Dr patnaik low back pain non surgical treatment options

Neck and Back Pain: Non Surgical Options
Gourishankar Patnaik

• October 16 each year, World Spine Day has
become a focus in raising awareness of back pain
and other spinal issues.
• Estimated one billion people worldwide suffering
all age groups(1 in 4 suffer )
• Biggest single cause of disability
• Prevention is therefore key and this year’s World
Spine Day will be encouraging people to take steps
to be kind to their spines.
www.docgspatnaik.com

Learning Objectives..
• Prevalence of acute and chronic low back and neck pain
• appropriate tools for the diagnosis of low back and neck
pain
• Identify red and yellow flags
• appropriate pharmacological and non-pharmacological
strategies for the management of back and neck pain
• An overview of American Spine Centre ,Muscat

What is low back pain?
• Pain below the costal margin and above
the gluteal folds, with or without
radiation to the lower extremity1
• Acute vs. chronic low back is pain
classified according to duration:
• Acute: less than 3 months2,3
• Chronic: more than 3 months2,3
1. Airaksinen O et al. Eur Spine J 2006; 15(Suppl 2):S192-300; 2. International Association for the Study of Pain. Unrelieved Pain Is a Major Global Healthcare Problem.
Available at: http://www.iasp-pain.org/AM/Template.cfm?Section=Press_Release&Template=/CM/ContentDisplay.cfm&ContentID=2908.
Accessed: July 22, 2013. 3. National Pain summit Initiative. National Pain Strategy: Pain Management for All Australians.
Available at: http://www.iasp-pain.org/PainSummit/Australia_2010PainStrategy.pdf. Accessed: July 22, 2013.

Back Pain : Definition
• Pain, muscle tension or
stiffness localized below
the costal margin and
above the inferior gluteal
folds, with or without leg
pain
• International Association
for the study of pain (IASP)
• Low Back Pain
• Lumbar spinal pain
• Sacral spinal pain
• Lumbosacral pain
• Gluteal and Loin pain
(not considered LBP)

Neck Pain
• Neck pain is a common
complaint and tends to
occur with increasing
frequency after the age of
30. Most are short-lived
and respond to
nonoperative management.
• Degenerative disease of the
cervical spine is an age-
related process that affects
many components of the
cervical spinal column.
• The spectrum of cervical
spondylosis ranges from
axial neck pain to
radiculopathy to frank
myelopathy.

Epidemiology of Low Back Pain
• >80% of adults experience back pain at
some point in life1
• Incidence is highest in third decade2
• Overall prevalence increase with age
until the age of
60–65 years2
• Men and women are equally affected3
• 5th leading reason for medical office
visits4
• 2nd most common reason (after
respiratory illness) for symptom-related
physician visits4
• Most common cause of work-related
disability5
1. Walker BF. J Spinal Disord 2000; 13(3):205-17; 2. Hoy D et al. Best Pract Res Clin Rheumatol 2010; 24(6):769-813;
3. Bassols A et al. Gac Sanit 2003; 17(2):97-107; 4. Hart LG et al. Spine (Phila PA 1976) 1995; 20(1):11-9; 5. National Institutes of Health.
Low Back Pain Fact Sheet. Available at: http://www.ninds.nih.gov/disorders/backpain/detail_backpain.htm. Accessed: July 22, 2013.

Epidemiology of Neck Pain

What is the anatomic source of Pain ?
• Controversial
• Possible sources
• Discs
• Facet (Zygapophysial)
Joints
• Sacroiliac Joints
• Ligaments
• Muscles

Neck Pain:clinical manifestations
• The clinical manifestations of neck
disorders range from midline posterior
neck pain to the neurologic sequelae
of cervical nerve root or spinal cord
compression.
• Axial neck pain may radiate from the
base of the skull down to the upper
trapezius region.
• Cervical radiculopathy involves
compression of a nerve root, with pain
radiating down the arm in an anatomic
distribution.
• Cervical myelopathy is characterized by
dysfunction of the spinal cord. This
may be caused by cord compression,
vascular abnormalities, or a
combination of both.

