Back Pain Algorithm

Initial assessment

1) Screen for potential emergencies with RED FLAGS

Constitutional symptoms of fever or weight loss

Progressive neurological deficit
Bowel or urinary incontinence
History of significant trauma
History of osteoporosis, heavy alcohol consumption or use of steroid
Other medical causes eg: zoster, aneurysms, etc.

2) Screen for risk factors for long-term disability and work loss with YELLOW FLAGS

Negative belief that pain is harmful or potentially severely disabling

Fear avoidance behaviour, with reduced activity
An expectation that passive, rather than active treatment is beneficial
Excessive focus on pain
Depressed mood, low morale and social withdrawal
Low self- efficacy
Co-existing social or financial problem
Poor job satisfaction

Suggested methods of assessment:

a. Screening questions:
-Have you had time off work in the past with back pain?
-What do you understand is the cause of your back pain?
-What are you expecting will help you?
-How is your employer responding to your back pain? Your co-workers? Your family?
-What are you doing to cope with back pain?
-Do you think that you will return to work? When?

b. Questionnaires:
-Pain intake form
-Pain catastrophising scale
-Pain self efficacy scale

3) Delineate somatic symptoms and its impact on patients function

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4) For lower limb pain, differentiate referred pain from radiculopathy

Referred pain Radiculopathy

Nature of pain Dull, aching, expanding Shooting, electrical
Location Above knee > below knee Below knee > above knee
Better defined Ill defined
Superficial and deep Deep only
Neurological Normal May have weakness /
reduced reflexes

4) Current treatment (including surgery)

5) Current coping skills
6) Examination for muscloskeletal, neurological and non-organic signs
7) Formulate plan of management

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

Red flags?

No
Yes
Note Yellow flags MRI

Potential surgical
candidate?
Yes

No MRI

Eligible
Eligible for block?
for block?
Yes
No

Regional
block

No
Eligible for
No surgery?
Yes

Significant cognitive Yes

behavioural issue?
No Yes

Regional Medication Cognitive behavioural Surgery

block therapy

Explanatory notes

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I. Surgery:
-Decompression
-Stabilization

Potential surgical candidates for MRI:

1) Red flags
2) New onset of neurological impairment
3) Severe pain with disability persists after non-operative treatment > 6 weeks

Contra-indications: patient refusal, significant psychiatric co-morbidities, on-going substance abuse

Indication of discogram:

1) Persistent pain in whom disc abnormality is suspected

2) Assessment of disc and disc level in patients in whom fusion is considered
3) Confirm a contained disc herniation when minimally invasive discectomy is considered

Contraindications: patient refusal, contraindication for surgery

II. Pharmacology

1) First line: NSAID / paracetamol

2) Second line: Tramadol 50-100 mg tds
3) Radiculopathy: Tricyclic antidepressants (eg: Amitriptyline 10-25 mg nocte)
4) Consider strong opioids (in opioid-nave patients) only if:

Chronic pain > 2 years, AND

Failed all other pharmacological / interventional management, AND
No history of substance abuse, AND
Good compliance with treatment and agree for long term FU, AND
Good insight on functional rather than symptomatic goal, AND
Informed consent

III. Intervention

-May be considered if duration of back pain> 6/52

-Diagnostic: to decide on operative treatment together with MRI
-Therapeutic

a. trigger point injection

1) For patients with identifiable trigger points only

2) Can be done at OPD straight, depend on staff and patient preference
3) Consider repeat if pain is responsive (> 2 weeks) up to 6 times per year for maximum of 1 year
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Contraindications: local sepsis, coagulopathy, patient refusal

b. epidural steroid

1) For radiculopathy only (regardless of pathology, eg: spinal stenosis, PID, Post-spine surgery, etc.)
2) Consider repeat if pain is responsive (> 6 weeks) up to 6 times per year
3) Trans-foraminal approach (i.e. nerve root block) preferred especially with documented root
compression or previous surgery. Other approaches include caudal and interlaminer approach.
4) X-ray with contrast is required for caudal and trans-foraminal approaches, and is recommended for
interlaminar approach.

Contraindications: coagulopathy, local sepsis, bleeding tendencies, immunodeficient, patient refusal

c. Facet or SI joint

1) For paramedian spinal tenderness +/- referred pain only, esp. when provoked by extension
2) Joint or nerve injection will depend on anatomy upon fluoroscopy. In general the median branch
block is preferred to joint injection
3) Consider repeat joint blocks if pain is responsive (> 4 weeks) up to 6 times per year.
4) Consider radiofrequency lesioning of median branch if nerve block is positive (immediate) up to 4
times per year

Contraindications: same as for epidural steroid

Discharge

1) Symptomatic and functional improvement, without maintenance treatment: home

2) Condition optimised with simple maintenance pharmacology (NSAID, Amitriptyline, etc.): GOPD
3) Condition optimised with more elaborate medications (Gabapentin, Tramadol, etc.): FM clinic or
other specialty clinics if agreeable to all parties
4) Static condition with significant cognitive-behavioral issues amenable to CBT: consider COPE
5) Defaults: review condition on CMS. Call back patients with medical reasons (eg: proven sick,
hospitalized). Call back once only for non-medical reasons. No medication refill during defaults unless
withdrawal is a concern and loss of medication is beyond doubt.

References

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1) Adult low back pain. Institute for Clinical Systems Improvement (ICSI); 2004. National Guideline
Clearinghouse. www.guideline.gov
2) Back pain. Australian Family Physician June 2004 Vol. 33; 6
3) Australian management strategies for oral opioid use in non-malignant pain Goucke. European
Journal of Pain 2001; 5(Supp. A): 99-101
4) Evidence based practice guidelines for interventional techniques in the management of chronic
spinal pain. American Society of Interventional Pain Physicians. Pain Physicians 2003; 6: 3-81
5) Chronic pain management: a paradigm. Chen. The Hong Kong Pracitioner 2004; 26:277-284
6) Guide to assessing psychosocial yellow flags in acute low back pain: Risk factors for long-term
disability and work loss. National Advisory Committee on Health and Disability. January 1997
edition
7) Lumbar discography. Position statement from the North American Spine Society Diagnostic and
Therapeutic Committee. Guyer. Spine 1995; 15;20(18):2048-59