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An algorithmic approach for clinical management of low back pain

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DOI: 10.4103/0028-3886.190252

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Original Article

An algorithmic approach for clinical management of low back

pain
V. V. Ramesh Chandra, B. C. M. Prasad, C. Krishna Mohan, T. C. Kalawat1, V. Satyanarayana2,
A. Y. Lakshmi3
Departments of Neurosurgery, 1Nuclear Medicine, 2Anaesthesiology and 3Radiology, Sri Venkateswara Institute of Medical Sciences,
Chittoor, Andhra Pradesh, India

ABSTRACT
Background: Low back pain is caused by a variety of conditions. When conventional imaging failed, single‑photon emission
computed tomography (SPECT) was superior to scintigraphy in identifying the pathology. Injection therapies are often helpful
in treating the pathology.
Aim: To determine the cause of chronic low backache in individuals with normal conventional imaging (radiographs, computed
tomography and magnetic resonance imaging), to determine the specific pathology using scintigraphic studies and diagnostic
blocks; and, to treat the individuals with various spinal injection techniques and determine their efficacy.
Material and Methods: All the patients having chronic back pain on presentation in the outpatient clinic from April 2013 to
October 2014 were prospectively evaluated.
Results: The 40 patients included in the study were followed up pre- and post operatively with various pain scales (visual
analogue scale [VAS], Oswestry disability index [ODI] and short form health survery 36 [SF36]). The mean age at presentation
was 41.3 years. Female patients formed the predominant subgroup in the study (57.5% female and 42.5% male patients).
Pain indices like VAS and ODI were helpful in assessing the efficacy of spinal injections. Preoperative and postoperative pain
scale assessment, supplemented by a SPECT evaluation of the sacroiliac and facet joints, showed a statistically significant
difference, which correlated with clinically significant pain relief.
Conclusions: SPECT imaging is helpful in diagnosing sacroiliac joint syndrome and facetal syndrome. Epidural injections were
a better choice in cases of low backache, where clinically, the patient had no signs of sacroiliac joint syndrome and facetal
syndrome. Spinal injections with steroid and local anaesthetic had better relief. Radiotracer uptake at the pain generating
area is a good predictor of outcome. Image guided spinal injection improves the accuracy of the injection.

Key words: Chronic back pain; epidural injection; mental component summary; Oswestry disability index; physical component
summary; single‑photon emission computed tomography; sacroiliac joint block; visual analog scale

Introduction and joint disorders, and neurological disorders.[2] According

to the available literature, when conventional imaging fails,
Low back pain is a very common presenting complaint
in the general population. No age group is completely
Address for correspondence: Dr. C. Krishna Mohan,
immune.[1] Low back pain may be caused by a variety of Department of Neurosurgery, Sri Venkateswara Institute of Medical
conditions including musculoligamentous disorders, bone Sciences, Alipiri Road, Tirupati, Chittoor, Andhra Pradesh, India.
E‑mail: krris.doctor@gmail.com

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10.4103/0028-3886.190252

PMID: How to cite this article: Ramesh Chandra VV, Prasad B, Mohan CK,
Kalawat TC, Satyanarayana V, Lakshmi AY. An algorithmic approach
xxxxx for clinical management of low back pain. Neurol India 2016;64:950-7.

950 © 2016 Neurology India | Published by Wolters Kluwer - Medknow

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Chandra, et al.: An algorithmic approach to low back pain

single‑photon emission computed tomography (SPECT) is
superior to scintigraphy in identifying the pathology.[3] The
aim of this study was to determine the cause of low back
pain by using clinical and advanced imaging methods (SPECT)
and to manage such pathologies with various interventional
techniques such as facet injections, sacroiliac joint injections,
and diagnostic nerve root blocks.
Materials and Methods
Study design
This was a prospective study of 243 patients with low back
pain and normal imaging. These patients, who presented
to our institution from April 2013 to October 2014, were
evaluated for chronic back pain. Patient presenting with
low back pain of more than 3 months duration and failing to
respond to conservative treatment were primarily included
in the study. An algorithm was designed in our institution as
depicted in Figure 1.
Statistical analysis
All data sets were collected and entered into a
spreadsheet (Microsoft Excel 2007) under various headings
that included the pre‑ and postprocedural pain scale (VAS,
ODI, SF36) assessment done after 6 months of treatment.
Statistical analysis was performed using SPSS version 16.0
for windows (IBM Inc., Chicago, IL.). The analysis of these
procedures was expressed in terms of means and standard
deviation; the significance levels were expressed by using
Student’s paired sample t‑test for comparison of variables
before and after treatment.
Clinical evaluation and workup of patients
Prior to the procedure, neurological examination along
with assessment of the functional status by using various
disability and pain scales such as the visual analog
score (VAS) chart, Oswestry disability index (ODI), and
short form 36 (SF36) health survey scoring was done. All
the patients were subjected to radiological investigations
which included plain radiographs and magnetic resonance
imaging (MRI) [Siemens, 1.5 Tesla, Germany 2002/2012]. If
these investigations were found to be normal, the possibility
of facet joint and sacroiliac joint pathology was suspected
and the patients were evaluated by bone scintigraphy and
SPECT‑computed tomography (CT) [the bone SPECT study
was performed on Symbia E dual‑head gamma camera
and SPECT images were fused with CT images performed
on Biograph 06 PET‑CT system, using multi‑modality
fusion software supplied by Siemens Ltd.], to accurately
localize the scintigraphically detectable lesion in the
spine. Based on the diagnosis, the patients were treated
with various modalities ranging from therapeutic facet
blocks, therapeutic sacroiliac joint blocks, and therapeutic
epidural blocks. The patients were assessed using various
pain scales (VAS, ODI, and SF36) and scintigraphy at the
end of 6 months.