Back Pain: Classification
Complicated (“Red Flag”
conditions)
Specific Diagnosis
Lumbar Radiculopathy
Lumbar Spinal Stenosis
Others such as Ankylosing
Spondylitis
Uncomplicated (Non-Specific)
A diagnosis of exclusion

Classification by duration !!
Acute: Lasts <4 weeks
 Often cause can’t be determined
 May be related to trauma or musculo-ligamentous strain
 Usually resolves within 4 weeks with self care
 Subacute: Lasts 4–12 weeks
 Transition period between acute and chronic back pain
 Improvement is not as pronounced as in the acute phase
 Chronic: Lasts >12 weeks
 Patients at risk for long-term pain or functional disability
 Episodes of pain may recur (“acute-on-chronic” symptoms)

History and physical exam : Evaluation
• Key elements
• Sensory loss? Muscle weakness?
• Limited range of motion in the legs and feet?
• Characterize the pain level
• 3 categories of back pain
• Nonspecific low back pain
• Back pain associated with radiculopathy or spinal stenosis
• Other specific systemic or spinal causes of back pain
• Identify any features indicating serious underlying cause
• Identify radiculopathy (compressed nerve in the spine)
• Identify any psychosocial factors

Factors are associated with development of low back pain
 Work that requires heavy lifting; bending and twisting; or whole-body
vibration, such as truck driving
 Physical inactivity
 Obesity
 Arthritis or osteoporosis
 Pregnancy
 Age >30 years
 Bad posture
 Stress or depression
 Smoking

Common Causes of Low Back Pain
Mechanical (80-90%)
(e.g., disc degeneration, fractured vertebrae, instability, unknown cause [most cases])
Neurogenic (5-15%)
(e.g., herniated disc, spinal stenosis, osteophyte damage to nerve root)
Non-mechanical spinal conditions (1-2%)
(e.g., neoplasm, infections, inflammatory arthritis, Paget’s disease)
Referred visceral pain (1-2%)
(e.g., gastrointestinal disease, kidney disease, abdominal aortic aneurism)
Other (2-4%)
(e.g., fibromyalgia, somatoform disorder, “faking” pain)
Cohen S. BMJ 2008; 337:a2718.

Inflammatory vs. Mechanical Back Pain
Inflammatory
 Age of onset < 40
 Insidious onset
 > 3 months duration
 > 60 min Morning stiffness
 Nocturnal pain
 Improves with activity
 Tenderness over SI joints
 Loss of mobility in all planes
 Decreased chest expansion
 Unlikely to have neurologic
deficits
Mechanical
 Any age
 Acute onset
 < 4 weeks duration
 < 30 min Morning stiffness
 No nocturnal pain
 Worse with activity
 No SI joint tenderness
 Abnormal flexion
 Normal chest expansion
 Possible neurologic deficits

RED FLAGS

EXAMINATIONS OF PATIENTS WITH BACK PAIN
• Physical examination is a crucial element of diagnosis.
• The straight leg raise test or The Lasègue sign can be
used to diagnose nerve-root irritation.
• Other simple tests include asking patients to walk on
heels and toes, trying pelvic tilts and a range of motion
of trunk movements – all of which may identify pain.
• The Schober test measures the flexibility of the spine
• Faber (Flexion Abduction External Rotation) test is used
to differentiate lumbar spinal problems from primary
hip pathology.
• Referral for imaging may be indicated in patients with
severe or progressive neurological deficits or signs of
radiculopathy or spinal stenosis.

Radicular vs. Referred Pain
Radicular Pain Somatic Referred Pain
Leg > Back Back > Leg
Shooting, Lancinating,
Cutaneous component
Dull, Pressure-like, Deep
Travels along the limb in a
narrow band
Extends into limbs across
a wide region
+/- neurologic deficit - neurologic deficit

Neuropathic Component of Low Back Pain
Neuropathic component of low
back pain may be caused by:
• Mechanical compression of
nerve root (mechanical
neuropathic nerve root pain)
• Damage to sprouting C-fibers
within the degenerated disc
(localized neuropathic pain)
• Action of inflammatory
mediators released from the
degenerated disc
(inflammatory neuropathic
nerve root pain), even without
mechanical compression
Freynhagen R, Baron R. Curr Pain Headache Rep 2009; 13(3):185-90.

Recognizing Neuropathic Pain
Burning Tingling Shooting Electric shock-like Numbness
Baron R et al. Lancet Neurol. 2010; 9(8):807-19; Bennett MI et al. Pain 2007; 127(3):199-203; Gilron I et al. CMAJ 2006; 175(3):265-75.
Be alert for common verbal descriptors of neuropathic pain.
• Various neuropathic pain screening tools exist
• Tools rely largely on common verbal descriptors of pain,
though some tools also include physical tests
• Tool selection should be based on ease of use

NECK PAIN:IMAGING STUDIES
PLAIN X-RAYS. A plain x-ray
series should include an
anterior/posterior view, a
lateralview, and oblique
views. Degeneration can
often be noted within the
disc spaces and the facet
joints. Look for osteophytes
noted along the area of the
disc space, and foraminal
narrowing.
COMPUTED TOMOGRAPHY
Computed tomography (CT)
is helpful in evaluating the
fractures and degee of
foraminal stenosis.

