low_back_pain_talk2 (2)

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PowerPoint Presentation:


PowerPoint Presentation:

I called 844-back I was told Dr. Khalil can fix my back by steroid injection or by kyphoplasty I rather see doctor Hanna for spinal cord stimulator

Back Pain is Unisex Disorder:

Back Pain is Unisex Disorder

PowerPoint Presentation:

King Ramses suffered from back pain (egy.2000 B.C)

Back Pain Epidemiology:

Back Pain Epidemiology

Low back pain -Epidemiology:

Low back pain -Epidemiology By the age of 20, 50% of people have experienced low back pain. By the age of 60, the number approaches 80%. “LBP is ubiquitous in the human race and not a disease.” –M. Ellenberg MD.

Low back pain -Epidemiology:

Low back pain -Epidemiology 60-90% of adults will experience low back pain during their lifetime - 50% resolve in 2 weeks. - 80% resolve in 6 months. - 85% resolve in 1 year. -15% will have persistent low back pain Second most common reason patients visit their primary care physician 55% of patients with back pain will have an annual occurrence

Low back pain -Epidemiology:

Low back pain -Epidemiology Children/ adolescence - 12% Adult – 15% Elderly – 27%

Low back pain -Epidemiology:

Low back pain -Epidemiology #1 cause of disability in people under the age of 45 Injury in the work place 6 mo’s off work = 50% return to work 2 or more years = 0-5% return to work

Financial stress of Low back pain :

Financial stress of Low back pain Economic implications - $25 billion direct medical cost annually - workers compensation - medical costs - $100 billion in indirect medical costs annually -lost wages -decreased productivity -litigation fees

Risk Factors for Low Back Pain :

Risk Factors for Low Back Pain Gender Weak association with female sex Increased risk in pregnancy Disc operation more in men Height and Weight Increased risk with height Weak correlation with weight

Risk Factors for Low Back Pain:

Risk Factors for Low Back Pain Occupation Top three high risk employee populations - truck drivers - health care workers - laborer and non-construction workers Smoking Posture error


Prevention - Government agencies have recognized the need to implement programs to help prevent low back pain and other musculoskeletal injuries


Prevention U.S. Department of Health and Human Services suggested work-site back injury prevention programs (1996) Department of Health and Human Services – Healthy People 2010 (2000) Department of Occupational Safety and Health Administration developed the Ergonomic Program Standard (2000)


Prevention Work Injury Prevention Program Five Phase Approach: Identification of high risk job tasks Analysis of those tasks Recommendations for changes made and supported by management and workers Implementation of job modifications Program monitoring and evaluation


Prevention Rehabilitation professional serve as ergonomic specialists Educated in Biomechanical function and dysfunction, proper body mechanics and analysis and screening of posture, movements, and activities Physicians Occupational therapists Physical therapists

Interventional Therapies for Chronic Back Pain:

Interventional Therapies for Chronic Back Pain


OBJECTIVES Review common causes of chronic back pain Summarize standard interventional therapies for the treatment of chronic back pain Future areas of interest

Spinal Pain:

Spinal Pain Anatomy

Common Causes of Back Pain:

Common Causes of Back Pain Myofascial (strains and sprains) Discogenic Facet Syndrome Sacroiliac Joint Dysfunction/Arthropathy Spinal Stenosis Post-laminectomy Syndrome Vertebral Compression Fractures

Axial Low Back Pain:

Axial Low Back Pain Myofascial Pain Facet arthropathy Discogenic Ankylosing spondylitis Sacroilitis Vertebral compression fractures

Myofascial Pain:

Myofascial Pain Common Back Strain or Strain Fibromyalgia Myofascial Pain Syndrome

Myofascial Pain:

Myofascial Pain Treatments Heat/Cool Physical Therapy Medications NSAIDs Muscle Relaxants Anti-depressants Trigger Point Injections Immediate and possibly long-term pain relief BOTOX

Discogenic Pain:

