“Ask The Expert”
How to Treat Back Pain
ABCs of Musculoskeletal Care
November 30 – December 1 2007, San Francisco
Sibel Demir-Deviren, MD
Assistant Clinical Professor
Spine Center
University of California, San Francisco
Case Presentation 1
4Deep, aching, stabbing pain
410/10 with VAS
4Sitting and walking make the pain worse
4Standing and bed rest make it better
4She came to clinic with her mom
4Severely limited in her ADL
Case Presentation 1
434 years old female presents to clinic with
complaint of severe LBP with right groin pain for 3
months
4She was thrown against a wall while she was
practicing martial arts
4She went to ER and pelvis 3 views x-rays were
taken
4She was told everything was WNL
4No evidence of fracture was reported
Case Presentation 1
4She has tried Advil 600 mg 3 times a day for a
week → didn’t get any relief
4She hasn’t tried any other NSAIDs
4She has had PT
4She hasn’t had any injections
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Case Presentation 1
4PMH: asthma and too many sports injuries
4Medications: no medication for pain
4Allergies: Sulfa, septra
4PE:
Case Presentation 1
hShe prefers to stand up during the PE
hROM is severely limited with moderate pain in every
direction
hParaspinal muscle spasm
hNeurologically intact
Case Presentation 1
Case Presentation 1
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Treatment Options for Chronic LBP
4Medications
4Physical Therapy
4Injections
4CAM
4Cognitive Behavioral Treatments
4Multidisciplinary rehabilitation
NSAIDs
4Evidence supports the efficacy of NSAIDs in
the treatment of chronic LBP
hBased on 6 randomized controlled trials
• pain, disability and mobility improved in 50-85% of
patients chronic LBP within 2-8 weeks
hVarious type of NSAIDs are equally effective
hLimited evidence shown that NSAIDs are more
effective than acetaminophen
Schnitzer et al, 2004
Medications
4NSAIDs
4Muscle relaxants
4Antidepressants
4Topical medications
4Opioids
Muscle Relaxants and
Benzodiazepines
4There is a good evidence that muscle relaxants can
provide short term relief
h64% in tetrazepam vs. 29% in placebo
Arbus et al, 1990
4Carisoprodol (Soma), drug abuse and dependency
4Short term use in acute exacerbations
hMetaxalone (skelaxin) least sedating
4Sleep assistive medication
hBaclofen or tizanidine (zanaflex)
4Don’t use benzodiazepines with opioids
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Antidepressants
4Based on 7 RCT
4Produce moderate symptom reduction with
Chronic LBP
4Analgesic effects
hTricyclic antidepressants
hSSRIs are not beneficial
4This effect is independent of patient’s
depression status
Staiger et al 2003
Exercise Therapy
4Does it matter which exercise?
hMulticentered RCT
hDirectional preference of patients were identified
– Repeated lumbar flexion
extension
side glide rotation
hRandomized to 3 groups
– Directional exercise matching their preference
– Exercise opposite to their DP
– Evidence based care
hThe matched group had statistically significant
improvement than others in pain intensity, disability,
medication use, recovery, work interference
Long et al 2004
Physical Therapy
4Exercise therapy
4Thermal modalities
4Traction
4TENS
4Massage therapy
4Back School
4Lumbar supports
Back School
4Education on anatomy, body mechanics,
muscle function and posture, advice on
physical activity
45 RCTs evaluated back school compared
to other conservative treatments
4Better short and intermediate term pain
relief and improvement
Cochrane Review, 2005
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Case Presentation 1
4Lumbar spine MRI was ordered
4Flexeril 10 mg tid
4Diclofenac 50 mg tid for a week trial
hShe will let us know how she is doing in a week
4PT
hStabilization of lumbar spine
hImproving flexibility of lower extremity muscles
hImproving cardiovascular fitness
hBack school
hHome exercise program
Case Presentation 1
Case Presentation 1
T2 sagittal images
Case Presentation 1
T2 axial image at L2-3
T1 sagittal images
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Case Presentation 1
T2 axial image at L4-5
Case Presentation 1
T1 axial image at L4-5
Case Presentation 1
T1 axial image at L2-3
Case Presentation 1
4Amitriptyline
4She stopped taking Flexeril
42 months after trying all conservative treatments
4Still limited in her ADL because of bilateral groin
and left hip pain
4She had bilateral L2 TFE at L2-3 and left L4 TFE
at L4-5
4Started pilates
4The pain is completely gone for 15 months
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Case Presentation 1
Sclerotomes
4She was 100% back to ADL for 15 months
4She stopped taking all the medications
4She started to experience another flare up
4Mainly left hip pain with mild buttock pain.
