This document discusses concepts in pain management, with a focus on back pain. It notes that 70-80% of the US population experiences back pain at some point, but only 15% receive a definitive diagnosis, with many receiving a diagnosis of chronic sprain or strain. Reasons diagnostic is elusive include initial recovery rates of 70-80% but high recurrence rates, and imaging often not correlating with clinical symptoms. Specific sources of back pain discussed include the lumbar facets, discs, sacroiliac joints, and cervical facets. Diagnostic techniques like medial branch blocks and discography are discussed.

1. Pain Management
New Concepts for a New
Generation
Solomon KAMSON, M.D., PhD.

2. 70-80% of the U.S. population
eventually experiences back-pain
* only 15% of back-pain patients have a
definitive diagnosis
* many patients carry a diagnosis of
chronic sprain or strain
Von Korff M, Saunders K The course of back Pain in
primary care. Spine 21:2833-9,1996
Wahlgren DR et al. One year follow up of first onset low
back pain. Pain 73:213-221,1997

3. Epidemiology
• 70-80% of the U.S. population eventually
experiences back-pain
• Only 15% of back-pain patients have a definitive
diagnosis
• Many patients carry a diagnosis of chronic
sprain or strain
Von Korff M, Saunders K The course of back Pain in primary care. Spine
21:2833-9,1996
Wahlgren DR et al. One year follow up of first onset low back pain. Pain
73:213-221,1997

4. Why is Specific Diagnosis Elusive?
Low back Pain Spine Pain
• Initial short term recovery • Clinical examination is often
70-80% non-focal
• At one year follow up 25-48% • Imaging studies often may not
will report recurrence correlate with clinical pain
syndromes
• 13-15% will have moderate to
severe chronic pain • Red flag conditions are usually
evident by history and clinical
examination such as acute
Von Korff M, Saunders K The course of back Pain in
primary care. Spine 21:2833-9,1996
neurological deficit require
Wahlgren DR et al. One year follow up of first onset low immediate medical attention
back pain. Pain 73:213-221,1997

5. BACK PAIN
 
RADICULAR NON-RADICULAR
5 - 15% 85 - 95%
 
NEURAL IRRITATION PAIN WITHOUT NERVE
OR COMPRESSION COMPRESSION
Disc Herniation Internal Disc Disruption (>39%)
Canal / Recess Stenosis Facets (15%)
Osteophytes SI Joints (12%)
Spondylolisthesis Soft Tissue
Tumors Fractures / Mechanical
Extra-spinal causes

6. Spine Pain Without Neurologic
Signs or Symptoms
SOURCE
Definitive Diagnosis
Appropriate Therapy

7. Innervation of the Lumbar
Spine
• Sino-vertebral nerve
• Median branch nerve
• Dorsal root ganglion

9. INJECTION TECHNIQUE
• Selective nerve root
injection with
fluoroscopic guidance

10. Lateral Recess Stenosis

12. SYNOVIAL CYST

13. SYNOVIAL CYST

15. Prevalence of Spinal Pain
• Lumbar facet joint pain: 15-40%
• Lumbar disc pain: 39% >66%
• Sacroiliac joint pain: 12%
• Cervical facet joint pain: 54%
(s/p whiplash)
• Cervical disc pain: ?

16. Degenerative Facet Cascade
Facet degeneration
Facet dysfunction
Synovitis
Cartilaginous destruction
Capsular Instability
Degenerative Subluxation Facet Hypertrophy
Spondylolysis Spondylolisthesis
Spinal Stenosis

17. Facet Referred Pain
Gluteal
Trochanteric
Proximal thigh
Groin
Lumbar
Considerable overlap
Fukui s, Ohseto K, Shiotani M, Ohno K,
Karasawa H, Naganuma Y. Distribution of
referred pain from lumbar zygapophyseal
joints and dorsal rami. Clin J Pain
13:303-307,1997

18. Facet Injections
• Utility
Mainly diagnostic
Rarely therapeutic
• Technique
Intra-articular
Medial Branch Block

19. Diagnosing Facet Syndrome
Neither clinical
examination nor
imaging is reliable
for diagnosis of facet
syndrome
•Diagnostic
Injections is gold
standard
Schwarzer A, Derby R, Aprill CN et al. Pain from lumbar zygapophyseal joints. A test of
two models J Spine Dis 7:331-8:1994

22. Sacro-iliac Joint Pain Syndrome

23. SI Joint Arthrogram

24. Posterior Epidural Space

25. Cervical Facet Pain Referral
Patterns

26. Cervical Pain: Facets
• Stimulation of
zygapophyseal joints
causes pain in normal
volunteers
• In patients with neck
pain produces relief
with anesthetizing
joints
Dwyer et al Spine 15:453-457,1990
Bogduk Spine 7:319-330,1982
Wedel & Wilson. Reg Anesth 10:7-11,1985
Dussault & Nicolet. J Can Assoc Radiol 36:79-80,1985

27. Cervical Facet Innervation

28. Facet Injections
• Radio frequency ablation medial branch
provides most definitive treatment
Dryfuss P, Holbrook B, Pauza K, Joshi A, McLarty J, Bogduk N.
Efficacy and validity of radiofrequency neurotomy for chronic lumbar
zygapophysial joint pain. Spine 25:1270-7,2000
Lord SM, Barnsley L, Wallis BJ and Bogduk N. A randomized double
blinded controlled trial of percutaneous radiofrequency neurotomy
for the treatment of chronic cervical zygapophysial joint pain. N
Engl J Med 335:1721-1726,1996

29. Cervical Medial Branch
Rhizotomy

30. Upper Thoracic and Cervical
• C7-T2 Facet Pain

31. INTERVERTEBRAL DISC

32. INNERVATION OF THE DISC

33. INNERVATION OF THE DISC

34. Nucleus pulposis
• 70-90% H2O
• 65% proteoglycans
• 15-20% type 2 collagen
• non-collagenous proteins
• cartilage cells
• enzymes

35. ANNULUS FIBROSIS
• 60-70% H2O
• 50-60% type 1 collagen
• 15-20% proteoglycans
• 10% elastic fibers
• chondrocytes
• fibroblasts

36. I.D.D. = AXIAL BACK PAIN
• THEORETICALLY A CONSTANT
DEEP ACHING PAIN IS PRESENT
SECONDARY TO CHEMICAL
NOCICEPTION THAT IS
AGGRAVATED BY ANY MOVEMENT
THAT MECHANICALLY STRESSES
THE AFFECTED DISC
• HIP PAIN, THIGH PAIN, GROIN PAIN

37. DIAGNOSING I.D.D.
• History
• physical exam
• imaging studies
• DIAGNOSTIC DISCOGRAPHY

38. HIGH INTENSITY ZONE
High Intensity Zone

39. DIAGNOSTIC
DISCOGRAPHY
• The role of diagnostic discography is to
identify a pathological and painful disc
and distinguish it from a disc that is not
painful.
• Diagnostic discography provides
information about the structure and
sensitivity of discs that can not be
obtained from any other source.
• It is a highly reliable and specific dx.
test when performed correctly.

40. DIAGNOSTIC
DISCOGRAPHY

41. DIAGNOSTIC
DISCOGRAPHY

44. Lytic Isthmic Spondylolisthesis

49. Principles Of Co-Management
1. Communication
• Visit, phone, write DIRECTLY!
2. Graduated (incremental) Progression
• Pain Management to Minimally
Invasive Surgery
• Rehabilitation
Reconditioning and Prevention