1. Are you getting the best treatment for your low back pain?
Dr.Rahimian
Orthopedic surgon
Spine fellowship resident

2. Why are we here?
To update you on the best evidence for the treatments available
To give you a better understanding of low back pain

3. Have you had low back pain?
How many of you have ever had back pain?
How many of you seek help for your back pain?
How many of you have ever had treatment for your back pain?

4. What causes back pain? Most cases, cause is unclear poor posture
lack of exercise
muscle strains and sprains(70%)
Some conditions have specific causes
Spondylosis (10%)
Herniation(4%)
Stenosis (3%)

5. How can I help myself?
Regular exercise e.g. swimming, walking, pilates, yoga, going to gym
Check posture frequently
Lift things correctly
Watch your weight
Stay at work if possible
Keep positive think!

6. What is the outlook for back pain?
75 – 90% recover within in a few weeks
Relapses are common
Most lead normal life and able to work
Emotional response to back pain important to
recovery e.g. worried, depressed,….

7. Red Flags History of cancer Unexplained weight loss
Intravenous drug use
Prolonged use of corticosteroids
Older age
Major Trauma
Osteoporosis
Fever
Back pain at rest or at night
Bowel or bladder dysfunction

8. What treatments are there for back pain?
guideline
specific exercise
manual therapy
Acupuncture
Combined psychological and physical therapy
Surgery or injections may be considered

9. Treatment Options for Back Pain

10. Exercise & Bed Rest Advice to stay active:
‘There is no evidence that advice to stay active is harmful for either acute low back pain or sciatica.’
One or two days of bed rest if necessary
Light activity, avoiding heavy lifting, bending or twisting .
No data on any particular exercises

11. What if my back pain is affecting my work?
Work is good for you! – financial and social
Stay at work or get back as soon as possible.
Discuss what can be done to help you when you return e.g. light duties, changing hours

12. Medications Anti-inflammatory medications (NSAID’s): Tylenol:
Beneficial; no differences; watch side-effects
Tylenol:
Narcotic Pain Relievers:
No more effective than NSAID’s
Many side effects
Muscle Relaxants :
Can decrease pain and improve mobility
70% with drowsiness/dizziness

13. Antidepressants
Anticonvulsants
Corticosteroids
Topical analgesics

14. Treatment Strategies for LBP
Clinical Presentation
Possible Cause of LBP
Treatment Strategies
Intermittent unilateral leg pain, numbness, weakness radiating to foot
Intermittent nerve entrapment with nerve root inflammation
Short-acting opioids
NSAIDs
Topical analgesics
Constant burning, stabbing, or deep aching groin or leg pain
Permanent nerve damage
Opioids
Tricyclic antidepressants
Anticonvulsants
Topical analgesics
This slide presents the pathophysiology in low back pain.
The slide includes clinical manifestations at presentation, probable causes of the low back pain, and various appropriate treatment regimens.
A patient with lumbar structural pathology may experience intermittent unilateral leg pain, numbness, and weakness radiating to the foot. This type of pain usually indicates intermittent nerve entrapment and nerve root inflammation and can be treated with such therapeutic agents as nonsteroidal anti-inflammatory drugs, the lidocaine patch 5%, and short-acting opioids.
Constant burning, stabbing, or deep aching pain in the groin or leg is indicative of permanent nerve damage and usually requires stronger medication, such as anticonvulsants, tricyclic antidepressants, or long-acting opioids.
Moskowitz MH. Pharmacotherapy of neuropathic low back pain. Curr Pain Headache Rep. 2003;7:
Moskowitz MH. Curr Pain Headache Rep. 2003;7:

15. Massage Might be beneficial More quality research is needed
Different types of massage

16. Acupuncture Very little quality research and data
Seems to indicate that acupuncture is not effective for the treatment of back pain

17. Injections Epidural injections: Facet joint injections:
Insufficient and conflicting evidence
Facet joint injections:
No improvement
Local/Trigger point injections:
Possibly some benefit

18. Role of Radiology Usually unnecessary and not helpful Plain X-ray:
Age>50 years
No improvement after 6 weeks
Red flag
MRI:
After 6 weeks if have sciatica

19. Other Modalities Back Brace/Corset/Lumbar Support Injections Hot/Cold
Ultrasound

20. Surgery
Discectomy improves pain in short term but not long term (ie. 10 years)
Fusion
Decompression