HAZEM EISSA, MD

Introduction One of the most common reason for healthcare & lost

work $$$

The majority will suffer with LBP at some point in their life

Variable etiologies

Etiology Injury

Degenerative disease

Psychological

Tumor

Infection

Idiopathic

Anatomy

Sagittal graphic of lumbar spine through neural foramen shows position of exiting nerves within the superior aspect of the neural foramen. The segmental vessels are located inferior to the exiting nerve. Neural foramina are bounded anteriorly by dorsal vertebral body above and intervertebral disc below, pedicle above and facet joint and ligamentum flavum posteriorly. The lumbar vertebral bodies are large with a large intervening intervertebral disc. The pedicles are directed posteriorly, giving rise to large superior and inferior articular facets.

Anatomy

Pain Generators

Facet Joint Disease

Degenerative

Disc

Sacroiliac Joint Dysfunction

Soft Tissue

Compression fracture

(Radicular)

History Acute or chronic

Functional impact

Location of pain

Type of pain

Radiation or referral patterns

Time of pain

Associated symptoms

Previous treatments

Physical Exam Gait/cadence

Toe walking

Muscle strength

Reflexes

Provocative maneuvers.

Management Physical therapy

Lifestyle/ergonomic changes

Medication

Intervention depending on etiology/pain generator

Facet/Zygapophysial joint Pain Injections intraarticular or medial branch

Radiofrequency ablation/Rhizotomy

Facet Joint Injection

Medial Branch RFA

Facet Synovial Cyst May compress surrounding structures

Aspiration/lysis/injections

In recurrent cases surgical management

Interspinus Ligament Spinous processes (Baastrup’s Dz) Local steroid injection

Compression fracture Always check & manage osteoporosis

Conservative management (PT, Pain meds, Bracing)

Interventions Kyphoplasty/vertebroplasty (better results expected in acute & subacute fractures)

What happens if not treated?

Kyphoplasty

Sacral Fractures Conservative (same as Compression fractures)

Sacroplasty for alar fractures

Sacroiliac dysfunction Conservative (PT, belt, meds)

Injection

Radiofrequency ablation

Surgical fusion

Bertolotti’s Syndrome Pseudoarticulation between L5 & sacral/iliac bones

Injection

Spinal Stenosis Classic presentation

PT and medications

ESI

Surgical decompression

Lumbar Radiculopathy Does NOT usually cause LBP

Specific radicular dermatomal pattern

ESI

Surgical management

Epidural Steroid Injections

Caudal ESI with Catheter

Discogenic pain Sometimes hard to manage

Clinical picture

ESI, Intradiscal diathermy/regenerative medicine injections

Spinal Cord Stimulator Indications

New technology

Thank you