2. Low back pain
⢠Low back pain is defined as lumbar spinal pain
or sacral spinal pain or any combination of the
two.
3. Idea of pain generator
A structure/tissue can
be a source of pain
only when it will have
nociceptive nerve
Local anesthetic
injection in those
nerves and/or those
tissue should relieve
pain
4. Pain Generators
⢠Facet joints
⢠Deg. Disc
⢠Sensitized ms
⢠S.I. Joints
Not a Pain
Generator
⢠Normal muscle
⢠Normal Disc
5. Major causes
1. Facet joint arthropathy 15-45% (M.C.Cz in elderly)
2. Interval disc disruption 25-40% (M.C.Cz in young)
3. Sacro-Iliac joint arthropathy 15-30%
4. Disc prolapse/ herniated disc/ slipped disc-2-5%
5. CRPS/ RSD 2-8%
Causes of Low Back Pain
6. Other causes of Low Back Pain
Osteoporotic Compression fracture 3-5%
Other fracture <1%
Fibromyalgia & Myofascial Pain 2-5%
Spinal canal stenosis 2-3%
Spondylolisthesis 2-3%
Tumor <1%
Infection <1%
Others: like FBSS <1%
7. Low Back Pain :
RED FLAGS
⢠Possible FRACTURE
⢠Possible TUMOR OR INFECTION.
⢠BLADDER OR BOWEL DYSFUNCTION.
⢠Severe or PROGRESSIVE NEUROLOGIC
DYSFUNCTION in the legs.
⢠MAJOR MOTOR WEAKNESS in quadriceps,
plantar flexors, evertors, and dorsiflexors.
11. Facet Joint pain
Back pain > leg pain
Paramedian pain
Pain on extension, rotation, lateral bending
Tenderness over facet joints
Non dermatomal distribution
12. Management of Facet Arthropathy
⢠Confirmation by dual diagnostic
block (L.A.âs)
⢠I/Articular Depo-steroid inj.
⢠Radio-frequency Rhizotomy of
Medial branch
33. Axial pain
Aggravated by sitting
-No tenderness
-No other signs except
painful deep percussion
M.R.I showing HIZ
I.D.D
R.Com.block
Epidurals
M.R.I showing #
with edema
Vertebral
compression #
Vertebroplasty
Local tenderness +
b/w spinous area
I.S. ligament sprain
Over coccyx
Coccydynia
Steroid inj.
34. Axial pain
âon sitting
No local tenderness
Neurogenic claudication +
Extension â leg pain
MRI- canal dia. <10 mm
b/l p/median tenderness+
Extensionâ back pain
Neurodeficit/leg pain -
Canal stenosis
Epidurals/Sx
Diagnostic facet jnt. inj.+ve
I/Articular steroid/ R.F of medial branch
35. Paramedian painâ on sitting
Tenderness over
Q.L.
Trigger point inj. + ve
Tenderness over
buttock+
FAIR +ve
Piriformis T.P. inj.+
Tenderness over S.I. jnt.
FABER + ve
Diag. S.I. jnt.inj .+ ve
Repeat T .P. inj./Botox
Repeat T . P.inj./Botox I/A steroid /R.F.
36. Paramedian pain â on sitting
Deep tenderness of paraspinal
muscle+
Extension â pain
Diag. Psoas T.P. inj.+ ve
Repeat T.P.inj./Botox
Local tenderness over facet+
Extension âpain
Diagnostic facet jnt. inj.+ve
I/Articular steroid/ R.F of
medial branch