1. Issues in Pain Management:
The Patient with
Chronic Low Back Pain
Robin Hamill-Ruth

2. Chronic Low Back Pain Demographics Anatomy Evaluation
Management Options
Medical
Adjunctive therapies
Interventional
Case Reports

4. Chronic LBP: Demographics
80% of Americans experience LBP at some point during their lifetime.
Annual prevalence of LBP about 30%
Most common cause of disability under age 45
Accounts for 12.5% of all sick days (Frank, 1993)
Second most common reason for visits to MD (Hart, 1995)
5th leading cause of hospital admission (Taylor, 1994)

5. Chronic LBP: Demographics
Each year, 3-4% of population is temporarily disabled, 1% of working age population is permanently, totally disabled
Annual cost to US in 1980 estimated at 85 million dollars/year
Between 1971 and 1981, # disabled grew 14 times the rate of population growth
Prevalence rising with increasing age up to 65 years after which it declines

6. Chronic LBP: The Good News?
Recovery from LBP
60-70% recover by 6 weeks
80-90% improve by 12 weeks
Recovery after 12 weeks is “slow and uncertain”
Those with isolated LBP recover more quickly than those with sciatica
non-work related back symptoms cause less lost time from work than work related symptoms

10. Differential Dx of LBP and Sciatica
Sacroiliitis, SI dysfunction
Piriformis syndrome
Iliolumbar syndrome
Quadratus lumborum syndrome
Trochanteric bursitis
Ischiogluteal bursitis
Facet syndrome
Meralgia paresthetica
Fibromyositis/Fibromyalgia
GI, GU, Vascular, Intraabdominal

11. Assessment: History S = site C = character R = radiation O = onset
D = discriminating features (time course, what aggravates, what relieves, etc)

12. Confounding Conditions
Depression, grief
Confusion, memory deficits
Medical conditions
ASCVD, DM, Obesity, CRF, COPD, Sleep apnea
Psycho-socio-economics
money
transportation
other responsibilities
litigation, disability worker’s comp issues

13. “Quantifying” Pain Assessment VAS (verbal, visual) pain sleep mood
function
Draw your pain
Self, significant other report
Pain scales, inventories

17. History 2 Past medications including dose, response, why stopped
Past interventions and therapies
Current meds, allergies
Past med history
ROS
Social, work history

18. Physical Exam General Spine visual, palpation, percussion
Posture, gait, movement during change in position
Neuro (sensation, strength, tone, reflexes)
ROM, flexibility
Provacative maneuvers (eg. SLR, distracted SLR, Patrick’s, facet loading)
Abdomen, chest, vascular, adjacent joints

19. Waddell’s Signs: Nonorganic Pathology
1. Nonanatomic tenderness
2. Simulation test (axial loading)
3. Distraction sign (eg. SLR v. DSLR)
4. Regional sensory or motor disturbance (stocking distrib, diffuse motor weakness)
5. Overreaction
3+ positive => poor outcome to spine surgery

20. Radiologic Evaluation
Plain Films
MRI CT
CT Myelogram
Discogram
Angio- and venograms

21. Goals of Therapy Educate the patient Address sleep dysfunction
differential diagnosis
management options
realistic goals, pacing
Address sleep dysfunction
Manage depression
Improve function physically, emotionally, socially
Decrease pain

22. Pharmacologic Options
Acetaminophen
Beware of other sources, toxic doses, other hepatotoxic agents
Anti-inflammatory Agents: Nonspecific
Piroxicam, Indocin, Ketorolac
Naproxen
Ibuprofen
Diclofenac, Nabumetone
Cox II specific agents
Rofecoxib, Celecoxib, Parecoxib, Etoricoxib, Valdecoxib, etc

23. NSAIDs Advantages: Concerns:
antiinflammatory, analgesic, limited sedation, non-addicting, +cheap, available OTC
Concerns:
available OTC in multiple preps, GI effects, renal and hepatic toxicity, platelet effects, fluid retention

24. Adjuvant Medications: Steroids
Oral, injection, topical, iontophoresis
3 doses of depo prep over 4-6 weeks, 4 mo. holiday
Concerns:
Adrenal suppression
Effect on glucose (DM), sodium excretion (HTN, CHF)
Osteoporosis
Altered wound healing, immunity

25. Adjuvant Medications Antidepressants
TCAs (elavil, doxepin, nortrip): v. low dose
sleep, anti-neuropathic effect
ataxia, orthostasis, constipation
Trazodone
low dose, primarily for sleep
SSRIs (Paxil, Prozac)
SNRIs (Effexor)

26. Adjuvant Medications Anticonvulsants Drugs
Pro: Neuropathic pain: lancinating, burning
Con: Ataxia, sedation, confusion (esp elderly)
Drugs
Carbamazepine (Tegretol)
Gabapentin (Neurontin)
Lamotrigine (Lamictal)
Topiramate (Topomax)
Trileptal, etc
Clonazepam

27. Medications: Tramadol
Tramadol (Ultram)
opiate effects
serotonergic effects
Max dose: 400 mg/day
Problems
Lowered seizure threshold
Increased risk of seizures with TCA > SSRI
? non-addicting

