Oh My Aching Back

Treatment Options for Back Pain

Dr Jayant Arora
MS(Orth), DNB(Orth), MRCS(Edinburgh) Fellowship In Joint Replacement and Arthroscopy(Newcastle,UK) Senior Consultant Orthopedics and Joint Replacement Surgeon Columbia Asia Hospital, Palam Vihar.

Etiology and Pathophysiology

Associated with low back pain

Prolonged periods of seating Repetitive heavy lifting

Vibration

Etiology and Pathophysiology

Several risk factors

Lack of muscle tone Excess body weight

Poor posture
Cigarette smoking Stress

Typical Presentation

Pt has had lower back pain for the past 24 hours that he feels is related to heavy work that he did over the weekend. He missed work today, Monday. He wants to know what can be done for his back pain?

What should Patient expect from his health care professional?

1.

2.

Be able to recognize the difference between routine lower back pain and dangerous forms of lower back pain. Provide information, advice, and a plan of action.

Causes of Low Back Pain

Lumbar strain or sprain 70% Degenerative changes 10% Herniated disk 4% Osteoporosis compression fractures 4% Spinal stenosis 3% Spondylolisthesis 2%

Causes of Low Back Pain

Spondylolysis, diskogenic low back pain or other instability 2% Traumatic fracture - <1% Congenital disease - <1% Cancer 0.7% Inflammatory arthritis 0.3% Infections 0.01%

Red Flags

History of cancer Unexplained weight loss Prolonged use of corticosteroids Older age

Major Trauma Osteoporosis Fever Back pain at rest or at night Bowel or bladder dysfunction

Medications

Anti-inflammatory medications (NSAIDs):

Beneficial; no differences; watch side-effects

Paracetamol Narcotic Pain Relievers:

No more effective than NSAIDs
Many side effects

Muscle Relaxants:
Can decrease pain and improve mobility
70% with drowsiness/dizziness

Exercise & Bed Rest

Advice to stay active:

There is no evidence that advice to stay active

is harmful for either acute low back pain or sciatica. Hurt does not equal harm

One or two days of bed rest if necessary Light activity, avoiding heavy lifting, bending or twisting (ie. walking) No data on any particular exercises

Dos
Prevent lower back from straining forward by

placing a foot on a step or stool during prolonged standing Sleep in a side-lying position with knees and hips bent Sleep on back with a lift under knees and legs or back with 10-inch-high pillow under knees to flex hips and kneesExercise 15 minutes in the morning and evening regularly Maintain appropriate body weight Use local heat and cold application Use a lumbar roll or pillow for sitting

SEATING POSTURE

Do nots
Lean forward without bending knees Lift anything above level of elbows

Stand in one position for prolonged time

Sleep on abdomen or on back or side with legs

out straight Exercise without consulting health care provider if having severe pain

Massage & Physical Therapy

Might be beneficial More quality research is needed Different types of massage

Acupuncture

Very little quality research and data Seems to indicate that acupuncture is not effective for the treatment of back pain

Other Modalities

Back Brace/Corset/Lumbar Support: Traction: Injections: Inconclusive evidence TENS: Hot/Cold: Ultrasound

Persistant pain

Now, patient has not had improvement in his lower back pain and 6 weeks have gone by since the initial painful event. What types of therapies might be beneficial now?

Role of X-rays (Radiology)

Usually unnecessary and not helpful Plain X-ray:

Age>50 years No improvement after 6 weeks Other worrisome findings

MRI:
After 6 weeks if have sciatica

Medications
Similar to acute pain. Antidepressant medications can improve pain relief

Exercises

Improves pain and function Many programs available, but difficult to make any scientific recommendations for one type versus another

Injections

Epidural injections:
Insufficient and conflicting evidence

Facet joint injections: only useful for facetal arthritis for short term Foraminal root blocks temporary pain relief from radicular pain. Local/Trigger point injections:
Possibly some benefit

Surgery

Diskectomy improves pain in short term but not long term (ie. 10 years) Microdiskectomy similar to standard diskectomy Automated percutaneous diskectomy and laser diskectomy both less effective ? Arthroscopic diskectomy

Prevention

Exercise:
Aerobic, back/leg strengthening

Back braces and education about proper lifting techniques are ineffective ? weight loss and smoking cessation

THANK YOU