Gingerich back pain presentation (sept. 2012)

Common Causes and
Treatments for Chronic
Low Back Pain
Troy C. Gingerich, MD
Southeast Anesthesiology Pain Consultant

Southeast Anesthesiology Consultants, PA - Southeast Pain Care

Pain Management

Pain Management is a medical specialty
that focuses on finding and treating the
source of your pain and pain symptoms


Goals
 Optimize Pain Control
 Minimize side effects, adverse outcomes, and
costs
 Enhance functionality and psychological well-
being
 Enhance the overall quality of life
 Ideal management is multidisciplinary,
multidimensional

Our Approach
Our overall approach to pain management can be
viewed as a four-pronged approach that may
include one or more of the following components.
Interventional techniques
Medication management
Rehabilitation
Counseling


Pain Definition
 ―an unpleasant sensory and EMOTIONAL experience
associated with actual or potential tissue damage, or
described in terms of such damage‖ (IASP)
 ―whatever the experiencing person says it is, existing
whenever he says it does‖ (McCaffery and Pasero)


Acute vs Chronic
 Acute - Pain during healing/repair of tissues

 Chronic - Pain present beyond healing and repair
of tissues or that lasts beyond 3 months


Duration of Pain
 Adults 20 years of age
and over who report pain
said that it lasted:
 <1 month – 32%
 1 to 3 months – 12%
 3 months to 1 year –
14%
 >1 year – 42%


Timely Treatment
Prompt treatment of pain is

Length of Time Off Work
vital. 2%
 The sooner pain is managed
 the more likely patients 19%

are to return to normal daily 94%
living activities

0% 20% 40% 60% 80% 100%
Percentage Returning to Work
<90 days >90 days <2 yrs

J. McGill, J. Occupational Medicine, 1968

Timely Treatment

Anyone who has had pain for more
than 2 weeks with no pain relief
should be evaluated by a
Pain Management Specialist.


Pain Statistics
• Pain is the #1 admitting diagnosis in US
• Pain is the #1 reason for missed work in US
• Chronic pain costs the US $100 Billion a year in direct
medical costs, lost income and productivity
• 76.5 million Americans reported that they have had a
problem with pain that persisted for more than 24
hours in duration
Stewart et al, Work-related cost of pain in the US, IASP/10th World Congress on Pain 2002, as cited
by Dr. John Stamatos, Medscape.com.

Pain Statistics
Pain affects more Americans than diabetes,
heart disease and cancer combined.

*Sources:
Pain – 76.2 million people, National Centers for Health Statistics
Diabetes – 20.8 million people (diagnosed and estimated undiagnosed), American Diabetes Assocition
Coronary Heart Disease (including heart attack and chest pain) and Stroke – 18.7 million people, American Heart Association

Cancer – 1.4 million people, American Cancer Society

Effects of Uncontrolled Pain
 Limits patient activity, function
 Decreased appetite, weight loss
 Sleep loss
 Mood change
 Decrease in quality of life
 Multiple effects on families and social interactions
 Thus, adequate pain control is essential to ensure
patients are able to function, sleep, maintain social
relationships, and improve overall quality of life


Comprehensive Exam
 History
 Physical Examination
 Psychosocial Evaluation
 Impression/Differential Diagnosis
 Diagnostic Evaluation
 Treatment Plan


Low Back Pain


Chronic Low Back
Pain Risk Factors
 Age
 Fitness Level
 Diet
 Occupational
 Smoking
 Obesity


Common Causes

 Malignant

 Benign


Malignant
Cancer
Primary—multiple myeloma
Metastatic—prostate, breast, liver

Infectious
Discitis, Osteomyelitis, Epidural abscess

Spinal Cord Compression
Cauda Equina Syndrome, Conus Medullaris Syndrome


Benign
 Radicular (Sciatic)
Herniated Disc
Spinal Stenosis
Failed Back Surgery Syndrome

 Musculoskeletal (Axial)
Facet joints
Sacroiliac joint
Myofascial Pain Syndrome


Diagnostic
Tests
 X-rays
 Good for evaluating gross bone structure
 Helps identify fractures and spondylolisthesis
 MRIs
 Evaluate soft tissue, discs, nerves
 CT scans
 More detailed imaging of bones and discs
 Other
 CBC, ESR

