
Pain from C1-2 occurs higher than pain from C2-3
vertex rather than forehead and temple
ATLANTO-OCCIPITAL JOINT (C 0-1)
Pain from C 0-1 almost superimposes pain stemming
from C1-2
Unusual source of neck pain
Note the close anatomic relationship between C0-
1 joint and C1 nerve
between C1-2 joint and C2 ganglia and nerve
and between these joints and the vertebral artery
OTHER SOURCES OF NECK PAIN
Posterior neck muscles
Cervical dura mater
Atlanto-axial joint ligaments
Vertebral artery
Cervical vertebral bodies
True synovial joints with a space a synovial membrane hyaline cartilage surfaces and a
fibrous capsule located in front of the plane of the foramina and the nerve root therein
Arthritic changes may cause axial low back pain withwithout lower extremity pain
LUMBAR FACET JOINTS
LUMBAR FACET JOINTS PAIN CHARACTERISTICS
More common in patients 65
yearolder
Axial low back pain
withwithout radiation to the
lower extremities
Morning stiffness Pain when
starting to move relieved by
the recumbent position
Worsening as day goes by
LUMBAR FACET JOINTS PAIN PATTERNS
L4-5 L5-S1
most frequent facetogenic
pain generators in the lumbar
spine
Pain does not extend down
beyond the level of the knee
Largest axial joint in the
body
Only the anterior third is a
true synovial joint
Complex innervation
including sensory fibers
from L5 through S4 spinal
nerves
SACRO-ILIAC JOINT
A B
No difference in gender
Mean age 40-50
Prevalence 13-30 of
patients with ho low back
pain
Most commonly causing
unilateral symptoms
SACRO-ILIAC JOINT
Pain is always maximal below L5
May radiate to hips groin buttocks
posterior thighs
Patterns of referred pain somewhat
similar to those due to disk and orfacet
joint mediated pain
SACRO-ILIAC JOINT PAIN PATTERN
PIRIFORMIS MUSCLE
Located in the gluteal region is one of the muscles of the lateral
rotator group
It is situated within the posterior wall of the pelvis partly at the
back of the hip joint
Passes out of the pelvis through the greater sciatic foramen
Sciatic nerve
PIRIFORMIS MUSCLE
Sport activities andor certain movements (running lunging) can
stress the piriformis muscle
The subsequent muscle spasm may manifest as MSK low back pain
radiating to the buttock and along the sciatic nerve
Prolonged sitting stretching climbing stairs or walking on inclines squatting
worsen the pain
REALLY A PAIN THE BUTT
OTHER SOURCES OF LOW BACK PAIN
Posterior lumbo-sacral paraspinal pelvic girdle muscles
Lumbar spine ligaments tendons
Vertebral bodies
CAUSES OF NECK AND LOW BACK PAIN
TUMORS
INFECTIONS Discitis Osteomyelitis Septic arthritis Meningitis
VASCULAR DISORDERS (egCarotid artery dissection)
AUTOIMMUNE DISORDERS Rheumatoid arthritis Ankylosing spondylitis Polymyalgia rheumatica
TRAUMA (FracturesDislocations)
MSK DISORDERS Soft tissue injuries Whiplash CervicalLumbosacral
strain Myofascial disorders Fibromyalgia
JOINT DISORDERS Spondylosis and Osteoarthritis
MANAGEMENT
Self limited condition
Symptoms and disability improve rapidly
Most patients return to work and normal activities in 4-6 weeks
(Pengel LH et al BMJ 2003 327 323)
NATURAL HISTORY
1 in 3 patients
Persistent moderate pain 1 year after an acute episode
1 in 5 patients report substantial limitations in activity (von Korff al et al Spine 1996 21 2833-7 ndash discussion 2838-9)
NATURAL HISTORY
History and Physical Exam
Blood work to rule out the
presence of a malignancy andor an infection
Plain radiographs of
cervicallumbar spine CTMRI in patients with neurologic
complaints or with pain not improving
DIAGNOSIS
MAIN GOAL
Achieve adequate pain control (NSAIDs Tylenol Muscle
Relaxants Gabapentinoids short acting opioids)
Relative rest
Activity modifications
INITIAL MANAGEMENT
Epidural steroid injections are an
option in patients with disk herniation back and leg pain
INITIAL MANAGEMENT
Anesth Analg 2016 Mar122(3)857-70 Bhatia A1 Flamer D Shah PS Cohen SP
CONCLUSIONS Epidural steroids injections provide
some analgesic benefit at 3 months in patients with lumbosacral radicular pain
due to herniated intervertebral disks but they have no impact on physical
disability or incidence of surgery
Epidural steroid injections are an option in
patients with spinal stenosis
INITIAL MANAGEMENT
Spinal stenosis causes mechanical compression of the nerve roots swelling
(microvascular injury) producing pain (Olmarker K et al Spine 1989 14 569-573)
L3-4 Spinal Stenosis
INITIAL MANAGEMENT
STEROIDS
inhibit swelling (edema) around the nerve root
(Rydevik B et al Spine 1984 9 7-15)
improve blood flow to neural elements decreasing ischemic neuritis
(Fukusaki M et al Clin J Pain 1998 14 148-51)
block conduction in nociceptive nerve fibers (Johansson A et al Acta Anesthesiol Scand
1990 34 335-38) L4-5 Severe Spinal Stenosis
INITIAL MANAGEMENT
Usually spinal stenosis occurs in pts of senior age
Some of these patients may significant comorbidities and higher sensitivity to
pain medications
Multilevel Cervical Spinal Stenosis
INITIAL MANAGEMENT
Intra-articular facet joint injections are appropriate when a clinical
diagnosis of facet joint ldquosyndromerdquo is confirmed
Axial back pain withwithout radiation
to the extremities
Morning neckback stiffness Pain when starting to move worse on necklumbar
spine extension relieved by the recumbent position
Intra-articular C3-4 facet joint injection
Intra-articular L5-S1 facet joint injection
INITIAL MANAGEMENT
Injections helpful in diagnosis and management of LBP secondary
to SI Joint ldquoSyndromerdquo
Pain is always maximal below L5
May radiate to hips groin buttocks posterior thighs
Patterns of referred pain somewhat similar to those due to disk and orfacet joint mediated
pain
Intra-articular SI Joint Injection
INITIAL MANAGEMENT
Injections helpful in diagnosis and management of LBP due to Piriformis Muscle Syndrome
A REAL PAIN THE BUTT
INITIAL MANAGEMENT ACUPUNCTURE
Some evidence that acupuncture and variations
thereof (acupressure cupping) potentially helpful in the acutesubacute period in
patients with NP and LBP
(Yuan QI et al PloS One 2015 Febr 1-37)
NEXT STEP
Rehabilitation and regaining of function
Physical Therapy very important component of the
rehabilitation
A symbiotic relationship between patient and
therapist key of a successful physical rehabilitation
program
The role of YOGA
Better pain control at rest and with
activities with yoga (9-week program with weekly 90-minute classes) when
compared to a self care exercise program in patients with neck pain
Significant treatment effects of yoga found for pain-related apprehension
disability quality of life and psychological outcomes (depression
fatigue anger)
(Michalsen A et al the J Pain 2012 13(11) 1122-30)
THE IMPORTANCE OF REMAINING ACTIVE
Increasing the amount of steps
walkedday by 1000 over the course of a year reduced the risk of neck pain by
14 in a group of people (men and women age 20-45) with sedentary jobs
(Sitthipornvorakul EA et al Eur Spine J
2015 24 417-24)
SPINAL MANIPULATION No Thank you
Systematic review of spinal
manipulation in patients with a variety of pain conditions including NP
and LBP
Failed to demonstrate that spinal manipulation is an effective
intervention for pain management
(Posadzki P Pain Med 2012 13 754-61)
CONCLUSIONS
Neck and Low Back pain syndromes are usually self limited conditions that can convert in chronic pain conditions causing
prolonged disability
The prevalence and cost of these conditions has significantly increased over the course of the last 15-20 years
Aggressive management of pain during the acute phase is
important because adequate pain control shortens the time and level of disability and facilitates the rehabilitation process
CONCLUSIONS
A variety of treatment modalities including medications acupuncture injections PT Yoga are utilized to manage pain and facilitate the
recovery process
Reducing stress and activities associated with the generation of pain maintaining an appropriate physical exercise regimen and a body weight
as close as possible to the ideal body weight will likely result in a decreased incidenceprevalence of short and long term NP and LBP
THANK YOU
QUESTIONS
SOURCES OF NECK AND LOW BACK PAIN
a Large disk herniation at the C5-6 disk level
b Right sided disk herniation with nerve root compromise
Patient likely to complain of NP radiated to right upper extremity shooting stabbing
electrical shock-like with paresthesiae
CERVICAL-LUMBAR INTERVERTEBRAL DISK
MECHANISM Inflammation of the nerve roots
When a disk ruptures inflammatory
mediators are released from the nucleus polposus (the inner part of the disk)
around the nerve root leading to chemical neuroradiculitis
CERVICAL-LUMBAR INTERVERTEBRAL DISK
True synovial joints
between the C2-C7 vertebrae located behind the plane of the intervertebral foramina
and the spinal nerves contained therein
Arthritic changes may cause axial neck pain withwithout upper extremity pain
CERVICAL FACET JOINTS
CERVICAL FACET JOINTS
C2-3 C5-6 C6-7
most frequent
facetogenic pain
generators in the cervical
spine
CERVICAL FACET JOINTS
C2-3 joint Pain in the sub-occipital region
radiating to occiput auricular region vertex of the head forehead and orbit
C5-6 joint
Pain radiates over the deltoid region and into the arm
C6-7 joint Pain radiates over
over the medial scapula
ATLANTO-AXIAL JOINT (C1-2)
Pain from C1-2 occurs higher than pain from C2-3
vertex rather than forehead and temple
ATLANTO-OCCIPITAL JOINT (C 0-1)
Pain from C 0-1 almost superimposes pain stemming
from C1-2
Unusual source of neck pain
Note the close anatomic relationship between C0-
1 joint and C1 nerve
between C1-2 joint and C2 ganglia and nerve
and between these joints and the vertebral artery
OTHER SOURCES OF NECK PAIN
Posterior neck muscles
Cervical dura mater
Atlanto-axial joint ligaments
Vertebral artery
Cervical vertebral bodies
True synovial joints with a space a synovial membrane hyaline cartilage surfaces and a
fibrous capsule located in front of the plane of the foramina and the nerve root therein
Arthritic changes may cause axial low back pain withwithout lower extremity pain
LUMBAR FACET JOINTS
LUMBAR FACET JOINTS PAIN CHARACTERISTICS
More common in patients 65
yearolder
Axial low back pain
withwithout radiation to the
lower extremities
Morning stiffness Pain when
starting to move relieved by
the recumbent position
Worsening as day goes by
LUMBAR FACET JOINTS PAIN PATTERNS
L4-5 L5-S1
most frequent facetogenic
pain generators in the lumbar
spine
Pain does not extend down
beyond the level of the knee
Largest axial joint in the
body
Only the anterior third is a
true synovial joint
Complex innervation
including sensory fibers
from L5 through S4 spinal
nerves
SACRO-ILIAC JOINT
A B
No difference in gender
Mean age 40-50
Prevalence 13-30 of
patients with ho low back
pain
Most commonly causing
unilateral symptoms
SACRO-ILIAC JOINT
Pain is always maximal below L5
May radiate to hips groin buttocks
posterior thighs
Patterns of referred pain somewhat
similar to those due to disk and orfacet
joint mediated pain
SACRO-ILIAC JOINT PAIN PATTERN
PIRIFORMIS MUSCLE
Located in the gluteal region is one of the muscles of the lateral
rotator group
It is situated within the posterior wall of the pelvis partly at the
back of the hip joint
Passes out of the pelvis through the greater sciatic foramen
Sciatic nerve
PIRIFORMIS MUSCLE
Sport activities andor certain movements (running lunging) can
stress the piriformis muscle
The subsequent muscle spasm may manifest as MSK low back pain
radiating to the buttock and along the sciatic nerve
Prolonged sitting stretching climbing stairs or walking on inclines squatting
worsen the pain
REALLY A PAIN THE BUTT
OTHER SOURCES OF LOW BACK PAIN
Posterior lumbo-sacral paraspinal pelvic girdle muscles
Lumbar spine ligaments tendons
Vertebral bodies
CAUSES OF NECK AND LOW BACK PAIN
TUMORS
INFECTIONS Discitis Osteomyelitis Septic arthritis Meningitis
VASCULAR DISORDERS (egCarotid artery dissection)
AUTOIMMUNE DISORDERS Rheumatoid arthritis Ankylosing spondylitis Polymyalgia rheumatica
TRAUMA (FracturesDislocations)
MSK DISORDERS Soft tissue injuries Whiplash CervicalLumbosacral
strain Myofascial disorders Fibromyalgia
JOINT DISORDERS Spondylosis and Osteoarthritis
MANAGEMENT
Self limited condition
Symptoms and disability improve rapidly
Most patients return to work and normal activities in 4-6 weeks
(Pengel LH et al BMJ 2003 327 323)
NATURAL HISTORY
1 in 3 patients
Persistent moderate pain 1 year after an acute episode
1 in 5 patients report substantial limitations in activity (von Korff al et al Spine 1996 21 2833-7 ndash discussion 2838-9)
NATURAL HISTORY
History and Physical Exam
Blood work to rule out the
presence of a malignancy andor an infection
Plain radiographs of
cervicallumbar spine CTMRI in patients with neurologic
complaints or with pain not improving
DIAGNOSIS
MAIN GOAL
Achieve adequate pain control (NSAIDs Tylenol Muscle
Relaxants Gabapentinoids short acting opioids)
Relative rest
Activity modifications
INITIAL MANAGEMENT
Epidural steroid injections are an
option in patients with disk herniation back and leg pain
INITIAL MANAGEMENT
Anesth Analg 2016 Mar122(3)857-70 Bhatia A1 Flamer D Shah PS Cohen SP
CONCLUSIONS Epidural steroids injections provide
some analgesic benefit at 3 months in patients with lumbosacral radicular pain
due to herniated intervertebral disks but they have no impact on physical
disability or incidence of surgery
Epidural steroid injections are an option in
patients with spinal stenosis
INITIAL MANAGEMENT
Spinal stenosis causes mechanical compression of the nerve roots swelling
(microvascular injury) producing pain (Olmarker K et al Spine 1989 14 569-573)
L3-4 Spinal Stenosis
INITIAL MANAGEMENT
STEROIDS
inhibit swelling (edema) around the nerve root
(Rydevik B et al Spine 1984 9 7-15)
improve blood flow to neural elements decreasing ischemic neuritis
(Fukusaki M et al Clin J Pain 1998 14 148-51)
block conduction in nociceptive nerve fibers (Johansson A et al Acta Anesthesiol Scand
1990 34 335-38) L4-5 Severe Spinal Stenosis
INITIAL MANAGEMENT
Usually spinal stenosis occurs in pts of senior age
Some of these patients may significant comorbidities and higher sensitivity to
pain medications
Multilevel Cervical Spinal Stenosis
INITIAL MANAGEMENT
Intra-articular facet joint injections are appropriate when a clinical
diagnosis of facet joint ldquosyndromerdquo is confirmed
Axial back pain withwithout radiation
to the extremities
Morning neckback stiffness Pain when starting to move worse on necklumbar
spine extension relieved by the recumbent position
Intra-articular C3-4 facet joint injection
Intra-articular L5-S1 facet joint injection
INITIAL MANAGEMENT
Injections helpful in diagnosis and management of LBP secondary
to SI Joint ldquoSyndromerdquo
Pain is always maximal below L5
May radiate to hips groin buttocks posterior thighs
Patterns of referred pain somewhat similar to those due to disk and orfacet joint mediated
pain
Intra-articular SI Joint Injection
INITIAL MANAGEMENT
Injections helpful in diagnosis and management of LBP due to Piriformis Muscle Syndrome
A REAL PAIN THE BUTT
INITIAL MANAGEMENT ACUPUNCTURE
Some evidence that acupuncture and variations
thereof (acupressure cupping) potentially helpful in the acutesubacute period in
patients with NP and LBP
(Yuan QI et al PloS One 2015 Febr 1-37)
NEXT STEP
Rehabilitation and regaining of function
Physical Therapy very important component of the
rehabilitation
A symbiotic relationship between patient and
therapist key of a successful physical rehabilitation
program
The role of YOGA
Better pain control at rest and with
activities with yoga (9-week program with weekly 90-minute classes) when
compared to a self care exercise program in patients with neck pain
Significant treatment effects of yoga found for pain-related apprehension
disability quality of life and psychological outcomes (depression
fatigue anger)
(Michalsen A et al the J Pain 2012 13(11) 1122-30)
THE IMPORTANCE OF REMAINING ACTIVE
Increasing the amount of steps
walkedday by 1000 over the course of a year reduced the risk of neck pain by
14 in a group of people (men and women age 20-45) with sedentary jobs
(Sitthipornvorakul EA et al Eur Spine J
2015 24 417-24)
SPINAL MANIPULATION No Thank you
Systematic review of spinal
manipulation in patients with a variety of pain conditions including NP
and LBP
Failed to demonstrate that spinal manipulation is an effective
intervention for pain management
(Posadzki P Pain Med 2012 13 754-61)
CONCLUSIONS
Neck and Low Back pain syndromes are usually self limited conditions that can convert in chronic pain conditions causing
prolonged disability
The prevalence and cost of these conditions has significantly increased over the course of the last 15-20 years
Aggressive management of pain during the acute phase is
important because adequate pain control shortens the time and level of disability and facilitates the rehabilitation process
CONCLUSIONS
A variety of treatment modalities including medications acupuncture injections PT Yoga are utilized to manage pain and facilitate the
recovery process
Reducing stress and activities associated with the generation of pain maintaining an appropriate physical exercise regimen and a body weight
as close as possible to the ideal body weight will likely result in a decreased incidenceprevalence of short and long term NP and LBP
THANK YOU
QUESTIONS
a Large disk herniation at the C5-6 disk level
b Right sided disk herniation with nerve root compromise
Patient likely to complain of NP radiated to right upper extremity shooting stabbing
electrical shock-like with paresthesiae
CERVICAL-LUMBAR INTERVERTEBRAL DISK
MECHANISM Inflammation of the nerve roots
When a disk ruptures inflammatory
mediators are released from the nucleus polposus (the inner part of the disk)
around the nerve root leading to chemical neuroradiculitis
CERVICAL-LUMBAR INTERVERTEBRAL DISK
True synovial joints
between the C2-C7 vertebrae located behind the plane of the intervertebral foramina
and the spinal nerves contained therein
Arthritic changes may cause axial neck pain withwithout upper extremity pain
CERVICAL FACET JOINTS
CERVICAL FACET JOINTS
C2-3 C5-6 C6-7
most frequent
facetogenic pain
generators in the cervical
spine
CERVICAL FACET JOINTS
C2-3 joint Pain in the sub-occipital region
radiating to occiput auricular region vertex of the head forehead and orbit
C5-6 joint
Pain radiates over the deltoid region and into the arm
C6-7 joint Pain radiates over
over the medial scapula
ATLANTO-AXIAL JOINT (C1-2)
Pain from C1-2 occurs higher than pain from C2-3
vertex rather than forehead and temple
ATLANTO-OCCIPITAL JOINT (C 0-1)
Pain from C 0-1 almost superimposes pain stemming
from C1-2
Unusual source of neck pain
Note the close anatomic relationship between C0-
1 joint and C1 nerve
between C1-2 joint and C2 ganglia and nerve
and between these joints and the vertebral artery
OTHER SOURCES OF NECK PAIN
Posterior neck muscles
Cervical dura mater
Atlanto-axial joint ligaments
Vertebral artery
Cervical vertebral bodies
True synovial joints with a space a synovial membrane hyaline cartilage surfaces and a
fibrous capsule located in front of the plane of the foramina and the nerve root therein
Arthritic changes may cause axial low back pain withwithout lower extremity pain
LUMBAR FACET JOINTS
LUMBAR FACET JOINTS PAIN CHARACTERISTICS
More common in patients 65
yearolder
Axial low back pain
withwithout radiation to the
lower extremities
Morning stiffness Pain when
starting to move relieved by
the recumbent position
Worsening as day goes by
LUMBAR FACET JOINTS PAIN PATTERNS
L4-5 L5-S1
most frequent facetogenic
pain generators in the lumbar
spine
Pain does not extend down
beyond the level of the knee
Largest axial joint in the
body
Only the anterior third is a
true synovial joint
Complex innervation
including sensory fibers
from L5 through S4 spinal
nerves
SACRO-ILIAC JOINT
A B
No difference in gender
Mean age 40-50
Prevalence 13-30 of
patients with ho low back
pain
Most commonly causing
unilateral symptoms
SACRO-ILIAC JOINT
Pain is always maximal below L5
May radiate to hips groin buttocks
posterior thighs
Patterns of referred pain somewhat
similar to those due to disk and orfacet
joint mediated pain
SACRO-ILIAC JOINT PAIN PATTERN
PIRIFORMIS MUSCLE
Located in the gluteal region is one of the muscles of the lateral
rotator group
It is situated within the posterior wall of the pelvis partly at the
back of the hip joint
Passes out of the pelvis through the greater sciatic foramen
Sciatic nerve
PIRIFORMIS MUSCLE
Sport activities andor certain movements (running lunging) can
stress the piriformis muscle
The subsequent muscle spasm may manifest as MSK low back pain
radiating to the buttock and along the sciatic nerve
Prolonged sitting stretching climbing stairs or walking on inclines squatting
worsen the pain
REALLY A PAIN THE BUTT
OTHER SOURCES OF LOW BACK PAIN
Posterior lumbo-sacral paraspinal pelvic girdle muscles
Lumbar spine ligaments tendons
Vertebral bodies
CAUSES OF NECK AND LOW BACK PAIN
TUMORS
INFECTIONS Discitis Osteomyelitis Septic arthritis Meningitis
VASCULAR DISORDERS (egCarotid artery dissection)
AUTOIMMUNE DISORDERS Rheumatoid arthritis Ankylosing spondylitis Polymyalgia rheumatica
TRAUMA (FracturesDislocations)
MSK DISORDERS Soft tissue injuries Whiplash CervicalLumbosacral
strain Myofascial disorders Fibromyalgia
JOINT DISORDERS Spondylosis and Osteoarthritis
MANAGEMENT
Self limited condition
Symptoms and disability improve rapidly
Most patients return to work and normal activities in 4-6 weeks
(Pengel LH et al BMJ 2003 327 323)
NATURAL HISTORY
1 in 3 patients
Persistent moderate pain 1 year after an acute episode
1 in 5 patients report substantial limitations in activity (von Korff al et al Spine 1996 21 2833-7 ndash discussion 2838-9)
NATURAL HISTORY
History and Physical Exam
Blood work to rule out the
presence of a malignancy andor an infection
Plain radiographs of
cervicallumbar spine CTMRI in patients with neurologic
complaints or with pain not improving
DIAGNOSIS
MAIN GOAL
Achieve adequate pain control (NSAIDs Tylenol Muscle
Relaxants Gabapentinoids short acting opioids)
Relative rest
Activity modifications
INITIAL MANAGEMENT
Epidural steroid injections are an
option in patients with disk herniation back and leg pain
INITIAL MANAGEMENT
Anesth Analg 2016 Mar122(3)857-70 Bhatia A1 Flamer D Shah PS Cohen SP
CONCLUSIONS Epidural steroids injections provide
some analgesic benefit at 3 months in patients with lumbosacral radicular pain
due to herniated intervertebral disks but they have no impact on physical
disability or incidence of surgery
Epidural steroid injections are an option in
patients with spinal stenosis
INITIAL MANAGEMENT
Spinal stenosis causes mechanical compression of the nerve roots swelling
(microvascular injury) producing pain (Olmarker K et al Spine 1989 14 569-573)
L3-4 Spinal Stenosis
INITIAL MANAGEMENT
STEROIDS
inhibit swelling (edema) around the nerve root
(Rydevik B et al Spine 1984 9 7-15)
improve blood flow to neural elements decreasing ischemic neuritis
(Fukusaki M et al Clin J Pain 1998 14 148-51)
block conduction in nociceptive nerve fibers (Johansson A et al Acta Anesthesiol Scand
1990 34 335-38) L4-5 Severe Spinal Stenosis
INITIAL MANAGEMENT
Usually spinal stenosis occurs in pts of senior age
Some of these patients may significant comorbidities and higher sensitivity to
pain medications
Multilevel Cervical Spinal Stenosis
INITIAL MANAGEMENT
Intra-articular facet joint injections are appropriate when a clinical
diagnosis of facet joint ldquosyndromerdquo is confirmed
Axial back pain withwithout radiation
to the extremities
Morning neckback stiffness Pain when starting to move worse on necklumbar
spine extension relieved by the recumbent position
Intra-articular C3-4 facet joint injection
Intra-articular L5-S1 facet joint injection
INITIAL MANAGEMENT
Injections helpful in diagnosis and management of LBP secondary
to SI Joint ldquoSyndromerdquo
Pain is always maximal below L5
May radiate to hips groin buttocks posterior thighs
Patterns of referred pain somewhat similar to those due to disk and orfacet joint mediated
pain
Intra-articular SI Joint Injection
INITIAL MANAGEMENT
Injections helpful in diagnosis and management of LBP due to Piriformis Muscle Syndrome
A REAL PAIN THE BUTT
INITIAL MANAGEMENT ACUPUNCTURE
Some evidence that acupuncture and variations
thereof (acupressure cupping) potentially helpful in the acutesubacute period in
patients with NP and LBP
(Yuan QI et al PloS One 2015 Febr 1-37)
NEXT STEP
Rehabilitation and regaining of function
Physical Therapy very important component of the
rehabilitation
A symbiotic relationship between patient and
therapist key of a successful physical rehabilitation
program
The role of YOGA
Better pain control at rest and with
activities with yoga (9-week program with weekly 90-minute classes) when
compared to a self care exercise program in patients with neck pain
Significant treatment effects of yoga found for pain-related apprehension
disability quality of life and psychological outcomes (depression
fatigue anger)
(Michalsen A et al the J Pain 2012 13(11) 1122-30)
THE IMPORTANCE OF REMAINING ACTIVE
Increasing the amount of steps
walkedday by 1000 over the course of a year reduced the risk of neck pain by
14 in a group of people (men and women age 20-45) with sedentary jobs
(Sitthipornvorakul EA et al Eur Spine J
2015 24 417-24)
SPINAL MANIPULATION No Thank you
Systematic review of spinal
manipulation in patients with a variety of pain conditions including NP
and LBP
Failed to demonstrate that spinal manipulation is an effective
intervention for pain management
(Posadzki P Pain Med 2012 13 754-61)
CONCLUSIONS
Neck and Low Back pain syndromes are usually self limited conditions that can convert in chronic pain conditions causing
prolonged disability
The prevalence and cost of these conditions has significantly increased over the course of the last 15-20 years
Aggressive management of pain during the acute phase is
important because adequate pain control shortens the time and level of disability and facilitates the rehabilitation process
CONCLUSIONS
A variety of treatment modalities including medications acupuncture injections PT Yoga are utilized to manage pain and facilitate the
recovery process
Reducing stress and activities associated with the generation of pain maintaining an appropriate physical exercise regimen and a body weight
as close as possible to the ideal body weight will likely result in a decreased incidenceprevalence of short and long term NP and LBP
THANK YOU
QUESTIONS
MECHANISM Inflammation of the nerve roots
When a disk ruptures inflammatory
mediators are released from the nucleus polposus (the inner part of the disk)
around the nerve root leading to chemical neuroradiculitis
CERVICAL-LUMBAR INTERVERTEBRAL DISK
True synovial joints
between the C2-C7 vertebrae located behind the plane of the intervertebral foramina
and the spinal nerves contained therein
Arthritic changes may cause axial neck pain withwithout upper extremity pain
CERVICAL FACET JOINTS
CERVICAL FACET JOINTS
C2-3 C5-6 C6-7
most frequent
facetogenic pain
generators in the cervical
spine
CERVICAL FACET JOINTS
C2-3 joint Pain in the sub-occipital region
radiating to occiput auricular region vertex of the head forehead and orbit
C5-6 joint
Pain radiates over the deltoid region and into the arm
C6-7 joint Pain radiates over
over the medial scapula
ATLANTO-AXIAL JOINT (C1-2)
Pain from C1-2 occurs higher than pain from C2-3
vertex rather than forehead and temple
ATLANTO-OCCIPITAL JOINT (C 0-1)
Pain from C 0-1 almost superimposes pain stemming
from C1-2
Unusual source of neck pain
Note the close anatomic relationship between C0-
1 joint and C1 nerve
between C1-2 joint and C2 ganglia and nerve
and between these joints and the vertebral artery
OTHER SOURCES OF NECK PAIN
Posterior neck muscles
Cervical dura mater
Atlanto-axial joint ligaments
Vertebral artery
Cervical vertebral bodies
True synovial joints with a space a synovial membrane hyaline cartilage surfaces and a
fibrous capsule located in front of the plane of the foramina and the nerve root therein
Arthritic changes may cause axial low back pain withwithout lower extremity pain
LUMBAR FACET JOINTS
LUMBAR FACET JOINTS PAIN CHARACTERISTICS
More common in patients 65
yearolder
Axial low back pain
withwithout radiation to the
lower extremities
Morning stiffness Pain when
starting to move relieved by
the recumbent position
Worsening as day goes by
LUMBAR FACET JOINTS PAIN PATTERNS
L4-5 L5-S1
most frequent facetogenic
pain generators in the lumbar
spine
Pain does not extend down
beyond the level of the knee
Largest axial joint in the
body
Only the anterior third is a
true synovial joint
Complex innervation
including sensory fibers