Patients with chronic low back pain who have

been on conservative management for
more than 3 months

Clinical assessment

Positive facet joint Positive Sacroiliac joint syndrome tests

dysfunction tests (Patrick’s/ Gaenslen/ Yeoman/ Gillet test) Radicular leg pain
(Kemp’s/springing test)

Diffuse non-dermatomal
Specific root pain
FACET JOINT SYNDROME SACROILIAC JOINT SYNDROME pattern

Interlaminar epidural route Transforaminal route

Imaging (X-ray L-S spine (Flexion, Extension),
MRI Normal) Discogenic

SPECT CT Discography

Facet syndrome Sacroiliac joint syndrome

Facet injections
Sacroiliac joint injections

Figure 1: Study plan. LS: lumbosacral; SPECT CT: Single photon emission computed tomography; CT: Computed tomography

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Chandra, et al.: An algorithmic approach to low back pain

Procedure
Sacroiliac joint injections
This procedure was performed in prone position. The
skin surface was marked exactly at the midpoint of the
line drawn from the ipsilateral posterior superior iliac
spine and S1 spinous process. A 22‑G needle measuring
10–12 cm was placed at the infiltrated site at a lateral
angle of 45° from the plane horizontal to the skin surface
and was slowly advanced until it made bony contact
with the posterior section of the sacroiliac joint. The
position of the needle was confirmed using fluoroscopy
and 3 ml of local anesthetic (1% lidocaine), along with Figure 2: Age distribution
steroids (triamcinolone), was injected.

Facet joint injections

This procedure was performed in a prone position. The
surface marking for the procedure included a point at a
distance of 2–2.5 cm lateral to the midline, exactly between
the spinous processes of the corresponding vertebrae.

Results

Of the 243 patients with low back pain and normal imaging,

forty patients were selected for therapeutic intervention
and their disability and pain assessment was pre‑ and
post‑operatively carried out utilizing various pain scales
(VAS, ODI, and SF36).
Figure 3: Sex distribution

Demographics, outcome, and correlation

The age of the patients included in the study ranged from
20 to 66 years with the mean age group being 41.3 years
[Table 1 and Figure 2]. 57.5% of the subjects were female
and 42.5% were male, with the male:female ratio being 1:1.3
[Table 2 and Figure 3].

The patients included in this study were assessed based on

their clinical examination as their imageology was normal.
Sacroiliac joint syndrome and facet syndrome were further
diagnosed based on the SPECT study. Other patients,
who did not confirm to this inclusion criteria underwent
epidural injections and diagnostic blocks and constituted
nearly 50% of the subjects. Sacroiliac joint syndrome was
present in 27.5%, and facet syndrome, in 22.5% of the
patients [Table 3 and Figure 4]. The preprocedural VAS
ranged from 4 to 8 with a mean of 6.35. The postprocedural
VAS ranged from 0 to 4 with a mean of 1.42. There was
a significant decrease in the mean scale from the pre‑ to
post‑procedural period (P < 0.0001) indicating that
the patients had a significant improvement after the
procedure [Table 4 and Figure 5]. The pre‑procedural ODI
ranged from 40.2 to 67.25 with a mean of 61.54. The
Figure 4: Low back pain and frequency
postprocedural ODI ranged from 8.8 to 33.33 with a mean
of 18.54. There is a significant decrease in the value of
ODI in the postprocedural period (P < 0.0001) [Table 5
and Figure 6]. The preprocedural physical component
summary (PCS) of the SF‑36 score ranged from 28.4 to
33.2 with a mean of 31.2. The postprocedural PCS ranged
from 32.4 to 43.8 with a mean of 38.68. There was,
therefore, a significant improvement in the mean scores
(P < 0.0001) [Table 6 and Figure 7].

