Low Back Pain. Adam Shuster DO Pain Management Consultants of SWFL

Transcription

1 Low Back Pain Adam Shuster DO Pain Management Consultants of SWFL

2 Low Back Pain Radicular pain DDD/HNP Spondylosis Scoliosis Stenosis Infection Spondylolisthesis SIJ pain Cancer Trauma/fractures Failed Back Syndrome Referred pain

3 Lumbar Pain Axial Inferior to T12 Superior to S1

4 Sacral Pain S1 Sacrococcygeal joint Lumbosacral pain includes pain of lumbar and/or sacral pain and typically constitutes low back pain.

5 Pain Definition An unpleasant SENSORY and EMOTIONAL experience associated with actual or potential tissue damage or that is described in terms of damage Physiologic process Tend to be well localized and associated with sensitivity in the injured region Nociceptive pain

6 Neuropathic Pain Persistent pain following injury to the nervous system Spontaneous (no stimulus) Hyperalgesia Allodynia

7 Back Pain Workup/Exam Back pain vs leg pain vs back and leg pain Assess for: Gait disturbance Numbness Weakness Paresthesias Diminished reflexes

8 Workup/Exam Radicular pain travels along specific dermatome Lancinating Shooting Sharp Stabbing

9 Workup/Exam L2 and L3 nerve roots (NR) Symptoms involving groin/inner thigh L4 NR Buttock, anterior thigh, knee, medial calf, may have weakness of knee extension and decreased patellar reflex L5 NR Buttock, around hip, lateral leg, dorsal foot, great toe, may have difficulty walking on heels

10 Workup/Exam S1 NR Buttock, posterior thigh and leg, plantar surface of foot, may have decreased achilles reflex, weakness of plantar flexion, difficulty walking on toes Sacral NRs Decreased sensation buttock perineum (saddle anesthesia), bowel/bladder dysfunction, autonomic dysfunction (loss of erection/vaginal anesthesia)

11 Red Flags Majority of patients have musculoskeletal origin to their pain and it will resolve in 4-6 weeks. Red flag conditions (Agency for Health Care Policy and Research) that may be lifethreatening or compromise neurologic function Infection Tumors Cauda equina syndrome Fractures

12 Red Flags Age younger than 20 Higher incidence of congenital and developmental abnormalities Age older than 50 Prone to neoplasms, pathologic fractures, infections

13 Red Flags Duration Acute and subacute back pain is less than 3 months Pain greater than 3 months is usually considered to be of less serious etiology Trauma

14 Red Flags Constitutional symptoms Fever Chills Night sweats Unexplained weight loss Malaise

15 Red Flags Systemic illness Hx cancer Serious bacterial infection IVDA Immunosupression

16 Red Flags Unrelenting pain Usually worse at night Not relieved with rest or analgesics

17 Cauda Equina Syndrome Caused by acute compression of the nerve roots comprising the cauda equina (horse's tail) Prevalence about 4/10,000 Most common cause is a large disc herniation, or disc herniation in a stenotic spine 70% of patients with cauda equina have a history of LBP

18 Cauda Equina Syndrome Other causes of CES METS Hematoma Epidural abscess Traumatic fracture Acute transverse myelitis Inflammation of the spinal cord

19 Cauda Equina Syndrome Present within 24 hrs Radicular pain Back pain Gait disturbance Weakness Abdominal discomfort Motor/sensory deficits Saddle anesthesia Diminished sphincter tone Evidence of urinary retention

20 Cauda Equina Syndrome MRI examination is the gold standard Once confirmed Tx includes Neurosurgical consultation/iv steroids

21 Imaging MRI Gold standard at determining etiology of lumbar radicular symptoms Best resolution of spinal canal, spinal cord, neural foramina, NR, disc spaces Contrast is used in patients with previous back surgery to differentiate scar tissue and recurrent herniation

22 Imaging MRI limitations Claustrophobia Overweight Most pacemakers SCS Retained metallic objects Mechanical heart valves Aneurysm clips Cost (insurance?)

