This document summarizes a presentation on the evaluation and treatment of low back pain. It discusses how low back pain is very common, affecting 80% of adults, and is a major cause of job disability. It reviews the anatomy of the spine and different potential sources of back pain, such as mechanical issues, infections, and tumors. Conservative treatments like physical therapy, medications, and interventional procedures are discussed. Imaging is generally not recommended for uncomplicated acute low back pain. The presentation provides an overview of evaluating the underlying cause of back pain and managing it through rehabilitation, medications, procedures and other approaches.

1. Evaluation & Treatment of Low
back Pain
GLOBAL CONFERENCE ON NEUROSCIENCE & NEUROLOGY
CHICAGO, ILLINOIS
KAVITA TRIVEDI, DO
Associate Professor
Physical Medicine & Rehabilitation
UT Southwestern Spine Center
Dallas, Texas
August 24, 2019

2. Why Is Back Pain Important?
About 80% of adults experience low back pain at some point in their
lives
According to the National Institute of Neurological Disorders and
Stroke, it is the most common cause of job-related disability and a
leading contributor to missed work days

3. RECOGNITION OF PAIN & SUFFERING
http://www.ektopia.co.uk/ektopia/images/pain.jpg http://www.time.com/time/covers/0,16641,20050228,00.html
LOW BACK PAIN IS THE 2ND MOST COMMON SYMPTOM-RELATED
REASON TO VISIT A PHYSICIAN

4. The effects of Pain
 ALTERS PHYSICAL & EMOTIONAL FUNCTIONING
 DECREASED QUALITY OF LIFE
 IMPAIRS THE ABILITY TO WORK
 PATIENTS WITH CHRONIC PAIN USE HEALTH CARE SERVICES UP TO 5X MORE
FREQUENTLY
 COST OF LOSS OF PRODUCTIVE TIME AMONG US WORKERS FROM COMMON
PAIN CONDITIONS:
≈ $61.2 BILLION/YEAR*
*Walter et al. JAMA. 2003; 290: 2443-2454

5. DECADE OF PAIN CONTROL & RESEARCH
 CONGRESSIONAL MANDATE
DECLARED FOR 2001-2010
 INCREASING NATIONAL
AWARENESS
 PAIN IS THE “FIFTH VITAL SIGN”
 RELIEF OF PAIN IS ONE OF THE
GREATEST OBJECTIVES OF
MEDICINE
http://z.about.com/d/headaches/1/G/u/9/decade-of-pain2.jpg

6. Opioids – What’s all the buzz?
This caused an increase in the number of opioid prescriptions written
Between 1991 and 2011, painkiller prescriptions in the U.S. tripled from 76 million
to 219 million per year
As of 2016, more than 289 million prescriptions were written for opioid drugs per
year
“Facing addiction in America” (PDF). U.S. Surgeon General. 2016. p 413. original pdf October 19, 2017.

7. Opioids – What’s all the buzz?
ACCORDING TO TRUSTY SOURCE WIKIPEDIA … THE OPIOID EPIDEMIC OR
OPIOID CRISIS IS A TERM THAT GENERALLY REFERS TO THE RAPID INCREASE
IN THE USE OF PRESCRIPTION AND NON-PRESCRIPTION OPIOID DRUGS,
PARTICULARLY IN THE UNITED STATES AND CANADA, BEGINNING IN THE LATE
1990S
OPIOIDS WERE RESPONSIBLE FOR 49,000 OF THE 72,000 DRUG OVERDOSE
DEATHS OVERALL IN THE US IN 2017
Overdose death rates. By national institute on drug abuse (nida).

8. Number of yearly U.S. opioid overdose deaths from all opioid drugs. There were
72,000 drug overdose deaths in 2017 in the U.S.