Anatomy


Radicular Causes of
Chronic Low Back Pain

 Herniated disc
 Spinal stenosis
 Failed back surgery syndrome (FBSS)


Herniated Disc


Herniated Disc

 90% lower lumbar discs (L4/5, L5/S1)
 Can present as low back pain or pain radiating into
leg
 Can be associated with muscle spasms


Spinal Stenosis


Spinal Stenosis

 Degenerated joints (―bone spurs‖), herniated disc,
and thickening of the ligaments
 Can present as neurogenic claudication
 Most common in 5th decade of life


Failed Back
Surgery Syndrome


Possible Causes
of FBSS
 Continued degenerative process from the altered
surgical anatomy
 Surgical nerve trauma
 Traction on neural elements from scar tissue
 Persistent pain secondary to central sensitization


Musculoskeletal
Causes of Low Back Pain

 Facet joints
 Sacroiliac joints
 Myofascial Pain Syndrome (MFPS)


Lumbar Facets


Facet Joints


Lumbar Facet
Referral Patterns


Sacroiliac Joint

 Where the back meets the
pelvis/hip
 Pain related to arthritis or
malrotation of the joint
 25% of low back pain


Sacroiliac Joint


Myofascial Pain
Syndrome

 Referred pain
 Repetitive use
 ―Knotted muscle‖


Piriformis
Syndrome


Treatments

 Conservative

 Advanced


Treatment Continuum
Advanced Pain
Second-Tier Therapies
Pain Therapies
Neurostimulation
Implantable
First-Tier Pain Drug Pumps
Opioids Surgical Intervention
Therapies Neurolysis Neuromodulation
Thermal
Procedures
NSAIDs
Diagnosis TENS
Psychological Rx
Nerve Blocks
Physical Rx
OTC pain meds

Chronic Pain Treatment Continuum

Source: Implantable Technologies: Spinal Cord Stimulation and Implantable Drug Delivery Systems, Elliot Krames, MD,
Pacific Pain Treatment Center, SF, www.painconnection.org

Conservative
 Physical therapy, Aqua therapy, Joint Mobilization,
TENS unit
 Patient Education/Ergonomics
 Pharmacologic
 NSAIDs
 Muscle relaxants
 Opioids


Advanced: Interventional
Therapy
Blocks and Injections
 Epidural steroid injections
 Nerve root blocks
 Facet injections
 Sacroiliac joint injections
 Trigger point injections
 Spinal Cord Stimulation


Epidural Steroid
Injections


Epidural Steroid
Injection


Epidural Steroid
Injections

 Series of ―3‖, three to four weeks apart
 Combination of local anesthetic and steroid
 Most effective for radicular pain


Facet Joint
Injections


Advanced Treatments
Radiofrequency Ablation
 Radiofrequency is a minimally
invasive procedure.
 A small radiofrequency current
will travel through the electrode
into the surrounding tissue,
causing the tissue to heat and
eliminate the pain pathways.
 Results usually last 6-9 months.
 Patient should be able to resume
normal activities, including work,
as soon as they feel able.


Radiofrequency Ablation

 Multiple nerves to each joint
 Most common facet joints are
L4/5 and L5/S1


Radiofrequency
Ablation


Sacroiliac Joint
Injection


Trigger Point
Injections

 Best relief with combination of
stretching exercises and heat
therapy
 Usually secondary, need to
identify cause


Spinal Cord
Stimulation


Advanced Treatments
Spinal Cord Stimulation
 Stimulators use low voltage
electrical signals to prevent
messages of pain from
reaching the brain. Instead of
pain, patients feel a tingling
sensation.
 Spinal cord stimulation is non-
addictive, allowing patients to
control their own therapy.
 Stimulators are very effective
when a patient is suffering from
neuropathic pain.


Spinal Cord
Stimulation
 Indications:
 FBSS
 Neuropathy of the extremity
 Intractable low back and/or extremity pain
 CRPS


Spinal Cord
Stimulation
 Gate theory
 Two phases process: trial and if successful then
permanent
 Outpatient surgery


Questions???


Gingerich back pain presentation (sept. 2012)

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