4The pain gets worse with sitting
4She started taking amitriptyline and diclofenac
4She couldn’t exercise because of the pain
Case Presentation 1
4She had left L4 TFE at L4-5 for both diagnostic
and therapeutic purposes
4100% relief from the injection for 6-7 weeks
4She started PT in 3 days after the injection
4The pain came back as both left hip and buttock
pain
4She had left L4 and L5 TFE at L4-5 and L5-S1
levels
4She is again pain free
Case Presentation 2
480 years old female
presents to clinic
with complaint of
LBP with mainly left
anterior thigh pain
4Sharp, throbbing,
constant pain
48-10/10 with VAS
4Severely limited in
her ADL
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Case Presentation 2
4Very nice, highly educated lady
4Very bad historian
Case Presentation 2
T2 axial image at L2-3
Case Presentation 2
4PMH: unremarkable
4Allergies: Opioids
4PE:
Muscle strength: 4/5 in all lower extremity
muscles
SLR was negative bilaterally
Case Presentation 2
T2 axial image at L3-4
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Case Presentation 2
T2 axial image at L4-5
Case Presentation 2
T2 sagittal images
Case Presentation 2
T2 axial image at L5-S1
Case Presentation 2
T1 sagittal images
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Dermatomes
4Study on dermatomes by mean
of selective nerve block
hBlock nerve roots with 1.5cc 2%
lidocaine
hIdentified the boundaries with
tactile method
• L4 88%
• L5 82%
• S1 83%
Case Presentation 2
4Left L2 and L3 TFE was performed
4She didn’t get any relief from the injection
4PT was also prescribed
4Meanwhile she started to complain about not able
to think clearly.
Spine 1993;18(13):1782-6
Case Presentation 2
4She was seen by Neurology
4CBC, RFT, LFT, Ca, P, Mg, TSH, RPR, free T4,
B12, EEG, MRI: All WNL
4Because of incredible fear, anxiety and
depression, she was not able to think clearly
4She was very worried she would never walk again
4She was also very worried that she would run out
of money soon if she was not able to return to
work
Cadaver Studies
4Sensory rootlets have unusual segmental
arrangement in many cases which is less
common in motor rootlets
Spine 1984;9(1):23-30
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Case Presentation 2
4Left L4 and L5 SNRB was performed
4She experienced concordant pain during L5
SNRB
4She had 100% relief from the SNRB for one day
Response to steroid is a predictor
of Surgical Outcome
4Retrospective clinical study
471 patients with radicular pain
41-2 ml 2% lidocaine and 6 mg betamethasone
4Patients who had 80% relief from the ESIs had greater
than 95% success in achieving average of 90% leg-pain
relief after decompression
Derby et.al. Spine 1992; 17(6 Suppl): S176-83
Case Presentation 2
4She underwent laminoforaminotomies
bilaterally with medial facetectomies for
decompression of L4 and L5 nerve roots
4She is a happy camper
Indications for Selective Nerve
Root Blocks
4Atypical extremity pain
4Patients with equivocal imaging studies
4Patients with equivocal neurologic examination
4Patients with multilevel imaging abnormalities, to be able
to define affected level
4For anomalous innervations
4Patients with transitional vertebrae
4Postoperative unexplainable or complex recurrent pain
4Patient with known cause of pain whom would get
benefit from temporary pain relief
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Case Presentation 3
431 years old female presents to clinic with complaint of
severe back with left buttock pain for 6 weeks
48/10 with VAS
4Sharp, shooting, stabbing, penetrating, numbing pain which
is worse in the morning
4Numbness in the genital area and in the toes on the left side
4Wakes up at night because of the pain
4Sitting and walking make the pain worse
4Severely limited in her ADL
4She can’t work
4She was recommended to have discectomy
Case Presentation 3
4Ibuprofen 800 mg tid
4Lortab 5/500 qid
4She has had ESI → didn’t get any relief
4She hasn’t had PT
Case Presentation 1
4PMH: healthy
4Medications: Ibuprofen, lortab and birth control pills
4Allergies: No known drug allergies
4PE:
hROM is moderately limited with moderate pain in every
direction
hParaspinal muscle spasm
hNeurologically intact
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Pharmacologic Treatment for Neuropathic Pain
4TCA
4Other antidepressants
4Gabapentin
4Other anticonvulsants
4Tramadol
4Topical drugs
4Nonsteroidal anti-inflammatory medications
4Steroids
4Opioids
