TIPS FOR TREATING LOW BACK PAIN DR BRENDON AUBREY
KEYS ON HISTORY • Where is the pain? • Low lumbar spine vs posterior pelvic girdle vs lateral hip • What is the duration of the pain? • Acute vs chronic • Does the pain radiate? • Any painful structure can refer pain elsewhere • Somatic vs radicular • What is the nature of the pain? • Inflammatory vs mechanical vs neuropathic • Is there any weakness or numbness? • Radiculopathy • What have you been treated with in the past • What worked, what didn’t
INFLAMMATORY ARTHROPATHIES • • • Morning and night pain Family history Younger age Lack of trauma Multiple joints or enthesopathy • Investigations • Autoimmune blood screen • MRI
SACROILIAC JOINT • Can’t sit • Can’t stand • Can’t lie down • SIJ tests 1. 2. 3. 4. PSIS movement during forward flexion SIJ laxity with an AP thrust Positive FABER test Improved straight leg raise with pelvic compression
KEYS ON EXAMINATION • Which movement hurts • All movements – discogenic (annular ligament tear, disc protrusion), SIJ, discitis • Forward flexion – discogenic, SIJ, muscular • Extension – Facet joint, SIJ • Slump test • Test for neural tension • Sensitivity 84%, specificity 83%
KEYS ON EXAMINATION • Palpation • Accept that we can never be very accurate • But we can localise what structures may be involved • Neurovascular status • Sensation + power • Peripheral pulses • American Spinal Injury Association (ASIA) • http: //www. asia-spinalinjury. org • Motor and Sensory Exam
INFLAMMATORY VS MECHANICAL Inflammatory Mechanical Worse in early morning and evening Worse as the day goes on Improves with mobilisation Improves with rest Responds to NSAIDs No response to NSAIDs
NEUROPATHIC PAIN • “Burning” • “Pins and needles” • “Sharp, shooting pain” • Complex Regional Pain Syndrome (CRPS) • • Temperature change Local skin swelling or discoloration Local sweating Hyperasthesia
SENSITISATION • Peripheral sensitisation • Local hypersensitivity in the area of original pathology following inflammation • Peripheral nocioceptive threshold is reduced • Central sensitisation • Hypersensitivity spreads to areas of non-inflamed tissue • Central nocioceptive threshold is reduced • This requires neuromodulating medication and patient education
SOMATIC VS RADICULAR • Somatic • Aching • Can also refer down the legs but not specifically follow a dermatome • Radicular • Sharp, lancinating, electric shocks, burning • Tends to be in the distribution of a dermatome • Not all pain radiating down the leg is “sciatica!”
RED FLAGS • • • Fever Night pain Night sweats Weight loss Progressive weakness or numbness History of IV drug use • Urgent MRI and blood tests
IMAGING • Preferably none • Radicular pain/radiculopathy • MRI • Somatic Pain • CT scan • Inflammatory Arthropathy • MRI - sacroiliitis
MANAGEMENT - FACET JOINT Oral Prednisolone for 2 weeks CT scan Steroid injection Referral to Pain Management Specialist Medial branch blocks Radiofrequency neurotomy
RADIOFREQUENCY
MANAGEMENT - DISCOGENIC BACK PAIN Acute • Exclude Discitis (MRI, bloods) Chronic • Oral Predniso lone 2 weeks
MANAGEMENT - SACROILIAC JOINT Instability Inflammati • Trial of on taping/SI • Oral J belt Predniso • Physio/P lone 2
MANAGEMENT – NEUROPATHIC PAIN • Pregabalin (Lyrica) • 25 mg nocte for 1 week • Then 50 mg nocte for 1 week • Then 75 mg nocte for 1 week then review • Amitriptyline (Endep) • 5 mg nocte for 1 week • Then 10 mg nocte for 1 week then review • Gabapentin (Neurontin) • 100 -300 mg nocte for 1 week then review
PATIENT BUY-IN • The patient needs to feel like you are the one who understands their pain……or you won’t see them again • Educate the patient • Avoid setting time frames • Avoid setting activity restrictions • Set realistic expectations
SUMMARY • • • Listen for keys on history Recognise red flag symptoms Keep the examination simple Have a low threshold to prescribe a neuromodulator Image to exclude significant pathology only if needed Develop your own treatment algorhythm based on experience • Educate the patient and get them to buy-in
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