Neck Pain : Radiology
 MRI has become perhaps
the primary imaging
modality for cervical spine
disorders.
 It provides excellent
visualization of the spinal
cord and soft tissues.
 Measurements of sagittal
and axial canal diameters
as well as cord compression
ratios can be calculated
from an MRI.

Neck Pain: DIFFERENTIAL DIAGNOSIS
Trauma :cervical sprain, traumatic
injury to the brachial plexus,
fracture, dislocation, or post-
traumatic instability need to be
considered.
Inflammatory conditions
including rheumatoid arthritis and
ankylosing spondylitis ,discitis,
osteomyeltis, or soft tissue
abscess.
Tumors: include metastatic
tumors, primary bone tumors,
and tumors within the spinal cord
Shoulder disorders rotator cuff
disease, instability, and
impingement
Neurologic demyelinating
disease, multipl sclerosis,

Treatment : Conservative care
Lifestyle modifications should be
instituted to avoid activities that
tend to create or aggravate neck
and arm symptoms.
medications NSAIDs ,mild
narcotics, steroids and muscle
relaxants .
Physical therapy is often useful
once the phase of severe pain
and radicular problems resolve.
Modalities including traction,
ultrasound, or diathermy can
give pain relief. exercise
regimen include active ROM
exercises along with some
isometric exercises can help
regain the strength of the neck.

Neck Pain Treatment
 Surgery is indicated in cases
of significant radicular pain
that has failed to respond to
conservative treatment, or in
the presence of significant
neurologic deficits.
 Only a small percentage of
patients with cervical spine
problems eventually require
surgery. The goal of surgery
with myelopathy is to
prevent progression of the
disease

Back Pain : Radiology
Plain X RAY : AP and
Lateral views
 Normal
 Degenerative changes
Finding of degenerative disc
disease, listhesis or pars
defect does not establish
the cause of low back pain.
CT scan
• Best in planning treatment
for spinal fractures

MRI
• MRI often shows abnormal
findings in asymptomatic
patients.
• Recommended initial imaging
study of choice in complicated
low back pain like cancer,
infection, cauda equina
syndrome and severe or
progressive neurologic deficit.
• Lumbar disc herniation
• Lumbar spinal stenosis :Spinal
stenosis in 25% of asymptomatic
adults over 60 years.

Management of Acute Low Back Pain
Adapted from: Lee J et al. Br J Anaesth 2013; 111(1):112-20.
Clinical presentation: acute low back pain
History and examination
Red flags?
Consider differential diagnosis
Advise mobilization
and avoidance of
bed rest
Provide appropriate
pain relief
Review and assess improvement within 2 weeks
Provide education
and counsel on
self-care
Investigation and
management;
consider referral
No Yes

Natural History
• Most recover rapidly
• 90% of patients seen within 3 days of symptom onset
recovered within 2 weeks
• Recurrences are common
• Most have chronic disease with intermittent
exacerbations
• Spinal stenosis is the exception  usually
gets progressively worse with time

Treatment of Uncomplicated LBP
• Life Style Changes
• Diet
• Exercise
• Weight control
• No smoking
• Physical Therapy
• Medications?
Opioids?
• Spinal Injections?
• Surgery?

Pharmacotherapy for Low Back Pain
 Treatment must balance patient expectations for pain
relief and possible analgesic effect of therapy
 Patients should be educated about the medication,
treatment objectives and expected results
 Psychosocial factors and emotional distress are stronger
predictors of treatment outcome than physical
examination findings or the duration and severity of pain
Miller S. Prim Care 2012; 39(3):499-510.

Back Pain : Therapy
• Herniated intervertebral discs
• Nonsurgical treatment for at least a month
• Exceptions: cauda equina syndrome, progressive neurologic deficits
• Early treatment same as for nonspecific low back pain, but may need
short courses of narcotics for pain control
• Bed rest not useful
• Some patients benefit from epidural corticosteroid injections
• If severe pain, neurologic deficits  MRI and consider surgery
• Prolonged inactivity is associated with worse outcomes
• Minimize bed rest
• Maintain activity levels as near to normal as possible
• Most patients with nonspecific occupational low back pain can return
to work quickly
• Back-specific exercises don’t need to be started while patient is in
acute pain

Chronic low back pain
 Treatment for chronic low back pain (pain persisting for
over 3 months) falls into three broad categories:
monotherapies, multidisciplinary therapy, and
reductionism.
 Most monotherapies either do not work or have
limited efficacy (e.g., analgesics, non-steroidal anti-
inflammatory drugs, muscle relaxants, antidepressants,
physiotherapy, manipulative therapy and surgery).
 Multidisciplinary therapy based on intensive exercises
improves physical function and has modest effects on
pain.
 The reductionist approach (pursuit of a patho-
anatomical diagnosis with the view to target-specific
treatment) should be implemented when a specific
diagnosis is needed.

