Painful GP dilemmas Low Back Pain Leg Pain. Dr. Rajiv Chawla Consultant in Pain Medicine The Walton Centre Liverpool

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1 Painful GP dilemmas Low Back Pain Leg Pain Dr. Rajiv Chawla Consultant in Pain Medicine The Walton Centre Liverpool

2 Low back Pain Up to 80% of all adults will eventually experience back pain, and it is a leading reason for physician visits, for hospitalisation and surgery, and for work disability. Clearly, back pain is one of society s most significant non-lethal medical conditions. And yet the prevalence of back pain is perhaps matched in degree only by the lingering mystery accompanying it. Deyo, 1998

3 Definitions Pain and/or discomfort below the costal margin and above the inferior gluteal folds, with or without leg pain. Non-specific LBP is defined as tension, soreness and/or stiffness in the lower back that is not attributed to a known specific pathology. Evidence suggest >85% cases

5 Acute back pain lasting up to 4 weeks Sub-acute Back pain lasting between 4 and 12 weeks Chronic Back pain persists for 12 weeks

6 Terminology Spondylosis arthritis of spine Spondylolisthesis- slippage (Gr I-IV) Spondylolysis Pars interarticularis fracture Spinal Stenosis local segmental, generalised Radiculopathy nerve root impairment may be with pain Cauda Equina Syndrome Sphincter weakness with LL weakness Lordosis Kyphosis Scoliosis

9 Facts 70-84% of adults experience non-specific LBP during their lifetime McIntosh G, Hall H. Low back pain (acute). Clin Evid 2008; 10: % of Acute LBP = Non-specific LBPChou R, Qaseem A, Snow V et al. Diagnosis and treatment of low back pain: a joint clinical practice guideline from the American College of Physicians and the American Pain Society. Ann Intern Med 2007; 147: Common age yearsmcintosh G, Hall H. Low back pain (acute). Clin Evid 2008; 10: Serious conditions are RareMcIntosh G, Hall H. Low back pain (acute). Clin Evid 2008; 10: Prevalence of persistent non-specific LBP around 23%, with 11-12% of the population disabled by LBP Shiri R, Karppinen J, Leino-Arjas P et al. The association between obesity and low back pain: a meta-analysis. Am J Epidemiol 2010; 171:

10 Serious causes Fracture Infection(Abscess, Osteomyelitis, Discitis) Cancer Systemic disease Serious pathology 0.9% Henshcke et al. ARTHRITIS & RHEUMATISM Vol. 60, No. 10, October 2009, pp

11 Prognosis 90% of people who take sick leave due to LBP return to work within 2 months, and 70% within 1 week McIntosh G, Hall H. Low back pain (acute). Clin Evid 2008; 10: Acute LBP has a high recurrence rate of between 44-80% within a year McIntosh G, Hall H. Low back pain (acute). Clin Evid 2008; 10: Acute LBP is usually self-limiting but 2-7% will develop persistent non-specific back pain McIntosh G, Hall H. Low back pain (acute). Clin Evid 2008; 10: Psychosocial and occupational factors are associated with the course of resolution of pain National Institute of Health and Clinical Excellence (NICE). Low back pain. Clinical guideline 88. London: NICE; 2009

12 Low Back Pain 2 nd Most common symptom on GP visit. High cost.

13 Type of disorder Biopsychosocial disorder

14 Effect on Individual Turk et al, Lancet 2011

15 At risk Obese individual Lifting heavy objects Posture Repetitive movements bending, twisting, and lifting Vibration of the whole body, e.g. from driving heavy machinery Psychosocial risk factors, eg stress and depression

16 Presenting complaints Ache, Pain, Tension, Soreness, Stiffness, Spasm Occasionally in the leg, groin and thigh Can be burning, Electric shock or shooting Worsens with activities and Flexion/extension Relieves with stopping the activity, taking rest, flexion/extension Clinical Knowledge Summaries (CKS). Back pain - low (without radiculopathy). Newcastle upon Tyne: CKS; [Map of Medicine (MoM) Clinical Editorial team and Fellows. London: MoM; 2011

17 History Location (ask to point out!) Onset, progression, frequency Distribution, radiation, severity Character, aggravated or relieved by? Previous similar episodes and treatments B/k Pain and numbness -?Radiculopathy

(fever, chills, sweating, drug, wounds, immunosuppressant's,

18 Rule out Cauda Equina (Bowel/Bladder/Perineal sensation) Cancer (<20,>55, night time, sweats, weight loss, spinal deformity Infection (fever, chills, sweating, drug, wounds, immunosuppressant's, steroids) Fractures( sudden onset, h/o injury, deformity) Neurological deficit limbs

19 To image or Not Most patients do not need immediate imaging, and an initial trial of therapy before imaging is warranted in many cases. Imaging is indicated only if there are severe progressive neurologic deficits or symptoms/signs suggesting a serious or specific underlying cause Chou R, Qaseem A, Owens DK. Diagnostic imaging for low back pain: advice for high-value health care from the American College of Physicians. Annals Intern Med 2011; 3:

20 LBP diagnostic Triage Simple Low Back Pain (95%) Low Back Pain and Root Pain (<5%) Serious Spinal Pathology (<1%)

21 Once you have ruled out other sinister causes Mechanical Non specific Low back pain Lumbar Radiculopathy (Sciatica)

22 Treatment MLBP Education (NO Botulin /Anti TNF inhibitor/methylene blue/epidural) No rest advised (activity modification) Short term Rx symptomatic relief (precautions) Physiotherapy based exercises No steroids Mattress/Corset/Traction/Braces

