What do we know?

• Is back pain a diagnosis?
• What is the cause of low back pain?
• How to make the diagnosis?
• What is the appropriate treatment?
• Role of the epidural?

Evidence based Practice.

Traditional / Normal Protocols

Low Back Pain

• Analgesic
• Physiotherapy
• Surgical Procedure

Structural Basis:

Structural Basis – Bogduk

• The structure should have a nerve supply;
• The structure should be susceptible to disease or injuries that are known to be  painful;
• The  structures should have been shown to be a source of pain in Points, using diagnostic techniques of known reliability and validity.

Structures proved to cause pain:

Controlled Diagnostic Blocks

With 2 types of separate local anesthetics, ( one short acting, other long acting ) are the only means to confirm the origin of the pain.

Rational Approach to lower back pain:

Anatomy:	Cause of back pain:	Path:	Prevalence:	Clinical
Muscles
Fascia
Ligaments
Dura	–	–	13%	–
Facet Joint	–	–	40%
SI Joint	–		2%
Disc	–	–	26%
Other			13%

Pain from the Dorsal root Ganlion:

	Radicular Syndrome:
History:	Provocation by coughing, sneezing & raise of abdominal pressure
Physical examination:	Positive straight leg raising test
Radiological Findings:	Sometimes nerve root compression on MRI/CT scan
Location of Pain:	Leg
Radiation of Pain:	Dermatomal
Occurrence of Pain:	Paroxysmal
Neurological Symptoms	Possible motor and/ or sensory  disfunction

Pain from the fact joint:

	Dorsal Compartment Syndrome:
History:	Pain on Hyperextension of spine.
Physical examination:	Pain on paravertebal pressure.

Pain on Dorsoflexion.Radiological Findings:Sometimes fact tropism or signs of arthritisLocation of Pain:Para-vertebral back painRadiation of Pain:Non-Dermatomal, usually not beyond kneeOccurrence of Pain:Continuous. Position & movement dependant.Neurological SymptomsNone.

Pain from the Sacro-lliac joint:

	Sacro-lliac joint  (SI) Syndrome:
History:	Pain in the sacroiliac area
Physical examination:	Pain on pressure over SIJ.

Pain on patrick’s & compression tests.Radiological Findings:Over the scroliac joint.Location of Pain:LegRadiation of Pain:Non-Dermatomal, usually not beyond kneeOccurrence of Pain:Continuous. Position & movement dependantNeurological SymptomsNone.

Pain from disc:

	Vertical compartment Syndrome:
History:	Prolonged sitting or standing position not tolerated.
Physical examination:	Pain on mid-spinal pressure. Pain when coming from flexion to upright position.
Radiological Findings:	Non-Specific.

Not always related to degeneration of disc.Location of Pain:Midline and/or paravertebral back pain.Radiation of Pain:Non-Dermatomal, usually not beyond kneeOccurrence of Pain:Continuous. Increases during day. Position & movement dependantNeurological SymptomsNone.

Value of clinical examination:

•  History
• Physical Examination
• Imaging
• Provide limited information

Rational Approach to lower back pain:

Anatomy:	Cause of back pain:	Path:	Prevalence:	Clinical	DX Block:
Muscles
Fascia
Ligaments
Dura	–	–	13%	–	Transformational
Facet Joint	–	–	40%	–
SI Joint	–		2%	–
Disc	–	–	26%	–
Other			13%

Guidelines for Radicular pain:

Radicular Pain:

• Step 1: Transformational Epidural
• Step 2: Percutaneous Adhesiolysis
• Step 3: Discography
• Step 4: Spinal Endoscopic Adhesiolysis
• Step 5: Implantable Therapy

Rational Approach to lower back pain:

Anatomy:	Cause of back pain:	Path:	Prevalence:	Clinical	DX Block:
Muscles
Fascia
Ligaments
Dura	–	–	13%	–	Transformational
Facet Joint	–	–	40%	–	Medium Branch
SI Joint	–		2%	–
Disc	–	–	26%	–
Other			13%

Rational Approach to lower back pain:

Anatomy:	Cause of back pain:	Path:	Prevalence:	Clinical	DX Block:
Muscles
Fascia
Ligaments
Dura	–	–	13%	–	Transformational
Facet Joint	–	–	40%	–	Medium Branch
SI Joint	–		2%	–	SIJ Block
Disc	–	–	26%	–
Other			13%

Rational Approach to lower back pain:

Anatomy:	Cause of back pain:	Path:	Prevalence:	Clinical	DX Block:
Muscles
Fascia
Ligaments
Dura	–	–	13%	–	Transformational
Facet Joint	–	–	40%	–	Medium Branch
SI Joint	–		2%	–	SIJ Block
Disc	–	–	26%	–	Discography
Other			13%

Rational Approach to lower back pain:

Anatomy:	Cause of back pain:	Path:	Prevalence:	Clinical	DX Block:	RX Block:
Muscles
Fascia
Ligaments
Dura	–	–	13%	–	Transformational	–
Facet Joint	–	–	40%	–	Medium Branch	–
SI Joint	–		2%	–	SIJ Block
Disc	–	–	26%	–	Discography	–
Other			13%

Therapeutic Interventional Epidurals:

Evidence:

• Strong short term
• Limited for long term
• Evidence in FBSS & Spinal Stenos is Limited