1. 1. NON SURGICAL INTERVENTION IN BACK PAIN Dr. SANDEEP KUMAR KESHARWANI MS (ORTHO), FNB SPINE FELLOW
2. 2. NON-PHARMACOLOGIC o Patient education (back school) o Physical therapy (stretching, strengthening exercise, massage, traction) o Heat/Cold therapy o TENS o Chiropractic manipulation o Orthotic devices
3. 3. MEDICATIONS o Acetaminophen o NSAIDs o Narcotics o Steroids o Adjuvants (Antidepressants, anticonvulsants, muscle relaxants)
4. 4. MODES OF INTERVENTION Transduction NSAIDs, Local Anesthetics & Anticonvulsants Transmission Opioids, NMDA Antagonists Modulation Tricyclic Antidepressants, Opioids, GABA Agonists
5. 5. Pain Step 1 Nonopioid Adjuvant Pain persisting or increasing Step 2 Opioid for mild to moderate pain Nonopioid Adjuvant Pain persisting or increasing Pain persisting or increasing Step 3 Opioid for moderate to severe pain Nonopioid Adjuvant Invasive treatments Opioid Delivery Quality of Life MODIFIED WHO 3- STEP ANALGESIC LADDER Proposed 4th Step The WHO Ladder Deer, et al., 1999 8 -10 4 - 7 1 - 3 Pain Severity
6. 6. INVASIVE PROCEDURES o Selective injection o Intradiscal electrothermal therapy o Radiofrequency denervation
7. 7. EARLY INTERVENTION 1. Medicines NSAIDS Acetaminophen Muscle Relaxants Narcotics (short duration) 2. Short term bed rest (2days maximum) 3. Physical therapy 4. Chiropractics
8. 8. LATER ALTERNATIVES 1.Medicines- Antidepressants 2.Orthotic devices 3. Physical therapy 4. Therapeutic injections Epidural Nerve Root Medical Branch 5. Radiofrequency denervation 6. IDET 7. Acupuncture
9. 9. THANKYOU