Upload
mlnagaraj
View
69
Download
0
Embed Size (px)
Citation preview
Dr Nagaraju MorubagalFCARCSI, Diploma in Pain Management
Consultant in Pain and Palliative careE mail : [email protected]
Low back pain (LBP) is a common disorder involving the muscles, nerves, and bones of the back. Pain can vary from a dull constant ache to a sudden sharp feeling
Radicular pain : Pain radiates to lower extremity along the distribution of the spinal nerve root. Usually sharp, shocking,
burning like pain
Radiculopathy : Pain associated with sensory or motor change in distribution of
nerve root
Second most frequent reason to visit a physician for a chronic condition,
The fifth most common cause for hospitalization
The third most frequent reason for a surgical procedure.
The socioeconomic impact of CLBP is massive.
LBP
Acute <6 weeks Sub acute6-12 weeks
Chronic > 6 months
LBP
MechanicalNon Mechanical
Referred
LBP
Mechanical Non Mechanical Referred
PlainParticulate VS
Systemic review conclusions NNT is 3 for short term(1 day to 3 months) NNT is 13 for long term pain relief (3mts-
1yr)
Ref: Mc Quay et al. epidural steriod for sciatica1998, oxford university press Chor R , et al. Non surgical interventional therapies for low back pain: a review of the evidence for an American pain
society guidelines.. Spine 2009:34:1078-1093
Three high quality , placebo controlled trials Showed benefit 1yr, Double blind ,randomised study LA with Steroid Vs LA only LA with steroid group 20/28 did not undergo
surgery as 9/27 (LA only), at follow up (13-28mts)
avoided surgery for 5 yrs
Riew et al. Nerve rot blocks in the treatment of lumbar radicular pain. A minimum five year follow up. J Bone joint surg am 2000,,2006;88:1722-1725 Karppinen et al. periradicular infiltration for sciatica . A randomised controlled trial. Spine 2001;26: 1059-1067 Ng L , Chaudhary et al. The efficacy of cortico sterids in periradicular infiltraton
ifor chronic radicular pain. Randomised , double blind,controlled trial.Spine 2005; 30:857-862
Disc herniation-extruded vs contained Extruded herniation group benefit for 3months Rebound effect after 3-6 months in this group Serious Complications: Anterior spinal artery
syndrome Retro peritoneal haematoma. Dural puncture,
discitis, transient blindness, cauda equine syndrome
Artery of Adamikiewacz in 80% T9-L1 Minority : T7-L4
Below L3, Real time imaging, LA first. Pain On injection DSA
O’Donnell C, Cano W, Eramo G. Comparison of triamcinolone to dexamethasone in the treatment of low back pain and leg pain via lumbar transforaminal epidural steroid injection. Spine J. 2008;8:65S.
Four placebo controlled , none high quality Mixed results
Retrospective study Radicular syndrome Disc herniation (NNT :1.38) Spinal canal stenosis (NNT : 1.19) FBSS ( NNT: 6.5)
Abejon et al. PRF in lumbar radicular ppain, clinical effects in various etiological groups . Pain practice 2007; 7:21-26
R/O Red & Yellow flags before interventions 95% LBP is self limiting Disc ( 25-40%) Facet (8-15%), and SIJ (1-
8%) SLR is sensitive ,Cross SLR specific test Trans foraminal route is the preferred
choice for subacute LS Radicular Pain DRG PRF is the preferred choice for Chronic
LS Radicular Pain