Transcript Outcomes Efficacy and Complications of Management of lower Back

Chronic Lower Back Pain
Dr Namal Senasinghe
MB.BS FFARCS DPMed FFPMCA
Consultant in Pain Medicine
Centre for Pain Medicine
Canterbury Hospital, Kent, UK
Potential sources for lower back pain
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Ligaments - Supraspinous
Post Longitudinal ligaments
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Muscular - Paraspinal M
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Vertebral body and plates
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Facets/SIJ
Patient Groups
1.
Genuine back problems
2.
Muscular Skeletal disorders & Fibromyalgia
3.
Pt’s with secondary intentions
Clinical features
General Features
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Localized back pain
Radiculopathy / Radiculitis
Muscular spasms
Difficulty in walking
Difficulty in getting up
History of trauma
Red Flags
 Features of cauda
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equina
Significant trauma
Weight loss
IVDA or HIV
Severe unremitting
night time pain
Fever
Management of Lower Back Pain
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Pharmacological
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Psychological
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Behavioural
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Complementary therapy
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Interventional
Pharmacological Management
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WHO Step Ladder
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By the oral route
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By the clock
Analgesic Types
1.
Simple analgesics
2.
Moderate
3.
Strong
Simple Analgesics
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Paracetamol
NSAIDS – Aspirin/Ibuprofen/Indometacin
Diclofenac/ Meloxicam
COX 2 Inhibitors -
Celecoxib (Celebrex)
Etoricoxib (Arcoxia)
Cautions
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All NSAIDS
Cardiac/Hepatic/Renal Impairment
COX 2
LVF/Hypertension
Contraindications
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Allergy/Hypersensitivity
Bleeding peptic ulcers
Severe heart failure
CVA
IHD
PVD
Moderate ht failure
Moderate Analgesics
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Codeine Phos
Co- Codamol (8/500, 30/500)
Tylex/Kapake
Strong Analgesics (Opiates)
Buprenorphine
Hydromorphone
Codeine
Meptazinol
Dextromoramide
Methadone
Dextropopoxyphene
Morphine
Diamorphine
Oxycodone
Dihydrocodeine
Pentazocine
Dipipanone
Pethidine
Fentanyl
Tramadol
Anti Neuropathic Medication
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Anti Epileptics – Gabapentin
Pregablin
Antidepressants – Amitriptyline
Dothiopin
Duloxetine
Psychological
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Psychological assessment
Cognitive behavioural therapy
Counselling
Supportive psychotherapy
Group therapy
Relaxation
Reflexology
Behavioural therapy
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Pain management programmes
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Back schools
Complimentary Therapy
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Acupuncture
Tai Chi
TENS/SCENAR (self controlled electro neuro adaptive regulation)
Reflexology
Alexandra
Aromatherapy – oil
Interventional Management
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Epidural Steroids
Facet Joint Injections/SIJ injections
Radiofrequency Denervations
Discography
IDET
Dorsal root ganglion denervations
Spinal cord Stimulators
Intrathecal pumps / Epidural pumps
Cordotomy
EPIDURAL STEROID INJECTIONS
Indications
Radiculopathy / Radiculitis
MRI Scan – Positive findings of a disc prolapse
Nerve root compression
Drugs
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Methylprednisolone 80mg
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Triamcinolone 60mg
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Local anaesthetic solution
Mechanism of Action
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Samples from herniated discs contain high level of
phospholipase A2.
Phospholipase A2 liberates arachidonic acid from
cell membrane.
Steroids induce the synthesis of phospholipase A2
inhibitor preventing the release of a substrate for
prostaglandin synthesis.
Steroids can block nociceptive input.
Contrast in the epidural space
Lumbar Epidurogram
Positive Predictors
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Presence of nerve root
irritation
Recent onset of symptoms
Absence of psychological
overlay
Radicular pain and
numbness
Short duration (< 6 months)
Advanced educational
background
*(White et al)
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Motor weakness correlating
with the involved nerve root
Positive SLR
Abnormality in the EMG in
the affected nerve root
Documentation of a
herniated disc in
radiological examination
Younger age group
Negative Predictors
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Previous back surgery
Pain > 6 months
Work related injury
Unemployment due to
pain
Presence of pending
litigation
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Previous multi-drug
therapy
Very high pain rating
Frequent sleep
disturbances
Smoking
Complications
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Flashing
Nausea
Vomiting
Sweating
Hypotension
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Dural puncture
Retinal haemorrhage
Epidural haematoma
FACET JOINT INJECTIONS ( FJI )
The Lumbar Facet Syndrome
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Intrduced by Ghormley in 1933
LBP with or without referred pain
Catching/Locking
Increased with standing/sitting
Decreased with mobility
Physical Exam Inves – X’ray / MRI
Indications for FJI
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Diagnostic
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Therapeutic
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Standard monitoring
Local infiltration - 2% Lignocaine
Drugs - 0.5% Bupivacaine
Prednisolone 25 mg
Complications - Intrathecal injections
Haematoma
Entry into spinal cord
Positive Predictors
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Acute onset of pain
Absence of leg pain
Absence of muscle spasm
Normal gait
RADIOFREQUENZY DENERVATION
Radiofrequency Lesion Generator (Radionics)
Uses of RF/Pulse RF denervations
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Facet & SIJ Denervation - RF
Lumbar Sympathectomy - RF
DRG – Pulse RF
Stellate Ganglion – Pulse RF
Suprascapular N – Pulse RF
Illioinguinal N – Pulse RF
Discogram
Diagnostic test performed to view and assess the
internal structure of a disc and determine if it is a
source of pain
Expected results
1. Recreation of painful symptoms
2. Confirmation of diagnosis
IDET
(Intradiscal Electrothermal Annuloplasty)
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To treat discogenic back pain
Procedure works by cauterizing the nerve endings
within the disc wall
Minimally invasive out patient procedure
SPINAL CORD STIMULATOR
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Used in failed back surgery syndrome (FBSS).
A lead with 2-4 electrodes is introduced into the
epidural space @ L1/L2
Threaded up to T8/T9
Equipment
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A totally implantable device (Implantable pulse
generator - IPG). The patient has control only on the
on-off button. The programming is done by the
doctor using a special console from outside.
How does it work ?
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A pulse is generated which activates the large A alpha fibres & A -beta fibres in the dorsal horns of
the spinal cord.
This inhibits the nociceptive input from the smaller A
delta fibres & C fibres closing the gate.
Other uses of SCS
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Complex regional pain syndrome
Ischaemic leg pains
Unstable angina
Phantom limb pain
Muscle spasm in MS
Surgical Option
Refer to
Orthopaedic and Neurosurgical colleagues
Red flags
Disc prolapses
Neurological Symptoms
Ct back pain not responding to interventions