from L5 through S4 spinal
nerves
SACRO-ILIAC JOINT
A B
No difference in gender
Mean age 40-50
Prevalence 13-30 of
patients with ho low back
pain
Most commonly causing
unilateral symptoms
SACRO-ILIAC JOINT
Pain is always maximal below L5
May radiate to hips groin buttocks
posterior thighs
Patterns of referred pain somewhat
similar to those due to disk and orfacet
joint mediated pain
SACRO-ILIAC JOINT PAIN PATTERN
PIRIFORMIS MUSCLE
Located in the gluteal region is one of the muscles of the lateral
rotator group
It is situated within the posterior wall of the pelvis partly at the
back of the hip joint
Passes out of the pelvis through the greater sciatic foramen
Sciatic nerve
PIRIFORMIS MUSCLE
Sport activities andor certain movements (running lunging) can
stress the piriformis muscle
The subsequent muscle spasm may manifest as MSK low back pain
radiating to the buttock and along the sciatic nerve
Prolonged sitting stretching climbing stairs or walking on inclines squatting
worsen the pain
REALLY A PAIN THE BUTT
OTHER SOURCES OF LOW BACK PAIN
Posterior lumbo-sacral paraspinal pelvic girdle muscles
Lumbar spine ligaments tendons
Vertebral bodies
CAUSES OF NECK AND LOW BACK PAIN
TUMORS
INFECTIONS Discitis Osteomyelitis Septic arthritis Meningitis
VASCULAR DISORDERS (egCarotid artery dissection)
AUTOIMMUNE DISORDERS Rheumatoid arthritis Ankylosing spondylitis Polymyalgia rheumatica
TRAUMA (FracturesDislocations)
MSK DISORDERS Soft tissue injuries Whiplash CervicalLumbosacral
strain Myofascial disorders Fibromyalgia
JOINT DISORDERS Spondylosis and Osteoarthritis
MANAGEMENT
Self limited condition
Symptoms and disability improve rapidly
Most patients return to work and normal activities in 4-6 weeks
(Pengel LH et al BMJ 2003 327 323)
NATURAL HISTORY
1 in 3 patients
Persistent moderate pain 1 year after an acute episode
1 in 5 patients report substantial limitations in activity (von Korff al et al Spine 1996 21 2833-7 ndash discussion 2838-9)
NATURAL HISTORY
History and Physical Exam
Blood work to rule out the
presence of a malignancy andor an infection
Plain radiographs of
cervicallumbar spine CTMRI in patients with neurologic
complaints or with pain not improving
DIAGNOSIS
MAIN GOAL
Achieve adequate pain control (NSAIDs Tylenol Muscle
Relaxants Gabapentinoids short acting opioids)
Relative rest
Activity modifications
INITIAL MANAGEMENT
Epidural steroid injections are an
option in patients with disk herniation back and leg pain
INITIAL MANAGEMENT
Anesth Analg 2016 Mar122(3)857-70 Bhatia A1 Flamer D Shah PS Cohen SP
CONCLUSIONS Epidural steroids injections provide
some analgesic benefit at 3 months in patients with lumbosacral radicular pain
due to herniated intervertebral disks but they have no impact on physical
disability or incidence of surgery
Epidural steroid injections are an option in
patients with spinal stenosis
INITIAL MANAGEMENT
Spinal stenosis causes mechanical compression of the nerve roots swelling
(microvascular injury) producing pain (Olmarker K et al Spine 1989 14 569-573)
L3-4 Spinal Stenosis
INITIAL MANAGEMENT
STEROIDS
inhibit swelling (edema) around the nerve root
(Rydevik B et al Spine 1984 9 7-15)
improve blood flow to neural elements decreasing ischemic neuritis
(Fukusaki M et al Clin J Pain 1998 14 148-51)
block conduction in nociceptive nerve fibers (Johansson A et al Acta Anesthesiol Scand
1990 34 335-38) L4-5 Severe Spinal Stenosis
INITIAL MANAGEMENT
Usually spinal stenosis occurs in pts of senior age
Some of these patients may significant comorbidities and higher sensitivity to
pain medications
Multilevel Cervical Spinal Stenosis
INITIAL MANAGEMENT
Intra-articular facet joint injections are appropriate when a clinical
diagnosis of facet joint ldquosyndromerdquo is confirmed
Axial back pain withwithout radiation
to the extremities
Morning neckback stiffness Pain when starting to move worse on necklumbar
spine extension relieved by the recumbent position
Intra-articular C3-4 facet joint injection
Intra-articular L5-S1 facet joint injection
INITIAL MANAGEMENT
Injections helpful in diagnosis and management of LBP secondary
to SI Joint ldquoSyndromerdquo
Pain is always maximal below L5
May radiate to hips groin buttocks posterior thighs
Patterns of referred pain somewhat similar to those due to disk and orfacet joint mediated
pain
Intra-articular SI Joint Injection
INITIAL MANAGEMENT
Injections helpful in diagnosis and management of LBP due to Piriformis Muscle Syndrome
A REAL PAIN THE BUTT
INITIAL MANAGEMENT ACUPUNCTURE
Some evidence that acupuncture and variations
thereof (acupressure cupping) potentially helpful in the acutesubacute period in
patients with NP and LBP
(Yuan QI et al PloS One 2015 Febr 1-37)
NEXT STEP
Rehabilitation and regaining of function
Physical Therapy very important component of the
rehabilitation
A symbiotic relationship between patient and
therapist key of a successful physical rehabilitation
program
The role of YOGA
Better pain control at rest and with
activities with yoga (9-week program with weekly 90-minute classes) when
compared to a self care exercise program in patients with neck pain
Significant treatment effects of yoga found for pain-related apprehension
disability quality of life and psychological outcomes (depression
fatigue anger)
(Michalsen A et al the J Pain 2012 13(11) 1122-30)
THE IMPORTANCE OF REMAINING ACTIVE
Increasing the amount of steps
walkedday by 1000 over the course of a year reduced the risk of neck pain by
14 in a group of people (men and women age 20-45) with sedentary jobs
(Sitthipornvorakul EA et al Eur Spine J
2015 24 417-24)
SPINAL MANIPULATION No Thank you
Systematic review of spinal
manipulation in patients with a variety of pain conditions including NP
and LBP
Failed to demonstrate that spinal manipulation is an effective
intervention for pain management
(Posadzki P Pain Med 2012 13 754-61)
CONCLUSIONS
Neck and Low Back pain syndromes are usually self limited conditions that can convert in chronic pain conditions causing
prolonged disability
The prevalence and cost of these conditions has significantly increased over the course of the last 15-20 years
Aggressive management of pain during the acute phase is
important because adequate pain control shortens the time and level of disability and facilitates the rehabilitation process
CONCLUSIONS
A variety of treatment modalities including medications acupuncture injections PT Yoga are utilized to manage pain and facilitate the
recovery process
Reducing stress and activities associated with the generation of pain maintaining an appropriate physical exercise regimen and a body weight
as close as possible to the ideal body weight will likely result in a decreased incidenceprevalence of short and long term NP and LBP
THANK YOU
QUESTIONS
True synovial joints
between the C2-C7 vertebrae located behind the plane of the intervertebral foramina
and the spinal nerves contained therein
Arthritic changes may cause axial neck pain withwithout upper extremity pain
CERVICAL FACET JOINTS
CERVICAL FACET JOINTS
C2-3 C5-6 C6-7
most frequent
facetogenic pain
generators in the cervical
spine
CERVICAL FACET JOINTS
C2-3 joint Pain in the sub-occipital region
radiating to occiput auricular region vertex of the head forehead and orbit
C5-6 joint
Pain radiates over the deltoid region and into the arm
C6-7 joint Pain radiates over
over the medial scapula
ATLANTO-AXIAL JOINT (C1-2)
Pain from C1-2 occurs higher than pain from C2-3
vertex rather than forehead and temple
ATLANTO-OCCIPITAL JOINT (C 0-1)
Pain from C 0-1 almost superimposes pain stemming
from C1-2
Unusual source of neck pain
Note the close anatomic relationship between C0-
1 joint and C1 nerve
between C1-2 joint and C2 ganglia and nerve
and between these joints and the vertebral artery
OTHER SOURCES OF NECK PAIN
Posterior neck muscles
Cervical dura mater
Atlanto-axial joint ligaments
Vertebral artery
Cervical vertebral bodies
True synovial joints with a space a synovial membrane hyaline cartilage surfaces and a
fibrous capsule located in front of the plane of the foramina and the nerve root therein
Arthritic changes may cause axial low back pain withwithout lower extremity pain
LUMBAR FACET JOINTS
LUMBAR FACET JOINTS PAIN CHARACTERISTICS
More common in patients 65
yearolder
Axial low back pain
withwithout radiation to the
lower extremities
Morning stiffness Pain when
starting to move relieved by
the recumbent position
Worsening as day goes by
LUMBAR FACET JOINTS PAIN PATTERNS
L4-5 L5-S1
most frequent facetogenic
pain generators in the lumbar
spine
Pain does not extend down
beyond the level of the knee
Largest axial joint in the
body
Only the anterior third is a
true synovial joint
Complex innervation
including sensory fibers
from L5 through S4 spinal
nerves
SACRO-ILIAC JOINT
A B
No difference in gender
Mean age 40-50
Prevalence 13-30 of
patients with ho low back
pain
Most commonly causing
unilateral symptoms
SACRO-ILIAC JOINT
Pain is always maximal below L5
May radiate to hips groin buttocks
posterior thighs
Patterns of referred pain somewhat
similar to those due to disk and orfacet
joint mediated pain
SACRO-ILIAC JOINT PAIN PATTERN
PIRIFORMIS MUSCLE
Located in the gluteal region is one of the muscles of the lateral
rotator group
It is situated within the posterior wall of the pelvis partly at the
back of the hip joint
Passes out of the pelvis through the greater sciatic foramen
Sciatic nerve
PIRIFORMIS MUSCLE
Sport activities andor certain movements (running lunging) can
stress the piriformis muscle
The subsequent muscle spasm may manifest as MSK low back pain
radiating to the buttock and along the sciatic nerve
Prolonged sitting stretching climbing stairs or walking on inclines squatting
worsen the pain
REALLY A PAIN THE BUTT
OTHER SOURCES OF LOW BACK PAIN
Posterior lumbo-sacral paraspinal pelvic girdle muscles
Lumbar spine ligaments tendons
Vertebral bodies
CAUSES OF NECK AND LOW BACK PAIN
TUMORS
INFECTIONS Discitis Osteomyelitis Septic arthritis Meningitis
VASCULAR DISORDERS (egCarotid artery dissection)
AUTOIMMUNE DISORDERS Rheumatoid arthritis Ankylosing spondylitis Polymyalgia rheumatica
TRAUMA (FracturesDislocations)
MSK DISORDERS Soft tissue injuries Whiplash CervicalLumbosacral
strain Myofascial disorders Fibromyalgia
JOINT DISORDERS Spondylosis and Osteoarthritis
MANAGEMENT
Self limited condition
Symptoms and disability improve rapidly
Most patients return to work and normal activities in 4-6 weeks
(Pengel LH et al BMJ 2003 327 323)
NATURAL HISTORY
1 in 3 patients
Persistent moderate pain 1 year after an acute episode
1 in 5 patients report substantial limitations in activity (von Korff al et al Spine 1996 21 2833-7 ndash discussion 2838-9)
NATURAL HISTORY
History and Physical Exam
Blood work to rule out the
presence of a malignancy andor an infection
Plain radiographs of
cervicallumbar spine CTMRI in patients with neurologic
complaints or with pain not improving
DIAGNOSIS
MAIN GOAL
Achieve adequate pain control (NSAIDs Tylenol Muscle
Relaxants Gabapentinoids short acting opioids)
Relative rest
Activity modifications
INITIAL MANAGEMENT
Epidural steroid injections are an
option in patients with disk herniation back and leg pain
INITIAL MANAGEMENT
Anesth Analg 2016 Mar122(3)857-70 Bhatia A1 Flamer D Shah PS Cohen SP
CONCLUSIONS Epidural steroids injections provide
some analgesic benefit at 3 months in patients with lumbosacral radicular pain
due to herniated intervertebral disks but they have no impact on physical
disability or incidence of surgery
Epidural steroid injections are an option in
patients with spinal stenosis
INITIAL MANAGEMENT
Spinal stenosis causes mechanical compression of the nerve roots swelling
(microvascular injury) producing pain (Olmarker K et al Spine 1989 14 569-573)
L3-4 Spinal Stenosis
INITIAL MANAGEMENT
STEROIDS
inhibit swelling (edema) around the nerve root
(Rydevik B et al Spine 1984 9 7-15)
improve blood flow to neural elements decreasing ischemic neuritis
(Fukusaki M et al Clin J Pain 1998 14 148-51)
block conduction in nociceptive nerve fibers (Johansson A et al Acta Anesthesiol Scand
1990 34 335-38) L4-5 Severe Spinal Stenosis
INITIAL MANAGEMENT
Usually spinal stenosis occurs in pts of senior age
Some of these patients may significant comorbidities and higher sensitivity to
pain medications
Multilevel Cervical Spinal Stenosis
INITIAL MANAGEMENT
Intra-articular facet joint injections are appropriate when a clinical
diagnosis of facet joint ldquosyndromerdquo is confirmed
Axial back pain withwithout radiation
to the extremities
Morning neckback stiffness Pain when starting to move worse on necklumbar
spine extension relieved by the recumbent position
Intra-articular C3-4 facet joint injection
Intra-articular L5-S1 facet joint injection
INITIAL MANAGEMENT
Injections helpful in diagnosis and management of LBP secondary
to SI Joint ldquoSyndromerdquo
Pain is always maximal below L5
May radiate to hips groin buttocks posterior thighs
Patterns of referred pain somewhat similar to those due to disk and orfacet joint mediated
pain
Intra-articular SI Joint Injection
INITIAL MANAGEMENT
Injections helpful in diagnosis and management of LBP due to Piriformis Muscle Syndrome
A REAL PAIN THE BUTT
INITIAL MANAGEMENT ACUPUNCTURE
Some evidence that acupuncture and variations
thereof (acupressure cupping) potentially helpful in the acutesubacute period in
patients with NP and LBP
(Yuan QI et al PloS One 2015 Febr 1-37)
NEXT STEP
Rehabilitation and regaining of function
Physical Therapy very important component of the
rehabilitation
A symbiotic relationship between patient and
therapist key of a successful physical rehabilitation
program
The role of YOGA
Better pain control at rest and with
activities with yoga (9-week program with weekly 90-minute classes) when
compared to a self care exercise program in patients with neck pain
Significant treatment effects of yoga found for pain-related apprehension
disability quality of life and psychological outcomes (depression
fatigue anger)
(Michalsen A et al the J Pain 2012 13(11) 1122-30)
THE IMPORTANCE OF REMAINING ACTIVE
Increasing the amount of steps
walkedday by 1000 over the course of a year reduced the risk of neck pain by
14 in a group of people (men and women age 20-45) with sedentary jobs
(Sitthipornvorakul EA et al Eur Spine J
2015 24 417-24)
SPINAL MANIPULATION No Thank you
Systematic review of spinal
manipulation in patients with a variety of pain conditions including NP
and LBP
Failed to demonstrate that spinal manipulation is an effective
intervention for pain management
(Posadzki P Pain Med 2012 13 754-61)
CONCLUSIONS
Neck and Low Back pain syndromes are usually self limited conditions that can convert in chronic pain conditions causing
prolonged disability
The prevalence and cost of these conditions has significantly increased over the course of the last 15-20 years
Aggressive management of pain during the acute phase is
important because adequate pain control shortens the time and level of disability and facilitates the rehabilitation process
CONCLUSIONS
A variety of treatment modalities including medications acupuncture injections PT Yoga are utilized to manage pain and facilitate the
recovery process
Reducing stress and activities associated with the generation of pain maintaining an appropriate physical exercise regimen and a body weight
as close as possible to the ideal body weight will likely result in a decreased incidenceprevalence of short and long term NP and LBP
THANK YOU
QUESTIONS
CERVICAL FACET JOINTS
C2-3 C5-6 C6-7
most frequent
facetogenic pain
generators in the cervical
spine
CERVICAL FACET JOINTS
C2-3 joint Pain in the sub-occipital region
radiating to occiput auricular region vertex of the head forehead and orbit
C5-6 joint
Pain radiates over the deltoid region and into the arm
C6-7 joint Pain radiates over
over the medial scapula
ATLANTO-AXIAL JOINT (C1-2)
Pain from C1-2 occurs higher than pain from C2-3
vertex rather than forehead and temple
ATLANTO-OCCIPITAL JOINT (C 0-1)
Pain from C 0-1 almost superimposes pain stemming
from C1-2
Unusual source of neck pain
Note the close anatomic relationship between C0-
1 joint and C1 nerve
between C1-2 joint and C2 ganglia and nerve
and between these joints and the vertebral artery
OTHER SOURCES OF NECK PAIN
Posterior neck muscles
Cervical dura mater
Atlanto-axial joint ligaments
Vertebral artery
Cervical vertebral bodies
True synovial joints with a space a synovial membrane hyaline cartilage surfaces and a
fibrous capsule located in front of the plane of the foramina and the nerve root therein
Arthritic changes may cause axial low back pain withwithout lower extremity pain
LUMBAR FACET JOINTS
LUMBAR FACET JOINTS PAIN CHARACTERISTICS
More common in patients 65
yearolder
Axial low back pain
withwithout radiation to the
lower extremities
Morning stiffness Pain when
starting to move relieved by
the recumbent position
Worsening as day goes by
LUMBAR FACET JOINTS PAIN PATTERNS
L4-5 L5-S1
most frequent facetogenic
pain generators in the lumbar
spine
Pain does not extend down
beyond the level of the knee
Largest axial joint in the
body
Only the anterior third is a
true synovial joint
Complex innervation
including sensory fibers
from L5 through S4 spinal
nerves
SACRO-ILIAC JOINT
A B
No difference in gender
Mean age 40-50
Prevalence 13-30 of
patients with ho low back
pain
Most commonly causing
unilateral symptoms
SACRO-ILIAC JOINT
Pain is always maximal below L5
May radiate to hips groin buttocks
posterior thighs
Patterns of referred pain somewhat
similar to those due to disk and orfacet
joint mediated pain
SACRO-ILIAC JOINT PAIN PATTERN
PIRIFORMIS MUSCLE
Located in the gluteal region is one of the muscles of the lateral
rotator group
It is situated within the posterior wall of the pelvis partly at the
back of the hip joint
Passes out of the pelvis through the greater sciatic foramen
Sciatic nerve
PIRIFORMIS MUSCLE
Sport activities andor certain movements (running lunging) can
stress the piriformis muscle
The subsequent muscle spasm may manifest as MSK low back pain
radiating to the buttock and along the sciatic nerve
Prolonged sitting stretching climbing stairs or walking on inclines squatting
worsen the pain
REALLY A PAIN THE BUTT
OTHER SOURCES OF LOW BACK PAIN
Posterior lumbo-sacral paraspinal pelvic girdle muscles
Lumbar spine ligaments tendons
Vertebral bodies
CAUSES OF NECK AND LOW BACK PAIN
TUMORS
INFECTIONS Discitis Osteomyelitis Septic arthritis Meningitis
VASCULAR DISORDERS (egCarotid artery dissection)
AUTOIMMUNE DISORDERS Rheumatoid arthritis Ankylosing spondylitis Polymyalgia rheumatica
TRAUMA (FracturesDislocations)
MSK DISORDERS Soft tissue injuries Whiplash CervicalLumbosacral
strain Myofascial disorders Fibromyalgia
JOINT DISORDERS Spondylosis and Osteoarthritis
MANAGEMENT
Self limited condition
Symptoms and disability improve rapidly
Most patients return to work and normal activities in 4-6 weeks
(Pengel LH et al BMJ 2003 327 323)
NATURAL HISTORY
1 in 3 patients
Persistent moderate pain 1 year after an acute episode
1 in 5 patients report substantial limitations in activity (von Korff al et al Spine 1996 21 2833-7 ndash discussion 2838-9)
NATURAL HISTORY
History and Physical Exam
Blood work to rule out the
presence of a malignancy andor an infection
Plain radiographs of
cervicallumbar spine CTMRI in patients with neurologic
complaints or with pain not improving
DIAGNOSIS
MAIN GOAL
Achieve adequate pain control (NSAIDs Tylenol Muscle
Relaxants Gabapentinoids short acting opioids)
Relative rest
Activity modifications
INITIAL MANAGEMENT
Epidural steroid injections are an
option in patients with disk herniation back and leg pain
INITIAL MANAGEMENT
Anesth Analg 2016 Mar122(3)857-70 Bhatia A1 Flamer D Shah PS Cohen SP
CONCLUSIONS Epidural steroids injections provide
some analgesic benefit at 3 months in patients with lumbosacral radicular pain
due to herniated intervertebral disks but they have no impact on physical
disability or incidence of surgery
Epidural steroid injections are an option in
patients with spinal stenosis
INITIAL MANAGEMENT
Spinal stenosis causes mechanical compression of the nerve roots swelling
(microvascular injury) producing pain (Olmarker K et al Spine 1989 14 569-573)
L3-4 Spinal Stenosis
INITIAL MANAGEMENT
STEROIDS
inhibit swelling (edema) around the nerve root
(Rydevik B et al Spine 1984 9 7-15)
improve blood flow to neural elements decreasing ischemic neuritis
(Fukusaki M et al Clin J Pain 1998 14 148-51)
block conduction in nociceptive nerve fibers (Johansson A et al Acta Anesthesiol Scand
1990 34 335-38) L4-5 Severe Spinal Stenosis
INITIAL MANAGEMENT
Usually spinal stenosis occurs in pts of senior age
Some of these patients may significant comorbidities and higher sensitivity to
pain medications
Multilevel Cervical Spinal Stenosis
INITIAL MANAGEMENT
Intra-articular facet joint injections are appropriate when a clinical
diagnosis of facet joint ldquosyndromerdquo is confirmed
Axial back pain withwithout radiation
to the extremities
Morning neckback stiffness Pain when starting to move worse on necklumbar
spine extension relieved by the recumbent position
Intra-articular C3-4 facet joint injection
Intra-articular L5-S1 facet joint injection
INITIAL MANAGEMENT
Injections helpful in diagnosis and management of LBP secondary
to SI Joint ldquoSyndromerdquo
Pain is always maximal below L5
May radiate to hips groin buttocks posterior thighs
Patterns of referred pain somewhat similar to those due to disk and orfacet joint mediated
pain
Intra-articular SI Joint Injection
INITIAL MANAGEMENT
Injections helpful in diagnosis and management of LBP due to Piriformis Muscle Syndrome
A REAL PAIN THE BUTT
INITIAL MANAGEMENT ACUPUNCTURE
Some evidence that acupuncture and variations
thereof (acupressure cupping) potentially helpful in the acutesubacute period in
patients with NP and LBP
(Yuan QI et al PloS One 2015 Febr 1-37)
NEXT STEP
Rehabilitation and regaining of function
Physical Therapy very important component of the
rehabilitation
A symbiotic relationship between patient and
therapist key of a successful physical rehabilitation
program
The role of YOGA
Better pain control at rest and with
activities with yoga (9-week program with weekly 90-minute classes) when
compared to a self care exercise program in patients with neck pain
Significant treatment effects of yoga found for pain-related apprehension
disability quality of life and psychological outcomes (depression
fatigue anger)
(Michalsen A et al the J Pain 2012 13(11) 1122-30)
THE IMPORTANCE OF REMAINING ACTIVE
Increasing the amount of steps
walkedday by 1000 over the course of a year reduced the risk of neck pain by
14 in a group of people (men and women age 20-45) with sedentary jobs
(Sitthipornvorakul EA et al Eur Spine J
2015 24 417-24)
SPINAL MANIPULATION No Thank you
Systematic review of spinal
manipulation in patients with a variety of pain conditions including NP
and LBP
Failed to demonstrate that spinal manipulation is an effective
intervention for pain management
(Posadzki P Pain Med 2012 13 754-61)
CONCLUSIONS
Neck and Low Back pain syndromes are usually self limited conditions that can convert in chronic pain conditions causing
prolonged disability
The prevalence and cost of these conditions has significantly increased over the course of the last 15-20 years
Aggressive management of pain during the acute phase is
important because adequate pain control shortens the time and level of disability and facilitates the rehabilitation process
CONCLUSIONS
A variety of treatment modalities including medications acupuncture injections PT Yoga are utilized to manage pain and facilitate the
recovery process
Reducing stress and activities associated with the generation of pain maintaining an appropriate physical exercise regimen and a body weight
as close as possible to the ideal body weight will likely result in a decreased incidenceprevalence of short and long term NP and LBP
THANK YOU
QUESTIONS
CERVICAL FACET JOINTS
C2-3 joint Pain in the sub-occipital region
radiating to occiput auricular region vertex of the head forehead and orbit
C5-6 joint
Pain radiates over the deltoid region and into the arm
C6-7 joint Pain radiates over
over the medial scapula
ATLANTO-AXIAL JOINT (C1-2)
Pain from C1-2 occurs higher than pain from C2-3
vertex rather than forehead and temple
ATLANTO-OCCIPITAL JOINT (C 0-1)
Pain from C 0-1 almost superimposes pain stemming
from C1-2
Unusual source of neck pain
Note the close anatomic relationship between C0-
1 joint and C1 nerve
between C1-2 joint and C2 ganglia and nerve
and between these joints and the vertebral artery
OTHER SOURCES OF NECK PAIN
Posterior neck muscles
Cervical dura mater
Atlanto-axial joint ligaments
Vertebral artery
Cervical vertebral bodies
True synovial joints with a space a synovial membrane hyaline cartilage surfaces and a
fibrous capsule located in front of the plane of the foramina and the nerve root therein
Arthritic changes may cause axial low back pain withwithout lower extremity pain
LUMBAR FACET JOINTS
LUMBAR FACET JOINTS PAIN CHARACTERISTICS
More common in patients 65
yearolder
Axial low back pain
withwithout radiation to the
lower extremities
Morning stiffness Pain when
starting to move relieved by
the recumbent position
Worsening as day goes by
LUMBAR FACET JOINTS PAIN PATTERNS
L4-5 L5-S1
most frequent facetogenic
pain generators in the lumbar
spine
Pain does not extend down
beyond the level of the knee
Largest axial joint in the
body
Only the anterior third is a
true synovial joint
Complex innervation
including sensory fibers
from L5 through S4 spinal
nerves
SACRO-ILIAC JOINT
A B
No difference in gender
Mean age 40-50
Prevalence 13-30 of
patients with ho low back
pain
Most commonly causing
unilateral symptoms
SACRO-ILIAC JOINT
Pain is always maximal below L5
May radiate to hips groin buttocks
posterior thighs
Patterns of referred pain somewhat
similar to those due to disk and orfacet
joint mediated pain
SACRO-ILIAC JOINT PAIN PATTERN
PIRIFORMIS MUSCLE
Located in the gluteal region is one of the muscles of the lateral
rotator group
It is situated within the posterior wall of the pelvis partly at the
back of the hip joint
Passes out of the pelvis through the greater sciatic foramen
Sciatic nerve
PIRIFORMIS MUSCLE
Sport activities andor certain movements (running lunging) can
stress the piriformis muscle
The subsequent muscle spasm may manifest as MSK low back pain
radiating to the buttock and along the sciatic nerve
Prolonged sitting stretching climbing stairs or walking on inclines squatting
worsen the pain
REALLY A PAIN THE BUTT
OTHER SOURCES OF LOW BACK PAIN
Posterior lumbo-sacral paraspinal pelvic girdle muscles
Lumbar spine ligaments tendons
Vertebral bodies
CAUSES OF NECK AND LOW BACK PAIN
TUMORS
INFECTIONS Discitis Osteomyelitis Septic arthritis Meningitis
VASCULAR DISORDERS (egCarotid artery dissection)
AUTOIMMUNE DISORDERS Rheumatoid arthritis Ankylosing spondylitis Polymyalgia rheumatica
TRAUMA (FracturesDislocations)
MSK DISORDERS Soft tissue injuries Whiplash CervicalLumbosacral
strain Myofascial disorders Fibromyalgia
JOINT DISORDERS Spondylosis and Osteoarthritis
MANAGEMENT
Self limited condition
Symptoms and disability improve rapidly
Most patients return to work and normal activities in 4-6 weeks
(Pengel LH et al BMJ 2003 327 323)
NATURAL HISTORY
1 in 3 patients
Persistent moderate pain 1 year after an acute episode
1 in 5 patients report substantial limitations in activity (von Korff al et al Spine 1996 21 2833-7 ndash discussion 2838-9)
NATURAL HISTORY
History and Physical Exam
Blood work to rule out the
presence of a malignancy andor an infection
Plain radiographs of
cervicallumbar spine CTMRI in patients with neurologic
complaints or with pain not improving
DIAGNOSIS
MAIN GOAL
Achieve adequate pain control (NSAIDs Tylenol Muscle
Relaxants Gabapentinoids short acting opioids)
Relative rest
Activity modifications
INITIAL MANAGEMENT
Epidural steroid injections are an
option in patients with disk herniation back and leg pain
INITIAL MANAGEMENT
Anesth Analg 2016 Mar122(3)857-70 Bhatia A1 Flamer D Shah PS Cohen SP
CONCLUSIONS Epidural steroids injections provide
some analgesic benefit at 3 months in patients with lumbosacral radicular pain
due to herniated intervertebral disks but they have no impact on physical
disability or incidence of surgery
Epidural steroid injections are an option in
patients with spinal stenosis
INITIAL MANAGEMENT
Spinal stenosis causes mechanical compression of the nerve roots swelling
(microvascular injury) producing pain (Olmarker K et al Spine 1989 14 569-573)
L3-4 Spinal Stenosis
INITIAL MANAGEMENT
STEROIDS
inhibit swelling (edema) around the nerve root
(Rydevik B et al Spine 1984 9 7-15)
improve blood flow to neural elements decreasing ischemic neuritis