Discogenic Pain Very common as we grow older May constitute up to 20% of chronic low back pains Symptoms Non-radiating back pain Worse with sitting/standing Better when in non-upright positions

Discogenic Pain:

Discogenic Pain

Discogenic Pain:

Discogenic Pain



Treatment of Discogenic Pain:

Treatment of Discogenic Pain Epidural Steroid Injections Minimally Invasive Intra-discal Procedures Spine Fusion Disc Replacement

Epidural Steroid Injection:

Epidural Steroid Injection

Minimally Invasive Intradiscal Procedures:

Minimally Invasive Intradiscal Procedures

PowerPoint Presentation:

Minimally invasive procedures Discogenic LBP (IDD) IDET Disc herniations APLD, Nucleoplasty, chemonucleolysis, laser Arthroscopic discectomy

Facet Pain 15-45% of low back pain 54-67% of neck pain:

Facet Pain 15-45% of low back pain 54-67% of neck pain

Facet Pain:

Facet Pain Mainly back pain Aching or sharp in nature Worse with twisting/bending Common as we age – arthritis Common after spine fusions

Treatments of Facet Pain:

Treatments of Facet Pain Physical Therapy – strengthen and flexion (Williams exercises) Medications - non-steroidal anti-inflammatory Nerve Blocks – Medial Branch Blocks Diagnostic Therapeutic Radiofrequency Ablation

Facet Medial Branch Nerve Blocks:

Facet Medial Branch Nerve Blocks

Radiofrequency Ablation:

Radiofrequency Ablation Localized heating of the nerves Not permanent, but long-lasting Safe

Sacroiliac Joint Pain:

Sacroiliac Joint Pain Low back pain +/- to the knees Common as we age Large joint with small amount of movement Develop arthritis or inflammation of the joint

Typical Sacroiliac Pain:

Typical Sacroiliac Pain

Treatment of Sacroiliac Pain:

Treatment of Sacroiliac Pain Physical Therapy Medications – Non-steroidal anti-inflammatory Joint Injections Radiofrequency Ablation

Sacroiliac Joint Injection:

Sacroiliac Joint Injection

Radicular Leg Pain:

Radicular Leg Pain Lumbar disc herniation Spinal stenosis Post-surgical fibrosis

Radicular Leg Pain:

Radicular Leg Pain Lumbar disc herniation Nerve root compression Large foraminal & far lateral HNP Axial and sagittal MRI L 5 -S 1 paracentral HNP

Radicular Leg Pain:

Radicular Leg Pain Spinal stenosis Nerve root compression Lateral recess Foraminal Central Myelogram showing lateral recess stenosis Axial MRI: lateral recess and foraminal stenosis

Radicular Leg Pain:

Radicular Leg Pain Spondylolisthesis with stenosis Nerve root compression Hypertrophic changes of facets and ligament flavum Disc bulging Myelogram: grade I spondylolisthesis with ventral extradural compression

Radicular Leg Pain:

Radicular Leg Pain Post-surgical fibrosis Epidural scar Nerve root compression Chronic nerve damage Neuropathic pain MRI pre- and post-contrast demonstrating enhancing scar surrounding S 1 nerve root.

Bilateral Leg Pain:

Bilateral Leg Pain Central disc herniations Spinal stenosis Arachnoiditis

Spinal Stenosis:

Spinal Stenosis Disease of age Multiple causes – treated differently Facet hypertrophy Osteoarthritis Herniated/Bulging discs

Symptoms of Spinal Stenosis:

Symptoms of Spinal Stenosis Back pain usually with a radiating component “Shopping cart sign”

Spinal Stenosis:

Spinal Stenosis


Treatments Epidural Steroid Injections Physical Therapy Disc Decompression Surgery

Epidural Steroid Injection:

Epidural Steroid Injection

PowerPoint Presentation:

Selective transforaminal epidural injections Lumbar disc herniations Spinal stenosis Spondylolisthesis with stenosis

Treatments for Herniated Discs:

Treatments for Herniated Discs Epidural Steroid Injections Disc Decompression (Nucleoplasty, Decompressor) Physical Therapy Surgery

Disc Herniation: Patterns of Pain (dermatomes):

Disc Herniation: Patterns of Pain (dermatomes)

Percutaneous Disc Decompression:

Percutaneous Disc Decompression

Post-laminectomy Syndrome:

Post-laminectomy Syndrome Pain after back surgeries is quite common Can be in same or different areas of pain from before the surgery Likely due to scar formation or persistent nerve irritation/damage Diminishing returns: as the number of surgeries increases, the chances of successful pain relief drastically declines.

