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Interventional Pain Management of Low Back Pain

ow back pain is defined as acute/ sub acute or chronic discomfort localizedto anatomic area below the posterior ribs and above the lower margin of the buttock line.Back pain is most expensive health care problem because it affects 20to 50 years age group which is the most productive age. Eighty-five percentof our population suffers at least one episode of back pain a year. Most of them (Between 75% and 90%) resolve with in 2-4 weeks time and, about 5%to 10% of LBP patients required Interventional management however,degree of invasiveness and costs of different treatment modalities varies.Interventional Pain Management is some minimally invasive procedures (procedures including percutaneous precision needle placement,with placement of drugs in targeted areas or ablation of targeted nerves)which gives permanent/long term pain relief. It fills the gap between pharmacologic management of pain & operative procedures. This newdiscipline of medicine devoted to the diagnosis and treatment of pain andrelated disorders by the application of interventional techniques in managingsub-acute, chronic, persistent, and intractable pain, independently or inconjunction with other modalities of treatments.

Mechanism of Action:

IPM procedures acts through different mechanism of actions

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Targeted delivery of drugs.

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Aims to correct the pathology

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Blocking of nerve signals

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Neuromodulation and correction of neuropathyLow Back Pain is multifacorial having a long list of causes however,4-5 major causes contribute to more than 90% of LBP.

Major

Causes of Low Back Pain:

1.Facet joint arthropathy 15-45%

Intervertebral disc disruption 25-40%3.Sacro-Iliac joint arthropathy 15-30%

Disc prolapse / herniated disc/ slipped disc-5%5.CRPS/ RSD 2-8%

Other causes of Low Back Pain

1.Osteoporotic Compression fracture 3-5%2.Other Fractures <1%3.Fibromyalgia & Myofascial Pain 2-5%4.Spinal canal stenosis 2-3%

Spondylolisthesis

2-3%6.Tumor <1%7.Infection <1%8.Failed Back FBSS <1%

Approach and Decision making in IPM for Low Back Pain:

The important point during management of LBP is to remember that,the positive finding in X-ray and MRI may not be indicative of pain pathology. It has been observed that in healthy volunteers without anysymptoms of LBP, positive MRI finding may be seen in 20-50% patientsshowing various degree of degenerative disc pathology. Contrary to this, it isalso possible that patients suffering with severe LBP, X-ray/CT/MRI or other conventional tests may not be able to diagnose the condition which iscausing pain.A stepwise approach (An algorithmic approach) should be adopted tomanage low back pain as it helps in reducing the economic burden anddegree of invasiveness of the procedure. It also helps in practice of evidence based interventional pain management. Therefore, before proceeding for anyintervention, differentiation of non-specific and uncomplicated pain should be done from radicular symptoms and alarming symptoms (Red Flag Signs)that need a referral to a spine surgeon.RED FLAG SIGNS:

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Possible fracture,

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Signs of tumor or infection.

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Bladder or Bowel dysfunction.

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Severe or progressive neurological dysfunction in the legs.

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Major motor weakness in quadriceps, plantar flexors, evertors, anddorsiflexors.

Why to do interventions in spinal pain?

Low back pain is a dynamic situation where acute pain have tendency tochange in chronic pain. Longer the duration of nerve root irritation pain,more the incidence of neuropathic component of pain. Constantinflammation & irritation of the root can initiate the process of centralsensitization. Disabling pain, Paresthesia can deteriorate the quality of lifesignificantly. Interventions are used to diagnose (pin point the origin of pain)and than manage them accordingly.

Low Back Pain ManagementAlgorithmic approach

Fig-2 Low Back Pain Management Algorithmic approach