Conservative Tx of Low Back Pain

Seoul Naeun HospitalKise Nam M.D. Ph.D.

E-Mail: osman@naver.comhttp://www.seoulnaeunhospital.com

Low Back Pain

• LBP : 80 ％ experience in their life.

• Sciatica : 13-40% experience.(Frymoyer JW : JBJS, 1983)

Natural History

• LBP : 50% resolve within 1 week, 95% within 3months

• Sciatica :50% resolve within 1 month, 75% within 3months (Bush K : Spine, 1992)

OP vs Conservative

• The controlled trial showed a statisti-cally significant better resull in the surgically treated group at the one-year follow-up examination.

• After four years the operated pa-tients still showed better results, but the difference was no longer statisti-cally significant (Weber H : Spine, 1983)

Etiology of LBP

• Spondylogenic• Neurogenic• Viscerogenic• Vasculogenic• Psychogenic

Common Ex of LBP

• Sprain• HIVD (Herniated interverteral disc)• Spinal Stenosis• Instability

Spondylolisthesis, Retrolisthesis.• Scoliosis, Kyphosis• Osteoporosis, Comp. Fx

Conservative Tx

• Bed rest for 3~5 days

• MedicationNSAID, M relexant, Antidepressant.

• Manipulation (chiropractic)• Back brace

Conservative Tx

• Physical TherapyHot pack, TENS, Traction, ESWT, Pain Scrambler

• InjectionTPI. Epidural Steroid Injection, Facet joint injection. Medial branch block.

Conservative Tx

• ExerciseFlexion, Extension exerciseAerobic exercise

• Back School.

Local Procedure

• Percutaneous Neurolysis• Nucleoplasty• IDET• Percutaneous Endoscopic Discectomy

Bed Rest

Medication

• NSAIDCelebrex 200mg qdNaxozol (naproxen 500mg esomeprazole 20mg)

• M relexant, • Antidepressant

Tricyclic antidepressants : amitriptylineSNRIs (duloxetine Cymbalta)

• Anti-convulsant medications : gabapentinoids (gabapentin/pregabalin)

• Opioid analgesics: oxycodone, tramadol

Manipulation

Physical Therapy

• Hot pack, TENS, Ultrasound,Traction• ESWT

(Extracorporeal shockwave therapy)• Pain Scrambler

ESWT

ESWT (Biological Effects)

• Relieving Pain • Increased blood flow • Induce an inflammatory-mediated

healing process• Release healing factors;

TGF-β1,IGF-1 Signs of inflammation and repair after 4 weeks

ESWT (Target Tissues)

• Tendon• Tendon sheath• Bone• Muscle• Ligament• Connective tissue, synovium

ESWT (protocol)

• Dependent upon the energy categoryHigh energy : 1,000 to 1,500 pulsesLow energy : 2,000 to 3,000

• Treatment area : greatest discomfort areapathologic tissuefunctional abnormal tissue

• Additional treatments may be benefi-cial

Pain Scrambler

What is Scrambler therapy?

• Patient‐specific cutaneous electro‐stimulation simi-lar to spinal cord stimulation, but non‐ invasive.

• Creates "non‐pain" information in packets of rapidly varying impulses, given non‐invasively using the patient’s own nerves.

• 30‐45 minute long sessions using EKG‐like pads. Above and below pain. Stinging, then tingling, then intermittent pulse; adjust to tolerance.

• No side effects reported in over 4000 patients; over 3000 in use in Italy. US FDA Cleared Feb 09.

Epidural Steroid Injection

Epidural Steroid Injection

Facet Joint Injection

Med Branch Block

Exercise with Medex

Back School

Back School

Spontaneous regression of HIVD 3Yrs later

Spontaneous regression of HIVD 3Yrs later

Arthroscopic Lumbar Discectomy

Arthroscopic Lumbar Discectomy

Arthroscopic Lumbar Discectomy

Epidural Neurolysis

Intradiscal Electrothermal Annuloplasty

Nucleoplasty

Vertebroplasty, Kyphoplasty

Principle of Tx of LBP

If possible, conservative

• Thank You