Non operative management of Low Back Pain

1. NON – SURGICAL
INTERVENTION IN BACK PAIN
Dr. SANDEEP KUMAR KESHARWANI
MS (ORTHO), FNB SPINE FELLOW

2. NON-PHARMACOLOGIC
o Patient education (back school)
o Physical therapy (stretching, strengthening
exercise, massage, traction)
o Heat/Cold therapy
o TENS
o Chiropractic manipulation
o Orthotic devices

3. MEDICATIONS
o Acetaminophen
o NSAIDs
o Narcotics
o Steroids
o Adjuvants (Antidepressants, anticonvulsants,
muscle relaxants)

5. MODES OF INTERVENTION
 Transduction
NSAIDs, Local Anesthetics & Anticonvulsants
 Transmission
Opioids, NMDA Antagonists
 Modulation
Tricyclic Antidepressants, Opioids, GABA
Agonists

6. Pain
Step 1  Nonopioid
 Adjuvant
Pain persisting or increasing
Step 2 Opioid for mild to moderate pain
 Nonopioid  Adjuvant
Pain persisting or increasing
Pain persisting or increasing
Step 3
Opioid for moderate to severe pain
 Nonopioid  Adjuvant
Invasive treatments
Opioid Delivery
Quality of Life
MODIFIED WHO 3- STEP
ANALGESIC LADDER
Proposed 4th Step
The WHO
Ladder
Deer, et al., 1999
8 -10
4 - 7
1 - 3
Pain
Severity

7. INVASIVE PROCEDURES
o Selective injection
o Intradiscal electrothermal therapy
o Radiofrequency denervation

8. EARLY INTERVENTION
1. Medicines
NSAIDS
Acetaminophen
Muscle Relaxants
Narcotics (short duration)
2. Short term bed rest (2days maximum)
3. Physical therapy
4. Chiropractics

9. LATER ALTERNATIVES
1.Medicines- Antidepressants
2.Orthotic devices
3. Physical therapy
4. Therapeutic injections
Epidural
Nerve Root
Medical Branch
5. Radiofrequency denervation
6. IDET
7. Acupuncture

10. THANKYOU