Back Pain Algorithm Initial assessment

1) Screen for potential emergencies with RED FLAGS Constitutional symptoms of fever or weight loss rogressive neurological !eficit "owel or urinary incontinence #istory of significant trauma #istory of osteoporosis$ heavy alcohol consumption or use of steroi! %ther me!ical causes eg& 'oster$ aneurysms$ etc(

)) Screen for ris* factors for long+term !isa,ility an! wor* loss with -ELL%. FLAGS / / / / / / / / 0egative ,elief that pain is harmful or potentially severely !isa,ling Fear avoi!ance ,ehaviour$ with re!uce! activity An e1pectation that passive$ rather than active treatment is ,eneficial E1cessive focus on pain Depresse! moo!$ low morale an! social with!rawal Low self+ efficacy Co+e1isting social or financial pro,lem oor 2o, satisfaction

Suggested methods of assessment: a( Screening 3uestions& +#ave you ha! time off wor* in the past with ,ac* pain4 +.hat !o you un!erstan! is the cause of your ,ac* pain4 +.hat are you e1pecting will help you4 +#ow is your employer respon!ing to your ,ac* pain4 -our co+wor*ers4 -our family4 +.hat are you !oing to cope with ,ac* pain4 +Do you thin* that you will return to wor*4 .hen4 ,( 5uestionnaires& + ain inta*e form + ain catastrophising scale + ain self efficacy scale 6) Delineate somatic symptoms an! its impact on patient7s function

8) For lower lim, pain$ !ifferentiate referre! pain from ra!iculopathy 0ature of pain Location 0eurological Referre! pain Dull$ aching$ e1pan!ing A,ove *nee 9 ,elow *nee "etter !efine! Superficial an! !eep 0ormal Ra!iculopathy Shooting$ electrical "elow *nee 9 a,ove *nee :ll !efine! Deep only ;ay have wea*ness < re!uce! refle1es

8) Current treatment =inclu!ing surgery) >) Current coping s*ills ?) E1amination for musclos*eletal$ neurological an! non+organic signs @) Formulate plan of management

Flowchart for Management of Back Pain at Combined Neurosurgery Pain Clinic:

Re! flags4 0o 0ote -ellow flags -es ;R:

otential surgical can!i!ate4

-es

0o

;R:

Eligi,le for ,loc*4 -es

Eligi,le for ,loc*4 0o

Regional ,loc* 0o -es 0o Eligi,le for surgery4

Significant cognitive ,ehavioural issue4 0o -es

-es

Regional ,loc*

;e!ication

Cognitive ,ehavioural therapy

Surgery

E !lanatory notes
6

I" #urgery:
+Decompression +Sta,ili'ation Potential surgical candidates for MRI: 1) Re! flags )) 0ew onset of neurological impairment 6) Severe pain with !isa,ility persists after non+operative treatment 9 ? wee*s Contra+in!ications& patient refusal$ significant psychiatric co+mor,i!ities$ on+going su,stance a,use Indication of discogram: 1) ersistent pain in whom !isc a,normality is suspecte! )) Assessment of !isc an! !isc level in patients in whom fusion is consi!ere! 6) Confirm a containe! !isc herniation when minimally invasive !iscectomy is consi!ere! Contrain!ications& patient refusal$ contrain!ication for surgery

II" Pharmacology
1) First line& 0SA:D < paracetamol )) Secon! line& Arama!ol >B+1BB mg t!s 6) Ra!iculopathy& Aricyclic anti!epressants =eg& Amitriptyline 1B+)> mg nocte) 8) Consi!er strong opioi!s =in opioi!+naCve patients) only if& Chronic pain 9 ) years$ A0D Faile! all other pharmacological < interventional management$ A0D 0o history of su,stance a,use$ A0D Goo! compliance with treatment an! agree for long term FD$ A0D Goo! insight on functional rather than symptomatic goal$ A0D :nforme! consent

III" Inter$ention
-May be considered if duration of back pain> 6/52 +Diagnostic& to !eci!e on operative treatment together with ;R: +Aherapeutic a" trigger !oint in%ection 1) For patients with i!entifia,le trigger points only )) Can ,e !one at % D straight$ !epen! on staff an! patient preference 8

6) Consi!er repeat if pain is responsive =9 ) wee*s) up to ? times per year for ma1imum of 1 year Contrain!ications& local sepsis$ coagulopathy$ patient refusal b" e!idural steroid 1) For ra!iculopathy only =regar!less of pathology$ eg& spinal stenosis$ :D$ ost+spine surgery$ etc() )) Consi!er repeat if pain is responsive =9 ? wee*s) up to ? times per year 6) Arans+foraminal approach =i(e( ner$e root block) preferre! especially with !ocumente! root compression or previous surgery( %ther approaches inclu!e cau!al an! interlaminer approach( 8) E+ray with contrast is re3uire! for cau!al an! trans+foraminal approaches$ an! is recommen!e! for interlaminar approach( Contrain!ications& coagulopathy$ local sepsis$ ,lee!ing ten!encies$ immuno!eficient$ patient refusal c" Facet or #I %oint 1) For parame!ian spinal ten!erness F<+ referre! pain only$ esp( when provo*e! ,y e1tension )) Goint or nerve in2ection will !epen! on anatomy upon fluoroscopy( :n general the me!ian ,ranch ,loc* is preferre! to 2oint in2ection 6) Consi!er repeat 2oint ,loc*s if pain is responsive =9 8 wee*s) up to ? times per year( 8) Consi!er ra!iofre3uency lesioning of me!ian ,ranch if nerve ,loc* is positive =imme!iate) up to 8 times per year Contrain!ications& same as for epi!ural steroi!

&ischarge
1) Symptomatic an! functional improvement$ without maintenance treatment& home )) Con!ition optimise! with simple maintenance pharmacology =0SA:D$ Amitriptyline$ etc()& G% D 6) Con!ition optimise! with more ela,orate me!ications =Ga,apentin$ Arama!ol$ etc()& F; clinic or other specialty clinics if agreea,le to all parties 8) Static con!ition with significant cognitive+,ehavioral issues amena,le to C"A& consi!er C% E >) Defaults& review con!ition on C;S( Call ,ac* patients with me!ical reasons =eg& proven sic*$ hospitali'e!)( Call ,ac* once only for non+me!ical reasons( 0o me!ication refill !uring !efaults unless with!rawal is a concern an! loss of me!ication is ,eyon! !ou,t(

'eferences >

1) A!ult low ,ac* pain( Institute for Clinical Systems Improvement (ICSI); 2 !" #ational $uideline Clearinghouse" %%%"guideline"gov )) "ac* pain( &ustralian 'amily Physician (une 2 ! )ol" **; + 6) Australian management strategies for oral opioi! use in non+malignant pain $ouc,e" -uropean (ournal of Pain 2 .; /(Supp" &): 001. . 8) Evi!ence ,ase! practice gui!elines for interventional techni3ues in the management of chronic spinal pain( &merican Society of Interventional Pain Physicians" Pain Physicians 2 *; +: *12. >) Chronic pain management& a para!igm( Chen" 3he 4ong 5ong Pracitioner 2 !; 2+:266122! ?) Gui!e to assessing psychosocial yellow flags in acute low ,ac* pain& Ris* factors for long+term !isa,ility an! wor* loss( #ational &dvisory Committee on 4ealth and 7isa8ility" (anuary .006 edition @) Lum,ar !iscography( osition statement from the 0orth American Spine Society Diagnostic an! Aherapeutic Committee( $uyer" Spine .00/; ./;2 (.2):2 !21/0