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Description : This medical presentation titled "Chronic Low Back Pain & Interventional Spine Procedures" provides us information on chronic low back pain and various interventional spine procedures.

Tags : Chronic, Low Back Pain, Interventional Spine Procedures, Pain, muscle tension, stiffness, Lumbar spinal pain, Sacral spinal pain, Lumbosacral pain, Gluteal and Loin pain

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Chronic Low Back Pain & Interventional Spine Procedures Henry Kim, MD Pain Medicine
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Epidemiology 80% lifetime prevalence Common reason for physician visits in the United States (2nd or 3rd leading cause) Most common cause of disability in patients < 45 years old
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Definition Pain, muscle tension or stiffness localized below the costal margin and above the inferior gluteal folds, with or without leg pain International Association for the study of pain (IASP) Low Back Pain Lumbar spinal pain Sacral spinal pain Lumbosacral pain Gluteal and Loin pain (not considered LBP)
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Classification Mechanical (HNP, OA, spinal stenosis, spondylolisthesis, compression fracture) Nonmechanical Tumor (metastases, MM, lymphoma) Infection (osteomyelitis, diskitis) Inflammatory arthritis (RA, AS) Visceral disease (AAA, nephrolithiasis, pancreatitis, prostatitis, PID)
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Classification Complicated (“Red Flag” conditions) Specific Diagnosis Lumbar Radiculopathy Lumbar Spinal Stenosis Others such as Ankylosing Spondylitis Uncomplicated (Non-Specific) A diagnosis of exclusion
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“Red Flags” Metastatic CA (History of cancer*, Unexplained weight loss, Rest pain, Age >50) Infection (Unexplained fever*, Recent bacterial infection, Immunosuppression, IVDA) Fracture (Steroids*, Osteoporosis, Recent trauma, Age >70) Cauda Equina Syndrome (Urinary retention or incontinence, Saddle anesthesia, Decreased rectal tone, Bilateral lower extremity weakness/numbness) Severe or progressive focal neurologic deficit Failure to improve with therapy Pain > 4 weeks (* Most important in the condition)
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“Red Flags” Compression Fracture (4%) Metastatic CA (0.7%) Cauda Equina Syndrome (0.04%) Infection (0.01%)
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Compression Fracture Osteoporosis Location Thoracolumbar junction Midthoracic spine Pain may not be localized to the level of fracture, as thoracolumbar fractures may present with low back or lumbosacral pain.
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Cancer Past history of cancer is by far the single strongest indicator of cancer related low back pain. Metastatic (Prostate, Lung, Breast) Multiple myeloma Lymphoma Increases post test probability from 0.7% to 9% Not including nonmelanoma skin CA
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Cauda Equina Syndrome Large central disc herniation (L4-5) Urinary retention (Retention develops initially and leads to overflow incontinence later.) Normal post-void residual essentially rules it out. Surgical emergency
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Nonspinal LBP AAA Nephrolithiasis Pancreatitis Prostatitis PID * Most spinal cause of low back pain will be aggravated by spinal movement.
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Lumbar Radiculopathy L4-5 or L5-S1 levels (90%) Inflammation > Mechanical compression Phospholipase A2, TNF-α Pain with sitting, bending and coughing Pain radiates below the knee in a narrow band.
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Lumbar Radiculopathy
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Not all leg pain is from sciatica. Uncomplicated low back pain is often referred to lower leg. (somatic referred pain) Ask “Where is the pain worst?” “Where do you feel the pain most consistently?”
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Radicular vs. Referred Pain
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Lumbar Radiculopathy Listing away from the side of disc herniation (paracentral herniation) Straight-leg-raise (SLR) for L5 or S1 root. Reproduction of radicular pain between 30-70˚ High sensitivity but low specificity Crossed SLR is more specific but less sensitive.
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Natural History Favorable Conservative and surgical treatments are both successful. Large extruded discs are more likely to decrease in size.