Treatments of Post-laminectomy Syndrome:

Treatments of Post-laminectomy Syndrome Caudal steroid injections Lysis of Adhesions Spinal Cord Stimulation Medications as adjuncts

Caudal Epidural Steroid Injection:

Caudal Epidural Steroid Injection Good for low back pain +/- leg pain

Lysis of Adhesions:

Lysis of Adhesions Attempt to break up scar tissue. Scar formation from prior surgeries.

Vertebral Compression Fractures:

Vertebral Compression Fractures

Vertebral Compression Fractures:

Vertebral Compression Fractures Between 700,000 and 1.2 million fractures per year Over 15 billion dollars per year Due to Osteoporosis, Malignancy, Non-malignant tumors, Trauma Associated with 25-30% increased mortality

Symptoms of Vertebral Compression Fracture:

Symptoms of Vertebral Compression Fracture Significant pain in the back Pain usually worse while sitting/standing Pain usually does not travel down the legs Can occur suddenly after a fall or even a cough (sometimes with no trauma at all)

Who is at Risk?:

Who is at Risk? Caucasian Female (2-3x more than men) Elderly Chronic Steroid Users

Vertebral Compression Fractures:

Vertebral Compression Fractures PREVENTION !!!!!! Weight-bearing exercise Calcium and Vitamin D intake beginning at a young age in women Safety precautions around the home of people who are at risk

Treatment of Vertebral Compression Fractures:

Treatment of Vertebral Compression Fractures Vertebroplasty/Kyphoplasty Epidural Steroid Injections Bed rest and bracing


Vertebroplasty Injection of cement into the fractured vertebra(s)

Outcomes of Vertebroplasty:

Outcomes of Vertebroplasty Almost immediate pain relief in greater than 85% of patients Allows patient to participate in physical activities the next day Avoids prolonged bed-rest


Conclusions Back pain can be from any number of causes. There are many interventional therapies available to treat back pain. Not every person is a candidate for each of these specific procedures.


Conclusions Prevention and early treatment Strict selection criteria for procedures/surgeries is how we can best treat our patients. Pain management is no longer just medication management. QUALITY OF LIFE IMPROVEMENT

Future Therapies:

Future Therapies Less Invasive Discectomies Intradiscal Stem Cell Transplants New Medications Better Understanding of Pain Generators



Spinal Cord Stimulation:

Spinal Cord Stimulation Rapidly advancing technology Very effective pain relief in select patients Involves minor surgical procedure for permanent implant IT IS NOT FOR EVERYONE

Spinal Cord Stimulation:

Spinal Cord Stimulation

PowerPoint Presentation:

Q uestions?

Spinal Cord Stimulator:

Spinal Cord Stimulator

Spinal Cord Stimulation:

Spinal Cord Stimulation How does it work? Stimulates the release of endogenous pain relievers “Like rubbing a bruise” Electrically blocks the pain impulse in the spinal cord from reaching the brain (gate theory of pain).

Spinal Cord Stimulation- who will it benefit?:

Spinal Cord Stimulation- who will it benefit? Post-laminectomy Syndrome Peripheral Vascular Disease CAD/Angina Visceral Pain (?)

Spinal Cord Stimulator:

Spinal Cord Stimulator

Intrathecal Pump:

Intrathecal Pump Spinal delivery of medications For very few select patients. Delivers 1/300 th the oral dose of narcotics For people with very high opiate requirements For people who do not tolerate oral opiates.