Low Back Pain

Injection Treatments for Back Injury

Rohit Oza, MDPhysiatry Department Summit Medical Group

Low Back Pain

60-90% of adults will have low back pain

2nd most common reason to see primary care physician

The Low Back Pain Story

Low Back Pain

40-50% of patients with low back pain will improve within one week

Common Thinking

Low Back Pain

62% of patients likely to have one or more relapses during a one-year follow-up

The Full Story

Low Back Pain

Low back pain is the #1 disability in patients under 45

The Full Story

Low Back Pain

90% of patients with low back pain improve without any medical care

Common Thinking

Low Back Pain

Longer pain for patients who wait 6-10 weeks

80% have pain at six months and one year

12% disability at one year

The Full Story

Low Back Pain

1. Difficult to diagnose source

2. Requires “whole care” approach

3. Preventive program needed to minimize recurrence

Difficulties in Treating LBP

Low Back Pain

Complexity

AHCPR guidelines

Lack of research

Managed care restrictions

Other Complicating Factors

Low Back Pain

Leading cause of disability

70-90% of adults will experience LBPIn their lifetime

Financial Impact:medical expense anuallyIn medical bills, disabilty, and loss of productivity

Low Back Pain

Physiological factors

Social factors

Psychological factors

Complex Problem Interdisciplinary Management

Interdisciplinary Team Approach at

SMG

• Orthopedic Surgeons

• Neurosurgeons

• Pain specialists

• Psychiatrists/ Psychologists

• Physiatrists• Radiologists• Neurologist• Internists• Chiropractor

Low Back Pain

Anatomy

– Vertebral body

– Disc

– Facet joints

Low Back Pain

Spine Anatomy

Cervical– C1-C7

Thoracic– T1-T12

Lumbar– L1-L5

Sacrum– S1-S5 (fused)

Low Back Pain

Spinal cord

Nerve roots

Disc

Low Back PainPrevention

Stretching

Strengthening

Posture

Lifting techniques

Ergonomics

Low Back Pain

Common sources for LBP:

Structural Myofascial

Neural Tissue

Joints

Intervertebraldiscs:

Skeletal boneabnormalities

Muscles, Tendons, ligaments, fascia

Nerve root irritation, epidural inflammation, epidural fibrosis, arachnoiditis

Facet joints, sacro iliac jointsDisc degeneration/disruption, disc herniation

Osteoporosis, compression fractures, spinal stenosis, spondylosis, spondylolysis, spondylolisthesis,

Low Back Pain

Injections Muscle

Nerve

Joint

Low Back Pain

Injection Treatments: Muscle/Ligaments

Trigger Point InjectionA trigger point is a knot or tight, rope-like band of muscle that forms when a muscle fails to relax after activity

Lidocaine is an injectable medication that can be used to numb a joint or treat muscle pain. Research shows that injections used to inactivate trigger points can provide prompt relief of painful symptoms related to joint and muscle ailments.

Low Back Pain

Injection Treatments: Muscle/Ligaments

Trigger Point Injection

Low Back Pain

Injection Treatments: Nerve

“Sciatica” - Sciatica is a relatively common form of low back and leg pain, but the true meaning of the term is often misunderstood.

Sciatica is a set of symptoms rather than a diagnosis

Symptoms include lower back pain, buttock pain, and pain, numbness or weakness in various parts of the leg and foot. Other symptoms include a "pins and needles" sensation, or tingling and difficulty moving or controlling the leg

Low Back Pain

Epidural Injection

GOAL: Control inflammation

Low Back Pain

Epidural Injection

Been around for 40 years.

The epidural space is accessed through the caudal, interlaminar approach and transforaminal approach.

Low Back Pain

Paracentral

Foraminal

Far Lateral

Disc Herniation Location Determines Affected Nerve

Low Back Pain

Caudal Epidural Blocks

Low risk for thecal puncture. Dura ends at S2.Unreliable above the L4-5 levels.Requires higher volumes of medication

Low Back PainZygapophyseal

Mediated Pain(Facet Joint)

1. Cartilage degeneration with or

2. Osteophyte formation

3. Biomechanical transfer of weight in disc degeneration

4. Trauma to the joint

5. Spondylolisthesis

Low Back Pain

Facet (Zygapophysial)

Joint PainLumbar facet joints recognized as a source of pain since 1911

Facet syndrome: lumbosacral pain with or without sciaticaPain after rotary movement or twistingLow back pain with radiation to thighs and buttocksPoor clinical correlation with imaging or exam

PrimaryPain

SecondaryPain

Low Back Pain

Facet Injections

Intra-articular Joint InjectionsTherapeutic (Local and steroid)

Paravertebral Facet Joint Nerve Blocks(Medial Branch Blocks)

Diagnostic (Local only)Therapeutic only with Neurolysis (Radiofrequency)

Low Back Pain

Low Back Pain

Neuroablation:RF

Radiofrequency ablation produces indescriminate destruction of all nervous tissue including motor and propioceptive fibers

Lesion Shape Produced by RF: 4 mm

Typical Energy Delivered 2-7 watts* Thermal lesion is least at tip and greatest along active shaft of RF needle* Typical tissue temp 70-90 degrees C* Optimum angle is parallel to nerve

Low Back Pain

SI Joint

Accepted source of low back and buttock pain

Prevalence of SI pain: 13 to 30% of cases of low back pain

Moderate evidence for efficacy of SI joint injections

Low Back PainDisc

Degeneration

Discs well innervated and can be source of pain

Internal architecture disruptedPresence of radial fissures that reach the outer third of the annulus

Low Back Pain

Severe Degenerative Disc Disease

CompleteDegradation ofNucleusPulposis

BiomechanicalTransfer ofLoad to theAnnulusand Z-joints

Internal architecture of the disc is disruptedExternal surface remains normal, no bulge or herniationCharacterized by degradation of the matrix of the nucleus pulposus and presence of radial fissures that reach the outer third of the annulus

Low Back Pain

In a recent study by Dr. Terry and Dr. Lutz, cells from a patient’s blood were taken out and injected into the disc to see if can stimulate a repair response.

They also worked on a study injecting growth factor into the disc to try toturn on the disc’s inherent ability to heal itself.

These are some of the first studies that havebeen done in the world in this area.

Stem Cells for Disc Degeneration

Dr. Alon Terry(newest SMG Physiatrist) trained at HSS where heworked on regenerative strategies for the disc

Low Back PainConclusion

Lumbar spine injections can be a valuable tool in the management of LBP

Some injections can be diagnostic and/or therapeutic

Injections represent one strategy in the management of LBP

Multimodal treatment strategies have shown to be most helpful in the long-term management of chronic LBP