11. Chronic pain
According to the CDC, about 50 million americans have chronic pain
(as of Sept 2018) – That’s over 20% of the adult US population!
20 million of those have “high-impact chronic pain” – that is, pain
severe enough that it frequently limits life or work activities

12. Let’s get back to the
low back pain …
Before deciding on treatment for low back pain, we must identify
the pain generator in the spine

13. SPINE ANATOMY REVIEW
• ANTERIOR COMPARTMENT
• VERTEBRAL BODIES
• DISCS
• NEURAXIAL COMPARTMENT
• NERVE ROOTS
• CAUDA EQUINA & SPINAL CORD
• POSTERIOR COMPARTMENT
• FACET JOINTS
• MUSCLES

14. DIFFERENTIAL DIAGNOSIS OF SPINE
PAIN
 MECHANICAL
 HERNIATED NUCLEUS PULPOSUS
 INTERNAL DISC DISRUPTION
 COMPRESSION FRACTURES
 RADICULITIS
 SPINAL STENOSIS
 SPONDYLOLISTHESIS
 SPONDYLOSIS, OSTEOARTHRITIS
 FACET ARTHROPATHY
98% OF BACK PAIN IS MECHANICAL

15.  NONMECHANICAL
 TUMOR: GIANT CELL TUMOR, METASTASES, MULTIPLE
MYELOMA, LYMPHOMA
 INFECTION: VERTEBRAL OSTEOMYELITIS, DISKITIS, HIV,
LYME DZ, TB
 INFLAMMATORY ARTHRITIS: RHEUMATOID ARTHRITIS,
DISH, ANKYLOSING SPONDYLOSIS
 VISCERAL DISEASES: NEPHROLITHIASIS,PROSTATIS, PID
 MISC: OSTEOPOROSIS, PARATHYROID DZ,
HEMOGLOBINOPATHIES, PSYCHOSOMATIC D/O,
NEUROPATHIC JOINTS
2% OF BACK PAIN IS NONMECHANICAL

16. POSTERIOR COMPARTMENT: FACET PAIN
 15-40% OF NON-RADICULAR LBP
 40-60% OF NON-RADICULAR NECK
PAIN
 SYNARHRODIAL JOINT SUBJECT
TO DEGENERATIVE ARTHRITIS
 CAN CO-EXIST WITH OTHER
CONDITIONS
http://www.advpain.com/diagnosis/kbImages
/facet-joint-mediated-pain.bmp
H&P OFTEN UNABLE TO PREDICT IF PAIN ORIGINATES FROM FACETS*
*SAAL, JS SPINE 2002; 27:2538-2545 & MANCHIKANTI, L ET AL CURR REV PAIN. 2000; 4:337-344

17. FACET PAIN
 PROLONGED STANDING IN LORDOTIC
POSTURE 16% OF AXIAL LOAD IS ASSUMED
BY FACETS
 IN LUMBAR SPONDYLOSIS, 70% OF LOAD
CAN BE TRANSMITTED TO THE FACET
 FACETS ARE SUBJECT TO MICRO-TRAUMA,
CAPSULAR TEARS, SYNOVIAL
INFLAMMATION, DEGENERATIVE ARTHRITIS,
SEGMENTAL INSTABILITY & POST-SURGICAL
STRESS (ADJ SEGMENT BREAKDOWN)

18. LUMBAR FACET PAIN
 LBP W/ RADIATION TO BUTTOCKS, GROIN, HIP & PROXIMAL LEGS
(ABOVE KNEE)
 DULL, DEEP & DIFFICULT TO DESCRIBE
 NO NEUROLOGIC DEFICIT
 PARALUMBAR TENDERNESS
 TWISTING, BENDING OR ROTATION
 IMPROVED BY WALKING
 DEGENERATIVE CHANGES ON RADIOLOGIC STUDIES
http://www.dcmsonline.org/jax-
medicine/1998journals/october98/hallfig3.jpg