(Fukusaki M et al Clin J Pain 1998 14 148-51)
block conduction in nociceptive nerve fibers (Johansson A et al Acta Anesthesiol Scand
1990 34 335-38) L4-5 Severe Spinal Stenosis
INITIAL MANAGEMENT
Usually spinal stenosis occurs in pts of senior age
Some of these patients may significant comorbidities and higher sensitivity to
pain medications
Multilevel Cervical Spinal Stenosis
INITIAL MANAGEMENT
Intra-articular facet joint injections are appropriate when a clinical
diagnosis of facet joint ldquosyndromerdquo is confirmed
Axial back pain withwithout radiation
to the extremities
Morning neckback stiffness Pain when starting to move worse on necklumbar
spine extension relieved by the recumbent position
Intra-articular C3-4 facet joint injection
Intra-articular L5-S1 facet joint injection
INITIAL MANAGEMENT
Injections helpful in diagnosis and management of LBP secondary
to SI Joint ldquoSyndromerdquo
Pain is always maximal below L5
May radiate to hips groin buttocks posterior thighs
Patterns of referred pain somewhat similar to those due to disk and orfacet joint mediated
pain
Intra-articular SI Joint Injection
INITIAL MANAGEMENT
Injections helpful in diagnosis and management of LBP due to Piriformis Muscle Syndrome
A REAL PAIN THE BUTT
INITIAL MANAGEMENT ACUPUNCTURE
Some evidence that acupuncture and variations
thereof (acupressure cupping) potentially helpful in the acutesubacute period in
patients with NP and LBP
(Yuan QI et al PloS One 2015 Febr 1-37)
NEXT STEP
Rehabilitation and regaining of function
Physical Therapy very important component of the
rehabilitation
A symbiotic relationship between patient and
therapist key of a successful physical rehabilitation
program
The role of YOGA
Better pain control at rest and with
activities with yoga (9-week program with weekly 90-minute classes) when
compared to a self care exercise program in patients with neck pain
Significant treatment effects of yoga found for pain-related apprehension
disability quality of life and psychological outcomes (depression
fatigue anger)
(Michalsen A et al the J Pain 2012 13(11) 1122-30)
THE IMPORTANCE OF REMAINING ACTIVE
Increasing the amount of steps
walkedday by 1000 over the course of a year reduced the risk of neck pain by
14 in a group of people (men and women age 20-45) with sedentary jobs
(Sitthipornvorakul EA et al Eur Spine J
2015 24 417-24)
SPINAL MANIPULATION No Thank you
Systematic review of spinal
manipulation in patients with a variety of pain conditions including NP
and LBP
Failed to demonstrate that spinal manipulation is an effective
intervention for pain management
(Posadzki P Pain Med 2012 13 754-61)
CONCLUSIONS
Neck and Low Back pain syndromes are usually self limited conditions that can convert in chronic pain conditions causing
prolonged disability
The prevalence and cost of these conditions has significantly increased over the course of the last 15-20 years
Aggressive management of pain during the acute phase is
important because adequate pain control shortens the time and level of disability and facilitates the rehabilitation process
CONCLUSIONS
A variety of treatment modalities including medications acupuncture injections PT Yoga are utilized to manage pain and facilitate the
recovery process
Reducing stress and activities associated with the generation of pain maintaining an appropriate physical exercise regimen and a body weight
as close as possible to the ideal body weight will likely result in a decreased incidenceprevalence of short and long term NP and LBP
THANK YOU
QUESTIONS
ATLANTO-AXIAL JOINT (C1-2)
Pain from C1-2 occurs higher than pain from C2-3
vertex rather than forehead and temple
ATLANTO-OCCIPITAL JOINT (C 0-1)
Pain from C 0-1 almost superimposes pain stemming
from C1-2
Unusual source of neck pain
Note the close anatomic relationship between C0-
1 joint and C1 nerve
between C1-2 joint and C2 ganglia and nerve
and between these joints and the vertebral artery
OTHER SOURCES OF NECK PAIN
Posterior neck muscles
Cervical dura mater
Atlanto-axial joint ligaments
Vertebral artery
Cervical vertebral bodies
True synovial joints with a space a synovial membrane hyaline cartilage surfaces and a
fibrous capsule located in front of the plane of the foramina and the nerve root therein
Arthritic changes may cause axial low back pain withwithout lower extremity pain
LUMBAR FACET JOINTS
LUMBAR FACET JOINTS PAIN CHARACTERISTICS
More common in patients 65
yearolder
Axial low back pain
withwithout radiation to the
lower extremities
Morning stiffness Pain when
starting to move relieved by
the recumbent position
Worsening as day goes by
LUMBAR FACET JOINTS PAIN PATTERNS
L4-5 L5-S1
most frequent facetogenic
pain generators in the lumbar
spine
Pain does not extend down
beyond the level of the knee
Largest axial joint in the
body
Only the anterior third is a
true synovial joint
Complex innervation
including sensory fibers
from L5 through S4 spinal
nerves
SACRO-ILIAC JOINT
A B
No difference in gender
Mean age 40-50
Prevalence 13-30 of
patients with ho low back
pain
Most commonly causing
unilateral symptoms
SACRO-ILIAC JOINT
Pain is always maximal below L5
May radiate to hips groin buttocks
posterior thighs
Patterns of referred pain somewhat
similar to those due to disk and orfacet
joint mediated pain
SACRO-ILIAC JOINT PAIN PATTERN
PIRIFORMIS MUSCLE
Located in the gluteal region is one of the muscles of the lateral
rotator group
It is situated within the posterior wall of the pelvis partly at the
back of the hip joint
Passes out of the pelvis through the greater sciatic foramen
Sciatic nerve
PIRIFORMIS MUSCLE
Sport activities andor certain movements (running lunging) can
stress the piriformis muscle
The subsequent muscle spasm may manifest as MSK low back pain
radiating to the buttock and along the sciatic nerve
Prolonged sitting stretching climbing stairs or walking on inclines squatting
worsen the pain
REALLY A PAIN THE BUTT
OTHER SOURCES OF LOW BACK PAIN
Posterior lumbo-sacral paraspinal pelvic girdle muscles
Lumbar spine ligaments tendons
Vertebral bodies
CAUSES OF NECK AND LOW BACK PAIN
TUMORS
INFECTIONS Discitis Osteomyelitis Septic arthritis Meningitis
VASCULAR DISORDERS (egCarotid artery dissection)
AUTOIMMUNE DISORDERS Rheumatoid arthritis Ankylosing spondylitis Polymyalgia rheumatica
TRAUMA (FracturesDislocations)
MSK DISORDERS Soft tissue injuries Whiplash CervicalLumbosacral
strain Myofascial disorders Fibromyalgia
JOINT DISORDERS Spondylosis and Osteoarthritis
MANAGEMENT
Self limited condition
Symptoms and disability improve rapidly
Most patients return to work and normal activities in 4-6 weeks
(Pengel LH et al BMJ 2003 327 323)
NATURAL HISTORY
1 in 3 patients
Persistent moderate pain 1 year after an acute episode
1 in 5 patients report substantial limitations in activity (von Korff al et al Spine 1996 21 2833-7 ndash discussion 2838-9)
NATURAL HISTORY
History and Physical Exam
Blood work to rule out the
presence of a malignancy andor an infection
Plain radiographs of
cervicallumbar spine CTMRI in patients with neurologic
complaints or with pain not improving
DIAGNOSIS
MAIN GOAL
Achieve adequate pain control (NSAIDs Tylenol Muscle
Relaxants Gabapentinoids short acting opioids)
Relative rest
Activity modifications
INITIAL MANAGEMENT
Epidural steroid injections are an
option in patients with disk herniation back and leg pain
INITIAL MANAGEMENT
Anesth Analg 2016 Mar122(3)857-70 Bhatia A1 Flamer D Shah PS Cohen SP
CONCLUSIONS Epidural steroids injections provide
some analgesic benefit at 3 months in patients with lumbosacral radicular pain
due to herniated intervertebral disks but they have no impact on physical
disability or incidence of surgery
Epidural steroid injections are an option in
patients with spinal stenosis
INITIAL MANAGEMENT
Spinal stenosis causes mechanical compression of the nerve roots swelling
(microvascular injury) producing pain (Olmarker K et al Spine 1989 14 569-573)
L3-4 Spinal Stenosis
INITIAL MANAGEMENT
STEROIDS
inhibit swelling (edema) around the nerve root
(Rydevik B et al Spine 1984 9 7-15)
improve blood flow to neural elements decreasing ischemic neuritis
(Fukusaki M et al Clin J Pain 1998 14 148-51)
block conduction in nociceptive nerve fibers (Johansson A et al Acta Anesthesiol Scand
1990 34 335-38) L4-5 Severe Spinal Stenosis
INITIAL MANAGEMENT
Usually spinal stenosis occurs in pts of senior age
Some of these patients may significant comorbidities and higher sensitivity to
pain medications
Multilevel Cervical Spinal Stenosis
INITIAL MANAGEMENT
Intra-articular facet joint injections are appropriate when a clinical
diagnosis of facet joint ldquosyndromerdquo is confirmed
Axial back pain withwithout radiation
to the extremities
Morning neckback stiffness Pain when starting to move worse on necklumbar
spine extension relieved by the recumbent position
Intra-articular C3-4 facet joint injection
Intra-articular L5-S1 facet joint injection
INITIAL MANAGEMENT
Injections helpful in diagnosis and management of LBP secondary
to SI Joint ldquoSyndromerdquo
Pain is always maximal below L5
May radiate to hips groin buttocks posterior thighs
Patterns of referred pain somewhat similar to those due to disk and orfacet joint mediated
pain
Intra-articular SI Joint Injection
INITIAL MANAGEMENT
Injections helpful in diagnosis and management of LBP due to Piriformis Muscle Syndrome
A REAL PAIN THE BUTT
INITIAL MANAGEMENT ACUPUNCTURE
Some evidence that acupuncture and variations
thereof (acupressure cupping) potentially helpful in the acutesubacute period in
patients with NP and LBP
(Yuan QI et al PloS One 2015 Febr 1-37)
NEXT STEP
Rehabilitation and regaining of function
Physical Therapy very important component of the
rehabilitation
A symbiotic relationship between patient and
therapist key of a successful physical rehabilitation
program
The role of YOGA
Better pain control at rest and with
activities with yoga (9-week program with weekly 90-minute classes) when
compared to a self care exercise program in patients with neck pain
Significant treatment effects of yoga found for pain-related apprehension
disability quality of life and psychological outcomes (depression
fatigue anger)
(Michalsen A et al the J Pain 2012 13(11) 1122-30)
THE IMPORTANCE OF REMAINING ACTIVE
Increasing the amount of steps
walkedday by 1000 over the course of a year reduced the risk of neck pain by
14 in a group of people (men and women age 20-45) with sedentary jobs
(Sitthipornvorakul EA et al Eur Spine J
2015 24 417-24)
SPINAL MANIPULATION No Thank you
Systematic review of spinal
manipulation in patients with a variety of pain conditions including NP
and LBP
Failed to demonstrate that spinal manipulation is an effective
intervention for pain management
(Posadzki P Pain Med 2012 13 754-61)
CONCLUSIONS
Neck and Low Back pain syndromes are usually self limited conditions that can convert in chronic pain conditions causing
prolonged disability
The prevalence and cost of these conditions has significantly increased over the course of the last 15-20 years
Aggressive management of pain during the acute phase is
important because adequate pain control shortens the time and level of disability and facilitates the rehabilitation process
CONCLUSIONS
A variety of treatment modalities including medications acupuncture injections PT Yoga are utilized to manage pain and facilitate the
recovery process
Reducing stress and activities associated with the generation of pain maintaining an appropriate physical exercise regimen and a body weight
as close as possible to the ideal body weight will likely result in a decreased incidenceprevalence of short and long term NP and LBP
THANK YOU
QUESTIONS
ATLANTO-OCCIPITAL JOINT (C 0-1)
Pain from C 0-1 almost superimposes pain stemming
from C1-2
Unusual source of neck pain
Note the close anatomic relationship between C0-
1 joint and C1 nerve
between C1-2 joint and C2 ganglia and nerve
and between these joints and the vertebral artery
OTHER SOURCES OF NECK PAIN
Posterior neck muscles
Cervical dura mater
Atlanto-axial joint ligaments
Vertebral artery
Cervical vertebral bodies
True synovial joints with a space a synovial membrane hyaline cartilage surfaces and a
fibrous capsule located in front of the plane of the foramina and the nerve root therein
Arthritic changes may cause axial low back pain withwithout lower extremity pain
LUMBAR FACET JOINTS
LUMBAR FACET JOINTS PAIN CHARACTERISTICS
More common in patients 65
yearolder
Axial low back pain
withwithout radiation to the
lower extremities
Morning stiffness Pain when
starting to move relieved by
the recumbent position
Worsening as day goes by
LUMBAR FACET JOINTS PAIN PATTERNS
L4-5 L5-S1
most frequent facetogenic
pain generators in the lumbar
spine
Pain does not extend down
beyond the level of the knee
Largest axial joint in the
body
Only the anterior third is a
true synovial joint
Complex innervation
including sensory fibers
from L5 through S4 spinal
nerves
SACRO-ILIAC JOINT
A B
No difference in gender
Mean age 40-50
Prevalence 13-30 of
patients with ho low back
pain
Most commonly causing
unilateral symptoms
SACRO-ILIAC JOINT
Pain is always maximal below L5
May radiate to hips groin buttocks
posterior thighs
Patterns of referred pain somewhat
similar to those due to disk and orfacet
joint mediated pain
SACRO-ILIAC JOINT PAIN PATTERN
PIRIFORMIS MUSCLE
Located in the gluteal region is one of the muscles of the lateral
rotator group
It is situated within the posterior wall of the pelvis partly at the
back of the hip joint
Passes out of the pelvis through the greater sciatic foramen
Sciatic nerve
PIRIFORMIS MUSCLE
Sport activities andor certain movements (running lunging) can
stress the piriformis muscle
The subsequent muscle spasm may manifest as MSK low back pain
radiating to the buttock and along the sciatic nerve
Prolonged sitting stretching climbing stairs or walking on inclines squatting
worsen the pain
REALLY A PAIN THE BUTT
OTHER SOURCES OF LOW BACK PAIN
Posterior lumbo-sacral paraspinal pelvic girdle muscles
Lumbar spine ligaments tendons
Vertebral bodies
CAUSES OF NECK AND LOW BACK PAIN
TUMORS
INFECTIONS Discitis Osteomyelitis Septic arthritis Meningitis
VASCULAR DISORDERS (egCarotid artery dissection)
AUTOIMMUNE DISORDERS Rheumatoid arthritis Ankylosing spondylitis Polymyalgia rheumatica
TRAUMA (FracturesDislocations)
MSK DISORDERS Soft tissue injuries Whiplash CervicalLumbosacral
strain Myofascial disorders Fibromyalgia
JOINT DISORDERS Spondylosis and Osteoarthritis
MANAGEMENT
Self limited condition
Symptoms and disability improve rapidly
Most patients return to work and normal activities in 4-6 weeks
(Pengel LH et al BMJ 2003 327 323)
NATURAL HISTORY
1 in 3 patients
Persistent moderate pain 1 year after an acute episode
1 in 5 patients report substantial limitations in activity (von Korff al et al Spine 1996 21 2833-7 ndash discussion 2838-9)
NATURAL HISTORY
History and Physical Exam
Blood work to rule out the
presence of a malignancy andor an infection
Plain radiographs of
cervicallumbar spine CTMRI in patients with neurologic
complaints or with pain not improving
DIAGNOSIS
MAIN GOAL
Achieve adequate pain control (NSAIDs Tylenol Muscle
Relaxants Gabapentinoids short acting opioids)
Relative rest
Activity modifications
INITIAL MANAGEMENT
Epidural steroid injections are an
option in patients with disk herniation back and leg pain
INITIAL MANAGEMENT
Anesth Analg 2016 Mar122(3)857-70 Bhatia A1 Flamer D Shah PS Cohen SP
CONCLUSIONS Epidural steroids injections provide
some analgesic benefit at 3 months in patients with lumbosacral radicular pain
due to herniated intervertebral disks but they have no impact on physical
disability or incidence of surgery
Epidural steroid injections are an option in
patients with spinal stenosis
INITIAL MANAGEMENT
Spinal stenosis causes mechanical compression of the nerve roots swelling
(microvascular injury) producing pain (Olmarker K et al Spine 1989 14 569-573)
L3-4 Spinal Stenosis
INITIAL MANAGEMENT
STEROIDS
inhibit swelling (edema) around the nerve root
(Rydevik B et al Spine 1984 9 7-15)
improve blood flow to neural elements decreasing ischemic neuritis
(Fukusaki M et al Clin J Pain 1998 14 148-51)
block conduction in nociceptive nerve fibers (Johansson A et al Acta Anesthesiol Scand
1990 34 335-38) L4-5 Severe Spinal Stenosis
INITIAL MANAGEMENT
Usually spinal stenosis occurs in pts of senior age
Some of these patients may significant comorbidities and higher sensitivity to
pain medications
Multilevel Cervical Spinal Stenosis
INITIAL MANAGEMENT
Intra-articular facet joint injections are appropriate when a clinical
diagnosis of facet joint ldquosyndromerdquo is confirmed
Axial back pain withwithout radiation
to the extremities
Morning neckback stiffness Pain when starting to move worse on necklumbar
spine extension relieved by the recumbent position
Intra-articular C3-4 facet joint injection
Intra-articular L5-S1 facet joint injection
INITIAL MANAGEMENT
Injections helpful in diagnosis and management of LBP secondary
to SI Joint ldquoSyndromerdquo
Pain is always maximal below L5
May radiate to hips groin buttocks posterior thighs
Patterns of referred pain somewhat similar to those due to disk and orfacet joint mediated
pain
Intra-articular SI Joint Injection
INITIAL MANAGEMENT
Injections helpful in diagnosis and management of LBP due to Piriformis Muscle Syndrome
A REAL PAIN THE BUTT
INITIAL MANAGEMENT ACUPUNCTURE
Some evidence that acupuncture and variations
thereof (acupressure cupping) potentially helpful in the acutesubacute period in
patients with NP and LBP
(Yuan QI et al PloS One 2015 Febr 1-37)
NEXT STEP
Rehabilitation and regaining of function
Physical Therapy very important component of the
rehabilitation
A symbiotic relationship between patient and
therapist key of a successful physical rehabilitation
program
The role of YOGA
Better pain control at rest and with
activities with yoga (9-week program with weekly 90-minute classes) when
compared to a self care exercise program in patients with neck pain
Significant treatment effects of yoga found for pain-related apprehension
disability quality of life and psychological outcomes (depression
fatigue anger)
(Michalsen A et al the J Pain 2012 13(11) 1122-30)
THE IMPORTANCE OF REMAINING ACTIVE
Increasing the amount of steps
walkedday by 1000 over the course of a year reduced the risk of neck pain by
14 in a group of people (men and women age 20-45) with sedentary jobs
(Sitthipornvorakul EA et al Eur Spine J
2015 24 417-24)
SPINAL MANIPULATION No Thank you
Systematic review of spinal
manipulation in patients with a variety of pain conditions including NP
and LBP
Failed to demonstrate that spinal manipulation is an effective
intervention for pain management
(Posadzki P Pain Med 2012 13 754-61)
CONCLUSIONS
Neck and Low Back pain syndromes are usually self limited conditions that can convert in chronic pain conditions causing
prolonged disability
The prevalence and cost of these conditions has significantly increased over the course of the last 15-20 years
Aggressive management of pain during the acute phase is
important because adequate pain control shortens the time and level of disability and facilitates the rehabilitation process
CONCLUSIONS
A variety of treatment modalities including medications acupuncture injections PT Yoga are utilized to manage pain and facilitate the
recovery process
Reducing stress and activities associated with the generation of pain maintaining an appropriate physical exercise regimen and a body weight
as close as possible to the ideal body weight will likely result in a decreased incidenceprevalence of short and long term NP and LBP
THANK YOU
QUESTIONS
Note the close anatomic relationship between C0-
1 joint and C1 nerve
between C1-2 joint and C2 ganglia and nerve
and between these joints and the vertebral artery
OTHER SOURCES OF NECK PAIN
Posterior neck muscles
Cervical dura mater
Atlanto-axial joint ligaments
Vertebral artery
Cervical vertebral bodies
True synovial joints with a space a synovial membrane hyaline cartilage surfaces and a
fibrous capsule located in front of the plane of the foramina and the nerve root therein
Arthritic changes may cause axial low back pain withwithout lower extremity pain
LUMBAR FACET JOINTS
LUMBAR FACET JOINTS PAIN CHARACTERISTICS
More common in patients 65
yearolder
Axial low back pain
withwithout radiation to the
lower extremities
Morning stiffness Pain when
starting to move relieved by
the recumbent position
Worsening as day goes by
LUMBAR FACET JOINTS PAIN PATTERNS
L4-5 L5-S1
most frequent facetogenic
pain generators in the lumbar
spine
Pain does not extend down
beyond the level of the knee
Largest axial joint in the
body
Only the anterior third is a
true synovial joint
Complex innervation
including sensory fibers
from L5 through S4 spinal
nerves
SACRO-ILIAC JOINT
A B
No difference in gender
Mean age 40-50
Prevalence 13-30 of
patients with ho low back
pain
Most commonly causing
unilateral symptoms
SACRO-ILIAC JOINT
Pain is always maximal below L5
May radiate to hips groin buttocks
posterior thighs
Patterns of referred pain somewhat
similar to those due to disk and orfacet
joint mediated pain
SACRO-ILIAC JOINT PAIN PATTERN
PIRIFORMIS MUSCLE
Located in the gluteal region is one of the muscles of the lateral
rotator group
It is situated within the posterior wall of the pelvis partly at the
back of the hip joint
Passes out of the pelvis through the greater sciatic foramen
Sciatic nerve
PIRIFORMIS MUSCLE
Sport activities andor certain movements (running lunging) can
stress the piriformis muscle
The subsequent muscle spasm may manifest as MSK low back pain
radiating to the buttock and along the sciatic nerve
Prolonged sitting stretching climbing stairs or walking on inclines squatting
worsen the pain
REALLY A PAIN THE BUTT
OTHER SOURCES OF LOW BACK PAIN
Posterior lumbo-sacral paraspinal pelvic girdle muscles
Lumbar spine ligaments tendons
Vertebral bodies
CAUSES OF NECK AND LOW BACK PAIN
TUMORS
INFECTIONS Discitis Osteomyelitis Septic arthritis Meningitis
VASCULAR DISORDERS (egCarotid artery dissection)
AUTOIMMUNE DISORDERS Rheumatoid arthritis Ankylosing spondylitis Polymyalgia rheumatica
TRAUMA (FracturesDislocations)
MSK DISORDERS Soft tissue injuries Whiplash CervicalLumbosacral
strain Myofascial disorders Fibromyalgia
JOINT DISORDERS Spondylosis and Osteoarthritis
MANAGEMENT
Self limited condition
Symptoms and disability improve rapidly
Most patients return to work and normal activities in 4-6 weeks
(Pengel LH et al BMJ 2003 327 323)
NATURAL HISTORY
1 in 3 patients
Persistent moderate pain 1 year after an acute episode
1 in 5 patients report substantial limitations in activity (von Korff al et al Spine 1996 21 2833-7 ndash discussion 2838-9)
NATURAL HISTORY
History and Physical Exam
Blood work to rule out the
presence of a malignancy andor an infection
Plain radiographs of
cervicallumbar spine CTMRI in patients with neurologic
complaints or with pain not improving
DIAGNOSIS
MAIN GOAL
Achieve adequate pain control (NSAIDs Tylenol Muscle
Relaxants Gabapentinoids short acting opioids)
Relative rest
Activity modifications
INITIAL MANAGEMENT
Epidural steroid injections are an
option in patients with disk herniation back and leg pain
INITIAL MANAGEMENT
Anesth Analg 2016 Mar122(3)857-70 Bhatia A1 Flamer D Shah PS Cohen SP
CONCLUSIONS Epidural steroids injections provide
some analgesic benefit at 3 months in patients with lumbosacral radicular pain
due to herniated intervertebral disks but they have no impact on physical
disability or incidence of surgery
Epidural steroid injections are an option in
patients with spinal stenosis
INITIAL MANAGEMENT
Spinal stenosis causes mechanical compression of the nerve roots swelling
(microvascular injury) producing pain (Olmarker K et al Spine 1989 14 569-573)
L3-4 Spinal Stenosis
INITIAL MANAGEMENT
STEROIDS
inhibit swelling (edema) around the nerve root
(Rydevik B et al Spine 1984 9 7-15)
improve blood flow to neural elements decreasing ischemic neuritis
(Fukusaki M et al Clin J Pain 1998 14 148-51)
block conduction in nociceptive nerve fibers (Johansson A et al Acta Anesthesiol Scand
1990 34 335-38) L4-5 Severe Spinal Stenosis
INITIAL MANAGEMENT
Usually spinal stenosis occurs in pts of senior age
Some of these patients may significant comorbidities and higher sensitivity to
pain medications
Multilevel Cervical Spinal Stenosis
INITIAL MANAGEMENT
Intra-articular facet joint injections are appropriate when a clinical
diagnosis of facet joint ldquosyndromerdquo is confirmed
Axial back pain withwithout radiation
to the extremities
Morning neckback stiffness Pain when starting to move worse on necklumbar
spine extension relieved by the recumbent position
Intra-articular C3-4 facet joint injection
Intra-articular L5-S1 facet joint injection
INITIAL MANAGEMENT
Injections helpful in diagnosis and management of LBP secondary
to SI Joint ldquoSyndromerdquo
Pain is always maximal below L5
May radiate to hips groin buttocks posterior thighs
Patterns of referred pain somewhat similar to those due to disk and orfacet joint mediated
pain
Intra-articular SI Joint Injection
INITIAL MANAGEMENT
Injections helpful in diagnosis and management of LBP due to Piriformis Muscle Syndrome
A REAL PAIN THE BUTT
INITIAL MANAGEMENT ACUPUNCTURE
Some evidence that acupuncture and variations
thereof (acupressure cupping) potentially helpful in the acutesubacute period in
patients with NP and LBP
(Yuan QI et al PloS One 2015 Febr 1-37)
NEXT STEP
Rehabilitation and regaining of function
Physical Therapy very important component of the
rehabilitation
A symbiotic relationship between patient and
therapist key of a successful physical rehabilitation
program
The role of YOGA
Better pain control at rest and with
activities with yoga (9-week program with weekly 90-minute classes) when
compared to a self care exercise program in patients with neck pain
Significant treatment effects of yoga found for pain-related apprehension
disability quality of life and psychological outcomes (depression
fatigue anger)
(Michalsen A et al the J Pain 2012 13(11) 1122-30)
THE IMPORTANCE OF REMAINING ACTIVE
Increasing the amount of steps
walkedday by 1000 over the course of a year reduced the risk of neck pain by
14 in a group of people (men and women age 20-45) with sedentary jobs
(Sitthipornvorakul EA et al Eur Spine J
2015 24 417-24)
SPINAL MANIPULATION No Thank you
Systematic review of spinal
manipulation in patients with a variety of pain conditions including NP
and LBP
Failed to demonstrate that spinal manipulation is an effective
intervention for pain management
(Posadzki P Pain Med 2012 13 754-61)
CONCLUSIONS
Neck and Low Back pain syndromes are usually self limited conditions that can convert in chronic pain conditions causing
prolonged disability
The prevalence and cost of these conditions has significantly increased over the course of the last 15-20 years
Aggressive management of pain during the acute phase is
important because adequate pain control shortens the time and level of disability and facilitates the rehabilitation process
CONCLUSIONS
A variety of treatment modalities including medications acupuncture injections PT Yoga are utilized to manage pain and facilitate the
recovery process
Reducing stress and activities associated with the generation of pain maintaining an appropriate physical exercise regimen and a body weight
as close as possible to the ideal body weight will likely result in a decreased incidenceprevalence of short and long term NP and LBP
THANK YOU
QUESTIONS
OTHER SOURCES OF NECK PAIN
Posterior neck muscles
Cervical dura mater
Atlanto-axial joint ligaments
Vertebral artery
Cervical vertebral bodies
True synovial joints with a space a synovial membrane hyaline cartilage surfaces and a
fibrous capsule located in front of the plane of the foramina and the nerve root therein
Arthritic changes may cause axial low back pain withwithout lower extremity pain
LUMBAR FACET JOINTS
LUMBAR FACET JOINTS PAIN CHARACTERISTICS
More common in patients 65
yearolder
Axial low back pain
withwithout radiation to the
lower extremities
Morning stiffness Pain when
starting to move relieved by
the recumbent position
Worsening as day goes by
LUMBAR FACET JOINTS PAIN PATTERNS
L4-5 L5-S1
most frequent facetogenic
pain generators in the lumbar
spine
Pain does not extend down
beyond the level of the knee
Largest axial joint in the
body
Only the anterior third is a
true synovial joint
Complex innervation
including sensory fibers
from L5 through S4 spinal
nerves
SACRO-ILIAC JOINT
A B
No difference in gender
Mean age 40-50
Prevalence 13-30 of
patients with ho low back
pain
Most commonly causing
unilateral symptoms
SACRO-ILIAC JOINT
Pain is always maximal below L5
May radiate to hips groin buttocks
posterior thighs