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Surgery vs. Prolonged Conservative Treatment for Sciatica – NEJM 2007 Prospective randomized 283 patients with severe sciatica for 6 to 12 weeks 141 → Early Microdiskectomy (2.2 weeks) 142 → Conservative treatments Faster pain relief in surgery Same 1 year outcomes
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Lumbar Spinal Stenosis Congenital - Onset in 30s Degenerative Most common Onset in late 50s or early 60s Most commonly involves L4-5 level followed by L3-4 Mechanical Compression Compression of microvasculature Nerve root ischemia Increased microvascular permeability and edema
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Lumbar Spinal Stenosis Insidious onset Chronic low back pain that progresses to buttock, thigh and leg pain. Fatigue, heaviness or pain in the legs with ambulation (Neurogenic claudication)
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Neurogenic vs. Vascular Claudication
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Lumbar Spinal Stenosis Most common exam findings Loss of lumbar lordosis with limited extension Trunk is flexed forward in standing and walking. (“Simian Posture”) No significant tenderness to palpation Negative SLR Normal motor exam despite the report of weakness
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Natural History At 4 years 70% No change 15% Improved 15% Worsened 5-15% may have coexisting cervical spinal stenosis.
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Ankylosing Spondylitis The earliest clinical features Gradual onset in males < 30 years old Morning stiffness Improvement with exercise Not relieved by bed rest Schober test Chest expansion < 2.5 cm (late stage) Plain films typically normal in early stages
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Classification Complicated (“Red Flag” conditions) Specific Diagnosis Lumbar Radiculopathy Lumbar Spinal Stenosis Others such as Ankylosing Spondylitis Uncomplicated (Non-Specific) A diagnosis of exclusion
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Uncomplicated Low Back Pain A diagnosis based on exclusion of specific pathology Generally classified by the duration of the pain Acute: < 1 month Subacute: 1-3 months Chronic: > 3 months
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Uncomplicated Low Back Pain Majority (> 85%) of low back pain in primary care Acute low back pain Rapid improvement in the first month in most patients High recurrence rate up to 1/3 Chronic low back pain (7-10%)
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What is the anatomic source of LBP? Controversial Possible sources Discs Facet (Zygapophysial) Joints Sacroiliac Joints Ligaments Muscles
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Uncomplicated Low Back Pain Cannot determine specific anatomic source based on history and exam alone. “Lumbar spinal pain of uncertain origin?” X ray? MRI ? Diagnostic Injections ?
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X ray Asymptomatic degenerative changes Finding of degenerative disc disease, spondylolisthesis or pars defect does not establish the cause of low back pain.
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MRI Recommended initial imaging study of choice in complicated low back pain Cancer Infection Cauda equina syndrome Severe or progressive neurologic deficit Lumbar disc herniation Lumbar spinal stenosis
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MRI MRI often shows abnormal findings in asymptomatic patients. At age 42, disc bulges in 52% and protrusion in 27% of asymptomatic adults After age 60, these findings are even more common. Spinal stenosis in 25% of asymptomatic adults over 60 years.
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MRI Indicated for complicated low back pain and specific diagnosis How about in uncomplicated LBP? Controversial Auto mechanic analogy? Opening up the hood?
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Diagnostic Injections Lumbar Transforaminal ESI (Selective Nerve Root Block) Lumbar Medial Branch Blocks Sacroiliac Joint Injections Lateral Branch Blocks
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Diagnostic Injections Identify the pain generator Plan long term treatment
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Treatment of Uncomplicated LBP Life Style Changes Diet Exercise Weight control No smoking Physical Therapy Medications? Opioids? Spinal Injections? Surgery?
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“Yellow Flags” Previous history of disability Inconsistent findings Abnormal pain behavior Litigation Work dissatisfaction Attention seeking Preference for prolonged bed rest Depression Chemical dependency History of abuse Family history of chronic pain
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Waddell’s Signs Superficial tenderness: Pain elicited from light touch on the skin Simulation: Back pain is produced by maneuvers that should not be painful such as axial loading of the head (1-2 lb) or passive rotation of shoulders and pelvis in the same plane. Distraction: A symptomatic response to a test, such as straight- leg-raise, changes when the test is repeated while the patient is distracted. Regionalization: Ratchet like “givingway” weakness or non-neuroanatomic numbness Overreaction: Disproportionate response to routine examination such as collapsing, grimacing, guarding, groans, tremors or any other type of overreaction. (Behavioral response to examination, Not a proof of malingering, > 3 signs suggest the presence of non-organic factors)
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Prognosis Psychosocial Risk Factors “Yellow Flags” and Waddell’s signs are psychosocial risk factors of delayed recovery. More predictive of outcome than severity of pain or any exam findings. Duration of Symptoms The status of patients at 2 months may help predictor the outcome at 12 months.
