1. NON SURGICAL INTERVENTION IN BACK PAIN Dr. SANDEEP KUMAR
KESHARWANI MS (ORTHO), FNB SPINE FELLOW
2. NON-PHARMACOLOGIC o Patient education (back school) o
Physical therapy (stretching, strengthening exercise, massage,
traction) o Heat/Cold therapy o TENS o Chiropractic manipulation o
Orthotic devices
3. MEDICATIONS o Acetaminophen o NSAIDs o Narcotics o Steroids
o Adjuvants (Antidepressants, anticonvulsants, muscle
relaxants)
4. MODES OF INTERVENTION Transduction NSAIDs, Local Anesthetics
& Anticonvulsants Transmission Opioids, NMDA Antagonists
Modulation Tricyclic Antidepressants, Opioids, GABA Agonists
5. Pain Step 1 Nonopioid Adjuvant Pain persisting or increasing
Step 2 Opioid for mild to moderate pain Nonopioid Adjuvant Pain
persisting or increasing Pain persisting or increasing Step 3
Opioid for moderate to severe pain Nonopioid Adjuvant Invasive
treatments Opioid Delivery Quality of Life MODIFIED WHO 3- STEP
ANALGESIC LADDER Proposed 4th Step The WHO Ladder Deer, et al.,
1999 8 -10 4 - 7 1 - 3 Pain Severity
6. INVASIVE PROCEDURES o Selective injection o Intradiscal
electrothermal therapy o Radiofrequency denervation
7. EARLY INTERVENTION 1. Medicines NSAIDS Acetaminophen Muscle
Relaxants Narcotics (short duration) 2. Short term bed rest (2days
maximum) 3. Physical therapy 4. Chiropractics
8. LATER ALTERNATIVES 1.Medicines- Antidepressants 2.Orthotic
devices 3. Physical therapy 4. Therapeutic injections Epidural
Nerve Root Medical Branch 5. Radiofrequency denervation 6. IDET 7.
Acupuncture