Patterns of referred pain somewhat
similar to those due to disk and orfacet
joint mediated pain
SACRO-ILIAC JOINT PAIN PATTERN
PIRIFORMIS MUSCLE
Located in the gluteal region is one of the muscles of the lateral
rotator group
It is situated within the posterior wall of the pelvis partly at the
back of the hip joint
Passes out of the pelvis through the greater sciatic foramen
Sciatic nerve
PIRIFORMIS MUSCLE
Sport activities andor certain movements (running lunging) can
stress the piriformis muscle
The subsequent muscle spasm may manifest as MSK low back pain
radiating to the buttock and along the sciatic nerve
Prolonged sitting stretching climbing stairs or walking on inclines squatting
worsen the pain
REALLY A PAIN THE BUTT
OTHER SOURCES OF LOW BACK PAIN
Posterior lumbo-sacral paraspinal pelvic girdle muscles
Lumbar spine ligaments tendons
Vertebral bodies
CAUSES OF NECK AND LOW BACK PAIN
TUMORS
INFECTIONS Discitis Osteomyelitis Septic arthritis Meningitis
VASCULAR DISORDERS (egCarotid artery dissection)
AUTOIMMUNE DISORDERS Rheumatoid arthritis Ankylosing spondylitis Polymyalgia rheumatica
TRAUMA (FracturesDislocations)
MSK DISORDERS Soft tissue injuries Whiplash CervicalLumbosacral
strain Myofascial disorders Fibromyalgia
JOINT DISORDERS Spondylosis and Osteoarthritis
MANAGEMENT
Self limited condition
Symptoms and disability improve rapidly
Most patients return to work and normal activities in 4-6 weeks
(Pengel LH et al BMJ 2003 327 323)
NATURAL HISTORY
1 in 3 patients
Persistent moderate pain 1 year after an acute episode
1 in 5 patients report substantial limitations in activity (von Korff al et al Spine 1996 21 2833-7 ndash discussion 2838-9)
NATURAL HISTORY
History and Physical Exam
Blood work to rule out the
presence of a malignancy andor an infection
Plain radiographs of
cervicallumbar spine CTMRI in patients with neurologic
complaints or with pain not improving
DIAGNOSIS
MAIN GOAL
Achieve adequate pain control (NSAIDs Tylenol Muscle
Relaxants Gabapentinoids short acting opioids)
Relative rest
Activity modifications
INITIAL MANAGEMENT
Epidural steroid injections are an
option in patients with disk herniation back and leg pain
INITIAL MANAGEMENT
Anesth Analg 2016 Mar122(3)857-70 Bhatia A1 Flamer D Shah PS Cohen SP
CONCLUSIONS Epidural steroids injections provide
some analgesic benefit at 3 months in patients with lumbosacral radicular pain
due to herniated intervertebral disks but they have no impact on physical
disability or incidence of surgery
Epidural steroid injections are an option in
patients with spinal stenosis
INITIAL MANAGEMENT
Spinal stenosis causes mechanical compression of the nerve roots swelling
(microvascular injury) producing pain (Olmarker K et al Spine 1989 14 569-573)
L3-4 Spinal Stenosis
INITIAL MANAGEMENT
STEROIDS
inhibit swelling (edema) around the nerve root
(Rydevik B et al Spine 1984 9 7-15)
improve blood flow to neural elements decreasing ischemic neuritis
(Fukusaki M et al Clin J Pain 1998 14 148-51)
block conduction in nociceptive nerve fibers (Johansson A et al Acta Anesthesiol Scand
1990 34 335-38) L4-5 Severe Spinal Stenosis
INITIAL MANAGEMENT
Usually spinal stenosis occurs in pts of senior age
Some of these patients may significant comorbidities and higher sensitivity to
pain medications
Multilevel Cervical Spinal Stenosis
INITIAL MANAGEMENT
Intra-articular facet joint injections are appropriate when a clinical
diagnosis of facet joint ldquosyndromerdquo is confirmed
Axial back pain withwithout radiation
to the extremities
Morning neckback stiffness Pain when starting to move worse on necklumbar
spine extension relieved by the recumbent position
Intra-articular C3-4 facet joint injection
Intra-articular L5-S1 facet joint injection
INITIAL MANAGEMENT
Injections helpful in diagnosis and management of LBP secondary
to SI Joint ldquoSyndromerdquo
Pain is always maximal below L5
May radiate to hips groin buttocks posterior thighs
Patterns of referred pain somewhat similar to those due to disk and orfacet joint mediated
pain
Intra-articular SI Joint Injection
INITIAL MANAGEMENT
Injections helpful in diagnosis and management of LBP due to Piriformis Muscle Syndrome
A REAL PAIN THE BUTT
INITIAL MANAGEMENT ACUPUNCTURE
Some evidence that acupuncture and variations
thereof (acupressure cupping) potentially helpful in the acutesubacute period in
patients with NP and LBP
(Yuan QI et al PloS One 2015 Febr 1-37)
NEXT STEP
Rehabilitation and regaining of function
Physical Therapy very important component of the
rehabilitation
A symbiotic relationship between patient and
therapist key of a successful physical rehabilitation
program
The role of YOGA
Better pain control at rest and with
activities with yoga (9-week program with weekly 90-minute classes) when
compared to a self care exercise program in patients with neck pain
Significant treatment effects of yoga found for pain-related apprehension
disability quality of life and psychological outcomes (depression
fatigue anger)
(Michalsen A et al the J Pain 2012 13(11) 1122-30)
THE IMPORTANCE OF REMAINING ACTIVE
Increasing the amount of steps
walkedday by 1000 over the course of a year reduced the risk of neck pain by
14 in a group of people (men and women age 20-45) with sedentary jobs
(Sitthipornvorakul EA et al Eur Spine J
2015 24 417-24)
SPINAL MANIPULATION No Thank you
Systematic review of spinal
manipulation in patients with a variety of pain conditions including NP
and LBP
Failed to demonstrate that spinal manipulation is an effective
intervention for pain management
(Posadzki P Pain Med 2012 13 754-61)
CONCLUSIONS
Neck and Low Back pain syndromes are usually self limited conditions that can convert in chronic pain conditions causing
prolonged disability
The prevalence and cost of these conditions has significantly increased over the course of the last 15-20 years
Aggressive management of pain during the acute phase is
important because adequate pain control shortens the time and level of disability and facilitates the rehabilitation process
CONCLUSIONS
A variety of treatment modalities including medications acupuncture injections PT Yoga are utilized to manage pain and facilitate the
recovery process
Reducing stress and activities associated with the generation of pain maintaining an appropriate physical exercise regimen and a body weight
as close as possible to the ideal body weight will likely result in a decreased incidenceprevalence of short and long term NP and LBP
THANK YOU
QUESTIONS
True synovial joints with a space a synovial membrane hyaline cartilage surfaces and a
fibrous capsule located in front of the plane of the foramina and the nerve root therein
Arthritic changes may cause axial low back pain withwithout lower extremity pain
LUMBAR FACET JOINTS
LUMBAR FACET JOINTS PAIN CHARACTERISTICS
More common in patients 65
yearolder
Axial low back pain
withwithout radiation to the
lower extremities
Morning stiffness Pain when
starting to move relieved by
the recumbent position
Worsening as day goes by
LUMBAR FACET JOINTS PAIN PATTERNS
L4-5 L5-S1
most frequent facetogenic
pain generators in the lumbar
spine
Pain does not extend down
beyond the level of the knee
Largest axial joint in the
body
Only the anterior third is a
true synovial joint
Complex innervation
including sensory fibers
from L5 through S4 spinal
nerves
SACRO-ILIAC JOINT
A B
No difference in gender
Mean age 40-50
Prevalence 13-30 of
patients with ho low back
pain
Most commonly causing
unilateral symptoms
SACRO-ILIAC JOINT
Pain is always maximal below L5
May radiate to hips groin buttocks
posterior thighs
Patterns of referred pain somewhat
similar to those due to disk and orfacet
joint mediated pain
SACRO-ILIAC JOINT PAIN PATTERN
PIRIFORMIS MUSCLE
Located in the gluteal region is one of the muscles of the lateral
rotator group
It is situated within the posterior wall of the pelvis partly at the
back of the hip joint
Passes out of the pelvis through the greater sciatic foramen
Sciatic nerve
PIRIFORMIS MUSCLE
Sport activities andor certain movements (running lunging) can
stress the piriformis muscle
The subsequent muscle spasm may manifest as MSK low back pain
radiating to the buttock and along the sciatic nerve
Prolonged sitting stretching climbing stairs or walking on inclines squatting
worsen the pain
REALLY A PAIN THE BUTT
OTHER SOURCES OF LOW BACK PAIN
Posterior lumbo-sacral paraspinal pelvic girdle muscles
Lumbar spine ligaments tendons
Vertebral bodies
CAUSES OF NECK AND LOW BACK PAIN
TUMORS
INFECTIONS Discitis Osteomyelitis Septic arthritis Meningitis
VASCULAR DISORDERS (egCarotid artery dissection)
AUTOIMMUNE DISORDERS Rheumatoid arthritis Ankylosing spondylitis Polymyalgia rheumatica
TRAUMA (FracturesDislocations)
MSK DISORDERS Soft tissue injuries Whiplash CervicalLumbosacral
strain Myofascial disorders Fibromyalgia
JOINT DISORDERS Spondylosis and Osteoarthritis
MANAGEMENT
Self limited condition
Symptoms and disability improve rapidly
Most patients return to work and normal activities in 4-6 weeks
(Pengel LH et al BMJ 2003 327 323)
NATURAL HISTORY
1 in 3 patients
Persistent moderate pain 1 year after an acute episode
1 in 5 patients report substantial limitations in activity (von Korff al et al Spine 1996 21 2833-7 ndash discussion 2838-9)
NATURAL HISTORY
History and Physical Exam
Blood work to rule out the
presence of a malignancy andor an infection
Plain radiographs of
cervicallumbar spine CTMRI in patients with neurologic
complaints or with pain not improving
DIAGNOSIS
MAIN GOAL
Achieve adequate pain control (NSAIDs Tylenol Muscle
Relaxants Gabapentinoids short acting opioids)
Relative rest
Activity modifications
INITIAL MANAGEMENT
Epidural steroid injections are an
option in patients with disk herniation back and leg pain
INITIAL MANAGEMENT
Anesth Analg 2016 Mar122(3)857-70 Bhatia A1 Flamer D Shah PS Cohen SP
CONCLUSIONS Epidural steroids injections provide
some analgesic benefit at 3 months in patients with lumbosacral radicular pain
due to herniated intervertebral disks but they have no impact on physical
disability or incidence of surgery
Epidural steroid injections are an option in
patients with spinal stenosis
INITIAL MANAGEMENT
Spinal stenosis causes mechanical compression of the nerve roots swelling
(microvascular injury) producing pain (Olmarker K et al Spine 1989 14 569-573)
L3-4 Spinal Stenosis
INITIAL MANAGEMENT
STEROIDS
inhibit swelling (edema) around the nerve root
(Rydevik B et al Spine 1984 9 7-15)
improve blood flow to neural elements decreasing ischemic neuritis
(Fukusaki M et al Clin J Pain 1998 14 148-51)
block conduction in nociceptive nerve fibers (Johansson A et al Acta Anesthesiol Scand
1990 34 335-38) L4-5 Severe Spinal Stenosis
INITIAL MANAGEMENT
Usually spinal stenosis occurs in pts of senior age
Some of these patients may significant comorbidities and higher sensitivity to
pain medications
Multilevel Cervical Spinal Stenosis
INITIAL MANAGEMENT
Intra-articular facet joint injections are appropriate when a clinical
diagnosis of facet joint ldquosyndromerdquo is confirmed
Axial back pain withwithout radiation
to the extremities
Morning neckback stiffness Pain when starting to move worse on necklumbar
spine extension relieved by the recumbent position
Intra-articular C3-4 facet joint injection
Intra-articular L5-S1 facet joint injection
INITIAL MANAGEMENT
Injections helpful in diagnosis and management of LBP secondary
to SI Joint ldquoSyndromerdquo
Pain is always maximal below L5
May radiate to hips groin buttocks posterior thighs
Patterns of referred pain somewhat similar to those due to disk and orfacet joint mediated
pain
Intra-articular SI Joint Injection
INITIAL MANAGEMENT
Injections helpful in diagnosis and management of LBP due to Piriformis Muscle Syndrome
A REAL PAIN THE BUTT
INITIAL MANAGEMENT ACUPUNCTURE
Some evidence that acupuncture and variations
thereof (acupressure cupping) potentially helpful in the acutesubacute period in
patients with NP and LBP
(Yuan QI et al PloS One 2015 Febr 1-37)
NEXT STEP
Rehabilitation and regaining of function
Physical Therapy very important component of the
rehabilitation
A symbiotic relationship between patient and
therapist key of a successful physical rehabilitation
program
The role of YOGA
Better pain control at rest and with
activities with yoga (9-week program with weekly 90-minute classes) when
compared to a self care exercise program in patients with neck pain
Significant treatment effects of yoga found for pain-related apprehension
disability quality of life and psychological outcomes (depression
fatigue anger)
(Michalsen A et al the J Pain 2012 13(11) 1122-30)
THE IMPORTANCE OF REMAINING ACTIVE
Increasing the amount of steps
walkedday by 1000 over the course of a year reduced the risk of neck pain by
14 in a group of people (men and women age 20-45) with sedentary jobs
(Sitthipornvorakul EA et al Eur Spine J
2015 24 417-24)
SPINAL MANIPULATION No Thank you
Systematic review of spinal
manipulation in patients with a variety of pain conditions including NP
and LBP
Failed to demonstrate that spinal manipulation is an effective
intervention for pain management
(Posadzki P Pain Med 2012 13 754-61)
CONCLUSIONS
Neck and Low Back pain syndromes are usually self limited conditions that can convert in chronic pain conditions causing
prolonged disability
The prevalence and cost of these conditions has significantly increased over the course of the last 15-20 years
Aggressive management of pain during the acute phase is
important because adequate pain control shortens the time and level of disability and facilitates the rehabilitation process
CONCLUSIONS
A variety of treatment modalities including medications acupuncture injections PT Yoga are utilized to manage pain and facilitate the
recovery process
Reducing stress and activities associated with the generation of pain maintaining an appropriate physical exercise regimen and a body weight
as close as possible to the ideal body weight will likely result in a decreased incidenceprevalence of short and long term NP and LBP
THANK YOU
QUESTIONS
LUMBAR FACET JOINTS PAIN CHARACTERISTICS
More common in patients 65
yearolder
Axial low back pain
withwithout radiation to the
lower extremities
Morning stiffness Pain when
starting to move relieved by
the recumbent position
Worsening as day goes by
LUMBAR FACET JOINTS PAIN PATTERNS
L4-5 L5-S1
most frequent facetogenic
pain generators in the lumbar
spine
Pain does not extend down
beyond the level of the knee
Largest axial joint in the
body
Only the anterior third is a
true synovial joint
Complex innervation
including sensory fibers
from L5 through S4 spinal
nerves
SACRO-ILIAC JOINT
A B
No difference in gender
Mean age 40-50
Prevalence 13-30 of
patients with ho low back
pain
Most commonly causing
unilateral symptoms
SACRO-ILIAC JOINT
Pain is always maximal below L5
May radiate to hips groin buttocks
posterior thighs
Patterns of referred pain somewhat
similar to those due to disk and orfacet
joint mediated pain
SACRO-ILIAC JOINT PAIN PATTERN
PIRIFORMIS MUSCLE
Located in the gluteal region is one of the muscles of the lateral
rotator group
It is situated within the posterior wall of the pelvis partly at the
back of the hip joint
Passes out of the pelvis through the greater sciatic foramen
Sciatic nerve
PIRIFORMIS MUSCLE
Sport activities andor certain movements (running lunging) can
stress the piriformis muscle
The subsequent muscle spasm may manifest as MSK low back pain
radiating to the buttock and along the sciatic nerve
Prolonged sitting stretching climbing stairs or walking on inclines squatting
worsen the pain
REALLY A PAIN THE BUTT
OTHER SOURCES OF LOW BACK PAIN
Posterior lumbo-sacral paraspinal pelvic girdle muscles
Lumbar spine ligaments tendons
Vertebral bodies
CAUSES OF NECK AND LOW BACK PAIN
TUMORS
INFECTIONS Discitis Osteomyelitis Septic arthritis Meningitis
VASCULAR DISORDERS (egCarotid artery dissection)
AUTOIMMUNE DISORDERS Rheumatoid arthritis Ankylosing spondylitis Polymyalgia rheumatica
TRAUMA (FracturesDislocations)
MSK DISORDERS Soft tissue injuries Whiplash CervicalLumbosacral
strain Myofascial disorders Fibromyalgia
JOINT DISORDERS Spondylosis and Osteoarthritis
MANAGEMENT
Self limited condition
Symptoms and disability improve rapidly
Most patients return to work and normal activities in 4-6 weeks
(Pengel LH et al BMJ 2003 327 323)
NATURAL HISTORY
1 in 3 patients
Persistent moderate pain 1 year after an acute episode
1 in 5 patients report substantial limitations in activity (von Korff al et al Spine 1996 21 2833-7 ndash discussion 2838-9)
NATURAL HISTORY
History and Physical Exam
Blood work to rule out the
presence of a malignancy andor an infection
Plain radiographs of
cervicallumbar spine CTMRI in patients with neurologic
complaints or with pain not improving
DIAGNOSIS
MAIN GOAL
Achieve adequate pain control (NSAIDs Tylenol Muscle
Relaxants Gabapentinoids short acting opioids)
Relative rest
Activity modifications
INITIAL MANAGEMENT
Epidural steroid injections are an
option in patients with disk herniation back and leg pain
INITIAL MANAGEMENT
Anesth Analg 2016 Mar122(3)857-70 Bhatia A1 Flamer D Shah PS Cohen SP
CONCLUSIONS Epidural steroids injections provide
some analgesic benefit at 3 months in patients with lumbosacral radicular pain
due to herniated intervertebral disks but they have no impact on physical
disability or incidence of surgery
Epidural steroid injections are an option in
patients with spinal stenosis
INITIAL MANAGEMENT
Spinal stenosis causes mechanical compression of the nerve roots swelling
(microvascular injury) producing pain (Olmarker K et al Spine 1989 14 569-573)
L3-4 Spinal Stenosis
INITIAL MANAGEMENT
STEROIDS
inhibit swelling (edema) around the nerve root
(Rydevik B et al Spine 1984 9 7-15)
improve blood flow to neural elements decreasing ischemic neuritis
(Fukusaki M et al Clin J Pain 1998 14 148-51)
block conduction in nociceptive nerve fibers (Johansson A et al Acta Anesthesiol Scand
1990 34 335-38) L4-5 Severe Spinal Stenosis
INITIAL MANAGEMENT
Usually spinal stenosis occurs in pts of senior age
Some of these patients may significant comorbidities and higher sensitivity to
pain medications
Multilevel Cervical Spinal Stenosis
INITIAL MANAGEMENT
Intra-articular facet joint injections are appropriate when a clinical
diagnosis of facet joint ldquosyndromerdquo is confirmed
Axial back pain withwithout radiation
to the extremities
Morning neckback stiffness Pain when starting to move worse on necklumbar
spine extension relieved by the recumbent position
Intra-articular C3-4 facet joint injection
Intra-articular L5-S1 facet joint injection
INITIAL MANAGEMENT
Injections helpful in diagnosis and management of LBP secondary
to SI Joint ldquoSyndromerdquo
Pain is always maximal below L5
May radiate to hips groin buttocks posterior thighs
Patterns of referred pain somewhat similar to those due to disk and orfacet joint mediated
pain
Intra-articular SI Joint Injection
INITIAL MANAGEMENT
Injections helpful in diagnosis and management of LBP due to Piriformis Muscle Syndrome
A REAL PAIN THE BUTT
INITIAL MANAGEMENT ACUPUNCTURE
Some evidence that acupuncture and variations
thereof (acupressure cupping) potentially helpful in the acutesubacute period in
patients with NP and LBP
(Yuan QI et al PloS One 2015 Febr 1-37)
NEXT STEP
Rehabilitation and regaining of function
Physical Therapy very important component of the
rehabilitation
A symbiotic relationship between patient and
therapist key of a successful physical rehabilitation
program
The role of YOGA
Better pain control at rest and with
activities with yoga (9-week program with weekly 90-minute classes) when
compared to a self care exercise program in patients with neck pain
Significant treatment effects of yoga found for pain-related apprehension
disability quality of life and psychological outcomes (depression
fatigue anger)
(Michalsen A et al the J Pain 2012 13(11) 1122-30)
THE IMPORTANCE OF REMAINING ACTIVE
Increasing the amount of steps
walkedday by 1000 over the course of a year reduced the risk of neck pain by
14 in a group of people (men and women age 20-45) with sedentary jobs
(Sitthipornvorakul EA et al Eur Spine J
2015 24 417-24)
SPINAL MANIPULATION No Thank you
Systematic review of spinal
manipulation in patients with a variety of pain conditions including NP
and LBP
Failed to demonstrate that spinal manipulation is an effective
intervention for pain management
(Posadzki P Pain Med 2012 13 754-61)
CONCLUSIONS
Neck and Low Back pain syndromes are usually self limited conditions that can convert in chronic pain conditions causing
prolonged disability
The prevalence and cost of these conditions has significantly increased over the course of the last 15-20 years
Aggressive management of pain during the acute phase is
important because adequate pain control shortens the time and level of disability and facilitates the rehabilitation process
CONCLUSIONS
A variety of treatment modalities including medications acupuncture injections PT Yoga are utilized to manage pain and facilitate the
recovery process
Reducing stress and activities associated with the generation of pain maintaining an appropriate physical exercise regimen and a body weight
as close as possible to the ideal body weight will likely result in a decreased incidenceprevalence of short and long term NP and LBP
THANK YOU
QUESTIONS
LUMBAR FACET JOINTS PAIN PATTERNS
L4-5 L5-S1
most frequent facetogenic
pain generators in the lumbar
spine
Pain does not extend down
beyond the level of the knee
Largest axial joint in the
body
Only the anterior third is a
true synovial joint
Complex innervation
including sensory fibers
from L5 through S4 spinal
nerves
SACRO-ILIAC JOINT
A B
No difference in gender
Mean age 40-50
Prevalence 13-30 of
patients with ho low back
pain
Most commonly causing
unilateral symptoms
SACRO-ILIAC JOINT
Pain is always maximal below L5
May radiate to hips groin buttocks
posterior thighs
Patterns of referred pain somewhat
similar to those due to disk and orfacet
joint mediated pain
SACRO-ILIAC JOINT PAIN PATTERN
PIRIFORMIS MUSCLE
Located in the gluteal region is one of the muscles of the lateral
rotator group
It is situated within the posterior wall of the pelvis partly at the
back of the hip joint
Passes out of the pelvis through the greater sciatic foramen
Sciatic nerve
PIRIFORMIS MUSCLE
Sport activities andor certain movements (running lunging) can
stress the piriformis muscle
The subsequent muscle spasm may manifest as MSK low back pain
radiating to the buttock and along the sciatic nerve
Prolonged sitting stretching climbing stairs or walking on inclines squatting
worsen the pain
REALLY A PAIN THE BUTT
OTHER SOURCES OF LOW BACK PAIN
Posterior lumbo-sacral paraspinal pelvic girdle muscles
Lumbar spine ligaments tendons
Vertebral bodies
CAUSES OF NECK AND LOW BACK PAIN
TUMORS
INFECTIONS Discitis Osteomyelitis Septic arthritis Meningitis
VASCULAR DISORDERS (egCarotid artery dissection)
AUTOIMMUNE DISORDERS Rheumatoid arthritis Ankylosing spondylitis Polymyalgia rheumatica
TRAUMA (FracturesDislocations)
MSK DISORDERS Soft tissue injuries Whiplash CervicalLumbosacral
strain Myofascial disorders Fibromyalgia
JOINT DISORDERS Spondylosis and Osteoarthritis
MANAGEMENT
Self limited condition
Symptoms and disability improve rapidly
Most patients return to work and normal activities in 4-6 weeks
(Pengel LH et al BMJ 2003 327 323)
NATURAL HISTORY
1 in 3 patients
Persistent moderate pain 1 year after an acute episode
1 in 5 patients report substantial limitations in activity (von Korff al et al Spine 1996 21 2833-7 ndash discussion 2838-9)
NATURAL HISTORY
History and Physical Exam
Blood work to rule out the
presence of a malignancy andor an infection
Plain radiographs of
cervicallumbar spine CTMRI in patients with neurologic
complaints or with pain not improving
DIAGNOSIS
MAIN GOAL
Achieve adequate pain control (NSAIDs Tylenol Muscle
Relaxants Gabapentinoids short acting opioids)
Relative rest
Activity modifications
INITIAL MANAGEMENT
Epidural steroid injections are an
option in patients with disk herniation back and leg pain
INITIAL MANAGEMENT
Anesth Analg 2016 Mar122(3)857-70 Bhatia A1 Flamer D Shah PS Cohen SP
CONCLUSIONS Epidural steroids injections provide
some analgesic benefit at 3 months in patients with lumbosacral radicular pain
due to herniated intervertebral disks but they have no impact on physical
disability or incidence of surgery
Epidural steroid injections are an option in
patients with spinal stenosis
INITIAL MANAGEMENT
Spinal stenosis causes mechanical compression of the nerve roots swelling
(microvascular injury) producing pain (Olmarker K et al Spine 1989 14 569-573)
L3-4 Spinal Stenosis
INITIAL MANAGEMENT
STEROIDS
inhibit swelling (edema) around the nerve root
(Rydevik B et al Spine 1984 9 7-15)
improve blood flow to neural elements decreasing ischemic neuritis
(Fukusaki M et al Clin J Pain 1998 14 148-51)
block conduction in nociceptive nerve fibers (Johansson A et al Acta Anesthesiol Scand
1990 34 335-38) L4-5 Severe Spinal Stenosis
INITIAL MANAGEMENT
Usually spinal stenosis occurs in pts of senior age
Some of these patients may significant comorbidities and higher sensitivity to
pain medications
Multilevel Cervical Spinal Stenosis
INITIAL MANAGEMENT
Intra-articular facet joint injections are appropriate when a clinical
diagnosis of facet joint ldquosyndromerdquo is confirmed
Axial back pain withwithout radiation
to the extremities
Morning neckback stiffness Pain when starting to move worse on necklumbar
spine extension relieved by the recumbent position
Intra-articular C3-4 facet joint injection
Intra-articular L5-S1 facet joint injection
INITIAL MANAGEMENT
Injections helpful in diagnosis and management of LBP secondary
to SI Joint ldquoSyndromerdquo
Pain is always maximal below L5
May radiate to hips groin buttocks posterior thighs
Patterns of referred pain somewhat similar to those due to disk and orfacet joint mediated
pain
Intra-articular SI Joint Injection
INITIAL MANAGEMENT
Injections helpful in diagnosis and management of LBP due to Piriformis Muscle Syndrome
A REAL PAIN THE BUTT
INITIAL MANAGEMENT ACUPUNCTURE
Some evidence that acupuncture and variations
thereof (acupressure cupping) potentially helpful in the acutesubacute period in
patients with NP and LBP
(Yuan QI et al PloS One 2015 Febr 1-37)
NEXT STEP
Rehabilitation and regaining of function
Physical Therapy very important component of the
rehabilitation
A symbiotic relationship between patient and
therapist key of a successful physical rehabilitation
program
The role of YOGA
Better pain control at rest and with
activities with yoga (9-week program with weekly 90-minute classes) when
compared to a self care exercise program in patients with neck pain
Significant treatment effects of yoga found for pain-related apprehension
disability quality of life and psychological outcomes (depression
fatigue anger)
(Michalsen A et al the J Pain 2012 13(11) 1122-30)
THE IMPORTANCE OF REMAINING ACTIVE
Increasing the amount of steps
walkedday by 1000 over the course of a year reduced the risk of neck pain by
14 in a group of people (men and women age 20-45) with sedentary jobs
(Sitthipornvorakul EA et al Eur Spine J
2015 24 417-24)
SPINAL MANIPULATION No Thank you
Systematic review of spinal
manipulation in patients with a variety of pain conditions including NP
and LBP
Failed to demonstrate that spinal manipulation is an effective
intervention for pain management
(Posadzki P Pain Med 2012 13 754-61)
CONCLUSIONS
Neck and Low Back pain syndromes are usually self limited conditions that can convert in chronic pain conditions causing
prolonged disability
The prevalence and cost of these conditions has significantly increased over the course of the last 15-20 years
Aggressive management of pain during the acute phase is
important because adequate pain control shortens the time and level of disability and facilitates the rehabilitation process
CONCLUSIONS
A variety of treatment modalities including medications acupuncture injections PT Yoga are utilized to manage pain and facilitate the
recovery process
Reducing stress and activities associated with the generation of pain maintaining an appropriate physical exercise regimen and a body weight
as close as possible to the ideal body weight will likely result in a decreased incidenceprevalence of short and long term NP and LBP
THANK YOU
QUESTIONS
Largest axial joint in the
body
Only the anterior third is a
true synovial joint
Complex innervation
including sensory fibers
from L5 through S4 spinal
nerves
SACRO-ILIAC JOINT
A B
No difference in gender
Mean age 40-50
Prevalence 13-30 of
patients with ho low back
pain
Most commonly causing
unilateral symptoms
SACRO-ILIAC JOINT
Pain is always maximal below L5
May radiate to hips groin buttocks
