Back Pain management Guidelines

1. BACK PAIN TREATMENT
GUIDELINES
• DR. KRISHNA PODDAR
• DIRECTOR KOLKATA PAIN CLINIC
• SENIOR PAIN SPECIALIST
• FORTIS HOSPITAL
• ASSOCIATE PROFESSOR
• VIMS WBHU INDIA
• www.kolkatapainrelief.com

2. Have you had low back pain?
1. How many of you have
ever had back pain?
2. How many of you seek
help for your back pain?

3. Low Back Pain
• Low back pain is the most common musculoskeletal
disorder
• Experienced by nearly everyone at some point in his
or her life.
• The annual prevalence of chronic back pain ranges
from 15% to 45%, with a point prevalence of 30%
• Lifetime prevalence-24% in men; 30% in women
• The average age related prevalence is 15% in adults
and 27% in the elderly
• In United States the total direct costs ($65 billion)
• Indirect costs ($106 billion)
(Manchikanti, Pain Physician Vol. 3, No. 2, 2000

4. Causes of Low Back Pain
• Facet joint arthropathy 15-45%
• Discogenic Pain- 25-40%
• Sacro-Iliac joint arthropathy15%
• Fibromyalgia & Myofascial Pain
2-5%
• Spinal canal stenosis 2-3%
• Spondylolisthesis 2-3%
• FBSS <1%
• Osteoporotic Compression
fracture <1%

5. Other Causes
• Trauma
• Infections
• Rheumatoid arthritis
• Aankylosing spondylitis
• Cancers
• Referred Pain like
Endometriosis,Pancreatitis or Renal
pathology

6. Types of Back Pain
• Acute back pain is defined as lasting less
than 4 weeks,
• Subacute back pain lasts 4 to 12 weeks,
and chronic
• Chronic back pain lasts more than 12
weeks
6

7. Treatment of Low Back pain
• Non-pharmacological treatment
• Pharmacological treatment
• Interventional Pain management
1. Gilron I et al. Can Med Assoc J 2006;175:265-275.
2. Bennett MI, Closs SJ. Pain Clinical Updates 2010;18:1-6.

8. Non pharmacologic Options
• Physical therapy
• Biofeedback
• Relaxation therapy
• Physical and occupational therapy
• Cognitive behavioral therapy
• Acupuncture
• Massage
• Transcutaneous electrical nerve stimulation

9. Pharmacological Treatment
• NSAIDs
• Muscle relaxants
• Antidepressants (nortriptyline,desipramine)
• Anticonvulsants (gabapentin, pregabalin)
• Alpha-2 adrenergic agonists
• Opioids
• Topical analgesics (capsaicin, lidocaine patch 5%)
• Miscellaneous

10. Interventional Pain Management
• Epidural steroid injection
• Facet joint injections
• Radio frequency denervation
• Sacro-Iliac joint injections
• Sympathetic blocks
• Percutaneous Disc Decompression
• Epidural Adhesiolysis
• Spinal cord stimulator

11. Clinical Practice Guidelines
• To describe appropriate care based
on the best available scientific
evidence and broad consensus
• To provide or promote:
a rational basis for referral
• focus for continuing education
• promote efficient use of resources
• focus for quality control
•suggest appropriate future research
?

12. THE CHALLENGES
• Recommendations for diagnosis and
treatment should be the same, are they?
• The guidelines are measured by the same
instrument?
• All Recommendation from Guidelines are
Evidence Based?
• The individuals on the guideline committees
are similar from one committee to the next?
12

13. 39 Guidelines
13
USA‐15
Canada 3
UK‐6
Europe‐4
Mexico Austria
Spain
Australia
New Zeland
Finland Norway

14. • 1. Australia, National Health and Medical Research Council (2003)
• 2. Austria, Center for Excellence for Orthopaedic Pain Management
Speising (2007)
• 3. Canada, Clinic on Low back Pain in Interdisciplinary Practice (2007)
• 4. Europe, COST B13 Working Group on Guidelines for the Management of
Acute Low Back Pain in Primary Care 1 (2004)
• 5. Europe, COST B13 Working Group on Guidelines for the Management of
Chronic Low Back Pain in Primary Care (2004)
• 6. France, Agence Nationale d’Accreditation et d’Evaluation en Sante (2000)
• 7. Germany, Drug Committee of the German Medical Society (2007)
• 8. Italy, Italian Scientific Spine Institute (2006)
• 9. New Zealand, New Zealand Guidelines Group (2004)
• 10. Norway, Formi & Sosial‐og helsedirectorated (2007)
• 11. Spain, the Spanish Back Pain Research Network (2005)
• 12. The Netherlands, The Dutch Institute for Healthcare Improvement (CBO)
(2003)
• 14. United Kingdom, National Health Service (2008)
• 15. United States, American College of Physicians and the American Pain
Society (2007)
14

15. Which guideline?
15

16. What makes a good guideline?
• Methodological quality – certain rules
regarding how guideline is developed and
written
• Analogy: RCT quality
– Randomised allocation
– Blinding
– Follow‐up rates
– Appopriate statistics and reporting
16