23 The spine has structures that are innervated and noxious mechanical or chemical stimulation of these structures can cause low back pain. Bogduk N (2005) Low Back Pain. In: Clinical anatomy of the lumbar spine and sacrum. 4th edn. Elsevier, Sydney pp

25 Cause of Mechanical Back pain The facet joints have been shown to be the source of chronic pain in 15% to 45% of patients with chronic low back pain * Schwarzer AC, Aprill CN, Derby R, Fortin J, Kine G, Bogduk N. Clinical features of patients with pain stemming from the lumbar zygapophysial joints. Is the lumbar facet syndrome a clinical entity? Spine 1994; 19: *Schwarzer AC, Wang S, Bogduk N, McNaught PJ, Laurent R. Prevalence and clinical features of lumbar zygapophysial joint pain: a study in an Australian population with chronic low back pain. Ann Rheum Dis 1995; 54: Disc: 39% Schwarzer AC, Aprill CN, Derby R, et al. The prevalence and clinical features of internal disc disruption in patients with chronic low back pain. Spine Sacroiliac Joint 13% Bogduk N. The anatomical basis for spinal pain syndromes. J Manipulative Physiol Ther.1995

26 Fact of Facet Joints MRI Prevalence of lumbar facet arthrosis and its relationship to age, sex, and race: an anatomic study of cadaveric specimens. Eubanks JD et al. Spine (Phila Pa 1976) Sep 1;32(19): By decade, facet Degeneration present in 57% of 20- to 29-year-olds, 82% of 30- to 39-year-olds, 93% of 40- to 49-year-olds, 97% in 50- to 59-year-olds, and 100% in those >60 years old.

27 Facet joint Pain No reliable clinical or imaging tests to determine the presence of facet joint pain. Hancock et al Systematic review of tests to identify the disc, SIJ or facet joint as the source of low back pain. Eur Spine J Oct;16(10): Valid diagnostic techniques have shown facet joint as source of pain. Sehgal et al. Systematic review of the diagnostic utility of facet (zygapophysial) joint injections in chronic spinal pain: An update. Pain Physician 2007; 10:

29 Localised unilateral low back pain > 6 weeks Red flags excluded? Yes Tenderness over facet joint(s) Referred not beyond knee Pain on extension, lateral flexion or rotation to Ipsilateral side Pain relief on flexion Indicative for facet pain Diagnostic Block >50% pain relief Yes RF Denervation

30 Evidence(SR) for RF Denervation Guerts 2001 Moderate Manchikanti 2002 Moderate to strong evidence Niemisto 2003 Conflicting short-term effect on chronic low back pain Slipman 2003 Level III or moderate Boswell 2005 Moderate to strong Boswell 2007: Moderate to strong in cervical and lumbar spine Datta 2009: Level II-2

31 Radicular Pain Mechanical:Neuropathic Many people with mechanical back pain also show a neuropathic presentation (traditionally classified as Radiculopathy) manifest by tingling, burning, or numbness or as pain Shooting into the distal affected part Audette et al., 2005

32 Acute and Chronic Intervertebral Disc prolapse Spinal stenosis (Degenerative)

34 Possible Level Areaof Pain Sensory loss Motor loss Reflex loss L1 Groin Groin May be Hip Flexion L2 L3 L4 Back + Thigh + Leg Thigh and Medial Leg Hip Flexion Knee Extension Knee L5 Back, Buttock, Lat leg, Dorsum of Foot, Big toe Calf, Dorsum of Foot Foot Dorsiflexion, Toe flexion, Eversion, Inversion S1 Back, Buttock, Posterior thigh and calf, foot sole Posterior Calf Sole Plantar flexion Ankle S2 S3 S4 Buttock, Posterior Thigh, Perineum Buttock Perineum Urinary Sphincter Anal Sphincter Anocutaneous Bulbocavernosus

35 Treatments Conservative NSAIDs, weak Opioids Anti Epileptic Drugs, Tricyclic Antidepressants Injection Epidural Root block Surgery Micro-Discectomy Spinal Cord Stimulation

Transforaminal Epidural Strong evidence for Short term, Moderate for long term pain relief Complications use continuous Fluoroscopy/DSA Results not good if done for failed back surgery Abdi et al

36 Transforaminal Epidural Strong evidence for Short term, Moderate for long term pain relief Complications use continuous Fluoroscopy/DSA Results not good if done for failed back surgery Abdi et al Epidural steroids in the management of chronic spinal pain: A systematic review. Pain Physician 2007; 10: , Manchikanti et al Reassessment of evidence synthesis of occupational medicine practice guidelines for interventional pain management. Pain Physician 2008; 11:

37 Evidence for Transforaminal epidural Abdi et al Epidural steroids in the management of chronic spinal pain: A systematic review. Pain Physician 2007; 10: , Manchikanti et al Reassessment of evidence synthesis of occupational medicine practice guidelines for interventional pain management. Pain Physician 2008; 11: Strong evidence for Short term, Moderate for long term pain relief Spinal surgery i.e. Microdiscetomy Failed back surgery syndrome

39 Antibiotics for Modic changes associated low back pain

40 Stereotactic radiosurgery (Gamma Knife)

41 THANK YOU VERY MUCH

Thoracolumbar Spine Conditions: Treatment and Return to Play

Thoracolumbar Spine Conditions: Treatment and Return to Play C H R I S T O P H E R B U R K S, MD B I E N V I L L E O R T H O P A E D I C S P E C I A L I S T S O C E A N S P R I N G S, MS Thoracolumbar