posterior thighs
Patterns of referred pain somewhat
similar to those due to disk and orfacet
joint mediated pain
SACRO-ILIAC JOINT PAIN PATTERN
PIRIFORMIS MUSCLE
Located in the gluteal region is one of the muscles of the lateral
rotator group
It is situated within the posterior wall of the pelvis partly at the
back of the hip joint
Passes out of the pelvis through the greater sciatic foramen
Sciatic nerve
PIRIFORMIS MUSCLE
Sport activities andor certain movements (running lunging) can
stress the piriformis muscle
The subsequent muscle spasm may manifest as MSK low back pain
radiating to the buttock and along the sciatic nerve
Prolonged sitting stretching climbing stairs or walking on inclines squatting
worsen the pain
REALLY A PAIN THE BUTT
OTHER SOURCES OF LOW BACK PAIN
Posterior lumbo-sacral paraspinal pelvic girdle muscles
Lumbar spine ligaments tendons
Vertebral bodies
CAUSES OF NECK AND LOW BACK PAIN
TUMORS
INFECTIONS Discitis Osteomyelitis Septic arthritis Meningitis
VASCULAR DISORDERS (egCarotid artery dissection)
AUTOIMMUNE DISORDERS Rheumatoid arthritis Ankylosing spondylitis Polymyalgia rheumatica
TRAUMA (FracturesDislocations)
MSK DISORDERS Soft tissue injuries Whiplash CervicalLumbosacral
strain Myofascial disorders Fibromyalgia
JOINT DISORDERS Spondylosis and Osteoarthritis
MANAGEMENT
Self limited condition
Symptoms and disability improve rapidly
Most patients return to work and normal activities in 4-6 weeks
(Pengel LH et al BMJ 2003 327 323)
NATURAL HISTORY
1 in 3 patients
Persistent moderate pain 1 year after an acute episode
1 in 5 patients report substantial limitations in activity (von Korff al et al Spine 1996 21 2833-7 ndash discussion 2838-9)
NATURAL HISTORY
History and Physical Exam
Blood work to rule out the
presence of a malignancy andor an infection
Plain radiographs of
cervicallumbar spine CTMRI in patients with neurologic
complaints or with pain not improving
DIAGNOSIS
MAIN GOAL
Achieve adequate pain control (NSAIDs Tylenol Muscle
Relaxants Gabapentinoids short acting opioids)
Relative rest
Activity modifications
INITIAL MANAGEMENT
Epidural steroid injections are an
option in patients with disk herniation back and leg pain
INITIAL MANAGEMENT
Anesth Analg 2016 Mar122(3)857-70 Bhatia A1 Flamer D Shah PS Cohen SP
CONCLUSIONS Epidural steroids injections provide
some analgesic benefit at 3 months in patients with lumbosacral radicular pain
due to herniated intervertebral disks but they have no impact on physical
disability or incidence of surgery
Epidural steroid injections are an option in
patients with spinal stenosis
INITIAL MANAGEMENT
Spinal stenosis causes mechanical compression of the nerve roots swelling
(microvascular injury) producing pain (Olmarker K et al Spine 1989 14 569-573)
L3-4 Spinal Stenosis
INITIAL MANAGEMENT
STEROIDS
inhibit swelling (edema) around the nerve root
(Rydevik B et al Spine 1984 9 7-15)
improve blood flow to neural elements decreasing ischemic neuritis
(Fukusaki M et al Clin J Pain 1998 14 148-51)
block conduction in nociceptive nerve fibers (Johansson A et al Acta Anesthesiol Scand
1990 34 335-38) L4-5 Severe Spinal Stenosis
INITIAL MANAGEMENT
Usually spinal stenosis occurs in pts of senior age
Some of these patients may significant comorbidities and higher sensitivity to
pain medications
Multilevel Cervical Spinal Stenosis
INITIAL MANAGEMENT
Intra-articular facet joint injections are appropriate when a clinical
diagnosis of facet joint ldquosyndromerdquo is confirmed
Axial back pain withwithout radiation
to the extremities
Morning neckback stiffness Pain when starting to move worse on necklumbar
spine extension relieved by the recumbent position
Intra-articular C3-4 facet joint injection
Intra-articular L5-S1 facet joint injection
INITIAL MANAGEMENT
Injections helpful in diagnosis and management of LBP secondary
to SI Joint ldquoSyndromerdquo
Pain is always maximal below L5
May radiate to hips groin buttocks posterior thighs
Patterns of referred pain somewhat similar to those due to disk and orfacet joint mediated
pain
Intra-articular SI Joint Injection
INITIAL MANAGEMENT
Injections helpful in diagnosis and management of LBP due to Piriformis Muscle Syndrome
A REAL PAIN THE BUTT
INITIAL MANAGEMENT ACUPUNCTURE
Some evidence that acupuncture and variations
thereof (acupressure cupping) potentially helpful in the acutesubacute period in
patients with NP and LBP
(Yuan QI et al PloS One 2015 Febr 1-37)
NEXT STEP
Rehabilitation and regaining of function
Physical Therapy very important component of the
rehabilitation
A symbiotic relationship between patient and
therapist key of a successful physical rehabilitation
program
The role of YOGA
Better pain control at rest and with
activities with yoga (9-week program with weekly 90-minute classes) when
compared to a self care exercise program in patients with neck pain
Significant treatment effects of yoga found for pain-related apprehension
disability quality of life and psychological outcomes (depression
fatigue anger)
(Michalsen A et al the J Pain 2012 13(11) 1122-30)
THE IMPORTANCE OF REMAINING ACTIVE
Increasing the amount of steps
walkedday by 1000 over the course of a year reduced the risk of neck pain by
14 in a group of people (men and women age 20-45) with sedentary jobs
(Sitthipornvorakul EA et al Eur Spine J
2015 24 417-24)
SPINAL MANIPULATION No Thank you
Systematic review of spinal
manipulation in patients with a variety of pain conditions including NP
and LBP
Failed to demonstrate that spinal manipulation is an effective
intervention for pain management
(Posadzki P Pain Med 2012 13 754-61)
CONCLUSIONS
Neck and Low Back pain syndromes are usually self limited conditions that can convert in chronic pain conditions causing
prolonged disability
The prevalence and cost of these conditions has significantly increased over the course of the last 15-20 years
Aggressive management of pain during the acute phase is
important because adequate pain control shortens the time and level of disability and facilitates the rehabilitation process
CONCLUSIONS
A variety of treatment modalities including medications acupuncture injections PT Yoga are utilized to manage pain and facilitate the
recovery process
Reducing stress and activities associated with the generation of pain maintaining an appropriate physical exercise regimen and a body weight
as close as possible to the ideal body weight will likely result in a decreased incidenceprevalence of short and long term NP and LBP
THANK YOU
QUESTIONS
No difference in gender
Mean age 40-50
Prevalence 13-30 of
patients with ho low back
pain
Most commonly causing
unilateral symptoms
SACRO-ILIAC JOINT
Pain is always maximal below L5
May radiate to hips groin buttocks
posterior thighs
Patterns of referred pain somewhat
similar to those due to disk and orfacet
joint mediated pain
SACRO-ILIAC JOINT PAIN PATTERN
PIRIFORMIS MUSCLE
Located in the gluteal region is one of the muscles of the lateral
rotator group
It is situated within the posterior wall of the pelvis partly at the
back of the hip joint
Passes out of the pelvis through the greater sciatic foramen
Sciatic nerve
PIRIFORMIS MUSCLE
Sport activities andor certain movements (running lunging) can
stress the piriformis muscle
The subsequent muscle spasm may manifest as MSK low back pain
radiating to the buttock and along the sciatic nerve
Prolonged sitting stretching climbing stairs or walking on inclines squatting
worsen the pain
REALLY A PAIN THE BUTT
OTHER SOURCES OF LOW BACK PAIN
Posterior lumbo-sacral paraspinal pelvic girdle muscles
Lumbar spine ligaments tendons
Vertebral bodies
CAUSES OF NECK AND LOW BACK PAIN
TUMORS
INFECTIONS Discitis Osteomyelitis Septic arthritis Meningitis
VASCULAR DISORDERS (egCarotid artery dissection)
AUTOIMMUNE DISORDERS Rheumatoid arthritis Ankylosing spondylitis Polymyalgia rheumatica
TRAUMA (FracturesDislocations)
MSK DISORDERS Soft tissue injuries Whiplash CervicalLumbosacral
strain Myofascial disorders Fibromyalgia
JOINT DISORDERS Spondylosis and Osteoarthritis
MANAGEMENT
Self limited condition
Symptoms and disability improve rapidly
Most patients return to work and normal activities in 4-6 weeks
(Pengel LH et al BMJ 2003 327 323)
NATURAL HISTORY
1 in 3 patients
Persistent moderate pain 1 year after an acute episode
1 in 5 patients report substantial limitations in activity (von Korff al et al Spine 1996 21 2833-7 ndash discussion 2838-9)
NATURAL HISTORY
History and Physical Exam
Blood work to rule out the
presence of a malignancy andor an infection
Plain radiographs of
cervicallumbar spine CTMRI in patients with neurologic
complaints or with pain not improving
DIAGNOSIS
MAIN GOAL
Achieve adequate pain control (NSAIDs Tylenol Muscle
Relaxants Gabapentinoids short acting opioids)
Relative rest
Activity modifications
INITIAL MANAGEMENT
Epidural steroid injections are an
option in patients with disk herniation back and leg pain
INITIAL MANAGEMENT
Anesth Analg 2016 Mar122(3)857-70 Bhatia A1 Flamer D Shah PS Cohen SP
CONCLUSIONS Epidural steroids injections provide
some analgesic benefit at 3 months in patients with lumbosacral radicular pain
due to herniated intervertebral disks but they have no impact on physical
disability or incidence of surgery
Epidural steroid injections are an option in
patients with spinal stenosis
INITIAL MANAGEMENT
Spinal stenosis causes mechanical compression of the nerve roots swelling
(microvascular injury) producing pain (Olmarker K et al Spine 1989 14 569-573)
L3-4 Spinal Stenosis
INITIAL MANAGEMENT
STEROIDS
inhibit swelling (edema) around the nerve root
(Rydevik B et al Spine 1984 9 7-15)
improve blood flow to neural elements decreasing ischemic neuritis
(Fukusaki M et al Clin J Pain 1998 14 148-51)
block conduction in nociceptive nerve fibers (Johansson A et al Acta Anesthesiol Scand
1990 34 335-38) L4-5 Severe Spinal Stenosis
INITIAL MANAGEMENT
Usually spinal stenosis occurs in pts of senior age
Some of these patients may significant comorbidities and higher sensitivity to
pain medications
Multilevel Cervical Spinal Stenosis
INITIAL MANAGEMENT
Intra-articular facet joint injections are appropriate when a clinical
diagnosis of facet joint ldquosyndromerdquo is confirmed
Axial back pain withwithout radiation
to the extremities
Morning neckback stiffness Pain when starting to move worse on necklumbar
spine extension relieved by the recumbent position
Intra-articular C3-4 facet joint injection
Intra-articular L5-S1 facet joint injection
INITIAL MANAGEMENT
Injections helpful in diagnosis and management of LBP secondary
to SI Joint ldquoSyndromerdquo
Pain is always maximal below L5
May radiate to hips groin buttocks posterior thighs
Patterns of referred pain somewhat similar to those due to disk and orfacet joint mediated
pain
Intra-articular SI Joint Injection
INITIAL MANAGEMENT
Injections helpful in diagnosis and management of LBP due to Piriformis Muscle Syndrome
A REAL PAIN THE BUTT
INITIAL MANAGEMENT ACUPUNCTURE
Some evidence that acupuncture and variations
thereof (acupressure cupping) potentially helpful in the acutesubacute period in
patients with NP and LBP
(Yuan QI et al PloS One 2015 Febr 1-37)
NEXT STEP
Rehabilitation and regaining of function
Physical Therapy very important component of the
rehabilitation
A symbiotic relationship between patient and
therapist key of a successful physical rehabilitation
program
The role of YOGA
Better pain control at rest and with
activities with yoga (9-week program with weekly 90-minute classes) when
compared to a self care exercise program in patients with neck pain
Significant treatment effects of yoga found for pain-related apprehension
disability quality of life and psychological outcomes (depression
fatigue anger)
(Michalsen A et al the J Pain 2012 13(11) 1122-30)
THE IMPORTANCE OF REMAINING ACTIVE
Increasing the amount of steps
walkedday by 1000 over the course of a year reduced the risk of neck pain by
14 in a group of people (men and women age 20-45) with sedentary jobs
(Sitthipornvorakul EA et al Eur Spine J
2015 24 417-24)
SPINAL MANIPULATION No Thank you
Systematic review of spinal
manipulation in patients with a variety of pain conditions including NP
and LBP
Failed to demonstrate that spinal manipulation is an effective
intervention for pain management
(Posadzki P Pain Med 2012 13 754-61)
CONCLUSIONS
Neck and Low Back pain syndromes are usually self limited conditions that can convert in chronic pain conditions causing
prolonged disability
The prevalence and cost of these conditions has significantly increased over the course of the last 15-20 years
Aggressive management of pain during the acute phase is
important because adequate pain control shortens the time and level of disability and facilitates the rehabilitation process
CONCLUSIONS
A variety of treatment modalities including medications acupuncture injections PT Yoga are utilized to manage pain and facilitate the
recovery process
Reducing stress and activities associated with the generation of pain maintaining an appropriate physical exercise regimen and a body weight
as close as possible to the ideal body weight will likely result in a decreased incidenceprevalence of short and long term NP and LBP
THANK YOU
QUESTIONS
Pain is always maximal below L5
May radiate to hips groin buttocks
posterior thighs
Patterns of referred pain somewhat
similar to those due to disk and orfacet
joint mediated pain
SACRO-ILIAC JOINT PAIN PATTERN
PIRIFORMIS MUSCLE
Located in the gluteal region is one of the muscles of the lateral
rotator group
It is situated within the posterior wall of the pelvis partly at the
back of the hip joint
Passes out of the pelvis through the greater sciatic foramen
Sciatic nerve
PIRIFORMIS MUSCLE
Sport activities andor certain movements (running lunging) can
stress the piriformis muscle
The subsequent muscle spasm may manifest as MSK low back pain
radiating to the buttock and along the sciatic nerve
Prolonged sitting stretching climbing stairs or walking on inclines squatting
worsen the pain
REALLY A PAIN THE BUTT
OTHER SOURCES OF LOW BACK PAIN
Posterior lumbo-sacral paraspinal pelvic girdle muscles
Lumbar spine ligaments tendons
Vertebral bodies
CAUSES OF NECK AND LOW BACK PAIN
TUMORS
INFECTIONS Discitis Osteomyelitis Septic arthritis Meningitis
VASCULAR DISORDERS (egCarotid artery dissection)
AUTOIMMUNE DISORDERS Rheumatoid arthritis Ankylosing spondylitis Polymyalgia rheumatica
TRAUMA (FracturesDislocations)
MSK DISORDERS Soft tissue injuries Whiplash CervicalLumbosacral
strain Myofascial disorders Fibromyalgia
JOINT DISORDERS Spondylosis and Osteoarthritis
MANAGEMENT
Self limited condition
Symptoms and disability improve rapidly
Most patients return to work and normal activities in 4-6 weeks
(Pengel LH et al BMJ 2003 327 323)
NATURAL HISTORY
1 in 3 patients
Persistent moderate pain 1 year after an acute episode
1 in 5 patients report substantial limitations in activity (von Korff al et al Spine 1996 21 2833-7 ndash discussion 2838-9)
NATURAL HISTORY
History and Physical Exam
Blood work to rule out the
presence of a malignancy andor an infection
Plain radiographs of
cervicallumbar spine CTMRI in patients with neurologic
complaints or with pain not improving
DIAGNOSIS
MAIN GOAL
Achieve adequate pain control (NSAIDs Tylenol Muscle
Relaxants Gabapentinoids short acting opioids)
Relative rest
Activity modifications
INITIAL MANAGEMENT
Epidural steroid injections are an
option in patients with disk herniation back and leg pain
INITIAL MANAGEMENT
Anesth Analg 2016 Mar122(3)857-70 Bhatia A1 Flamer D Shah PS Cohen SP
CONCLUSIONS Epidural steroids injections provide
some analgesic benefit at 3 months in patients with lumbosacral radicular pain
due to herniated intervertebral disks but they have no impact on physical
disability or incidence of surgery
Epidural steroid injections are an option in
patients with spinal stenosis
INITIAL MANAGEMENT
Spinal stenosis causes mechanical compression of the nerve roots swelling
(microvascular injury) producing pain (Olmarker K et al Spine 1989 14 569-573)
L3-4 Spinal Stenosis
INITIAL MANAGEMENT
STEROIDS
inhibit swelling (edema) around the nerve root
(Rydevik B et al Spine 1984 9 7-15)
improve blood flow to neural elements decreasing ischemic neuritis
(Fukusaki M et al Clin J Pain 1998 14 148-51)
block conduction in nociceptive nerve fibers (Johansson A et al Acta Anesthesiol Scand
1990 34 335-38) L4-5 Severe Spinal Stenosis
INITIAL MANAGEMENT
Usually spinal stenosis occurs in pts of senior age
Some of these patients may significant comorbidities and higher sensitivity to
pain medications
Multilevel Cervical Spinal Stenosis
INITIAL MANAGEMENT
Intra-articular facet joint injections are appropriate when a clinical
diagnosis of facet joint ldquosyndromerdquo is confirmed
Axial back pain withwithout radiation
to the extremities
Morning neckback stiffness Pain when starting to move worse on necklumbar
spine extension relieved by the recumbent position
Intra-articular C3-4 facet joint injection
Intra-articular L5-S1 facet joint injection
INITIAL MANAGEMENT
Injections helpful in diagnosis and management of LBP secondary
to SI Joint ldquoSyndromerdquo
Pain is always maximal below L5
May radiate to hips groin buttocks posterior thighs
Patterns of referred pain somewhat similar to those due to disk and orfacet joint mediated
pain
Intra-articular SI Joint Injection
INITIAL MANAGEMENT
Injections helpful in diagnosis and management of LBP due to Piriformis Muscle Syndrome
A REAL PAIN THE BUTT
INITIAL MANAGEMENT ACUPUNCTURE
Some evidence that acupuncture and variations
thereof (acupressure cupping) potentially helpful in the acutesubacute period in
patients with NP and LBP
(Yuan QI et al PloS One 2015 Febr 1-37)
NEXT STEP
Rehabilitation and regaining of function
Physical Therapy very important component of the
rehabilitation
A symbiotic relationship between patient and
therapist key of a successful physical rehabilitation
program
The role of YOGA
Better pain control at rest and with
activities with yoga (9-week program with weekly 90-minute classes) when
compared to a self care exercise program in patients with neck pain
Significant treatment effects of yoga found for pain-related apprehension
disability quality of life and psychological outcomes (depression
fatigue anger)
(Michalsen A et al the J Pain 2012 13(11) 1122-30)
THE IMPORTANCE OF REMAINING ACTIVE
Increasing the amount of steps
walkedday by 1000 over the course of a year reduced the risk of neck pain by
14 in a group of people (men and women age 20-45) with sedentary jobs
(Sitthipornvorakul EA et al Eur Spine J
2015 24 417-24)
SPINAL MANIPULATION No Thank you
Systematic review of spinal
manipulation in patients with a variety of pain conditions including NP
and LBP
Failed to demonstrate that spinal manipulation is an effective
intervention for pain management
(Posadzki P Pain Med 2012 13 754-61)
CONCLUSIONS
Neck and Low Back pain syndromes are usually self limited conditions that can convert in chronic pain conditions causing
prolonged disability
The prevalence and cost of these conditions has significantly increased over the course of the last 15-20 years
Aggressive management of pain during the acute phase is
important because adequate pain control shortens the time and level of disability and facilitates the rehabilitation process
CONCLUSIONS
A variety of treatment modalities including medications acupuncture injections PT Yoga are utilized to manage pain and facilitate the
recovery process
Reducing stress and activities associated with the generation of pain maintaining an appropriate physical exercise regimen and a body weight
as close as possible to the ideal body weight will likely result in a decreased incidenceprevalence of short and long term NP and LBP
THANK YOU
QUESTIONS
PIRIFORMIS MUSCLE
Located in the gluteal region is one of the muscles of the lateral
rotator group
It is situated within the posterior wall of the pelvis partly at the
back of the hip joint
Passes out of the pelvis through the greater sciatic foramen
Sciatic nerve
PIRIFORMIS MUSCLE
Sport activities andor certain movements (running lunging) can
stress the piriformis muscle
The subsequent muscle spasm may manifest as MSK low back pain
radiating to the buttock and along the sciatic nerve
Prolonged sitting stretching climbing stairs or walking on inclines squatting
worsen the pain
REALLY A PAIN THE BUTT
OTHER SOURCES OF LOW BACK PAIN
Posterior lumbo-sacral paraspinal pelvic girdle muscles
Lumbar spine ligaments tendons
Vertebral bodies
CAUSES OF NECK AND LOW BACK PAIN
TUMORS
INFECTIONS Discitis Osteomyelitis Septic arthritis Meningitis
VASCULAR DISORDERS (egCarotid artery dissection)
AUTOIMMUNE DISORDERS Rheumatoid arthritis Ankylosing spondylitis Polymyalgia rheumatica
TRAUMA (FracturesDislocations)
MSK DISORDERS Soft tissue injuries Whiplash CervicalLumbosacral
strain Myofascial disorders Fibromyalgia
JOINT DISORDERS Spondylosis and Osteoarthritis
MANAGEMENT
Self limited condition
Symptoms and disability improve rapidly
Most patients return to work and normal activities in 4-6 weeks
(Pengel LH et al BMJ 2003 327 323)
NATURAL HISTORY
1 in 3 patients
Persistent moderate pain 1 year after an acute episode
1 in 5 patients report substantial limitations in activity (von Korff al et al Spine 1996 21 2833-7 ndash discussion 2838-9)
NATURAL HISTORY
History and Physical Exam
Blood work to rule out the
presence of a malignancy andor an infection
Plain radiographs of
cervicallumbar spine CTMRI in patients with neurologic
complaints or with pain not improving
DIAGNOSIS
MAIN GOAL
Achieve adequate pain control (NSAIDs Tylenol Muscle
Relaxants Gabapentinoids short acting opioids)
Relative rest
Activity modifications
INITIAL MANAGEMENT
Epidural steroid injections are an
option in patients with disk herniation back and leg pain
INITIAL MANAGEMENT
Anesth Analg 2016 Mar122(3)857-70 Bhatia A1 Flamer D Shah PS Cohen SP
CONCLUSIONS Epidural steroids injections provide
some analgesic benefit at 3 months in patients with lumbosacral radicular pain
due to herniated intervertebral disks but they have no impact on physical
disability or incidence of surgery
Epidural steroid injections are an option in
patients with spinal stenosis
INITIAL MANAGEMENT
Spinal stenosis causes mechanical compression of the nerve roots swelling
(microvascular injury) producing pain (Olmarker K et al Spine 1989 14 569-573)
L3-4 Spinal Stenosis
INITIAL MANAGEMENT
STEROIDS
inhibit swelling (edema) around the nerve root
(Rydevik B et al Spine 1984 9 7-15)
improve blood flow to neural elements decreasing ischemic neuritis
(Fukusaki M et al Clin J Pain 1998 14 148-51)
block conduction in nociceptive nerve fibers (Johansson A et al Acta Anesthesiol Scand
1990 34 335-38) L4-5 Severe Spinal Stenosis
INITIAL MANAGEMENT
Usually spinal stenosis occurs in pts of senior age
Some of these patients may significant comorbidities and higher sensitivity to
pain medications
Multilevel Cervical Spinal Stenosis
INITIAL MANAGEMENT
Intra-articular facet joint injections are appropriate when a clinical
diagnosis of facet joint ldquosyndromerdquo is confirmed
Axial back pain withwithout radiation
to the extremities
Morning neckback stiffness Pain when starting to move worse on necklumbar
spine extension relieved by the recumbent position
Intra-articular C3-4 facet joint injection
Intra-articular L5-S1 facet joint injection
INITIAL MANAGEMENT
Injections helpful in diagnosis and management of LBP secondary
to SI Joint ldquoSyndromerdquo
Pain is always maximal below L5
May radiate to hips groin buttocks posterior thighs
Patterns of referred pain somewhat similar to those due to disk and orfacet joint mediated
pain
Intra-articular SI Joint Injection
INITIAL MANAGEMENT
Injections helpful in diagnosis and management of LBP due to Piriformis Muscle Syndrome
A REAL PAIN THE BUTT
INITIAL MANAGEMENT ACUPUNCTURE
Some evidence that acupuncture and variations
thereof (acupressure cupping) potentially helpful in the acutesubacute period in
patients with NP and LBP
(Yuan QI et al PloS One 2015 Febr 1-37)
NEXT STEP
Rehabilitation and regaining of function
Physical Therapy very important component of the
rehabilitation
A symbiotic relationship between patient and
therapist key of a successful physical rehabilitation
program
The role of YOGA
Better pain control at rest and with
activities with yoga (9-week program with weekly 90-minute classes) when
compared to a self care exercise program in patients with neck pain
Significant treatment effects of yoga found for pain-related apprehension
disability quality of life and psychological outcomes (depression
fatigue anger)
(Michalsen A et al the J Pain 2012 13(11) 1122-30)
THE IMPORTANCE OF REMAINING ACTIVE
Increasing the amount of steps
walkedday by 1000 over the course of a year reduced the risk of neck pain by
14 in a group of people (men and women age 20-45) with sedentary jobs
(Sitthipornvorakul EA et al Eur Spine J
2015 24 417-24)
SPINAL MANIPULATION No Thank you
Systematic review of spinal
manipulation in patients with a variety of pain conditions including NP
and LBP
Failed to demonstrate that spinal manipulation is an effective
intervention for pain management
(Posadzki P Pain Med 2012 13 754-61)
CONCLUSIONS
Neck and Low Back pain syndromes are usually self limited conditions that can convert in chronic pain conditions causing
prolonged disability
The prevalence and cost of these conditions has significantly increased over the course of the last 15-20 years
Aggressive management of pain during the acute phase is
important because adequate pain control shortens the time and level of disability and facilitates the rehabilitation process
CONCLUSIONS
A variety of treatment modalities including medications acupuncture injections PT Yoga are utilized to manage pain and facilitate the
recovery process
Reducing stress and activities associated with the generation of pain maintaining an appropriate physical exercise regimen and a body weight
as close as possible to the ideal body weight will likely result in a decreased incidenceprevalence of short and long term NP and LBP
THANK YOU
QUESTIONS
PIRIFORMIS MUSCLE
Sport activities andor certain movements (running lunging) can
stress the piriformis muscle
The subsequent muscle spasm may manifest as MSK low back pain
radiating to the buttock and along the sciatic nerve
Prolonged sitting stretching climbing stairs or walking on inclines squatting
worsen the pain
REALLY A PAIN THE BUTT
OTHER SOURCES OF LOW BACK PAIN
Posterior lumbo-sacral paraspinal pelvic girdle muscles
Lumbar spine ligaments tendons
Vertebral bodies
CAUSES OF NECK AND LOW BACK PAIN
TUMORS
INFECTIONS Discitis Osteomyelitis Septic arthritis Meningitis
VASCULAR DISORDERS (egCarotid artery dissection)
AUTOIMMUNE DISORDERS Rheumatoid arthritis Ankylosing spondylitis Polymyalgia rheumatica
TRAUMA (FracturesDislocations)
MSK DISORDERS Soft tissue injuries Whiplash CervicalLumbosacral
strain Myofascial disorders Fibromyalgia
JOINT DISORDERS Spondylosis and Osteoarthritis
MANAGEMENT
Self limited condition
Symptoms and disability improve rapidly
Most patients return to work and normal activities in 4-6 weeks
(Pengel LH et al BMJ 2003 327 323)
NATURAL HISTORY
1 in 3 patients
Persistent moderate pain 1 year after an acute episode
1 in 5 patients report substantial limitations in activity (von Korff al et al Spine 1996 21 2833-7 ndash discussion 2838-9)
NATURAL HISTORY
History and Physical Exam
Blood work to rule out the
presence of a malignancy andor an infection
Plain radiographs of
cervicallumbar spine CTMRI in patients with neurologic
complaints or with pain not improving
DIAGNOSIS
MAIN GOAL
Achieve adequate pain control (NSAIDs Tylenol Muscle
Relaxants Gabapentinoids short acting opioids)
Relative rest
Activity modifications
INITIAL MANAGEMENT
Epidural steroid injections are an
option in patients with disk herniation back and leg pain
INITIAL MANAGEMENT
Anesth Analg 2016 Mar122(3)857-70 Bhatia A1 Flamer D Shah PS Cohen SP
CONCLUSIONS Epidural steroids injections provide
some analgesic benefit at 3 months in patients with lumbosacral radicular pain
due to herniated intervertebral disks but they have no impact on physical
disability or incidence of surgery
Epidural steroid injections are an option in
patients with spinal stenosis
INITIAL MANAGEMENT
Spinal stenosis causes mechanical compression of the nerve roots swelling
(microvascular injury) producing pain (Olmarker K et al Spine 1989 14 569-573)
L3-4 Spinal Stenosis
INITIAL MANAGEMENT
STEROIDS
inhibit swelling (edema) around the nerve root
(Rydevik B et al Spine 1984 9 7-15)
improve blood flow to neural elements decreasing ischemic neuritis
(Fukusaki M et al Clin J Pain 1998 14 148-51)
block conduction in nociceptive nerve fibers (Johansson A et al Acta Anesthesiol Scand