17. ACP GUIDELINES
• Ann Intern Med. 2017;166:514-530.
doi:10.7326/M16-2367 Annals.org
• These guidelines are based on 2 background evidence
reviews and a systematic review sponsored by the
Agency for Healthcare Research and Quality(AHRQ)
• Reviewers searched several databases for studies
published in English from January 2008 through April
2015 and updated the search through November 2016.
17

18. Quality of
Evidence
Benefits Clearly
Outweigh Risks
and Burden
Risks and Burden
Clearly Outweigh
Benefits
High Strong Weak
Moderate Strong Weak
Low Strong Weak
Insufficient evidence to
determine net benefits or
risks
18

19. PHARMACOLOGICAL
Acute/Subacute Chronic Back Pain RADICULAR
ACETAMINOPHEN LOW INSUFFICIENT
NSAID VS PLACEBO
NSAID VS NSAID
MODERATE
LOW-NO
MODERATE
LOW-NO
BENZODIAGEPALMS LOW-NO LOW-NO LOW-NO
SMRs MODERATE LOW
SMRs VS SMRs
SMRs+NSAIDS VS NSAIDS
NO
NO
NO
CORTICOSTEROIDS LOW INSUFFICIENT MODERATE-NO
ANTIDEPRESSANTS
DULOXETINE
NO NO
SMALL EFFECT
NO
ANTICONVULSANTS NO INSUFFICIENT
OPIOIDS VS NSAIDS
STRONG OPIOIDS
BUPRENORPHINE PATCH
TRAMADOL
NO
STRONG
LOW
MODERATE
NO

20. ADVERSE EFFECTS
ACETAMINOPHEN MODERATR-NO
NSAID VS PLACEBO
NSAID VS NSAID
MODERATE-NO
BENZODIAGEPALMS LOW-SOMNOLENCE
SMRs SEDATION
CORTICOSTEROIDS MODERATE-INCRESED
ANTIDEPRESSANTS
DULOXETINE
MODERATE-INCREASED
ANTICONVULSANTS LOW-NO
OPIOIDS VS NSAIDS
STRONG OPIOIDS
BUPRENORPHINE PATCH
TRAMADOL
NAUSEA,VOMITTING,SOMNOLENCE,
CONTIPATION
20

21. Acute low back pain
Non Pharmacologic
Non pharmacologic
• Heat wrap: improved pain and function (moderate
effect)
• Massage: improved pain and function (at 1 but not 5
wk) (small to moderate effect)
• Acupuncture: improved pain (small effect)
• Spinal manipulation: improved function (small effect)
21

22. CHRONIC-Non pharmacologic
• Exercise: improved pain and function (small effect)
• Motor control exercise: improved pain (moderate
effect) and function (small effect)
• Tai chi: improved pain (moderate effect) and function
(small effect)
• Mindfulness- improved pain and function (small effect)
• Yoga: improved pain and function (small to moderate
effect, )
• Progressive relaxation: improved pain and function
(moderate effect)
22

23. • Multidisciplinary rehabilitation: improved pain
(moderate effect) and function (no to small effect)
• Acupuncture: improved pain (moderate effect) and
function (no to moderate effect,
• LLLT: improved pain and function (small effect)
• Electromyography biofeedback: improved pain
(moderate effect)
• Operant therapy: improved pain (small effect)
• Cognitive behavioral therapy: improved pain
(moderate effect)
• Spinal manipulation: improved pain (small effect)
23

24. Recommendation
1- Most patients with acute or subacute low back pain
improve over time regardless of treatment
2- Nonpharmacologic treatment with superficial heat
massage, acupuncture, or spinal manipulation
3-Reassurance and activity advice,self‐care
4-pharmacologic treatment -nonsteroidal anti-
inflammatory drugs or skeletal muscle relaxants
24

25. Recommendation
• Chronic low back pain pharmacologic treatment with
nonsteroidal anti-inflammatory drugs as first-line therapy
• Tramadol or duloxetine as second-line therapy.
• Opioids as an option in patients who have failed the
aforementioned treatments and only if the potential benefits
outweigh the risks for individual patients and after a discussion
of known risks and realistic benefits with patients
• Avoid long-term opioids, tricyclic antidepressants and SSNRI
• Exercise- supervised for chronic back pain
• Don’ts– Routine x‐ray, bedrest, electrotherapies lumbar
supports
• Unclear– Massage, traction
25

26. Interventional Techniques:
Evidence-based Practice Guidelines in the
Management of Chronic Spinal Pain
Mark V. Boswell et al
Pain Physician 2007; 10:7-111 • ISSN 1533-3159
American Society of Interventional Pain Physicians
(ASIPP) guidelines

27. Definitions:
Level I
Conclusive: Research-based evidence with multiple relevant and
high-quality scientific studies or consistent reviews of meta-
analyses
Level II
Strong: Research-based evidence from at least one properly
designed randomized, controlled trial; or research-based evidence
from multiple properly designed studies of smaller size; or multiple
low quality trials
Level III
Moderate: a) Evidence obtained from well-designed
pseudorandomized controlled trials; b) evidence obtained from
comparative studies with concurrent controls and allocation not
Level IV
Limited: Evidence from well-designed nonexperimental studies
from more than one center or research group
Level V
Indeterminate: Opinions of respected authorities, based on
clinical evidence,

28. Epidural Steroid Injection (ESI)
-Transforaminal Epidural Injections or Selective Nerve Route
Blocks
moderate for preoperative evaluation of patients with negative or
inconclusive imaging studies and clinical findings of nerve root
irritation
•Caudal epidural steroid injections is strong for short-term relief
and moderate for long-term relief, in managing chronic low back
and radicular pain.
• in post-lumbar laminectomy syndrome and spinal stenosis is
limited.