4NMDA receptor antagonists
4Others: Baclofen, Clonidine
TCA
4Analgesia is independent of antidepressive effect
4Analgesia is often achieved at lower dosage and faster
4Initiate treatment with amitriptyline and switch to alternative
TCA if some pain relief is achieved, but side effects are
troublesome
4Initial dose is 10-20 mg qhs and then titrate every 3-7 days
by 10-25 mg/day up to 75-150 mg/day as tolerated
4NNH for withdrawal for TCA was 14.7
420% of participants with drew because of intolerable side
effects
4Na channel blockers
TCA
hinhibit ectopic discharge in nociceptive fibers
4Inhibit reuptake of NE and serotonin
hresponsible from partial restoration of inhibitory controls
4Increase expression of leu-enkephalin
hmimic therapeutic opioid effects
4Amitriptyline,Imipramine, Clomipramine
hbalanced serotonin and noradrenalin reuptake blocker
hNNT: 2.1
4Nortriptyline,Desipramine
hmainly inhibit noradrenalin reuptake blocker
hNNT: 2.5
TCA
4TCAs must be used cautiously in patients with a history of
cardiovascular disease, glaucoma, urinary retention, autonomic
neuropathy, seizure and bipolar disorders
4Side effects: dry moth and eyes, blurry vision, urinary
constipation, constipation, weight gain, erectile dysfunction,
night sweats, orthostatic hypotension, palpitation, cardiac
arrhythmias
4Block the effect of certain antihypertensive drugs like clonidine
or guanethidine
4Increase side effects of thyroid supplements
4Increase sedative effects of alcohol and other sedatives
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Gabapentin
413 RCT
48 provides evidence for the effectiveness of
gabapentin
42 studies compared gabapentin with amitriptyline
(Morello 1999, Dallocchia 2000)
4NNT was 4
4NNH for minor side effects was 3.7
4NNH for withdrawal was 26.1
(Cochrane review 2005, Finnerup 2005)
Tramadol
413 RCT
48 provides evidence for the effectiveness of gabapentin
42 studies compared gabapentin with amitriptyline
(Morello 1999, Dallocchia 2000)
4Effective dose is 200-400 mg/day
4NNT was 4
4NNH for minor side effects: 3.7 and withdrawal: 26.1
4Side effects: dizziness, dry mouth, constipation and
somnolence
4Decrease seizure threshold
4Serotonergic syndrome with other serotonergic medications
Gabapentin
4Initial dose is 100-300 mg qhs or tid and then titrate every 17 days by 100-300 mg/day up to 1,800 mg/day as tolerated
4An adequate trial would be include 3-8 weeks for titration
plus 1-2 weeks at the max tolerated dosage
4Side effects:
dizziness 24%
somnolence 20%
headache 10%
diarrhea 10%
confusion 7%
nausea 8%
mild peripheral edema
Case Presentation 3
4Amitriptyline was prescribed
4We told her that she would sleep like a baby with
amitriptyline
4She called back in 3 days complain about not able
to sleep at all
4Amitriptyline increases the effect of caffeine
(Cochrane review 2005, Finnerup 2005)
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Results of TFE
4Prospective, randomized, double blinded clinical trial
4182 patients with radicular pain
hOne study compared TFE, interlaminar ESI and
paravertebral local anesthetic
4TFE was more effective than interlaminar ESI (68%
versus 53%)
4Patients were assessed at 3 weeks and 3 months
Results of TFE
4A case control study
440 patients with single level disc herniation
confirmed with MRI
4All patient had radicular symptoms
4TFE was more effective than interlaminar ESI (70%
versus 45%)
4TFE resulted in fewer long term surgical intervention
than interlaminar ESI
Kraemer et. al. Eur Spine J 1997; 6: 357-361
Case Presentation 3
4She had left L5 and S1 TFE
4She started PT in 4 days after the injection
4PT
hStabilization of lumbar spine
hImproving flexibility of lower extremity muscles
hImproving cardiovascular fitness
hBack school
hHome exercise program
Schaufele et. al. Pain Physician 2006; 9: 361-366
Case Presentation 3
4In 2 weeks
hnumbness is completely gone
h3/10 with VAS
hstill takes ibuprofen, amitriptyline and Lortab
hback to work part-time with limitations
hstill limited in her ADL
4She had another left L5, S1 TFE
4Continue with PT and medications
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Case Presentation 3
4In 3 weeks
h2/10 with VAS
hstop taking Lortab
hTakes ibuprofen prn
4Continue with PT, ibuprofen and amitriptyline
Case Presentation 3
4In 6 weeks
hNo pain
hstop taking all the medications
4She has started pilates
4She is back to work full time
Thank you
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