1990 34 335-38) L4-5 Severe Spinal Stenosis
INITIAL MANAGEMENT
Usually spinal stenosis occurs in pts of senior age
Some of these patients may significant comorbidities and higher sensitivity to
pain medications
Multilevel Cervical Spinal Stenosis
INITIAL MANAGEMENT
Intra-articular facet joint injections are appropriate when a clinical
diagnosis of facet joint ldquosyndromerdquo is confirmed
Axial back pain withwithout radiation
to the extremities
Morning neckback stiffness Pain when starting to move worse on necklumbar
spine extension relieved by the recumbent position
Intra-articular C3-4 facet joint injection
Intra-articular L5-S1 facet joint injection
INITIAL MANAGEMENT
Injections helpful in diagnosis and management of LBP secondary
to SI Joint ldquoSyndromerdquo
Pain is always maximal below L5
May radiate to hips groin buttocks posterior thighs
Patterns of referred pain somewhat similar to those due to disk and orfacet joint mediated
pain
Intra-articular SI Joint Injection
INITIAL MANAGEMENT
Injections helpful in diagnosis and management of LBP due to Piriformis Muscle Syndrome
A REAL PAIN THE BUTT
INITIAL MANAGEMENT ACUPUNCTURE
Some evidence that acupuncture and variations
thereof (acupressure cupping) potentially helpful in the acutesubacute period in
patients with NP and LBP
(Yuan QI et al PloS One 2015 Febr 1-37)
NEXT STEP
Rehabilitation and regaining of function
Physical Therapy very important component of the
rehabilitation
A symbiotic relationship between patient and
therapist key of a successful physical rehabilitation
program
The role of YOGA
Better pain control at rest and with
activities with yoga (9-week program with weekly 90-minute classes) when
compared to a self care exercise program in patients with neck pain
Significant treatment effects of yoga found for pain-related apprehension
disability quality of life and psychological outcomes (depression
fatigue anger)
(Michalsen A et al the J Pain 2012 13(11) 1122-30)
THE IMPORTANCE OF REMAINING ACTIVE
Increasing the amount of steps
walkedday by 1000 over the course of a year reduced the risk of neck pain by
14 in a group of people (men and women age 20-45) with sedentary jobs
(Sitthipornvorakul EA et al Eur Spine J
2015 24 417-24)
SPINAL MANIPULATION No Thank you
Systematic review of spinal
manipulation in patients with a variety of pain conditions including NP
and LBP
Failed to demonstrate that spinal manipulation is an effective
intervention for pain management
(Posadzki P Pain Med 2012 13 754-61)
CONCLUSIONS
Neck and Low Back pain syndromes are usually self limited conditions that can convert in chronic pain conditions causing
prolonged disability
The prevalence and cost of these conditions has significantly increased over the course of the last 15-20 years
Aggressive management of pain during the acute phase is
important because adequate pain control shortens the time and level of disability and facilitates the rehabilitation process
CONCLUSIONS
A variety of treatment modalities including medications acupuncture injections PT Yoga are utilized to manage pain and facilitate the
recovery process
Reducing stress and activities associated with the generation of pain maintaining an appropriate physical exercise regimen and a body weight
as close as possible to the ideal body weight will likely result in a decreased incidenceprevalence of short and long term NP and LBP
THANK YOU
QUESTIONS
OTHER SOURCES OF LOW BACK PAIN
Posterior lumbo-sacral paraspinal pelvic girdle muscles
Lumbar spine ligaments tendons
Vertebral bodies
CAUSES OF NECK AND LOW BACK PAIN
TUMORS
INFECTIONS Discitis Osteomyelitis Septic arthritis Meningitis
VASCULAR DISORDERS (egCarotid artery dissection)
AUTOIMMUNE DISORDERS Rheumatoid arthritis Ankylosing spondylitis Polymyalgia rheumatica
TRAUMA (FracturesDislocations)
MSK DISORDERS Soft tissue injuries Whiplash CervicalLumbosacral
strain Myofascial disorders Fibromyalgia
JOINT DISORDERS Spondylosis and Osteoarthritis
MANAGEMENT
Self limited condition
Symptoms and disability improve rapidly
Most patients return to work and normal activities in 4-6 weeks
(Pengel LH et al BMJ 2003 327 323)
NATURAL HISTORY
1 in 3 patients
Persistent moderate pain 1 year after an acute episode
1 in 5 patients report substantial limitations in activity (von Korff al et al Spine 1996 21 2833-7 ndash discussion 2838-9)
NATURAL HISTORY
History and Physical Exam
Blood work to rule out the
presence of a malignancy andor an infection
Plain radiographs of
cervicallumbar spine CTMRI in patients with neurologic
complaints or with pain not improving
DIAGNOSIS
MAIN GOAL
Achieve adequate pain control (NSAIDs Tylenol Muscle
Relaxants Gabapentinoids short acting opioids)
Relative rest
Activity modifications
INITIAL MANAGEMENT
Epidural steroid injections are an
option in patients with disk herniation back and leg pain
INITIAL MANAGEMENT
Anesth Analg 2016 Mar122(3)857-70 Bhatia A1 Flamer D Shah PS Cohen SP
CONCLUSIONS Epidural steroids injections provide
some analgesic benefit at 3 months in patients with lumbosacral radicular pain
due to herniated intervertebral disks but they have no impact on physical
disability or incidence of surgery
Epidural steroid injections are an option in
patients with spinal stenosis
INITIAL MANAGEMENT
Spinal stenosis causes mechanical compression of the nerve roots swelling
(microvascular injury) producing pain (Olmarker K et al Spine 1989 14 569-573)
L3-4 Spinal Stenosis
INITIAL MANAGEMENT
STEROIDS
inhibit swelling (edema) around the nerve root
(Rydevik B et al Spine 1984 9 7-15)
improve blood flow to neural elements decreasing ischemic neuritis
(Fukusaki M et al Clin J Pain 1998 14 148-51)
block conduction in nociceptive nerve fibers (Johansson A et al Acta Anesthesiol Scand
1990 34 335-38) L4-5 Severe Spinal Stenosis
INITIAL MANAGEMENT
Usually spinal stenosis occurs in pts of senior age
Some of these patients may significant comorbidities and higher sensitivity to
pain medications
Multilevel Cervical Spinal Stenosis
INITIAL MANAGEMENT
Intra-articular facet joint injections are appropriate when a clinical
diagnosis of facet joint ldquosyndromerdquo is confirmed
Axial back pain withwithout radiation
to the extremities
Morning neckback stiffness Pain when starting to move worse on necklumbar
spine extension relieved by the recumbent position
Intra-articular C3-4 facet joint injection
Intra-articular L5-S1 facet joint injection
INITIAL MANAGEMENT
Injections helpful in diagnosis and management of LBP secondary
to SI Joint ldquoSyndromerdquo
Pain is always maximal below L5
May radiate to hips groin buttocks posterior thighs
Patterns of referred pain somewhat similar to those due to disk and orfacet joint mediated
pain
Intra-articular SI Joint Injection
INITIAL MANAGEMENT
Injections helpful in diagnosis and management of LBP due to Piriformis Muscle Syndrome
A REAL PAIN THE BUTT
INITIAL MANAGEMENT ACUPUNCTURE
Some evidence that acupuncture and variations
thereof (acupressure cupping) potentially helpful in the acutesubacute period in
patients with NP and LBP
(Yuan QI et al PloS One 2015 Febr 1-37)
NEXT STEP
Rehabilitation and regaining of function
Physical Therapy very important component of the
rehabilitation
A symbiotic relationship between patient and
therapist key of a successful physical rehabilitation
program
The role of YOGA
Better pain control at rest and with
activities with yoga (9-week program with weekly 90-minute classes) when
compared to a self care exercise program in patients with neck pain
Significant treatment effects of yoga found for pain-related apprehension
disability quality of life and psychological outcomes (depression
fatigue anger)
(Michalsen A et al the J Pain 2012 13(11) 1122-30)
THE IMPORTANCE OF REMAINING ACTIVE
Increasing the amount of steps
walkedday by 1000 over the course of a year reduced the risk of neck pain by
14 in a group of people (men and women age 20-45) with sedentary jobs
(Sitthipornvorakul EA et al Eur Spine J
2015 24 417-24)
SPINAL MANIPULATION No Thank you
Systematic review of spinal
manipulation in patients with a variety of pain conditions including NP
and LBP
Failed to demonstrate that spinal manipulation is an effective
intervention for pain management
(Posadzki P Pain Med 2012 13 754-61)
CONCLUSIONS
Neck and Low Back pain syndromes are usually self limited conditions that can convert in chronic pain conditions causing
prolonged disability
The prevalence and cost of these conditions has significantly increased over the course of the last 15-20 years
Aggressive management of pain during the acute phase is
important because adequate pain control shortens the time and level of disability and facilitates the rehabilitation process
CONCLUSIONS
A variety of treatment modalities including medications acupuncture injections PT Yoga are utilized to manage pain and facilitate the
recovery process
Reducing stress and activities associated with the generation of pain maintaining an appropriate physical exercise regimen and a body weight
as close as possible to the ideal body weight will likely result in a decreased incidenceprevalence of short and long term NP and LBP
THANK YOU
QUESTIONS
CAUSES OF NECK AND LOW BACK PAIN
TUMORS
INFECTIONS Discitis Osteomyelitis Septic arthritis Meningitis
VASCULAR DISORDERS (egCarotid artery dissection)
AUTOIMMUNE DISORDERS Rheumatoid arthritis Ankylosing spondylitis Polymyalgia rheumatica
TRAUMA (FracturesDislocations)
MSK DISORDERS Soft tissue injuries Whiplash CervicalLumbosacral
strain Myofascial disorders Fibromyalgia
JOINT DISORDERS Spondylosis and Osteoarthritis
MANAGEMENT
Self limited condition
Symptoms and disability improve rapidly
Most patients return to work and normal activities in 4-6 weeks
(Pengel LH et al BMJ 2003 327 323)
NATURAL HISTORY
1 in 3 patients
Persistent moderate pain 1 year after an acute episode
1 in 5 patients report substantial limitations in activity (von Korff al et al Spine 1996 21 2833-7 ndash discussion 2838-9)
NATURAL HISTORY
History and Physical Exam
Blood work to rule out the
presence of a malignancy andor an infection
Plain radiographs of
cervicallumbar spine CTMRI in patients with neurologic
complaints or with pain not improving
DIAGNOSIS
MAIN GOAL
Achieve adequate pain control (NSAIDs Tylenol Muscle
Relaxants Gabapentinoids short acting opioids)
Relative rest
Activity modifications
INITIAL MANAGEMENT
Epidural steroid injections are an
option in patients with disk herniation back and leg pain
INITIAL MANAGEMENT
Anesth Analg 2016 Mar122(3)857-70 Bhatia A1 Flamer D Shah PS Cohen SP
CONCLUSIONS Epidural steroids injections provide
some analgesic benefit at 3 months in patients with lumbosacral radicular pain
due to herniated intervertebral disks but they have no impact on physical
disability or incidence of surgery
Epidural steroid injections are an option in
patients with spinal stenosis
INITIAL MANAGEMENT
Spinal stenosis causes mechanical compression of the nerve roots swelling
(microvascular injury) producing pain (Olmarker K et al Spine 1989 14 569-573)
L3-4 Spinal Stenosis
INITIAL MANAGEMENT
STEROIDS
inhibit swelling (edema) around the nerve root
(Rydevik B et al Spine 1984 9 7-15)
improve blood flow to neural elements decreasing ischemic neuritis
(Fukusaki M et al Clin J Pain 1998 14 148-51)
block conduction in nociceptive nerve fibers (Johansson A et al Acta Anesthesiol Scand
1990 34 335-38) L4-5 Severe Spinal Stenosis
INITIAL MANAGEMENT
Usually spinal stenosis occurs in pts of senior age
Some of these patients may significant comorbidities and higher sensitivity to
pain medications
Multilevel Cervical Spinal Stenosis
INITIAL MANAGEMENT
Intra-articular facet joint injections are appropriate when a clinical
diagnosis of facet joint ldquosyndromerdquo is confirmed
Axial back pain withwithout radiation
to the extremities
Morning neckback stiffness Pain when starting to move worse on necklumbar
spine extension relieved by the recumbent position
Intra-articular C3-4 facet joint injection
Intra-articular L5-S1 facet joint injection
INITIAL MANAGEMENT
Injections helpful in diagnosis and management of LBP secondary
to SI Joint ldquoSyndromerdquo
Pain is always maximal below L5
May radiate to hips groin buttocks posterior thighs
Patterns of referred pain somewhat similar to those due to disk and orfacet joint mediated
pain
Intra-articular SI Joint Injection
INITIAL MANAGEMENT
Injections helpful in diagnosis and management of LBP due to Piriformis Muscle Syndrome
A REAL PAIN THE BUTT
INITIAL MANAGEMENT ACUPUNCTURE
Some evidence that acupuncture and variations
thereof (acupressure cupping) potentially helpful in the acutesubacute period in
patients with NP and LBP
(Yuan QI et al PloS One 2015 Febr 1-37)
NEXT STEP
Rehabilitation and regaining of function
Physical Therapy very important component of the
rehabilitation
A symbiotic relationship between patient and
therapist key of a successful physical rehabilitation
program
The role of YOGA
Better pain control at rest and with
activities with yoga (9-week program with weekly 90-minute classes) when
compared to a self care exercise program in patients with neck pain
Significant treatment effects of yoga found for pain-related apprehension
disability quality of life and psychological outcomes (depression
fatigue anger)
(Michalsen A et al the J Pain 2012 13(11) 1122-30)
THE IMPORTANCE OF REMAINING ACTIVE
Increasing the amount of steps
walkedday by 1000 over the course of a year reduced the risk of neck pain by
14 in a group of people (men and women age 20-45) with sedentary jobs
(Sitthipornvorakul EA et al Eur Spine J
2015 24 417-24)
SPINAL MANIPULATION No Thank you
Systematic review of spinal
manipulation in patients with a variety of pain conditions including NP
and LBP
Failed to demonstrate that spinal manipulation is an effective
intervention for pain management
(Posadzki P Pain Med 2012 13 754-61)
CONCLUSIONS
Neck and Low Back pain syndromes are usually self limited conditions that can convert in chronic pain conditions causing
prolonged disability
The prevalence and cost of these conditions has significantly increased over the course of the last 15-20 years
Aggressive management of pain during the acute phase is
important because adequate pain control shortens the time and level of disability and facilitates the rehabilitation process
CONCLUSIONS
A variety of treatment modalities including medications acupuncture injections PT Yoga are utilized to manage pain and facilitate the
recovery process
Reducing stress and activities associated with the generation of pain maintaining an appropriate physical exercise regimen and a body weight
as close as possible to the ideal body weight will likely result in a decreased incidenceprevalence of short and long term NP and LBP
THANK YOU
QUESTIONS
TUMORS
INFECTIONS Discitis Osteomyelitis Septic arthritis Meningitis
VASCULAR DISORDERS (egCarotid artery dissection)
AUTOIMMUNE DISORDERS Rheumatoid arthritis Ankylosing spondylitis Polymyalgia rheumatica
TRAUMA (FracturesDislocations)
MSK DISORDERS Soft tissue injuries Whiplash CervicalLumbosacral
strain Myofascial disorders Fibromyalgia
JOINT DISORDERS Spondylosis and Osteoarthritis
MANAGEMENT
Self limited condition
Symptoms and disability improve rapidly
Most patients return to work and normal activities in 4-6 weeks
(Pengel LH et al BMJ 2003 327 323)
NATURAL HISTORY
1 in 3 patients
Persistent moderate pain 1 year after an acute episode
1 in 5 patients report substantial limitations in activity (von Korff al et al Spine 1996 21 2833-7 ndash discussion 2838-9)
NATURAL HISTORY
History and Physical Exam
Blood work to rule out the
presence of a malignancy andor an infection
Plain radiographs of
cervicallumbar spine CTMRI in patients with neurologic
complaints or with pain not improving
DIAGNOSIS
MAIN GOAL
Achieve adequate pain control (NSAIDs Tylenol Muscle
Relaxants Gabapentinoids short acting opioids)
Relative rest
Activity modifications
INITIAL MANAGEMENT
Epidural steroid injections are an
option in patients with disk herniation back and leg pain
INITIAL MANAGEMENT
Anesth Analg 2016 Mar122(3)857-70 Bhatia A1 Flamer D Shah PS Cohen SP
CONCLUSIONS Epidural steroids injections provide
some analgesic benefit at 3 months in patients with lumbosacral radicular pain
due to herniated intervertebral disks but they have no impact on physical
disability or incidence of surgery
Epidural steroid injections are an option in
patients with spinal stenosis
INITIAL MANAGEMENT
Spinal stenosis causes mechanical compression of the nerve roots swelling
(microvascular injury) producing pain (Olmarker K et al Spine 1989 14 569-573)
L3-4 Spinal Stenosis
INITIAL MANAGEMENT
STEROIDS
inhibit swelling (edema) around the nerve root
(Rydevik B et al Spine 1984 9 7-15)
improve blood flow to neural elements decreasing ischemic neuritis
(Fukusaki M et al Clin J Pain 1998 14 148-51)
block conduction in nociceptive nerve fibers (Johansson A et al Acta Anesthesiol Scand
1990 34 335-38) L4-5 Severe Spinal Stenosis
INITIAL MANAGEMENT
Usually spinal stenosis occurs in pts of senior age
Some of these patients may significant comorbidities and higher sensitivity to
pain medications
Multilevel Cervical Spinal Stenosis
INITIAL MANAGEMENT
Intra-articular facet joint injections are appropriate when a clinical
diagnosis of facet joint ldquosyndromerdquo is confirmed
Axial back pain withwithout radiation
to the extremities
Morning neckback stiffness Pain when starting to move worse on necklumbar
spine extension relieved by the recumbent position
Intra-articular C3-4 facet joint injection
Intra-articular L5-S1 facet joint injection
INITIAL MANAGEMENT
Injections helpful in diagnosis and management of LBP secondary
to SI Joint ldquoSyndromerdquo
Pain is always maximal below L5
May radiate to hips groin buttocks posterior thighs
Patterns of referred pain somewhat similar to those due to disk and orfacet joint mediated
pain
Intra-articular SI Joint Injection
INITIAL MANAGEMENT
Injections helpful in diagnosis and management of LBP due to Piriformis Muscle Syndrome
A REAL PAIN THE BUTT
INITIAL MANAGEMENT ACUPUNCTURE
Some evidence that acupuncture and variations
thereof (acupressure cupping) potentially helpful in the acutesubacute period in
patients with NP and LBP
(Yuan QI et al PloS One 2015 Febr 1-37)
NEXT STEP
Rehabilitation and regaining of function
Physical Therapy very important component of the
rehabilitation
A symbiotic relationship between patient and
therapist key of a successful physical rehabilitation
program
The role of YOGA
Better pain control at rest and with
activities with yoga (9-week program with weekly 90-minute classes) when
compared to a self care exercise program in patients with neck pain
Significant treatment effects of yoga found for pain-related apprehension
disability quality of life and psychological outcomes (depression
fatigue anger)
(Michalsen A et al the J Pain 2012 13(11) 1122-30)
THE IMPORTANCE OF REMAINING ACTIVE
Increasing the amount of steps
walkedday by 1000 over the course of a year reduced the risk of neck pain by
14 in a group of people (men and women age 20-45) with sedentary jobs
(Sitthipornvorakul EA et al Eur Spine J
2015 24 417-24)
SPINAL MANIPULATION No Thank you
Systematic review of spinal
manipulation in patients with a variety of pain conditions including NP
and LBP
Failed to demonstrate that spinal manipulation is an effective
intervention for pain management
(Posadzki P Pain Med 2012 13 754-61)
CONCLUSIONS
Neck and Low Back pain syndromes are usually self limited conditions that can convert in chronic pain conditions causing
prolonged disability
The prevalence and cost of these conditions has significantly increased over the course of the last 15-20 years
Aggressive management of pain during the acute phase is
important because adequate pain control shortens the time and level of disability and facilitates the rehabilitation process
CONCLUSIONS
A variety of treatment modalities including medications acupuncture injections PT Yoga are utilized to manage pain and facilitate the
recovery process
Reducing stress and activities associated with the generation of pain maintaining an appropriate physical exercise regimen and a body weight
as close as possible to the ideal body weight will likely result in a decreased incidenceprevalence of short and long term NP and LBP
THANK YOU
QUESTIONS
MSK DISORDERS Soft tissue injuries Whiplash CervicalLumbosacral
strain Myofascial disorders Fibromyalgia
JOINT DISORDERS Spondylosis and Osteoarthritis
MANAGEMENT
Self limited condition
Symptoms and disability improve rapidly
Most patients return to work and normal activities in 4-6 weeks
(Pengel LH et al BMJ 2003 327 323)
NATURAL HISTORY
1 in 3 patients
Persistent moderate pain 1 year after an acute episode
1 in 5 patients report substantial limitations in activity (von Korff al et al Spine 1996 21 2833-7 ndash discussion 2838-9)
NATURAL HISTORY
History and Physical Exam
Blood work to rule out the
presence of a malignancy andor an infection
Plain radiographs of
cervicallumbar spine CTMRI in patients with neurologic
complaints or with pain not improving
DIAGNOSIS
MAIN GOAL
Achieve adequate pain control (NSAIDs Tylenol Muscle
Relaxants Gabapentinoids short acting opioids)
Relative rest
Activity modifications
INITIAL MANAGEMENT
Epidural steroid injections are an
option in patients with disk herniation back and leg pain
INITIAL MANAGEMENT
Anesth Analg 2016 Mar122(3)857-70 Bhatia A1 Flamer D Shah PS Cohen SP
CONCLUSIONS Epidural steroids injections provide
some analgesic benefit at 3 months in patients with lumbosacral radicular pain
due to herniated intervertebral disks but they have no impact on physical
disability or incidence of surgery
Epidural steroid injections are an option in
patients with spinal stenosis
INITIAL MANAGEMENT
Spinal stenosis causes mechanical compression of the nerve roots swelling
(microvascular injury) producing pain (Olmarker K et al Spine 1989 14 569-573)
L3-4 Spinal Stenosis
INITIAL MANAGEMENT
STEROIDS
inhibit swelling (edema) around the nerve root
(Rydevik B et al Spine 1984 9 7-15)
improve blood flow to neural elements decreasing ischemic neuritis
(Fukusaki M et al Clin J Pain 1998 14 148-51)
block conduction in nociceptive nerve fibers (Johansson A et al Acta Anesthesiol Scand
1990 34 335-38) L4-5 Severe Spinal Stenosis
INITIAL MANAGEMENT
Usually spinal stenosis occurs in pts of senior age
Some of these patients may significant comorbidities and higher sensitivity to
pain medications
Multilevel Cervical Spinal Stenosis
INITIAL MANAGEMENT
Intra-articular facet joint injections are appropriate when a clinical
diagnosis of facet joint ldquosyndromerdquo is confirmed
Axial back pain withwithout radiation
to the extremities
Morning neckback stiffness Pain when starting to move worse on necklumbar
spine extension relieved by the recumbent position
Intra-articular C3-4 facet joint injection
Intra-articular L5-S1 facet joint injection
INITIAL MANAGEMENT
Injections helpful in diagnosis and management of LBP secondary
to SI Joint ldquoSyndromerdquo
Pain is always maximal below L5
May radiate to hips groin buttocks posterior thighs
Patterns of referred pain somewhat similar to those due to disk and orfacet joint mediated
pain
Intra-articular SI Joint Injection
INITIAL MANAGEMENT
Injections helpful in diagnosis and management of LBP due to Piriformis Muscle Syndrome
A REAL PAIN THE BUTT
INITIAL MANAGEMENT ACUPUNCTURE
Some evidence that acupuncture and variations
thereof (acupressure cupping) potentially helpful in the acutesubacute period in
patients with NP and LBP
(Yuan QI et al PloS One 2015 Febr 1-37)
NEXT STEP
Rehabilitation and regaining of function
Physical Therapy very important component of the
rehabilitation
A symbiotic relationship between patient and
therapist key of a successful physical rehabilitation
program
The role of YOGA
Better pain control at rest and with
activities with yoga (9-week program with weekly 90-minute classes) when
compared to a self care exercise program in patients with neck pain
Significant treatment effects of yoga found for pain-related apprehension
disability quality of life and psychological outcomes (depression
fatigue anger)
(Michalsen A et al the J Pain 2012 13(11) 1122-30)
THE IMPORTANCE OF REMAINING ACTIVE
Increasing the amount of steps
walkedday by 1000 over the course of a year reduced the risk of neck pain by
14 in a group of people (men and women age 20-45) with sedentary jobs
(Sitthipornvorakul EA et al Eur Spine J
2015 24 417-24)
SPINAL MANIPULATION No Thank you
Systematic review of spinal
manipulation in patients with a variety of pain conditions including NP
and LBP
Failed to demonstrate that spinal manipulation is an effective
intervention for pain management
(Posadzki P Pain Med 2012 13 754-61)
CONCLUSIONS
Neck and Low Back pain syndromes are usually self limited conditions that can convert in chronic pain conditions causing
prolonged disability
The prevalence and cost of these conditions has significantly increased over the course of the last 15-20 years
Aggressive management of pain during the acute phase is
important because adequate pain control shortens the time and level of disability and facilitates the rehabilitation process
CONCLUSIONS
A variety of treatment modalities including medications acupuncture injections PT Yoga are utilized to manage pain and facilitate the
recovery process
Reducing stress and activities associated with the generation of pain maintaining an appropriate physical exercise regimen and a body weight
as close as possible to the ideal body weight will likely result in a decreased incidenceprevalence of short and long term NP and LBP
THANK YOU
QUESTIONS
MANAGEMENT
Self limited condition
Symptoms and disability improve rapidly
Most patients return to work and normal activities in 4-6 weeks
(Pengel LH et al BMJ 2003 327 323)
NATURAL HISTORY
1 in 3 patients
Persistent moderate pain 1 year after an acute episode
1 in 5 patients report substantial limitations in activity (von Korff al et al Spine 1996 21 2833-7 ndash discussion 2838-9)
NATURAL HISTORY
History and Physical Exam
Blood work to rule out the
presence of a malignancy andor an infection
Plain radiographs of
cervicallumbar spine CTMRI in patients with neurologic
complaints or with pain not improving
DIAGNOSIS
MAIN GOAL
Achieve adequate pain control (NSAIDs Tylenol Muscle
Relaxants Gabapentinoids short acting opioids)
Relative rest
Activity modifications
INITIAL MANAGEMENT
Epidural steroid injections are an
option in patients with disk herniation back and leg pain
INITIAL MANAGEMENT
Anesth Analg 2016 Mar122(3)857-70 Bhatia A1 Flamer D Shah PS Cohen SP
CONCLUSIONS Epidural steroids injections provide
some analgesic benefit at 3 months in patients with lumbosacral radicular pain
due to herniated intervertebral disks but they have no impact on physical
disability or incidence of surgery
Epidural steroid injections are an option in
patients with spinal stenosis
INITIAL MANAGEMENT
Spinal stenosis causes mechanical compression of the nerve roots swelling
(microvascular injury) producing pain (Olmarker K et al Spine 1989 14 569-573)
L3-4 Spinal Stenosis
INITIAL MANAGEMENT
STEROIDS
inhibit swelling (edema) around the nerve root
(Rydevik B et al Spine 1984 9 7-15)
improve blood flow to neural elements decreasing ischemic neuritis
(Fukusaki M et al Clin J Pain 1998 14 148-51)
block conduction in nociceptive nerve fibers (Johansson A et al Acta Anesthesiol Scand
1990 34 335-38) L4-5 Severe Spinal Stenosis
INITIAL MANAGEMENT
Usually spinal stenosis occurs in pts of senior age
Some of these patients may significant comorbidities and higher sensitivity to
pain medications
Multilevel Cervical Spinal Stenosis
INITIAL MANAGEMENT
Intra-articular facet joint injections are appropriate when a clinical
diagnosis of facet joint ldquosyndromerdquo is confirmed
Axial back pain withwithout radiation
to the extremities
Morning neckback stiffness Pain when starting to move worse on necklumbar
spine extension relieved by the recumbent position
Intra-articular C3-4 facet joint injection
Intra-articular L5-S1 facet joint injection
INITIAL MANAGEMENT
Injections helpful in diagnosis and management of LBP secondary
to SI Joint ldquoSyndromerdquo
Pain is always maximal below L5
May radiate to hips groin buttocks posterior thighs
Patterns of referred pain somewhat similar to those due to disk and orfacet joint mediated
pain
Intra-articular SI Joint Injection
INITIAL MANAGEMENT
Injections helpful in diagnosis and management of LBP due to Piriformis Muscle Syndrome
A REAL PAIN THE BUTT
INITIAL MANAGEMENT ACUPUNCTURE
Some evidence that acupuncture and variations
thereof (acupressure cupping) potentially helpful in the acutesubacute period in
patients with NP and LBP
(Yuan QI et al PloS One 2015 Febr 1-37)