29. Interlaminar Epidural Steroid
Injection (ESI)
The evidence for lumbar radiculopathy is strong for
short-term relief and limited for long-term relief.
For cervical radiculopathy, the evidence is moderate for
short-term and long-term relief.
Indeterminate in the management of neck pain, low back
pain, and lumbar spinal stenosis.
Intralaminar

30. Sacroiliac Joint Blocks
• The evidence for the accuracy of sacroiliac
joint diagnostic injections is moderate for
the diagnosis of sacroiliac joint pain

31. Facet or Zygapophysial Joint Diagnostic
Blocks
• The accuracy of facet joint nerve blocks is
strong in the diagnosis of lumbar and
cervical facet joint pain, whereas it is
moderate in the diagnosis of thoracic facet
joint pain.

32. Therapeutic Facet Joint Interventions
• Intraarticular Blocks -moderate evidence for short and long-
term improvement in managing low back pain and the
evidence is limited for short and long-term relief in the
management of neck pain
• Medial Branch Blocks. The evidence for lumbar, cervical, and
thoracic medial branch blocks in managing chronic low back,
neck, mid back and upper back pain is moderate for short-
term and long-term pain relief.

33. RF Ablation
•Medial Branch Neurotomy. Evidence for radiofrequency
neurotomy of medial branch of cervical spine, is strong for short
and long-term relief
•lumbar region, the evidence for radiofrequency neurotomy of
medial branches is strong for short-term and moderate for long-
term relief
• Evidence for cryo denervation, and pulsed radiofrequency is
indeterminate.

34. Provocation Discography
• The evidence for lumbar discography is strong for
discogenic pain
• There is no evidence to support discography without
other non-invasive or less invasive modalities of
treatments or other precision diagnostic injections
• The evidence for cervical and thoracic discography is
limited.

35. Radiofrequency posterior annuloplasty &
Intradiscal electrothermal therapy
The evidence for radiofrequency posterior annuloplasty
was limited for short-term improvement, and
indeterminate for long-term improvement in managing
chronic discogenic low back pain.
The evidence for intradiscal electrothermal therapy is
moderate in managing chronic discogenic low back
pain.

36. Percutaneous Adhesiolysis
• The number of procedures are preferably limited
to:
– With a 3-day protocol, 2 interventions per year
– With a 1-day protocol, 4 interventions per year
• Spinal Endoscopic Adhesiolysis
• The procedures are preferably limited to a
maximum of 2 per year provided the relief was
>50% for >4 months.
Contrast injection after adhesiolysis

37. • The level of evidence for vertebroplasty is
moderate
• The level of evidence for kyphoplasty is
moderate
Vertebroplasty & kyphoplasty

38. Implantable intrathecal infusion
systems
The evidence for implantable intrathecal infusion
systems is strong for short-term improvement in
pain of malignancy or neuropathic pain.
The evidence is moderate for long-term
management of chronic pain.

39. Spinal cord stimulation
strong for failed back surgery syndrome and
complex regional pain syndrome for short-
term relief and moderate for long-term
relief.

40. Chronic neck pain
Based on clinical evaluation
Facet Joint Blocks Epidural Injections
Positive Positive NegativeNegative
Epidural Injections
Positive Negative
Stop process
OR
Provocative Discography*
Facet Joint Blocks
Positive Negative
Stop process
OR
Provocative Discography*
Positive
Positive
Negative
Negative
Mark V. Boswell et al, Interventional Techniques: Evidence-based Practice Guidelines in the Management
of Chronic Spinal Pain :Pain Physician 2007; 10:7-111 • ISSN 1533-3159

41. Chronic low back pain
Somatic pain Radicular pain
i. Facet Joint Pain
Intraarticular
Facet joint blocks /
Medial branch blocks or
Radiofrequency
ii. SI Joint Pain
SI joint blocks
iii. Discogenic Pain Intradiscal
therapy
i. No Surgery/ Post Surgery/ Spinal Stenosis
Step I: Caudal / Interlaminar
or Transforaminal epidural
ii. No Surgery
Step II: Discography and
Intradiscal therapy
iii. Post Surgery
Step IV: Spinal Endoscopic
Adhesiolysis
Step V: Implantable therapy
management of chronic low back pain
Mark V. Boswell et al, Interventional Techniques: Evidence-based Practice Guidelines in the Managemen
Chronic Spinal Pain :Pain Physician 2007; 10:7-111 • ISSN 1533-3159