This document provides an algorithm for evaluating and managing low back pain. It outlines various pain generators like facet joints, degenerative discs, and sacroiliac joints. Facet joint arthropathy and internal disc disruption are major causes of low back pain. The algorithm describes evaluating patients through history, examination including range of motion and special tests, and imaging. It provides guidance on treating different sources of back pain non-surgically through injections and ablations or surgically if needed.

1. Back Pain Algorithm
Ravi shankar
sharma

2. Low back pain
• Low back pain is defined as lumbar spinal pain
or sacral spinal pain or any combination of the
two.

3. Idea of pain generator
A structure/tissue can
be a source of pain
only when it will have
nociceptive nerve
Local anesthetic
injection in those
nerves and/or those
tissue should relieve
pain

4. Pain Generators
• Facet joints
• Deg. Disc
• Sensitized ms
• S.I. Joints
Not a Pain
Generator
• Normal muscle
• Normal Disc

5. Major causes
1. Facet joint arthropathy 15-45% (M.C.Cz in elderly)
2. Interval disc disruption 25-40% (M.C.Cz in young)
3. Sacro-Iliac joint arthropathy 15-30%
4. Disc prolapse/ herniated disc/ slipped disc-2-5%
5. CRPS/ RSD 2-8%
Causes of Low Back Pain

6. Other causes of Low Back Pain
Osteoporotic Compression fracture 3-5%
Other fracture <1%
Fibromyalgia & Myofascial Pain 2-5%
Spinal canal stenosis 2-3%
Spondylolisthesis 2-3%
Tumor <1%
Infection <1%
Others: like FBSS <1%

7. Low Back Pain :
RED FLAGS
• Possible FRACTURE
• Possible TUMOR OR INFECTION.
• BLADDER OR BOWEL DYSFUNCTION.
• Severe or PROGRESSIVE NEUROLOGIC
DYSFUNCTION in the legs.
• MAJOR MOTOR WEAKNESS in quadriceps,
plantar flexors, evertors, and dorsiflexors.

8. History
Chief complain/s
H/O Present
illness
Site
Onset
Intensity
Radiation
Aggravating &
relieving factors
Diurnal variation
Family history Medical history Personal history
Occupational
history

9. Examination
• Inspection
• palpation
• Range of movements
• Special tests

10. Facet Joints
Commonest cause of back pain in elderly.

11. Facet Joint pain
Back pain > leg pain
Paramedian pain
Pain on extension, rotation, lateral bending
Tenderness over facet joints
Non dermatomal distribution

12. Management of Facet Arthropathy
• Confirmation by dual diagnostic
block (L.A.’s)
• I/Articular Depo-steroid inj.
• Radio-frequency Rhizotomy of
Medial branch

13. Radio-frequency Rhizotomy of Medial branch

16. Degenerative Disc Disease

17. Grading:-

18. Disc Prolapse

19. DISC PROLAPSE

20. TYPES OF DISC PATHOLOGY
Degenerated Disc/
IDD/Discogenic Pain
No nerve root compression
Non-dermatomal
distribution of pain
Back pain > leg pain
Incidence: 40%
Herniated Disc/
Prolapsed/Slipped D
Nerve root compression
Dermatomal distribution
of pain
Back pain < leg pain
Incidence: 4%

21. Types of disc pathology
Degenerated Disc
Axial pain, SLR –ve
Neuro-deficits -ve
Provocative
discogram/ HIZ in
MRI correlates with
pain
Herniated Disc
Lateral pain,SLR+ve
Neuro-deficits +
Clinical + MRI

22. Internal disc disruption
• IDET/ Posterior annuloplasty
• Neucleoplasty
• Laser Discectomy
• Conventional radio-frequency lesioning
• Pulsed radio-frequency lesioning
• Percutaneous Discectomy
• Ozone Nucleolysis/ ozone Discectomy
• Surgery: Fusion, Disc replacement

23. Ramus communicans block via c-arm (AP/lateral )

24. DISC PROLAPSE
Epidural steroid inj
Ozone Nucleolysis & Transforaminal Ozone
injection.
Epidural neuroplasty
Percutaneous discectomy
Surgery: Discectomy/ laminectomy/
Fenestration

26. Sacro-iliac Joint Arthropathy
FABER test

27. S.I.joint RF ablation –Needle
Placement

28. Myofascial Pain Syndrmoes:

29. Vertebral compression #

30. Vertebroplasty

31. Interspinous ligament sprain

32. Low back pain
Back pain >leg
pain
Axial pain Paramedian pain

33. Axial pain
Aggravated by sitting
-No tenderness
-No other signs except
painful deep percussion
M.R.I showing HIZ
I.D.D
R.Com.block
Epidurals
M.R.I showing #
with edema
Vertebral
compression #
Vertebroplasty
Local tenderness +
b/w spinous area
I.S. ligament sprain
Over coccyx
Coccydynia
Steroid inj.

34. Axial pain
↓on sitting
No local tenderness
Neurogenic claudication +
Extension ↑ leg pain
MRI- canal dia. <10 mm
b/l p/median tenderness+
Extension↑ back pain
Neurodeficit/leg pain -
Canal stenosis
Epidurals/Sx
Diagnostic facet jnt. inj.+ve
I/Articular steroid/ R.F of medial branch

35. Paramedian pain↑ on sitting
Tenderness over
Q.L.
Trigger point inj. + ve
Tenderness over
buttock+
FAIR +ve
Piriformis T.P. inj.+
Tenderness over S.I. jnt.
FABER + ve
Diag. S.I. jnt.inj .+ ve
Repeat T .P. inj./Botox
Repeat T . P.inj./Botox I/A steroid /R.F.

36. Paramedian pain ↓ on sitting
Deep tenderness of paraspinal
muscle+
Extension ↑ pain
Diag. Psoas T.P. inj.+ ve
Repeat T.P.inj./Botox
Local tenderness over facet+
Extension ↑pain
Diagnostic facet jnt. inj.+ve
I/Articular steroid/ R.F of
medial branch