23 Imaging CT scan is superior to MRI at evaluating the bony structures of the spine May be combined with myelography

24 Imaging Plain radiographs may detect fractures or deformities Can help identify spondylolisthesis Not helpful in evaluating for disc displacement Flexion and Extension films may assess spinal instability

25 EMG EMG and NCS helpful in the diagnosis of establishing radicular pain vs some other type of neuropathy May also be used if MRI does not necessarily correlate with symptoms and pt continues to complain of extremity pain/weakness/ paresthesias

26 Normal Disc

27 Disc Structure

28 Nucleus Pulposus Nucleus pulposus: located in the center of the disc, has a chondroid matrix of proteoglycans and collagen. The proteoglycans of the nucleus has the ability of attracting and retaining water and can absorb and disperse forces.

29 Annulus Fibrosus Annulus fibrosus composed of a 3 dimensional network of collagen fibers surrounds the internal gelatinous nucleus pulposus. The concentric lamellae of fibrocartilage in the annulus fibrosus run obliquely from 1 vertebra to another, inserting Sharpey fiber onto the articular surface of the vertebral end plates.

30 Vascular Supply There is no blood vessel in the nucleus. The nucleus pulposus obtains its nutrition from the adjacent vertebral body surfaces and blood vessels in the annulus fibrosus by diffusion and possibly in conjunction with compressive loading.

31 Innervation appleventral Rami/gray rami communicans supply anterior and lateral annulus and ALL applesinuvertebral (recurrent branch of the ventral rami/ gray rami communicans) supply posterior annulus and PLL

32 Innervation applemost of the afferent fibers from the low lumbar discs are believed to travel in the sinuvertebral nerve, pass through the ramus communicans and lumbar sympathetic chain, and finally enter the spinal cord through L2 ramus communicans and L2 spinal nerve roots.

33 Age-related Changes applenumber of blood vessels disappear by the third decade of life. applethe number of viable cells in the inner regions of the disc diminishes apple The ratio of type I to type II collagen changes, with an increase in type I collagen. applecollagen cross links decrease with age. applealterations in load bearing capability, leading to the development of localized tissue damage, such as IDD or annular tears.

34 Discogenic Pain appledisc inflammation causes an increase in NGF dependent neurons in the DRG, suggesting that NGF dependent neurons are possibly responsible for discogenic pain. applenerve endings are positive for substance P

35 Discogenic Pain appledegenerative human disc tissue spontaneously secrete a number of proinflammatory mediators apple These agents include interleukin (IL) 1[beta], IL 6, IL 8, prostaglandin E 2, nitric oxide, monocyte chemotactic protein 1, basic fibroblast growth factor, and transforming growth factor [beta]. appleit has been demonstrated that human nucleus pulposus can synthesize increased amounts of IL 6, IL 8, prostaglandin E 2, and nitric oxide in response to stimulation. appleepidural inflammation due to annular tear can also contribute to the pathogenesis of pain. Human discs contain high levels of phospholipase A2.

36 IDD

37 IDD appleidd was first coined by Crock in 1970 applehe described IDD as a condition marked by alteration in the internal structure and metabolic functions of the intervertebral disc, usually proceeded by injuries. apple Annular tears (including radial tear and circumferential tear) are the major forms of IDD

38 Clinical Symptoms appleno specific history or findings in physical examination has high diagnostic value applesitting intolerance is often a primary complaint. Pain usually gets worse when they sit without support, especially when sitting forward. applediscogenic pain is usually located in the low back area, with frequent radiation to bilateral lower extremities.

