1. TIPS FOR TREATING LOW BACK PAIN
DR BRENDON AUBREY

2. 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

3. INFLAMMATORY ARTHROPATHIES
Morning and night pain
Family history
Younger age
Lack of trauma
Multiple joints or enthesopathy
Investigations
Autoimmune blood screen
MRI

4. 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

5. 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%

6. 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)
Motor and Sensory Exam

7. 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

8. NEUROPATHIC PAIN “Burning” “Pins and needles” “Sharp, shooting pain”
Complex Regional Pain Syndrome (CRPS)
Temperature change
Local skin swelling or discoloration
Local sweating
Hyperasthesia

9. 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

10. 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!”

11. RED FLAGS Fever Night pain Night sweats Weight loss
Progressive weakness or numbness
History of IV drug use
Urgent MRI and blood tests

12. IMAGING Preferably none Radicular pain/radiculopathy Somatic Pain
MRI
Somatic Pain
CT scan
Inflammatory Arthropathy
MRI - sacroiliitis

13. MANAGEMENT - FACET JOINT
Oral Prednisolone for 2 weeks
CT scan
Steroid injection
Referral to Pain Management Specialist
Medial branch blocks
Radiofrequency neurotomy

14. RADIOFREQUENCY

15. MANAGEMENT - DISCOGENIC BACK PAIN
Acute
Exclude Discitis (MRI, bloods)
Oral Prednisolone 2 weeks
Caudal epidural
Chronic
MRI
Augmentin or caudal epidural

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

17. 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)
mg nocte for 1 week then review

18. 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

19. 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