1. Dr Angela Jenkins ST3 Anaesthetics 10 th September 2008

2. Introduction  Epidemiology  Presentation  Investigations  Management  Conclusions

3. Epidemiology  Incidence - Lifetime prevalence 60-85% - Peak incidence age 40-60y - No difference between male and female - More common in heavy, manual occupations - Increased incidence in smokers

4. Epidemiology  Impact on Society  Approx 52 million working days lost per annum  500 000 people receive Incapacity Benefit  £481 million pa cost to NHS  £5 billion pa cost to society  50% chance of returning to work after 6 months absence

5. Impact on NHS

6. Transition from Acute to Chronic Pain  Risk factors:  Signs of nerve root involvement  Ongoing compensation claim  Long time off work  Psychological distress +/- depression  Poor physical fitness  Heavy smoking

7. Presentation  Simple musculoskeletal pain (95%)  Spinal nerve root pain (4-5%)  Serious spinal pathology (~1%)

8. Musculoskeletal Back Pain  Mechanical in nature  Age 20 – 55 years  Pain in lumbosacral area and buttocks  Referred into upper thighs  Dull ache, varies with activity  Otherwise physically well

9. Musculoskeletal - Causes  Discogenic pain  Sacroiliac Joint pain  Facet Joint pain  Ligament and Muscle pain

10. Nerve Root Pain  Well localised, sharp, electric shock-like  Dermatomal radiation down leg into foot  Neuropathic element worse than back pain  May have paraesthesia +/- loss of reflexes  Exacerbated by coughing, straining, sneezing  Nerve root pain with SLR test

11. Nerve Root - Causes  Posterior Disc Herniation  Spinal Stenosis  Epidural Adhesions

12. Serious Spinal Pathology  Differential Diagnosis  Spinal tumours / myeloma  Infection  Trauma  Inflammatory disease  Cauda Equina Syndrome  AAA  Retroperitoneal fibrosis

13. Serious Spinal Pathology  ‘Red flag markers’  Age 55y  Constant / progressive pain  Acute onset in the elderly  H/O tumour  Fever / night sweats  Immunosuppression / HIV  Recent bacterial infection  Acute neurological symptoms  Unexplained weight loss  Systemically unwell

14. Serious Spinal Pathology  Examination  Tenderness on SI springing  Multiple nerve root signs  Dissociative signs  Symmetrical limitation of SLR  Signs of lower limb ischaemia  Abdominal mass

15. Investigations  Radiology  X-ray, CT, MRI, isotope bone scan  Blood tests  FBC, ESR, Ca, plasma viscosity  Nerve conduction studies  Diagnostic nerve blocks

16. Management  Aims:  Improve pain  Optimise physical, psychological and social functions

17. Management  Pharmaclogy  NSAIDs  Anti-depressants  Anti-convulsants  Opioids  Anti-spasmodics  Psychology  CBT  Pain management programmes

18. Management  Physiotherapy  TENS  Accupuncture  Injections  Radiofrequency Lesioning  Spinal Cord Stimulation  Surgery

19. Conclusions  Consequences may be more problematic than the pain itself  Huge cost to society and NHS  Multiple presentations / causes  Must exclude serious pathology  Multi-disciplinary management

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