TIPS FOR TREATING LOW BACK PAIN DR BRENDON AUBREY

KEYS ON HISTORY Where is the pain? What is the duration of 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 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 Slump test 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 Neurovascular status 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 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 Central 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 Radicular 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 Somatic Pain 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) Oral Prednisolone 2 weeks Caudal epidural Chronic MRI Augmentin or caudal epidural

MANAGEMENT - SACROILIAC JOINT Instability Trial of taping/SIJ belt Physio/Pilates Prolotherapy Inflammation Oral Prednisolone 2 weeks CT guided steroid injection

MANAGEMENT – NEUROPATHIC PAIN Pregabalin (Lyrica) 25mg nocte for 1 week Then 50mg nocte for 1 week Then 75mg nocte for 1 week then review Amitriptyline (Endep) 5mg nocte for 1 week Then 10mg nocte for 1 week then review Gabapentin (Neurontin) 100-300mg 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