19. NEURAXIAL COMPARTMENT PAIN
 CAN CAUSE RADICULAR & AXIAL PAIN
 SPONDYLOSIS
 SPINAL STENOSIS
 HERNIATED NUCLEUS PULPOSUS
 DISC MATERIAL IN EPIDURAL SPACE CAUSING
INFLAMMATION OF NERVE ROOTS
http://stemcelldoc.files.wordpress.com/2009/05/lumbar_herniation_intro011.jpg

20. NEURAXIAL COMPARTMENT PAIN
CLASSIC SIGNS OF RADICULOPATHY:
 SHARP, SUDDEN SHOOTING PAIN
 INCREASED PAIN WITH COUGHING,
SNEEZING OR STRAINING
 LIFTING HEAVY LOAD WHILE IN AN
AWKWARD POSITION (BENDING &
TWISTING MOTION)
 REPETITIVE SPINAL MOTIONS CAN
BE CAUSATIVE

21. http://www.backpain-guide.com/Chapter_Fig_folders/Ch07_Symptoms_Folder/Ch7_Images/07-1_Lumb_Radic.jpg

22. NERVE ROOT PAIN
 DORSAL ROOT GANGLION IS THE PAIN SENSITIVE STRUCTURE
 CHEMICAL IRRITATION: DISC DEGENERATION RELEASES
INFLAMMATORY MEDIATORS, RESULTING IN PROLOGNED
ABNORMAL DISCHARGES FROM DRG
 MECHANICAL IRRITATION: HERNIATION & FORAMINAL STENOSIS
COMPRESS DRG & NERVE ROOT, CAUSING ABNORMAL NEURONAL
DISCHARGES RESULTING IN PAIN

23. SPINAL STENOSIS
PATHOPHYSIOLOGY:
- CONGENITALLY SMALL CANAL SIZE
- DEGENERATIVE OSTEOPHYTES
- SPONDYLOLISTHESIS
- FACET JOINT HYPERTROPHY
- THICKENING OF LF
- DISC HERNIATION
http://rezidentiat.3x.ro/eng/lombalgiaeng.files/image012.jpg

24. SPINAL STENOSIS
 HALLMARK SYMPTOM: NEUROGENIC CLAUDICATION
 ACHY PAIN WITH PARESTHESIAS IN LE
 PAIN PROVOKED BY PROLONGED STANDING & WALKING
 RELIEVED BY LEANING FORWARD & SITTING

25. ANTERIOR COMPARTMENT
 DISCOGENIC PAIN:
 39% OF CHRONIC LBP IS A RESULT OF INTERNAL DISC DISRUPTION
 DISRUPTION OF INTERNAL ARCHITECTURE OF A DISC
 WORSENS WITH PROLONGED SITTING
 EXCESSIVE COMPRESSION FORCE MAY RESULT IN FRACTURE OF
VERTEBRAL ENDPLATE
 DISC DEGENERATION SPREADING RADIALLY TO ANNULUS FIBROSIS
CAUSING FISSURE
 NERVE ENDINGS ARE ONLY AT OUTER 1/3 OF ANNULUS FIBROSIS

26. LUMBAR DEGENERATIVE DISC DISEASE
SYMPTOMS:
CAN RANGE FROM
INTERMITTENT EPISODES TO
CHRONIC LOW BACK PAIN
WORSE WITH BENDING,
LIFTING, TWISTING

28. LUMBAR DISC HERNIATION
DISC BULGE: ANNULAR FIBERS INTACT
DISC PROTRUSION: LOCALIZED BULGE WITH DAMAGE OF
SOME ANNULAR FIBERS
DISC EXTRUSION: EXTENDED BULGE WITH LOSS OF ANNULAR
FIBERS BUT DISC REMAINS INTACT
DISC SEQUESTRATION: FRAGMENT OF DISC BROKEN OFF
FROM NUCLEUS PULPOSUS

29. LUMBAR DISC HERNIATION
SYMPTOMS:
SHARP, STABBING, BURNING PAIN IN LOW
BACK AREA WHICH CAN EXTEND TO LEG
SOMETIMES ASSOCIATED WITH NUMBNESS &
TINGLING
ADVANCED DISC HERNIATIONS CAN BE ASSOC
WITH WEAKNESS & DIMINISHED REFLEXES
CLASSICALLY, SITTING MAKES THE PAIN
WORSE