Back Pain : Prognosis
• Long Term outcome of low back
pain is generally favorable
• Higher expectation of recovery
have better outcomes
• Psychosocial variables are
stronger predictors of long term
disability than anatomic findings
in imaging studies
• Predictors of disabling chronic
low back pain include
maladaptive pain coping
behaviors, functional
impairments, poor general health
status, presence of psychiatric
comorbidities or non organic
signs

Interventional Spine Procedures
 Epidural Steroid
Injections
 Facet Interventions
 Sacroiliac Joint
Interventions
 Sympathetic blocks
(Stellate ganglion and
lumbar paravertebral)
 Discography (Intradiscal
Procedures)
 Spinal Cord Stimulation
(Neuromodulation)
 Intrathecal Pain Pump

Patient selection for Epidural Spinal Injections
• Positive Factors
• Radicular pain
• Radicular
numbness
• Short duration of
pain
• No significant
psychological
factors
• Negative Factors
• Axial pain primarily
• Work-related injury
• Unemployed due to pain
• High number of past
treatments and drugs taken
• Previous back surgeries
• Smoking
• Very high pain rating
• Litigation

Medical Evidence for ESIs
Why not ESI for axial LBP?
• Different anatomical origin of
pain– Facet arthropathy, Internal
Disc Disruption (Annular tear),
or Sacroiliac joint pain
• Epidural route of administration
of steroid does not reach the
target area any better than
systemic administration.
Medical Evidence for ESIs
• Lumbosacral radiculopathy
secondary to disc herniation
• Literature support – Yes
• Lumbar Spinal Stenosis with
leg pain --Literature support –
limited
• Failed back surgery syndrome
with leg pain
• Literature support - Don’t
know
• Other causes of axial back pain
• Literature support – No

Lumbar Facet Pain
• Clinical Symptoms
• Predominantly axial pain
• May have somatic referred
pain to legs
• Generally older patients
• Exam
• Lumbar paraspinal
tenderness
• Positive facet loading
• Negative nerve tension tests
• No focal neurologic deficit

Lumbar Facet Pain : procedures
 Intra-articular Steroid
Injection
 Medial Branch Block
 Percutaneous
Radiofrequency Medial
Branch Neurotomy

Radiofrequency Ablation
• Therapeutic procedure for
lumbar and cervical facet
pain
• Teflon-coated electrode with
an exposed tip is inserted
onto the target nerve.
• High frequency electrical
current is concentrated
around the exposed tip.
• The nerve is heated and
coagulated.

Sacroiliac Joint Pain
• Sacroilitis (Inflammatory
Arthritis)
• Ankylosing Sopondylitis
• Rheumatoid Arthritis
• Sacroiliac Joint Dysfunction
• Abnormal gait pattern
• Leg length discrepancy
• Lumbar fusion
• Trauma
• Scoliosis
• Pregnancy

Sacroiliac Joint Dysfunction
• Clinical Symptoms
• Pain near PSIS in gluteal
area
• Unilateral
• Pain when rising from
sitting
• May have somatic
referred pain down the
leg
• Does not pass above L4-5
level (iliac crest)
• Exam
• Multiple clinical exams
• Fortin Finger Test –
simplest

Sacroiliac Dysfunction: Treatment
Intra-Articular Injection
Radiofrequency Ablation
 Minimally invasive procedure that
introduces radiofrequency waves
and heat to the irritated nerve(s)
surrounding the dysfunctional SI
joint,
 The goal of permanently disrupting
the pain signals being sent to the
brain by the affected nerves.
 It can give Long term relief. It is a
developing techniques

American Spine Centre, Muscat, Oman
American Spine Centre is specialized in the
non-surgical treatment of spine and joint
pain by utilizing cutting-edge technology
from the USA with a success rate of 82% .
Comprised of patient-centric multiple
diagnostic and treatment steps, American
Spine Centre utilizes cutting-edge
technologies and methodologies for the
benefit of each patient with outcome
superseding surgical result.
We have successfully treated more than
1500 patients in in Oman non-surgically with
great outcome, saving them the need for
surgery.