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Summary – Low Back Pain Be aware of “Red Flags.” Identify specific diagnosis. (LR, LSS, AS) Uncomplicated LBP is a diagnosis of exclusion. MRI for complicated and specific diagnosis. MRI for uncomplicated? Diagnostic Injections Don’t forget the “Yellow Flags.”
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Interventional Spine Procedures Epidural Steroid Injections Facet Interventions Sacroiliac Joint Interventions Sympathetic blocks (Stellate ganglion and lumbar paravertebral) Discography (Intradiscal Procedures) Spinal Cord Stimulation(Neuromodulation) Intrathecal Pain Pump
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Epidural Steroid Injections Anatomy Clinical Indications Complications Medical Evidence
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Epidural Steroid Injection Interlaminar Transforaminal Caudal
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Patient selection for ESI Positive Factors Radicular pain Radicular numbness Short duration of pain No significant psychological factors Negative Factors Axial pain primarily Work-related injury Unemployed due to pain High number of past treatments and drugs taken Previous back surgeries Smoking Very high pain rating Litigation
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Why not ESI for axial LBP? Different anatomical origin of pain– Facet arthropathy, Internal Disc Disruption (Annular tear), or Sacroiliac joint pain Epidural route of administration of steroid does not reach the target area any better than systemic administration.
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Complications Infection Bleeding Spinal Cord Infarct Increased vertebral fracture?
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Multistate Outbreak of Fungal Meningitis and Other Infections CDC investigation in September 2012 Contaminated steroid (methylprednisolone) New England Compounding Center in Framingham, MA Fungal meningitis and spinal abscess 751 cases across 20 states – 64 deaths Don’t use contaminated steroids!
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Lumbar ESI Complications Multi-institutional study 16,638 consecutive procedures 14,956 TF ESIs and 1,682 IL ESIs Minor complications Vasovagal reactions – 1.2% Dural puncture – 0.04% No neurologic, bleeding or infectious complications EI-Yahchouchi CA. Complication rates of transforaminal and interlaminar epidural steroid injections: a multi-institutional study
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Spinal Cord Infarct
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Extremely rare but devastating complication of lumbar transforaminal ESI Injection of particulate steroids into radicular artery Paraplegia Using non-particulate steroid and digital subtraction angiography mitigate the risk. Spinal Cord Infarct
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Lumbar ESI Meta-analysis 39 publications on lumbar TF ESIs Disc herniation 60% achieved at least 50% relief at between 1 and 2 months 40% maintained this outcome for 12 months Effective in reducing pain, restoring function and avoiding surgery The Effectiveness of Lumbar Transforaminal Injection of Steroids: A Comprehensive Review with Systemic Analysis of the Published Data. Pain Medicine 2013;14:14-28
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Lumbar ESI Lumbar spinal stenosis 50% achieved 50% relief of pain for 6 months but rigorous studies are lacking and no controlled studies have corroborated this outcome. Failed back surgery syndrome or Epidural lipomatosis The literature on TF ESI is sorely limited. The Effectiveness of Lumbar Transforaminal Injection of Steroids: A Comprehensive Review with Systemic Analysis of the Published Data. Pain Medicine 2013;14:14-28
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Lumbar Spinal Stenosis Multisite (16) randomized trial 400 patients Central lumbar spinal stenosis Buttock and/or leg pain > back pain Glucocorticoids + Lidocaine vs. Lidocaine alone No control group with sham injections A Randomized Trial of Epidural Glucocorticoid Injections for Spinal Stenosis. NEJM 2014:371(1):11-21
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Lumbar Spinal Stenosis Primary outcomes: Roland-Morris Disability Questionnaire (0-24) and the intensity of leg pain (0-10) Secondary outcomes: >30% relief at 6 weeks >50% relief at 6 weeks A Randomized Trial of Epidural Glucocorticoid Injections for Spinal Stenosis. NEJM 2014:371(1):11-21
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Lumbar Spinal Stenosis Steroid + Lidocaine (200) RMDQ – 14.4 to 12 Intensity of 1week avg pain – 7.0 to 4.9 >30% relief at 6wks – 49.2% >50% relief at 6wks – 38.3% Lidocaine only (200) RMDQ – 14.8 to 12.1 Intensity of 1 week avg pain – 7.0 to 4.9 >30% relief at 6 wk – 49.7% >50% relief at 6 wks – 38.3%
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Lumbar Spinal Stenosis Both groups improved Subgroup analyses: Glucocorticoids-Lidocaine group reported better physical function on RMDQ (-2.5)and less leg pain (-0.9) at 3 weeks No statistically significant difference between the two groups at 6 weeks Negative Study?