30. ANTERIOR COMPARTMENT
VERTEBRAL COMPRESSION FRACTURES:
 MOST COMMON FX IN OSTEOPOROTIC PT
• 700,000 FRACTURES ANNUALLY
1
• 260,000 PTS W/ 1ST PAINFUL FX DX EACH YR
2
• AFTER 1ST VCF, RISK OF SUBSEQUENT VCF
INCREASES BY MORE THAN 5-FOLD
3
1
Riggs and Melton, Bone, Vol 17, No 5, Nov 1995
2
Cooper et al, J Bone Min Research, Vol 7, No 2, 1992
3 Ross et al, Annals Int Med, June 1991

31. VERTEBRAL COMPRESSION FRACTURES
ACUTE OR CHRONIC BACK PAIN
FOLLOWS MINOR INJURY OR ACTIVITY
SHARP PAIN WITH MOVEMENT
PAIN BETTER WITH REST
CHRONIC PAIN IN THORACIC OR LS
SPINE

33. SPINE IMAGING
According to the ACR Appropriateness Criteria for Low Back Pain:
“It is now clear that uncomplicated acute LBP and/or radiculopathy is a benign,
self-limited condition that does not warrant any imaging studies.”
“Imaging is considered for those without improvement after 6 weeks and for those
with red flags” [Trauma, unexplained weight loss, age > 50
(osteoporosis/compression fx), unexplained fever/hx of infection, immunosuppression,
hx of cancer, IVDA, prolonged use of corticosteroids, age > 70, focal neurologic
deficit with progressive symptoms/cauda equina, duration > 6 weeks, prior sx]

34. PRINCIPLES OF
SPINE PAIN MANAGEMENT:
FUNCTIONAL
RESTORATION
REHABILITATION MODALITIES
PHARAMCOLOGIC THERAPY
PSYCHOLOGICAL TX
INTERVENTIONAL PROCEDURES

35. PHYSICAL THERAPY
STRETCHING
INCREASES RANGE OF MOTION OF
LOW BACK AND LOWER
EXTREMITIES
HAMSTRING & PSOAS MUSCLE
STRETCHES

36. HAMSTRING STRETCHES
DEFINED CONNECTION BTWN
TIGHT HAMSTRINGS & LOW
BACK PAIN
TIGHT HAMSTRINGS 
LIMITS PELVIC MOTION 
PLACES EXTRA STRAIN ON
LOW BACK

37. HAMSTRING STRETCHES

38. PSOAS MUSCLE
FUNCTION:
* HIP FLEXOR
* SPINE FLEXION
* STABILIZE & BALANCE
TRUNK

39. PSOAS MUSCLE STRETCHES

40. POSTURAL TRAINING

41. McKENZIE EXERCISES
DEVELOPED IN THE 1980s BY ROBIN McKENZIE (PHYSICAL
THERAPIST IN NEW ZEALAND)

42. McKENZIE EXERCISES
BASED ON CENTRALIZATION OF PAIN

43. McKENZIE EXERCISES
PRONE LYING
PRONE LYING ON ELBOWS
PRONE PRESS-UPS
PROGRESSIVE EXTENSION WITH PILLOWS
STANDING EXTENSION

44. EVIDENCE FOR McKENZIE THERAPY
McKENZIE vs BACK SCHOOL
LOWER PAIN SCORES FAVORING
McKENZIE PAIN SCORES FAVORING
McKENZIE AT SHORT & LONG-TERM
FOLLOW-UP
HIGHER RETURN TO WORK RATE
STANKOVIC R & JOHNELL O. CONSERVATIVE TREATMENT OF ACUTE LOW BACK PAIN: A PROSPECTIVE RANDOMIZED TRIAL. MCKENZIE METHOD OF
TREATMENT VS PATIENT EDUCATION IN ‘MINI BACK SCHOOL’ SPINE 1990; 15: 120-3.