NEXT STEP
Rehabilitation and regaining of function
Physical Therapy very important component of the
rehabilitation
A symbiotic relationship between patient and
therapist key of a successful physical rehabilitation
program
The role of YOGA
Better pain control at rest and with
activities with yoga (9-week program with weekly 90-minute classes) when
compared to a self care exercise program in patients with neck pain
Significant treatment effects of yoga found for pain-related apprehension
disability quality of life and psychological outcomes (depression
fatigue anger)
(Michalsen A et al the J Pain 2012 13(11) 1122-30)
THE IMPORTANCE OF REMAINING ACTIVE
Increasing the amount of steps
walkedday by 1000 over the course of a year reduced the risk of neck pain by
14 in a group of people (men and women age 20-45) with sedentary jobs
(Sitthipornvorakul EA et al Eur Spine J
2015 24 417-24)
SPINAL MANIPULATION No Thank you
Systematic review of spinal
manipulation in patients with a variety of pain conditions including NP
and LBP
Failed to demonstrate that spinal manipulation is an effective
intervention for pain management
(Posadzki P Pain Med 2012 13 754-61)
CONCLUSIONS
Neck and Low Back pain syndromes are usually self limited conditions that can convert in chronic pain conditions causing
prolonged disability
The prevalence and cost of these conditions has significantly increased over the course of the last 15-20 years
Aggressive management of pain during the acute phase is
important because adequate pain control shortens the time and level of disability and facilitates the rehabilitation process
CONCLUSIONS
A variety of treatment modalities including medications acupuncture injections PT Yoga are utilized to manage pain and facilitate the
recovery process
Reducing stress and activities associated with the generation of pain maintaining an appropriate physical exercise regimen and a body weight
as close as possible to the ideal body weight will likely result in a decreased incidenceprevalence of short and long term NP and LBP
THANK YOU
QUESTIONS
Self limited condition
Symptoms and disability improve rapidly
Most patients return to work and normal activities in 4-6 weeks
(Pengel LH et al BMJ 2003 327 323)
NATURAL HISTORY
1 in 3 patients
Persistent moderate pain 1 year after an acute episode
1 in 5 patients report substantial limitations in activity (von Korff al et al Spine 1996 21 2833-7 ndash discussion 2838-9)
NATURAL HISTORY
History and Physical Exam
Blood work to rule out the
presence of a malignancy andor an infection
Plain radiographs of
cervicallumbar spine CTMRI in patients with neurologic
complaints or with pain not improving
DIAGNOSIS
MAIN GOAL
Achieve adequate pain control (NSAIDs Tylenol Muscle
Relaxants Gabapentinoids short acting opioids)
Relative rest
Activity modifications
INITIAL MANAGEMENT
Epidural steroid injections are an
option in patients with disk herniation back and leg pain
INITIAL MANAGEMENT
Anesth Analg 2016 Mar122(3)857-70 Bhatia A1 Flamer D Shah PS Cohen SP
CONCLUSIONS Epidural steroids injections provide
some analgesic benefit at 3 months in patients with lumbosacral radicular pain
due to herniated intervertebral disks but they have no impact on physical
disability or incidence of surgery
Epidural steroid injections are an option in
patients with spinal stenosis
INITIAL MANAGEMENT
Spinal stenosis causes mechanical compression of the nerve roots swelling
(microvascular injury) producing pain (Olmarker K et al Spine 1989 14 569-573)
L3-4 Spinal Stenosis
INITIAL MANAGEMENT
STEROIDS
inhibit swelling (edema) around the nerve root
(Rydevik B et al Spine 1984 9 7-15)
improve blood flow to neural elements decreasing ischemic neuritis
(Fukusaki M et al Clin J Pain 1998 14 148-51)
block conduction in nociceptive nerve fibers (Johansson A et al Acta Anesthesiol Scand
1990 34 335-38) L4-5 Severe Spinal Stenosis
INITIAL MANAGEMENT
Usually spinal stenosis occurs in pts of senior age
Some of these patients may significant comorbidities and higher sensitivity to
pain medications
Multilevel Cervical Spinal Stenosis
INITIAL MANAGEMENT
Intra-articular facet joint injections are appropriate when a clinical
diagnosis of facet joint ldquosyndromerdquo is confirmed
Axial back pain withwithout radiation
to the extremities
Morning neckback stiffness Pain when starting to move worse on necklumbar
spine extension relieved by the recumbent position
Intra-articular C3-4 facet joint injection
Intra-articular L5-S1 facet joint injection
INITIAL MANAGEMENT
Injections helpful in diagnosis and management of LBP secondary
to SI Joint ldquoSyndromerdquo
Pain is always maximal below L5
May radiate to hips groin buttocks posterior thighs
Patterns of referred pain somewhat similar to those due to disk and orfacet joint mediated
pain
Intra-articular SI Joint Injection
INITIAL MANAGEMENT
Injections helpful in diagnosis and management of LBP due to Piriformis Muscle Syndrome
A REAL PAIN THE BUTT
INITIAL MANAGEMENT ACUPUNCTURE
Some evidence that acupuncture and variations
thereof (acupressure cupping) potentially helpful in the acutesubacute period in
patients with NP and LBP
(Yuan QI et al PloS One 2015 Febr 1-37)
NEXT STEP
Rehabilitation and regaining of function
Physical Therapy very important component of the
rehabilitation
A symbiotic relationship between patient and
therapist key of a successful physical rehabilitation
program
The role of YOGA
Better pain control at rest and with
activities with yoga (9-week program with weekly 90-minute classes) when
compared to a self care exercise program in patients with neck pain
Significant treatment effects of yoga found for pain-related apprehension
disability quality of life and psychological outcomes (depression
fatigue anger)
(Michalsen A et al the J Pain 2012 13(11) 1122-30)
THE IMPORTANCE OF REMAINING ACTIVE
Increasing the amount of steps
walkedday by 1000 over the course of a year reduced the risk of neck pain by
14 in a group of people (men and women age 20-45) with sedentary jobs
(Sitthipornvorakul EA et al Eur Spine J
2015 24 417-24)
SPINAL MANIPULATION No Thank you
Systematic review of spinal
manipulation in patients with a variety of pain conditions including NP
and LBP
Failed to demonstrate that spinal manipulation is an effective
intervention for pain management
(Posadzki P Pain Med 2012 13 754-61)
CONCLUSIONS
Neck and Low Back pain syndromes are usually self limited conditions that can convert in chronic pain conditions causing
prolonged disability
The prevalence and cost of these conditions has significantly increased over the course of the last 15-20 years
Aggressive management of pain during the acute phase is
important because adequate pain control shortens the time and level of disability and facilitates the rehabilitation process
CONCLUSIONS
A variety of treatment modalities including medications acupuncture injections PT Yoga are utilized to manage pain and facilitate the
recovery process
Reducing stress and activities associated with the generation of pain maintaining an appropriate physical exercise regimen and a body weight
as close as possible to the ideal body weight will likely result in a decreased incidenceprevalence of short and long term NP and LBP
THANK YOU
QUESTIONS
1 in 3 patients
Persistent moderate pain 1 year after an acute episode
1 in 5 patients report substantial limitations in activity (von Korff al et al Spine 1996 21 2833-7 ndash discussion 2838-9)
NATURAL HISTORY
History and Physical Exam
Blood work to rule out the
presence of a malignancy andor an infection
Plain radiographs of
cervicallumbar spine CTMRI in patients with neurologic
complaints or with pain not improving
DIAGNOSIS
MAIN GOAL
Achieve adequate pain control (NSAIDs Tylenol Muscle
Relaxants Gabapentinoids short acting opioids)
Relative rest
Activity modifications
INITIAL MANAGEMENT
Epidural steroid injections are an
option in patients with disk herniation back and leg pain
INITIAL MANAGEMENT
Anesth Analg 2016 Mar122(3)857-70 Bhatia A1 Flamer D Shah PS Cohen SP
CONCLUSIONS Epidural steroids injections provide
some analgesic benefit at 3 months in patients with lumbosacral radicular pain
due to herniated intervertebral disks but they have no impact on physical
disability or incidence of surgery
Epidural steroid injections are an option in
patients with spinal stenosis
INITIAL MANAGEMENT
Spinal stenosis causes mechanical compression of the nerve roots swelling
(microvascular injury) producing pain (Olmarker K et al Spine 1989 14 569-573)
L3-4 Spinal Stenosis
INITIAL MANAGEMENT
STEROIDS
inhibit swelling (edema) around the nerve root
(Rydevik B et al Spine 1984 9 7-15)
improve blood flow to neural elements decreasing ischemic neuritis
(Fukusaki M et al Clin J Pain 1998 14 148-51)
block conduction in nociceptive nerve fibers (Johansson A et al Acta Anesthesiol Scand
1990 34 335-38) L4-5 Severe Spinal Stenosis
INITIAL MANAGEMENT
Usually spinal stenosis occurs in pts of senior age
Some of these patients may significant comorbidities and higher sensitivity to
pain medications
Multilevel Cervical Spinal Stenosis
INITIAL MANAGEMENT
Intra-articular facet joint injections are appropriate when a clinical
diagnosis of facet joint ldquosyndromerdquo is confirmed
Axial back pain withwithout radiation
to the extremities
Morning neckback stiffness Pain when starting to move worse on necklumbar
spine extension relieved by the recumbent position
Intra-articular C3-4 facet joint injection
Intra-articular L5-S1 facet joint injection
INITIAL MANAGEMENT
Injections helpful in diagnosis and management of LBP secondary
to SI Joint ldquoSyndromerdquo
Pain is always maximal below L5
May radiate to hips groin buttocks posterior thighs
Patterns of referred pain somewhat similar to those due to disk and orfacet joint mediated
pain
Intra-articular SI Joint Injection
INITIAL MANAGEMENT
Injections helpful in diagnosis and management of LBP due to Piriformis Muscle Syndrome
A REAL PAIN THE BUTT
INITIAL MANAGEMENT ACUPUNCTURE
Some evidence that acupuncture and variations
thereof (acupressure cupping) potentially helpful in the acutesubacute period in
patients with NP and LBP
(Yuan QI et al PloS One 2015 Febr 1-37)
NEXT STEP
Rehabilitation and regaining of function
Physical Therapy very important component of the
rehabilitation
A symbiotic relationship between patient and
therapist key of a successful physical rehabilitation
program
The role of YOGA
Better pain control at rest and with
activities with yoga (9-week program with weekly 90-minute classes) when
compared to a self care exercise program in patients with neck pain
Significant treatment effects of yoga found for pain-related apprehension
disability quality of life and psychological outcomes (depression
fatigue anger)
(Michalsen A et al the J Pain 2012 13(11) 1122-30)
THE IMPORTANCE OF REMAINING ACTIVE
Increasing the amount of steps
walkedday by 1000 over the course of a year reduced the risk of neck pain by
14 in a group of people (men and women age 20-45) with sedentary jobs
(Sitthipornvorakul EA et al Eur Spine J
2015 24 417-24)
SPINAL MANIPULATION No Thank you
Systematic review of spinal
manipulation in patients with a variety of pain conditions including NP
and LBP
Failed to demonstrate that spinal manipulation is an effective
intervention for pain management
(Posadzki P Pain Med 2012 13 754-61)
CONCLUSIONS
Neck and Low Back pain syndromes are usually self limited conditions that can convert in chronic pain conditions causing
prolonged disability
The prevalence and cost of these conditions has significantly increased over the course of the last 15-20 years
Aggressive management of pain during the acute phase is
important because adequate pain control shortens the time and level of disability and facilitates the rehabilitation process
CONCLUSIONS
A variety of treatment modalities including medications acupuncture injections PT Yoga are utilized to manage pain and facilitate the
recovery process
Reducing stress and activities associated with the generation of pain maintaining an appropriate physical exercise regimen and a body weight
as close as possible to the ideal body weight will likely result in a decreased incidenceprevalence of short and long term NP and LBP
THANK YOU
QUESTIONS
History and Physical Exam
Blood work to rule out the
presence of a malignancy andor an infection
Plain radiographs of
cervicallumbar spine CTMRI in patients with neurologic
complaints or with pain not improving
DIAGNOSIS
MAIN GOAL
Achieve adequate pain control (NSAIDs Tylenol Muscle
Relaxants Gabapentinoids short acting opioids)
Relative rest
Activity modifications
INITIAL MANAGEMENT
Epidural steroid injections are an
option in patients with disk herniation back and leg pain
INITIAL MANAGEMENT
Anesth Analg 2016 Mar122(3)857-70 Bhatia A1 Flamer D Shah PS Cohen SP
CONCLUSIONS Epidural steroids injections provide
some analgesic benefit at 3 months in patients with lumbosacral radicular pain
due to herniated intervertebral disks but they have no impact on physical
disability or incidence of surgery
Epidural steroid injections are an option in
patients with spinal stenosis
INITIAL MANAGEMENT
Spinal stenosis causes mechanical compression of the nerve roots swelling
(microvascular injury) producing pain (Olmarker K et al Spine 1989 14 569-573)
L3-4 Spinal Stenosis
INITIAL MANAGEMENT
STEROIDS
inhibit swelling (edema) around the nerve root
(Rydevik B et al Spine 1984 9 7-15)
improve blood flow to neural elements decreasing ischemic neuritis
(Fukusaki M et al Clin J Pain 1998 14 148-51)
block conduction in nociceptive nerve fibers (Johansson A et al Acta Anesthesiol Scand
1990 34 335-38) L4-5 Severe Spinal Stenosis
INITIAL MANAGEMENT
Usually spinal stenosis occurs in pts of senior age
Some of these patients may significant comorbidities and higher sensitivity to
pain medications
Multilevel Cervical Spinal Stenosis
INITIAL MANAGEMENT
Intra-articular facet joint injections are appropriate when a clinical
diagnosis of facet joint ldquosyndromerdquo is confirmed
Axial back pain withwithout radiation
to the extremities
Morning neckback stiffness Pain when starting to move worse on necklumbar
spine extension relieved by the recumbent position
Intra-articular C3-4 facet joint injection
Intra-articular L5-S1 facet joint injection
INITIAL MANAGEMENT
Injections helpful in diagnosis and management of LBP secondary
to SI Joint ldquoSyndromerdquo
Pain is always maximal below L5
May radiate to hips groin buttocks posterior thighs
Patterns of referred pain somewhat similar to those due to disk and orfacet joint mediated
pain
Intra-articular SI Joint Injection
INITIAL MANAGEMENT
Injections helpful in diagnosis and management of LBP due to Piriformis Muscle Syndrome
A REAL PAIN THE BUTT
INITIAL MANAGEMENT ACUPUNCTURE
Some evidence that acupuncture and variations
thereof (acupressure cupping) potentially helpful in the acutesubacute period in
patients with NP and LBP
(Yuan QI et al PloS One 2015 Febr 1-37)
NEXT STEP
Rehabilitation and regaining of function
Physical Therapy very important component of the
rehabilitation
A symbiotic relationship between patient and
therapist key of a successful physical rehabilitation
program
The role of YOGA
Better pain control at rest and with
activities with yoga (9-week program with weekly 90-minute classes) when
compared to a self care exercise program in patients with neck pain
Significant treatment effects of yoga found for pain-related apprehension
disability quality of life and psychological outcomes (depression
fatigue anger)
(Michalsen A et al the J Pain 2012 13(11) 1122-30)
THE IMPORTANCE OF REMAINING ACTIVE
Increasing the amount of steps
walkedday by 1000 over the course of a year reduced the risk of neck pain by
14 in a group of people (men and women age 20-45) with sedentary jobs
(Sitthipornvorakul EA et al Eur Spine J
2015 24 417-24)
SPINAL MANIPULATION No Thank you
Systematic review of spinal
manipulation in patients with a variety of pain conditions including NP
and LBP
Failed to demonstrate that spinal manipulation is an effective
intervention for pain management
(Posadzki P Pain Med 2012 13 754-61)
CONCLUSIONS
Neck and Low Back pain syndromes are usually self limited conditions that can convert in chronic pain conditions causing
prolonged disability
The prevalence and cost of these conditions has significantly increased over the course of the last 15-20 years
Aggressive management of pain during the acute phase is
important because adequate pain control shortens the time and level of disability and facilitates the rehabilitation process
CONCLUSIONS
A variety of treatment modalities including medications acupuncture injections PT Yoga are utilized to manage pain and facilitate the
recovery process
Reducing stress and activities associated with the generation of pain maintaining an appropriate physical exercise regimen and a body weight
as close as possible to the ideal body weight will likely result in a decreased incidenceprevalence of short and long term NP and LBP
THANK YOU
QUESTIONS
MAIN GOAL
Achieve adequate pain control (NSAIDs Tylenol Muscle
Relaxants Gabapentinoids short acting opioids)
Relative rest
Activity modifications
INITIAL MANAGEMENT
Epidural steroid injections are an
option in patients with disk herniation back and leg pain
INITIAL MANAGEMENT
Anesth Analg 2016 Mar122(3)857-70 Bhatia A1 Flamer D Shah PS Cohen SP
CONCLUSIONS Epidural steroids injections provide
some analgesic benefit at 3 months in patients with lumbosacral radicular pain
due to herniated intervertebral disks but they have no impact on physical
disability or incidence of surgery
Epidural steroid injections are an option in
patients with spinal stenosis
INITIAL MANAGEMENT
Spinal stenosis causes mechanical compression of the nerve roots swelling
(microvascular injury) producing pain (Olmarker K et al Spine 1989 14 569-573)
L3-4 Spinal Stenosis
INITIAL MANAGEMENT
STEROIDS
inhibit swelling (edema) around the nerve root
(Rydevik B et al Spine 1984 9 7-15)
improve blood flow to neural elements decreasing ischemic neuritis
(Fukusaki M et al Clin J Pain 1998 14 148-51)
block conduction in nociceptive nerve fibers (Johansson A et al Acta Anesthesiol Scand
1990 34 335-38) L4-5 Severe Spinal Stenosis
INITIAL MANAGEMENT
Usually spinal stenosis occurs in pts of senior age
Some of these patients may significant comorbidities and higher sensitivity to
pain medications
Multilevel Cervical Spinal Stenosis
INITIAL MANAGEMENT
Intra-articular facet joint injections are appropriate when a clinical
diagnosis of facet joint ldquosyndromerdquo is confirmed
Axial back pain withwithout radiation
to the extremities
Morning neckback stiffness Pain when starting to move worse on necklumbar
spine extension relieved by the recumbent position
Intra-articular C3-4 facet joint injection
Intra-articular L5-S1 facet joint injection
INITIAL MANAGEMENT
Injections helpful in diagnosis and management of LBP secondary
to SI Joint ldquoSyndromerdquo
Pain is always maximal below L5
May radiate to hips groin buttocks posterior thighs
Patterns of referred pain somewhat similar to those due to disk and orfacet joint mediated
pain
Intra-articular SI Joint Injection
INITIAL MANAGEMENT
Injections helpful in diagnosis and management of LBP due to Piriformis Muscle Syndrome
A REAL PAIN THE BUTT
INITIAL MANAGEMENT ACUPUNCTURE
Some evidence that acupuncture and variations
thereof (acupressure cupping) potentially helpful in the acutesubacute period in
patients with NP and LBP
(Yuan QI et al PloS One 2015 Febr 1-37)
NEXT STEP
Rehabilitation and regaining of function
Physical Therapy very important component of the
rehabilitation
A symbiotic relationship between patient and
therapist key of a successful physical rehabilitation
program
The role of YOGA
Better pain control at rest and with
activities with yoga (9-week program with weekly 90-minute classes) when
compared to a self care exercise program in patients with neck pain
Significant treatment effects of yoga found for pain-related apprehension
disability quality of life and psychological outcomes (depression
fatigue anger)
(Michalsen A et al the J Pain 2012 13(11) 1122-30)
THE IMPORTANCE OF REMAINING ACTIVE
Increasing the amount of steps
walkedday by 1000 over the course of a year reduced the risk of neck pain by
14 in a group of people (men and women age 20-45) with sedentary jobs
(Sitthipornvorakul EA et al Eur Spine J
2015 24 417-24)
SPINAL MANIPULATION No Thank you
Systematic review of spinal
manipulation in patients with a variety of pain conditions including NP
and LBP
Failed to demonstrate that spinal manipulation is an effective
intervention for pain management
(Posadzki P Pain Med 2012 13 754-61)
CONCLUSIONS
Neck and Low Back pain syndromes are usually self limited conditions that can convert in chronic pain conditions causing
prolonged disability
The prevalence and cost of these conditions has significantly increased over the course of the last 15-20 years
Aggressive management of pain during the acute phase is
important because adequate pain control shortens the time and level of disability and facilitates the rehabilitation process
CONCLUSIONS
A variety of treatment modalities including medications acupuncture injections PT Yoga are utilized to manage pain and facilitate the
recovery process
Reducing stress and activities associated with the generation of pain maintaining an appropriate physical exercise regimen and a body weight
as close as possible to the ideal body weight will likely result in a decreased incidenceprevalence of short and long term NP and LBP
THANK YOU
QUESTIONS
Epidural steroid injections are an
option in patients with disk herniation back and leg pain
INITIAL MANAGEMENT
Anesth Analg 2016 Mar122(3)857-70 Bhatia A1 Flamer D Shah PS Cohen SP
CONCLUSIONS Epidural steroids injections provide
some analgesic benefit at 3 months in patients with lumbosacral radicular pain
due to herniated intervertebral disks but they have no impact on physical
disability or incidence of surgery
Epidural steroid injections are an option in
patients with spinal stenosis
INITIAL MANAGEMENT
Spinal stenosis causes mechanical compression of the nerve roots swelling
(microvascular injury) producing pain (Olmarker K et al Spine 1989 14 569-573)
L3-4 Spinal Stenosis
INITIAL MANAGEMENT
STEROIDS
inhibit swelling (edema) around the nerve root
(Rydevik B et al Spine 1984 9 7-15)
improve blood flow to neural elements decreasing ischemic neuritis
(Fukusaki M et al Clin J Pain 1998 14 148-51)
block conduction in nociceptive nerve fibers (Johansson A et al Acta Anesthesiol Scand
1990 34 335-38) L4-5 Severe Spinal Stenosis
INITIAL MANAGEMENT
Usually spinal stenosis occurs in pts of senior age
Some of these patients may significant comorbidities and higher sensitivity to
pain medications
Multilevel Cervical Spinal Stenosis
INITIAL MANAGEMENT
Intra-articular facet joint injections are appropriate when a clinical
diagnosis of facet joint ldquosyndromerdquo is confirmed
Axial back pain withwithout radiation
to the extremities
Morning neckback stiffness Pain when starting to move worse on necklumbar
spine extension relieved by the recumbent position
Intra-articular C3-4 facet joint injection
Intra-articular L5-S1 facet joint injection
INITIAL MANAGEMENT
Injections helpful in diagnosis and management of LBP secondary
to SI Joint ldquoSyndromerdquo
Pain is always maximal below L5
May radiate to hips groin buttocks posterior thighs
Patterns of referred pain somewhat similar to those due to disk and orfacet joint mediated
pain
Intra-articular SI Joint Injection
INITIAL MANAGEMENT
Injections helpful in diagnosis and management of LBP due to Piriformis Muscle Syndrome
A REAL PAIN THE BUTT
INITIAL MANAGEMENT ACUPUNCTURE
Some evidence that acupuncture and variations
thereof (acupressure cupping) potentially helpful in the acutesubacute period in
patients with NP and LBP
(Yuan QI et al PloS One 2015 Febr 1-37)
NEXT STEP
Rehabilitation and regaining of function
Physical Therapy very important component of the
rehabilitation
A symbiotic relationship between patient and
therapist key of a successful physical rehabilitation
program
The role of YOGA
Better pain control at rest and with
activities with yoga (9-week program with weekly 90-minute classes) when
compared to a self care exercise program in patients with neck pain
Significant treatment effects of yoga found for pain-related apprehension
disability quality of life and psychological outcomes (depression
fatigue anger)
(Michalsen A et al the J Pain 2012 13(11) 1122-30)
THE IMPORTANCE OF REMAINING ACTIVE
Increasing the amount of steps
walkedday by 1000 over the course of a year reduced the risk of neck pain by
14 in a group of people (men and women age 20-45) with sedentary jobs
(Sitthipornvorakul EA et al Eur Spine J
2015 24 417-24)
SPINAL MANIPULATION No Thank you
Systematic review of spinal
manipulation in patients with a variety of pain conditions including NP
and LBP
Failed to demonstrate that spinal manipulation is an effective
intervention for pain management
(Posadzki P Pain Med 2012 13 754-61)
CONCLUSIONS
Neck and Low Back pain syndromes are usually self limited conditions that can convert in chronic pain conditions causing
prolonged disability
The prevalence and cost of these conditions has significantly increased over the course of the last 15-20 years
Aggressive management of pain during the acute phase is
important because adequate pain control shortens the time and level of disability and facilitates the rehabilitation process
CONCLUSIONS
A variety of treatment modalities including medications acupuncture injections PT Yoga are utilized to manage pain and facilitate the
recovery process
Reducing stress and activities associated with the generation of pain maintaining an appropriate physical exercise regimen and a body weight
as close as possible to the ideal body weight will likely result in a decreased incidenceprevalence of short and long term NP and LBP
THANK YOU
QUESTIONS
Epidural steroid injections are an option in
patients with spinal stenosis
INITIAL MANAGEMENT
Spinal stenosis causes mechanical compression of the nerve roots swelling
(microvascular injury) producing pain (Olmarker K et al Spine 1989 14 569-573)
L3-4 Spinal Stenosis
INITIAL MANAGEMENT
STEROIDS
inhibit swelling (edema) around the nerve root
(Rydevik B et al Spine 1984 9 7-15)
improve blood flow to neural elements decreasing ischemic neuritis
(Fukusaki M et al Clin J Pain 1998 14 148-51)
block conduction in nociceptive nerve fibers (Johansson A et al Acta Anesthesiol Scand
1990 34 335-38) L4-5 Severe Spinal Stenosis
INITIAL MANAGEMENT
Usually spinal stenosis occurs in pts of senior age
Some of these patients may significant comorbidities and higher sensitivity to
pain medications
Multilevel Cervical Spinal Stenosis
INITIAL MANAGEMENT
Intra-articular facet joint injections are appropriate when a clinical
diagnosis of facet joint ldquosyndromerdquo is confirmed
Axial back pain withwithout radiation
to the extremities
Morning neckback stiffness Pain when starting to move worse on necklumbar
spine extension relieved by the recumbent position
Intra-articular C3-4 facet joint injection
Intra-articular L5-S1 facet joint injection
INITIAL MANAGEMENT
Injections helpful in diagnosis and management of LBP secondary
to SI Joint ldquoSyndromerdquo
Pain is always maximal below L5
May radiate to hips groin buttocks posterior thighs
Patterns of referred pain somewhat similar to those due to disk and orfacet joint mediated
pain
Intra-articular SI Joint Injection
INITIAL MANAGEMENT
Injections helpful in diagnosis and management of LBP due to Piriformis Muscle Syndrome
A REAL PAIN THE BUTT
INITIAL MANAGEMENT ACUPUNCTURE
Some evidence that acupuncture and variations
thereof (acupressure cupping) potentially helpful in the acutesubacute period in
patients with NP and LBP
(Yuan QI et al PloS One 2015 Febr 1-37)
NEXT STEP
Rehabilitation and regaining of function
Physical Therapy very important component of the
rehabilitation
A symbiotic relationship between patient and
therapist key of a successful physical rehabilitation
program
The role of YOGA
Better pain control at rest and with
activities with yoga (9-week program with weekly 90-minute classes) when
compared to a self care exercise program in patients with neck pain
Significant treatment effects of yoga found for pain-related apprehension
disability quality of life and psychological outcomes (depression
fatigue anger)
(Michalsen A et al the J Pain 2012 13(11) 1122-30)
THE IMPORTANCE OF REMAINING ACTIVE
Increasing the amount of steps
walkedday by 1000 over the course of a year reduced the risk of neck pain by
14 in a group of people (men and women age 20-45) with sedentary jobs
(Sitthipornvorakul EA et al Eur Spine J