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Medical Evidence for ESIs Lumbosacral radiculopathy secondary to disc herniation Literature support – Yes Lumbar Spinal Stenosis with leg pain Literature support – limited FBSS with leg pain Literature support - Don’t know Other causes of axial back pain Literature support – No
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Summary Lumbar ESI ESIs may be an option for relief of severe radicular pain unresponsive to conservative treatments. Not for axial low back pain Safe procedure Good support for disc herniation Controversial support for lumbar spinal stenosis
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Lumbar Facet Pain Clinical Symptoms Predominantly axial pain May have somatic referred pain to legs Generally older patients Exam Lumbar paraspinal tenderness Positive facet loading Negative nerve tension tests No focal neurologic deficit
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Anatomy Synovial joint Medial branches from dorsal rami innervate the facet joints. L4-5 and L5-S1 levels are most commonly affected.
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Anatomy
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Anatomy
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Lumbar Facet Procedures Intra-articular Steroid Injection Medial Branch Block Percutaneous Radiofrequency Medial Branch Neurotomy
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Intraarticular Injection
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Lumbar Medial Branch Block Diagnostic Test – No therapeutic benefit Placebo Injection of Normal Saline Most rigorous control block Impractical in most clinical settings Comparative Block Lidocaine Bupivacaine
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Medial Branch Blocks
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Radiofrequency Ablation Therapeutic procedure for lumbar and cervical facet pain Teflon-coated electrode with an exposed tip is inserted onto the target nerve. High frequency electrical current is concentrated around the exposed tip. The nerve is heated and coagulated.
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Gofeld – Pain Physician 2007 209 patients 10 year period 70% relief to diagnostic blocks 35% had 50% relief 22% had 100% relief Mean duration of relief 12 months
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MacVicar – Pain Medicine 2012 106 patients 100% relief to diagnostic blocks 56% achieved complete relief Mean duration of relief 13 months Restoration of normal activities
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Summary -Lumbar Facet Procedures Predominantly axial low back pain Intra-articular Facet Injection Primarily diagnostic Long term relief? Radiofrequency Ablation Select patients with diagnostic MBBs Only helpful if facet mediated pain About 50% chance of relief for about 12 months
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Sacroiliac Joint Pain Sacroilitis (Inflammatory Arthritis) AS RA Sacroiliac Joint Dysfunction Abnormal gait pattern Leg length discrepancy Lumbar fusion Trauma Scoliosis Pregnancy
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Anatomy Diathrodial Synovial Joint Anterior: true synovial Posterior: syndesmosis (ligaments and muscles – gluteal and piriformis) Innervation Anterior: lumbosacral plexus Posterior: primarily dorsal ramus L5 and lateral branches S1 to S4
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Sacroiliac Joint Dysfunction Clinical Symptoms Pain near PSIS in gluteal area Unilateral Pain when rising from sitting May have somatic referred pain down the leg Does not pass above L4-5 level (iliac crest) Exam Multiple clinical exams Fortin Finger Test – simplest
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Sacroiliac Joint Interventions Intraarticular Injections Primarily diagnostic Long term relief? Radiofrequency Ablations Select patients with LBBs Designed for long term relief Improving techniques Emerging evidence
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Intraarticular SI Joint Injection
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Radiofrequency Neurotomy
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Summary – SI Joint Procedures SI Joint Dysfunction Intra-Articular Injection Radiofrequency Ablation Diagnostic LBBs for patient selection Long term relief Developing techniques