45. OTHER CONSERVATIVE TREATMENTS FOR
SPINE ISSUES…
MEDICATIONS

46. WHO ANALGESIC PAIN LADDER

47. OVERVIEW OF INTERVENTIONAL SPINE
PROCEDURES
 POSTERIOR:
 FACET INJECTIONS
 MEDIAL BRANCH BLOCKS
 MEDIAL BRANCH RADIOFREQUENCY ABLATION
 NEURAXIAL:
 EPIDURAL STEROID INJECTIONS
 SPINAL CORD STIMULATION
 ANTERIOR:
 PERCUTANEOUS DISC PROCEDURES
 VETEBRAL AUGMENTATION

48. POSTERIOR ELEMENT INTERVENTIONS
 FACET INJECTIONS
 MEDIAL BRANCH
DIAGNOSTIC BLOCKS
 MEDIAL BRANCH
RADIOFREQUENCY
ABLATION

49. EPIDURAL STEROID INJECTION
RATIONALE: INFLAMMATION OF NERVE ROOT IN EPIDURAL SPACE
- BY LEAKAGE OF DISC MATERIAL
- COMPRESSION OF NERVE ROOT VASCULATURE
- IRRITATION OF DRG FROM SPINAL STENOSIS
EPIDURAL STEROID INDUCED ANALGESIA:
- INHIBITION OF PLA2 & INFLAMMATION
- INHIBITION OF NEURAL TRANSMISSION IN C-FIBERS
- REDUCTION OF CAPILLARY PERMEABILITY

50. http://www.eorthopod.com/images/ContentImages/pm/pm_general_esi/pmp_general_esi_fluoro02.jpg

51. EPIDURAL STEROID INJECTION
INDICATIONS: LUMBAR
 LUMBOSACRAL DISC HERNIATION WITH RADICULAR PAIN
 SPINAL STENOSIS WITH RADICULAR PAIN (CENTRAL CANAL,
FORAMINAL & LATERAL RECESS STENOSIS)
 COMPRESSION FRACTURE OF LUMBAR SPINE WITH RADICULAR
PAIN
 FACET OR NERVE ROOT CYST WITH RADICULAR PAIN

53. SPINAL CORD STIMULATION
 AN SCS SYSTEM INVOLVES
PLACEMENT OF AN ELECTRIC
PADDLE OR LEADS WHICH SEND
ELECTRICAL PULSES TOWARD
SPINAL CORD
 THESE ELECTRICAL SIGNALS
CAN REPLACE THE FEELING OF
PAIN WITH A TINGLING
PARESTHESIA

54. SPINAL CORD STIMULATION

55. ANTERIOR COMPARTMENT
INTERVENTIONS
 PERCUTANEOUS DISC PROCEDURES
 VERTEBRAL CEMENT
AUGMENTATION
http://www.nationalpainfoundation.org/images/BackAndNeck_IDET%20f
ig%2016%5D.jpg

56. VERTEBRAL AUGMENTATION
VERTEBROPLASTY KYPHOPLASTY

57. INDICATIONS:
 PAINFUL OSTEOPOROTIC VCF REFRACTORY TO 3 WKS OF ANALGESIC
THERAPY
 PAINFUL VERTEBRAE DUE TO BENIGN OR MALIGNANT PRIMARY OR
SECONDARY BONE TUMORS
 PAINFUL VCF WITH OSTEONECROSIS (KUMMEL’S DISEASE)
 REINFORCEMENT OF VERTEBRAL BODY PRIOR TO SURGICAL
PROCEDURE*
 CHRONIC TRAUMATIC VCF WITH NONUNION*
J VASC INTERV RADIOL 2003;14:827-831.
*CARDIOVASC INTERVENT RADIOL 2006;29:173-178.

59. THANK YOU