28. Adjuvant Medications Muscle Relaxants
Muscle spasm (acute strain/sprain, fibromyalgia)
Spasticity due to denervation (baclofen, dantrolene)
Secondary effects:
Sleep, anxiolysis
anti-neuropathic effect (baclofen)

29. Adjuvant Medications Topical agents NSAID preparations Capsaicin
Lidoderm
Cica-care type skin covers
Commercial OTC preps

30. Medications: Opiates Chronic Opiate Therapy
Trial of short-acting medication ??
Darvocet
Hydrocodone (Vicodin, Lortab)
Oxycodone (Roxicodone, Percocet, Tylox)
Hydromorphone (Dilaudid)
Morphine (MSIR, Roxanol)

31. Medications: Opiates Chronic Opiate Therapy Long-acting Agents
Methadone
Morphine SR (MS Contin, Kadian, Oramorph SR)
Oxycondone SR (Oxycontin)
Fentanyl Patch (Duragesic)
Hydromorphone SR (Dilaudid SR in future)

32. Adjuvant Therapies Education Weight loss Exercise, Yoga
Heat, cold, elevation, rest
Massage, TENS
Physical Therapy
strengthening, mobility, aquatics, low impact aerobics

33. Psychologic Therapy Counseling Self-regulation techniques
Pain counseling
Grief, depression
Pacing strategies
Appropriate goal setting
Self-regulation techniques
Self-hypnosis
Relaxation training
Biofeedback

34. Interventional Techniques
Advantages:
“One shot”
Simple
Low risk
Disadvantages
Positioning, technical difficulties
Cost
Cumulative steroid doses
Anticoagulation?

35. Interventional Techniques
Trigger Point Injections
Joint Injections (steroid, hyaluronate)
Epidural Steroid Injections
translaminar vs. transforaminal
Medial Branch Nerve Blocks, Denervation
Implantable Spinal Cord Stims, Intrathecal Pumps
Intradiscal Electrothermal Therapy (IDET)
Vertebroplasty

37. Sacroiliac Joint Injection

38. SNRB L1, Epidurogram

39. SNRB L1, Lateral View

41. Selective Nerve Root Block: AP View

42. SNRB: Lateral View

43. S1 Selective Transforaminal Block

44. Epidural Steroid Injection

45. Epidural Steroid Injection

46. ESI: Lateral View

48. Medial Branch Nerve Block

49. Medial Branch Nerve Block

50. Medial Branch N Blocks, Oblique

51. Medial Branch N Block, AP

52. Implantable Therapies
Spinal Cord Stimulator
Fairly focal pain, eg. Single extremity radiculopathy, ischemia, neuropathic or sympathetically-maintained pain
Intrathecal Pump
Refractory pain or intolerance to adequate dosage of medications
longevity > 3-6 months
opiates, local anesthetic, baclofen, clonidine

53. When and Whom to Refer Possible procedural answer
NSAIDs, PT, low dose opiates,
Intolerance of multiple medications
Not responding to simple interventions
Significant psycho-social issues impeding function
Concerns with polypharmacy, possible abuse issues
You want another opinion, you’re uncomfortable
Patient wants another opinion

54. Osteoarthritis: Case Report
82 yo female referred for implantation of intrathecal pump for refractory LBP
Xrays: severe DJD, stenosis
Pt (and husband) reports worst time is sleeping. Inspite of PE, films, feels she functions just fine during the day.
On Coumadin, Cox II agents -> inadequate relief.
Percocet qhs only lasts 2 hours
Recommendations: Methadone 5 mg. PO qhs with acetaminophen, PRN
Result: Both she and her husband slept much better, both satisfied with regimen.

55. Arthritis: Case Report
78 yo male with long hx steroid dependent RA, with osteoporosis, compression fractures, degenerative disc disease and facet arthropathy.
Presents with acute compression fracture T12, bilat. T 12 radiculopathy, secondary muscle spasm and marked LBP due to facet arthropathy.
Effectively bedridden. History complicated by severe peripheral neuropathy, problems with ataxia and frequent falls. Also has PHN R flank, low abdomen.

56. Arthritis: Case Report, cont.
Amitriptyline 10 qhs--good pain relief, sleep; increased falls
Oxycodone--constipation, sedation
Methadone--good pain relief but severe constipation, lethargy
Low dose gabapentin caused increased ataxia, falls, confusion
Ultram was actually tolerated well with partial relief.

57. Arthritis: Case Report, Interventions
Vertebroplasty of T12 gave some relief of back pain, but patient fell several days later, which led to vertebroplasty at T11
Bilateral T12 SNRBs done x2 with steroid for persistent radicular pain with some improvement
Lumbar diagnositic facets gave good temporary relief so did radiofrequency ablation of medial branch nerves
Trigger point injections in paraspinous muscles gave excellent relief

58. Arthritis: Case Report, Conclusion
Lidoderm to flank/abdomen for PHN
Physical therapy improved mobility, endurance.
Pt given walker for stability
Home exercise program, +/- compliance
TENS for myofascial component added
Pain, sleep improved. Back at work. Falls improved with elimination of multiple medication.
Effexor added recently for further mood modulation.
Recommended counseling re. Grief, loss of previous level of function. Declined by patient.

59. Adjuvant Medications/Treatments
Glucosamine/Chondroitin
Hyaluronate preparations (Synvisc)
Iontophoresis
TENS
Orthotic devices