AMERICAN SPINE CENTER’s 3600 protocol
• Consultation & Education: consultation and education, detailed
history and physical examination and review of previous records with
appropriate medication regimen.
• Decompression Therapy: This treatment targets the disc to provide
negative intra-discal pressure which improves blood flow and hydration
of the affected disc. This creates the best possible healing environment
to improve spinal disease. Intervertebral Disc Decompression is an
advanced nonsurgical technology.
• Non-Surgical Pain Procedures: Therapeutic injections are administered
to very specific areas of the spine to alleviate pain .
• Nutrition & Wellness patient’s active participation in the treatment
protocol produces long-lasting results. We address issues such as
smoking cessation, overweight problems, ergonomic posture, and
exercises that can fit into any lifestyle or schedule.

Decompression Therapy
 Intervertebral Disc Decompression is a
modern non-surgical technology
providing decompression therapy to
the spine.
 It comprises of a series of treatment
sessions that are specifically designed
for each patient.
 This technology is designed to provide
non-surgical treatment utilizing
differential dynamics.
 This relieves pressure on the spinal
nerves involved, especially those
associated with herniated discs,
degenerative disc disease, posterior
facet syndrome, and alleviates sciatica.
Features of IDD therapy
 Computerized & personalized program
based on the patient’s pathology.
 Mobilize and manipulate specific spinal
segments to induce negative intradiscal
pressure.
 Designed to provide static, intermittent
and cyclic oscillation forces.
 Forces applied to a specific disc in variable
direction, frequency and amplitude.

Role of IDD Therapy in the Back and Neck Pain
Patnaik G, J Med Stud Res 2018, 1: 002 HSOA Journal of Medicine: Study & Research
Conclusion: In the future, we see the IDD Therapy spinal treatment programme as a key cost-
effective resource to tackle both back pain itself and the ever-increasing costs of chronic back
pain to society and health care.

IDD - How does it work ??
 The treatment protocol achieves
decompression of intervertebral
discs, unloading through
distraction and positioning.
 Each treatment session is
designed according to the level of
problem.
 During the session, the patient is
closely monitored and after 10
treatments, the patient is
reviewed in terms of pain, motor
activity, sensation, function &
ROM.
 IDD is a highly integrated
software program allowed to
keep real time tracking of the
force applied to the specific
segment of the spine that is
injured.
 The IDD program gives real time
patient response, to the specific
program applied during therapy
session to ensure suitability of
the forces applied.

Key Messages
 Most acute nonspecific pain resolves w/o medical intervention
 Maintain normal activities as much as possible
 If symptoms persist, consider non drug interventions
 Exercise, spinal manipulation, acupuncture, massage
 Psychological therapies
 If analgesia needed
 First-line therapy: acetaminophen or NSAIDs
 Muscle relaxants / opiates: short course only, cautiously
 Antidepressants: may be helpful for chronic symptoms
 Urgent surgical referral indicated: if infection, cancer, acute nerve compression, or
cauda equina syndrome suspected
 Non urgent surgical referral: if back pain persists + symptoms suggest non acute
nerve compression or spinal stenosis

Multimodal Treatment of Low Back Pain
Pharmacotherapy
Stress management
Interventional
management
BiofeedbackComplementary therapies
Physical/
occupational therapy
Education
Lifestyle management
Sleep hygiene
Gatchel RJ et al. Psychol Bull 2007; 133(4):581-624; Institute of Medicine. Relieving Pain in America: A Blueprint for Transforming Prevention, Care, Education, and Research;
National Academies Press; Washington, DC: 2011; Mayo Foundation for Medical Education and Research. Comprehensive Pain Rehabilitation Center Program Guide. Mayo Clinic; Rochester, MN: 2006.

To conclude…..
 Most people suffer from low back pain at some point in
their life
 90% of the time low back pain is benign and
self-limiting
 “Yellow flags” may help identify individuals at risk for
chronic pain
 “Red flags” requiring immediate action should be assessed
in all patients presenting with low back pain
 Pain should be addressed using an interdisciplinary
approach including patient education and non-
pharmacological therapies
55

“For each ailment that doctors
cure with medications (as I am
told they do occasionally
succeed in doing) they produce
ten others in healthy individuals
by inoculating them with the
pathological agent a thousand
times more virulent than all the
microbes— the idea that they
are ill.”PROUST
The Remembrance of Things Past

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