39 Annular Tear

40 Disc displacement Displacement of the disc material beyond the IVD space Disc bulging happens when the nucleus pulposus loses its turgor and the annulus loses its elasticity allowing the disc to bulge out beyond the IVD space

41 Disc Displacement Herniated material may contain bone, annular tissue, and cartilage Protruted disc Extrusion Sequestration No continuity between herniated material and disc Most common level is L4-L5 Second most common L5-S1

42 Natural History Majority of patients (60%) experience significant resolution of symptoms within the first few months Clinical improvement may be accompanied by normalized imaging Larger extrusions have a higher tendency to decrease in size then smaller protrusions

43 Natural History Spontaneous regression is thought to be carried out by phagocytic processes, predominantly involving macrophages

44 Disc Bulge

45 Nerve Compression

46 Discogenic Pain

47 Protrusion

48 Extrusion

49 Acute Radicular Pain Typically caused by HNP Can also be caused by narrowing if the foramina secondary to age/degenerative changes May need surgical consult if conservative treatment not effective or patient has neurologic deficit 90% of patients realize symptomatic relief without specific treatment (six weeks)

50 Lumbosacral Sprain No radicular symptoms No obvious abnormalities on exam Can have traumatic sprain of muscles and ligaments Typically see improved function in 3-4 weeks with modification of daily activities and symptomatic management

51 Spondylosis/Facet Syndrome Similar presentation to discogenic pain Deep, aching, sitting and standing intolerance Worse with extension and rotation of the L/S spine Pts may also complain of morning stiffness Referred pain to buttocks, groin, hip, proximal thighs (anterior or posterior) No neurologic deficits

52 Spondylosis/Facet Syndrome

53 Failed Back Syndrome Patients who have pain after spine surgery Adjacent disease Pseudoarthrosis Disc herniation Scar tissue

54 Non-invasive Interventions

55 Non-invasive Interventions Bed Rest Bracing Traction Prolonged bed rest is no longer recommend

56

57 LESI

58 ESI

59 Facet Injection

60 Facet Medial Branch Block

61 Facet Radiofrequency Ablation

62 Facet RFTC

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64 Neuromodulation

65 Neuromodulation Consists of peripheral and spinal cord stimulators Intrathecal drug delivery systems Deep brain stimulation Gastric pacemakers etc

66 SCS Also known as dorsal column stimulator Uses pulsed energy near the spinal cord First placed in epidural space 1967 Three companies currently produce SCS Medtronic Boston Scientific St. Jude (ANS)

67 SCS

68 Spinal Cord Stimulation

69 Gate Theory Melzack and Wall Foundation for SCS The notion that stimulation of A-beta fibers closes the dorsal horn (gate) reducing nociceptive input from the periphery

70 Neuromodulation Activation of descending and spinal pathways by serotonin and norepinephrine Increased dorsal horn activity of GABA Suppression of CGRP

71 Advantages Analgesia on demand Option when other treatments fail Pt in control Improved morale/quality of life Avoids medication side effects

72 Advantages No restriction of daily activity Reduction in pain medications Reversible

73 Disadvantages Not effective in all cases (50-70%) Invasive Cost Disconnection or equipment failure

74 SCS vs Reoperation

75 SCS

76 Failed Back Syndrome Most common in the US SCS Indications CRPS Extremity pain (neuropathic or vascular) Phantom Limb pain PVD Ischemic heart disease Abdominal pain Pelvic pain

77 SCS Contraindications Infection Drug Abuse Uncontrolled psychiatric disease

78 SCS

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80 Intrathecal Drug Delivery System

81 IDDS IDD therapy involves the delivery of pain medicine in the intrathecal space The pump is connected to a thin, flexible catheter; both are implanted under the skin Smaller doses of medication are needed for effective pain relief because drug is delivered directly to the pain receptors

82 Potential Advantages

83 Efficacy

84 Non-Malignant Indications FBSS Spinal stenosis Spondylosis Compression fx Radiculitis Post-thoracotomy pain Postmastectomy syndrome Peripheral neuropathy Interstitial cystits Chronic abdominal pain Postherpetic neuralgia RA

85 Important Considerations Is life expectancy greater than 3 months Are pain complaints related to a physiologic diagnosis Is function limited by the pain Is patient psychologically stable Are there appropriate expectations and understanding of risks Has conservative treatment failed

86

87 MRI Synchromed II performance has not been established for greater than 3.0 Tesla horizontal, closed-bore MRI scanners Can cause motor stall Pump can detect motor stall and motor stall recovery Pump should be interrogated after MRI to confirm proper functioning

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