2015 24 417-24)
SPINAL MANIPULATION No Thank you
Systematic review of spinal
manipulation in patients with a variety of pain conditions including NP
and LBP
Failed to demonstrate that spinal manipulation is an effective
intervention for pain management
(Posadzki P Pain Med 2012 13 754-61)
CONCLUSIONS
Neck and Low Back pain syndromes are usually self limited conditions that can convert in chronic pain conditions causing
prolonged disability
The prevalence and cost of these conditions has significantly increased over the course of the last 15-20 years
Aggressive management of pain during the acute phase is
important because adequate pain control shortens the time and level of disability and facilitates the rehabilitation process
CONCLUSIONS
A variety of treatment modalities including medications acupuncture injections PT Yoga are utilized to manage pain and facilitate the
recovery process
Reducing stress and activities associated with the generation of pain maintaining an appropriate physical exercise regimen and a body weight
as close as possible to the ideal body weight will likely result in a decreased incidenceprevalence of short and long term NP and LBP
THANK YOU
QUESTIONS
INITIAL MANAGEMENT
STEROIDS
inhibit swelling (edema) around the nerve root
(Rydevik B et al Spine 1984 9 7-15)
improve blood flow to neural elements decreasing ischemic neuritis
(Fukusaki M et al Clin J Pain 1998 14 148-51)
block conduction in nociceptive nerve fibers (Johansson A et al Acta Anesthesiol Scand
1990 34 335-38) L4-5 Severe Spinal Stenosis
INITIAL MANAGEMENT
Usually spinal stenosis occurs in pts of senior age
Some of these patients may significant comorbidities and higher sensitivity to
pain medications
Multilevel Cervical Spinal Stenosis
INITIAL MANAGEMENT
Intra-articular facet joint injections are appropriate when a clinical
diagnosis of facet joint ldquosyndromerdquo is confirmed
Axial back pain withwithout radiation
to the extremities
Morning neckback stiffness Pain when starting to move worse on necklumbar
spine extension relieved by the recumbent position
Intra-articular C3-4 facet joint injection
Intra-articular L5-S1 facet joint injection
INITIAL MANAGEMENT
Injections helpful in diagnosis and management of LBP secondary
to SI Joint ldquoSyndromerdquo
Pain is always maximal below L5
May radiate to hips groin buttocks posterior thighs
Patterns of referred pain somewhat similar to those due to disk and orfacet joint mediated
pain
Intra-articular SI Joint Injection
INITIAL MANAGEMENT
Injections helpful in diagnosis and management of LBP due to Piriformis Muscle Syndrome
A REAL PAIN THE BUTT
INITIAL MANAGEMENT ACUPUNCTURE
Some evidence that acupuncture and variations
thereof (acupressure cupping) potentially helpful in the acutesubacute period in
patients with NP and LBP
(Yuan QI et al PloS One 2015 Febr 1-37)
NEXT STEP
Rehabilitation and regaining of function
Physical Therapy very important component of the
rehabilitation
A symbiotic relationship between patient and
therapist key of a successful physical rehabilitation
program
The role of YOGA
Better pain control at rest and with
activities with yoga (9-week program with weekly 90-minute classes) when
compared to a self care exercise program in patients with neck pain
Significant treatment effects of yoga found for pain-related apprehension
disability quality of life and psychological outcomes (depression
fatigue anger)
(Michalsen A et al the J Pain 2012 13(11) 1122-30)
THE IMPORTANCE OF REMAINING ACTIVE
Increasing the amount of steps
walkedday by 1000 over the course of a year reduced the risk of neck pain by
14 in a group of people (men and women age 20-45) with sedentary jobs
(Sitthipornvorakul EA et al Eur Spine J
2015 24 417-24)
SPINAL MANIPULATION No Thank you
Systematic review of spinal
manipulation in patients with a variety of pain conditions including NP
and LBP
Failed to demonstrate that spinal manipulation is an effective
intervention for pain management
(Posadzki P Pain Med 2012 13 754-61)
CONCLUSIONS
Neck and Low Back pain syndromes are usually self limited conditions that can convert in chronic pain conditions causing
prolonged disability
The prevalence and cost of these conditions has significantly increased over the course of the last 15-20 years
Aggressive management of pain during the acute phase is
important because adequate pain control shortens the time and level of disability and facilitates the rehabilitation process
CONCLUSIONS
A variety of treatment modalities including medications acupuncture injections PT Yoga are utilized to manage pain and facilitate the
recovery process
Reducing stress and activities associated with the generation of pain maintaining an appropriate physical exercise regimen and a body weight
as close as possible to the ideal body weight will likely result in a decreased incidenceprevalence of short and long term NP and LBP
THANK YOU
QUESTIONS
INITIAL MANAGEMENT
Usually spinal stenosis occurs in pts of senior age
Some of these patients may significant comorbidities and higher sensitivity to
pain medications
Multilevel Cervical Spinal Stenosis
INITIAL MANAGEMENT
Intra-articular facet joint injections are appropriate when a clinical
diagnosis of facet joint ldquosyndromerdquo is confirmed
Axial back pain withwithout radiation
to the extremities
Morning neckback stiffness Pain when starting to move worse on necklumbar
spine extension relieved by the recumbent position
Intra-articular C3-4 facet joint injection
Intra-articular L5-S1 facet joint injection
INITIAL MANAGEMENT
Injections helpful in diagnosis and management of LBP secondary
to SI Joint ldquoSyndromerdquo
Pain is always maximal below L5
May radiate to hips groin buttocks posterior thighs
Patterns of referred pain somewhat similar to those due to disk and orfacet joint mediated
pain
Intra-articular SI Joint Injection
INITIAL MANAGEMENT
Injections helpful in diagnosis and management of LBP due to Piriformis Muscle Syndrome
A REAL PAIN THE BUTT
INITIAL MANAGEMENT ACUPUNCTURE
Some evidence that acupuncture and variations
thereof (acupressure cupping) potentially helpful in the acutesubacute period in
patients with NP and LBP
(Yuan QI et al PloS One 2015 Febr 1-37)
NEXT STEP
Rehabilitation and regaining of function
Physical Therapy very important component of the
rehabilitation
A symbiotic relationship between patient and
therapist key of a successful physical rehabilitation
program
The role of YOGA
Better pain control at rest and with
activities with yoga (9-week program with weekly 90-minute classes) when
compared to a self care exercise program in patients with neck pain
Significant treatment effects of yoga found for pain-related apprehension
disability quality of life and psychological outcomes (depression
fatigue anger)
(Michalsen A et al the J Pain 2012 13(11) 1122-30)
THE IMPORTANCE OF REMAINING ACTIVE
Increasing the amount of steps
walkedday by 1000 over the course of a year reduced the risk of neck pain by
14 in a group of people (men and women age 20-45) with sedentary jobs
(Sitthipornvorakul EA et al Eur Spine J
2015 24 417-24)
SPINAL MANIPULATION No Thank you
Systematic review of spinal
manipulation in patients with a variety of pain conditions including NP
and LBP
Failed to demonstrate that spinal manipulation is an effective
intervention for pain management
(Posadzki P Pain Med 2012 13 754-61)
CONCLUSIONS
Neck and Low Back pain syndromes are usually self limited conditions that can convert in chronic pain conditions causing
prolonged disability
The prevalence and cost of these conditions has significantly increased over the course of the last 15-20 years
Aggressive management of pain during the acute phase is
important because adequate pain control shortens the time and level of disability and facilitates the rehabilitation process
CONCLUSIONS
A variety of treatment modalities including medications acupuncture injections PT Yoga are utilized to manage pain and facilitate the
recovery process
Reducing stress and activities associated with the generation of pain maintaining an appropriate physical exercise regimen and a body weight
as close as possible to the ideal body weight will likely result in a decreased incidenceprevalence of short and long term NP and LBP
THANK YOU
QUESTIONS
INITIAL MANAGEMENT
Intra-articular facet joint injections are appropriate when a clinical
diagnosis of facet joint ldquosyndromerdquo is confirmed
Axial back pain withwithout radiation
to the extremities
Morning neckback stiffness Pain when starting to move worse on necklumbar
spine extension relieved by the recumbent position
Intra-articular C3-4 facet joint injection
Intra-articular L5-S1 facet joint injection
INITIAL MANAGEMENT
Injections helpful in diagnosis and management of LBP secondary
to SI Joint ldquoSyndromerdquo
Pain is always maximal below L5
May radiate to hips groin buttocks posterior thighs
Patterns of referred pain somewhat similar to those due to disk and orfacet joint mediated
pain
Intra-articular SI Joint Injection
INITIAL MANAGEMENT
Injections helpful in diagnosis and management of LBP due to Piriformis Muscle Syndrome
A REAL PAIN THE BUTT
INITIAL MANAGEMENT ACUPUNCTURE
Some evidence that acupuncture and variations
thereof (acupressure cupping) potentially helpful in the acutesubacute period in
patients with NP and LBP
(Yuan QI et al PloS One 2015 Febr 1-37)
NEXT STEP
Rehabilitation and regaining of function
Physical Therapy very important component of the
rehabilitation
A symbiotic relationship between patient and
therapist key of a successful physical rehabilitation
program
The role of YOGA
Better pain control at rest and with
activities with yoga (9-week program with weekly 90-minute classes) when
compared to a self care exercise program in patients with neck pain
Significant treatment effects of yoga found for pain-related apprehension
disability quality of life and psychological outcomes (depression
fatigue anger)
(Michalsen A et al the J Pain 2012 13(11) 1122-30)
THE IMPORTANCE OF REMAINING ACTIVE
Increasing the amount of steps
walkedday by 1000 over the course of a year reduced the risk of neck pain by
14 in a group of people (men and women age 20-45) with sedentary jobs
(Sitthipornvorakul EA et al Eur Spine J
2015 24 417-24)
SPINAL MANIPULATION No Thank you
Systematic review of spinal
manipulation in patients with a variety of pain conditions including NP
and LBP
Failed to demonstrate that spinal manipulation is an effective
intervention for pain management
(Posadzki P Pain Med 2012 13 754-61)
CONCLUSIONS
Neck and Low Back pain syndromes are usually self limited conditions that can convert in chronic pain conditions causing
prolonged disability
The prevalence and cost of these conditions has significantly increased over the course of the last 15-20 years
Aggressive management of pain during the acute phase is
important because adequate pain control shortens the time and level of disability and facilitates the rehabilitation process
CONCLUSIONS
A variety of treatment modalities including medications acupuncture injections PT Yoga are utilized to manage pain and facilitate the
recovery process
Reducing stress and activities associated with the generation of pain maintaining an appropriate physical exercise regimen and a body weight
as close as possible to the ideal body weight will likely result in a decreased incidenceprevalence of short and long term NP and LBP
THANK YOU
QUESTIONS
INITIAL MANAGEMENT
Injections helpful in diagnosis and management of LBP secondary
to SI Joint ldquoSyndromerdquo
Pain is always maximal below L5
May radiate to hips groin buttocks posterior thighs
Patterns of referred pain somewhat similar to those due to disk and orfacet joint mediated
pain
Intra-articular SI Joint Injection
INITIAL MANAGEMENT
Injections helpful in diagnosis and management of LBP due to Piriformis Muscle Syndrome
A REAL PAIN THE BUTT
INITIAL MANAGEMENT ACUPUNCTURE
Some evidence that acupuncture and variations
thereof (acupressure cupping) potentially helpful in the acutesubacute period in
patients with NP and LBP
(Yuan QI et al PloS One 2015 Febr 1-37)
NEXT STEP
Rehabilitation and regaining of function
Physical Therapy very important component of the
rehabilitation
A symbiotic relationship between patient and
therapist key of a successful physical rehabilitation
program
The role of YOGA
Better pain control at rest and with
activities with yoga (9-week program with weekly 90-minute classes) when
compared to a self care exercise program in patients with neck pain
Significant treatment effects of yoga found for pain-related apprehension
disability quality of life and psychological outcomes (depression
fatigue anger)
(Michalsen A et al the J Pain 2012 13(11) 1122-30)
THE IMPORTANCE OF REMAINING ACTIVE
Increasing the amount of steps
walkedday by 1000 over the course of a year reduced the risk of neck pain by
14 in a group of people (men and women age 20-45) with sedentary jobs
(Sitthipornvorakul EA et al Eur Spine J
2015 24 417-24)
SPINAL MANIPULATION No Thank you
Systematic review of spinal
manipulation in patients with a variety of pain conditions including NP
and LBP
Failed to demonstrate that spinal manipulation is an effective
intervention for pain management
(Posadzki P Pain Med 2012 13 754-61)
CONCLUSIONS
Neck and Low Back pain syndromes are usually self limited conditions that can convert in chronic pain conditions causing
prolonged disability
The prevalence and cost of these conditions has significantly increased over the course of the last 15-20 years
Aggressive management of pain during the acute phase is
important because adequate pain control shortens the time and level of disability and facilitates the rehabilitation process
CONCLUSIONS
A variety of treatment modalities including medications acupuncture injections PT Yoga are utilized to manage pain and facilitate the
recovery process
Reducing stress and activities associated with the generation of pain maintaining an appropriate physical exercise regimen and a body weight
as close as possible to the ideal body weight will likely result in a decreased incidenceprevalence of short and long term NP and LBP
THANK YOU
QUESTIONS
INITIAL MANAGEMENT
Injections helpful in diagnosis and management of LBP due to Piriformis Muscle Syndrome
A REAL PAIN THE BUTT
INITIAL MANAGEMENT ACUPUNCTURE
Some evidence that acupuncture and variations
thereof (acupressure cupping) potentially helpful in the acutesubacute period in
patients with NP and LBP
(Yuan QI et al PloS One 2015 Febr 1-37)
NEXT STEP
Rehabilitation and regaining of function
Physical Therapy very important component of the
rehabilitation
A symbiotic relationship between patient and
therapist key of a successful physical rehabilitation
program
The role of YOGA
Better pain control at rest and with
activities with yoga (9-week program with weekly 90-minute classes) when
compared to a self care exercise program in patients with neck pain
Significant treatment effects of yoga found for pain-related apprehension
disability quality of life and psychological outcomes (depression
fatigue anger)
(Michalsen A et al the J Pain 2012 13(11) 1122-30)
THE IMPORTANCE OF REMAINING ACTIVE
Increasing the amount of steps
walkedday by 1000 over the course of a year reduced the risk of neck pain by
14 in a group of people (men and women age 20-45) with sedentary jobs
(Sitthipornvorakul EA et al Eur Spine J
2015 24 417-24)
SPINAL MANIPULATION No Thank you
Systematic review of spinal
manipulation in patients with a variety of pain conditions including NP
and LBP
Failed to demonstrate that spinal manipulation is an effective
intervention for pain management
(Posadzki P Pain Med 2012 13 754-61)
CONCLUSIONS
Neck and Low Back pain syndromes are usually self limited conditions that can convert in chronic pain conditions causing
prolonged disability
The prevalence and cost of these conditions has significantly increased over the course of the last 15-20 years
Aggressive management of pain during the acute phase is
important because adequate pain control shortens the time and level of disability and facilitates the rehabilitation process
CONCLUSIONS
A variety of treatment modalities including medications acupuncture injections PT Yoga are utilized to manage pain and facilitate the
recovery process
Reducing stress and activities associated with the generation of pain maintaining an appropriate physical exercise regimen and a body weight
as close as possible to the ideal body weight will likely result in a decreased incidenceprevalence of short and long term NP and LBP
THANK YOU
QUESTIONS
INITIAL MANAGEMENT ACUPUNCTURE
Some evidence that acupuncture and variations
thereof (acupressure cupping) potentially helpful in the acutesubacute period in
patients with NP and LBP
(Yuan QI et al PloS One 2015 Febr 1-37)
NEXT STEP
Rehabilitation and regaining of function
Physical Therapy very important component of the
rehabilitation
A symbiotic relationship between patient and
therapist key of a successful physical rehabilitation
program
The role of YOGA
Better pain control at rest and with
activities with yoga (9-week program with weekly 90-minute classes) when
compared to a self care exercise program in patients with neck pain
Significant treatment effects of yoga found for pain-related apprehension
disability quality of life and psychological outcomes (depression
fatigue anger)
(Michalsen A et al the J Pain 2012 13(11) 1122-30)
THE IMPORTANCE OF REMAINING ACTIVE
Increasing the amount of steps
walkedday by 1000 over the course of a year reduced the risk of neck pain by
14 in a group of people (men and women age 20-45) with sedentary jobs
(Sitthipornvorakul EA et al Eur Spine J
2015 24 417-24)
SPINAL MANIPULATION No Thank you
Systematic review of spinal
manipulation in patients with a variety of pain conditions including NP
and LBP
Failed to demonstrate that spinal manipulation is an effective
intervention for pain management
(Posadzki P Pain Med 2012 13 754-61)
CONCLUSIONS
Neck and Low Back pain syndromes are usually self limited conditions that can convert in chronic pain conditions causing
prolonged disability
The prevalence and cost of these conditions has significantly increased over the course of the last 15-20 years
Aggressive management of pain during the acute phase is
important because adequate pain control shortens the time and level of disability and facilitates the rehabilitation process
CONCLUSIONS
A variety of treatment modalities including medications acupuncture injections PT Yoga are utilized to manage pain and facilitate the
recovery process
Reducing stress and activities associated with the generation of pain maintaining an appropriate physical exercise regimen and a body weight
as close as possible to the ideal body weight will likely result in a decreased incidenceprevalence of short and long term NP and LBP
THANK YOU
QUESTIONS
NEXT STEP
Rehabilitation and regaining of function
Physical Therapy very important component of the
rehabilitation
A symbiotic relationship between patient and
therapist key of a successful physical rehabilitation
program
The role of YOGA
Better pain control at rest and with
activities with yoga (9-week program with weekly 90-minute classes) when
compared to a self care exercise program in patients with neck pain
Significant treatment effects of yoga found for pain-related apprehension
disability quality of life and psychological outcomes (depression
fatigue anger)
(Michalsen A et al the J Pain 2012 13(11) 1122-30)
THE IMPORTANCE OF REMAINING ACTIVE
Increasing the amount of steps
walkedday by 1000 over the course of a year reduced the risk of neck pain by
14 in a group of people (men and women age 20-45) with sedentary jobs
(Sitthipornvorakul EA et al Eur Spine J
2015 24 417-24)
SPINAL MANIPULATION No Thank you
Systematic review of spinal
manipulation in patients with a variety of pain conditions including NP
and LBP
Failed to demonstrate that spinal manipulation is an effective
intervention for pain management
(Posadzki P Pain Med 2012 13 754-61)
CONCLUSIONS
Neck and Low Back pain syndromes are usually self limited conditions that can convert in chronic pain conditions causing
prolonged disability
The prevalence and cost of these conditions has significantly increased over the course of the last 15-20 years
Aggressive management of pain during the acute phase is
important because adequate pain control shortens the time and level of disability and facilitates the rehabilitation process
CONCLUSIONS
A variety of treatment modalities including medications acupuncture injections PT Yoga are utilized to manage pain and facilitate the
recovery process
Reducing stress and activities associated with the generation of pain maintaining an appropriate physical exercise regimen and a body weight
as close as possible to the ideal body weight will likely result in a decreased incidenceprevalence of short and long term NP and LBP
THANK YOU
QUESTIONS
Physical Therapy very important component of the
rehabilitation
A symbiotic relationship between patient and
therapist key of a successful physical rehabilitation
program
The role of YOGA
Better pain control at rest and with
activities with yoga (9-week program with weekly 90-minute classes) when
compared to a self care exercise program in patients with neck pain
Significant treatment effects of yoga found for pain-related apprehension
disability quality of life and psychological outcomes (depression
fatigue anger)
(Michalsen A et al the J Pain 2012 13(11) 1122-30)
THE IMPORTANCE OF REMAINING ACTIVE
Increasing the amount of steps
walkedday by 1000 over the course of a year reduced the risk of neck pain by
14 in a group of people (men and women age 20-45) with sedentary jobs
(Sitthipornvorakul EA et al Eur Spine J
2015 24 417-24)
SPINAL MANIPULATION No Thank you
Systematic review of spinal
manipulation in patients with a variety of pain conditions including NP
and LBP
Failed to demonstrate that spinal manipulation is an effective
intervention for pain management
(Posadzki P Pain Med 2012 13 754-61)
CONCLUSIONS
Neck and Low Back pain syndromes are usually self limited conditions that can convert in chronic pain conditions causing
prolonged disability
The prevalence and cost of these conditions has significantly increased over the course of the last 15-20 years
Aggressive management of pain during the acute phase is
important because adequate pain control shortens the time and level of disability and facilitates the rehabilitation process
CONCLUSIONS
A variety of treatment modalities including medications acupuncture injections PT Yoga are utilized to manage pain and facilitate the
recovery process
Reducing stress and activities associated with the generation of pain maintaining an appropriate physical exercise regimen and a body weight
as close as possible to the ideal body weight will likely result in a decreased incidenceprevalence of short and long term NP and LBP
THANK YOU
QUESTIONS
The role of YOGA
Better pain control at rest and with
activities with yoga (9-week program with weekly 90-minute classes) when
compared to a self care exercise program in patients with neck pain
Significant treatment effects of yoga found for pain-related apprehension
disability quality of life and psychological outcomes (depression
fatigue anger)
(Michalsen A et al the J Pain 2012 13(11) 1122-30)
THE IMPORTANCE OF REMAINING ACTIVE
Increasing the amount of steps
walkedday by 1000 over the course of a year reduced the risk of neck pain by
14 in a group of people (men and women age 20-45) with sedentary jobs
(Sitthipornvorakul EA et al Eur Spine J
2015 24 417-24)
SPINAL MANIPULATION No Thank you
Systematic review of spinal
manipulation in patients with a variety of pain conditions including NP
and LBP
Failed to demonstrate that spinal manipulation is an effective
intervention for pain management
(Posadzki P Pain Med 2012 13 754-61)
CONCLUSIONS
Neck and Low Back pain syndromes are usually self limited conditions that can convert in chronic pain conditions causing
prolonged disability
The prevalence and cost of these conditions has significantly increased over the course of the last 15-20 years
Aggressive management of pain during the acute phase is
important because adequate pain control shortens the time and level of disability and facilitates the rehabilitation process
CONCLUSIONS
A variety of treatment modalities including medications acupuncture injections PT Yoga are utilized to manage pain and facilitate the
recovery process
Reducing stress and activities associated with the generation of pain maintaining an appropriate physical exercise regimen and a body weight
as close as possible to the ideal body weight will likely result in a decreased incidenceprevalence of short and long term NP and LBP
THANK YOU
QUESTIONS
THE IMPORTANCE OF REMAINING ACTIVE
Increasing the amount of steps
walkedday by 1000 over the course of a year reduced the risk of neck pain by
14 in a group of people (men and women age 20-45) with sedentary jobs
(Sitthipornvorakul EA et al Eur Spine J
2015 24 417-24)
SPINAL MANIPULATION No Thank you
Systematic review of spinal
manipulation in patients with a variety of pain conditions including NP
and LBP
Failed to demonstrate that spinal manipulation is an effective
intervention for pain management
(Posadzki P Pain Med 2012 13 754-61)
CONCLUSIONS
Neck and Low Back pain syndromes are usually self limited conditions that can convert in chronic pain conditions causing
prolonged disability
The prevalence and cost of these conditions has significantly increased over the course of the last 15-20 years
Aggressive management of pain during the acute phase is
important because adequate pain control shortens the time and level of disability and facilitates the rehabilitation process
CONCLUSIONS
A variety of treatment modalities including medications acupuncture injections PT Yoga are utilized to manage pain and facilitate the
recovery process
Reducing stress and activities associated with the generation of pain maintaining an appropriate physical exercise regimen and a body weight
as close as possible to the ideal body weight will likely result in a decreased incidenceprevalence of short and long term NP and LBP
THANK YOU
QUESTIONS
SPINAL MANIPULATION No Thank you
Systematic review of spinal
manipulation in patients with a variety of pain conditions including NP
and LBP
Failed to demonstrate that spinal manipulation is an effective
intervention for pain management
(Posadzki P Pain Med 2012 13 754-61)
CONCLUSIONS
Neck and Low Back pain syndromes are usually self limited conditions that can convert in chronic pain conditions causing
prolonged disability
The prevalence and cost of these conditions has significantly increased over the course of the last 15-20 years
Aggressive management of pain during the acute phase is
important because adequate pain control shortens the time and level of disability and facilitates the rehabilitation process
CONCLUSIONS
A variety of treatment modalities including medications acupuncture injections PT Yoga are utilized to manage pain and facilitate the
recovery process
Reducing stress and activities associated with the generation of pain maintaining an appropriate physical exercise regimen and a body weight
as close as possible to the ideal body weight will likely result in a decreased incidenceprevalence of short and long term NP and LBP
THANK YOU
QUESTIONS
CONCLUSIONS
Neck and Low Back pain syndromes are usually self limited conditions that can convert in chronic pain conditions causing
prolonged disability
The prevalence and cost of these conditions has significantly increased over the course of the last 15-20 years
Aggressive management of pain during the acute phase is
important because adequate pain control shortens the time and level of disability and facilitates the rehabilitation process
CONCLUSIONS
A variety of treatment modalities including medications acupuncture injections PT Yoga are utilized to manage pain and facilitate the
recovery process
Reducing stress and activities associated with the generation of pain maintaining an appropriate physical exercise regimen and a body weight
as close as possible to the ideal body weight will likely result in a decreased incidenceprevalence of short and long term NP and LBP
THANK YOU
QUESTIONS
CONCLUSIONS
A variety of treatment modalities including medications acupuncture injections PT Yoga are utilized to manage pain and facilitate the
recovery process
Reducing stress and activities associated with the generation of pain maintaining an appropriate physical exercise regimen and a body weight
as close as possible to the ideal body weight will likely result in a decreased incidenceprevalence of short and long term NP and LBP
THANK YOU
QUESTIONS
THANK YOU
QUESTIONS