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Chandra, et al.: An algorithmic approach to low back pain

The pre‑procedural mental component summary (MCS) of the Discussion

SF‑36 score ranged from 32.4 to 40.7 with a mean of 36.68.
The postprocedural MCS ranged from 32.7 to 38.7 with a mean Our study was intended to evaluate the cause of low back
of 36.43. There was only a slight decrease in the mean levels pain using an algorithmic approach and to determine the
of MCS in the postprocedural period, and the difference was efficacy of injection therapies for various causes of low back
not statistically significant (P < 0.486) [Table 7 and Figure 8]. pain. The injection therapies included in the study were
facet injection (n = 9), sacroiliac joint injection (n = 11),
Table 1: The age distribution in the study epidural injection (n = 13), and diagnostic block (n = 7)
Age group in years Frequency Percentage [Figures 9-15]. On using the algorithmic approach to
20‑30 05 12.5 assess various pain pathologies, it was noticed that the
31‑40 15 37.5 sites capable of causing low back pain in the presence of
41‑50 11 27.5 a normal radiological imaging included the facet joints,
51‑60 08 20.0
61‑70 01 2.5
Total 40 100

Table 2: The gender distribution in the study

Sex Frequency Percentage
Male 17 42.5
Female 23 57.5
Total 40 100

Table 3: Various causes of low backache found in patients

without radiological abnormalities
Diagnosis Frequency Percentage
Low back ache excluding sacroiliac joint 20 50 Figure 5: Visual analog scale
syndrome and facetal syndrome
Sacroliliac joint syndrome 11 27.5
Facetal syndrome 9 22.5

Table 4: The comparison between the pre‑and postprocedural

visual analogue scale (VAS)
VAS Mean SD P
Pre‑procedure 6.35 1.272 <0.0001
Post‑procedure 1.43 1.217

Table 5: The comparison between the pre‑and postprocedural

Oswestry disability index (ODI)
ODI Mean SD P
Figure 6: Oswestry disability index scores
Pre procedure 61.54 6.4 <0.0001
Post procedure 18.54 4.43

Table 6: The comparison between the pre‑and postprocedural

physical component summary (PCS) of short form‑36 scale
PCS Mean SD P
Pre procedure 31.2 0.26 <0.0001
Post procedure 38.68 0.65

Table  7: The comparison between the pre‑and postprocedural

mental component summary (MCS) of short form‑36 scale
MCS Mean SD P
Pre procedure 38.68 2.04 <0.486
Post procedure 36.43 1.72 Figure 7: Physical component summary

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Chandra, et al.: An algorithmic approach to low back pain

Figure 8: Mental component summary Figure 9: The pre- and post-treatment single-photon emission computed
tomography images in the facet syndrome (axial view)

Figure 10: The pre- and post-treatment single-photon emission computed

tomography images in the sacroiliac joint syndrome (axial view)

Figure 11: Surface marking for facet injection

Figure 12: External positioning of the spinal needle

sacroiliac joints, and nerve roots; similar findings were

noticed in a study by Kuslich et al.,[4] who conducted a
study on 193 patients prospectively. In all the patients
in the latter study, local anesthesia was used and various
pain generating structures in and around the disc were
stimulated, and the patients were asked to define their Figure 13: Confirmation of spinal needle position under C-arm in facet
pain. In our study, we used various clinical tests to identify injection
the probable pain generating pathology and then proceeded
with the conventional imaging techniques (radiographs/ A male:female ratio of 1:1.3 was observed in the study.
MRI), which were then followed by advanced imaging A similar female predominance was noted in the study by Von
techniques such as the SPECT‑CT. Korff et al.[5] In our study, when radiological assessment of the

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Chandra, et al.: An algorithmic approach to low back pain
Figure 14: Confirmation of spinal needle position under C-arm in sacroiliac
joint injection
patients done with roentgenograms and MRIs did not reveal
any significant abnormality, these patients were subjected
to a SPECT study, which was able to identify the presence
of either a facet syndrome or a sacroiliac joint syndrome;
the same findings were observed in a study by Chung et al.[6]
Different provocative tests were used to diagnose the
sacroiliac joint syndrome (Patrick/Gaenslen/Yeoman/Gillet).
Among these tests, Patrick’s (flexion, abduction, external
rotation at the hip joint) test was found to be effective in
most of the cases; however, we could not unequivocally
differentiate the sacroiliac joint pathology from the hip joint
pathology using this test. Lanslett et al.,[7] in their study quoted
that most of the provocative maneuvers also cause stress at
other pain sensitive structures, including the intervertebral
discs, facet joints, muscles, and hip joint at the same time,
and therefore, do not clearly diagnose the sacroiliac joint
as being the back pain generator. Thus, sacroiliac pain
provocation tests do not definitely demonstrate the presence
of sacroiliac joint pain.
The efficacy of various injection therapies was assessed
by various pain scales (VAS, ODI, and SF‑36). In our study,
there was a significant decrease in the VAS scores from
a preoperative mean of 6.35 to a postoperative mean of
1.42. There was a significant decrease in the ODI from a
preoperative mean of 61.54 to a postoperative mean of 18.54,
which was statistically significant (P < 0.0001). In the study
by Maugars et al.,[8] there was a significant improvement in
the ODI scores, which was similar to the findings found in
our study.
In our study, patients who were suspected to have sacroiliac
joint syndrome underwent a SPECT study, which was helpful
in localizing the pathology. In all these patients, plain
Neurology India / September 2016 / Volume 64 / Issue 5
a b
Figure 15: (a and b) Surface markings for an interforaminal epidural injection
X‑rays and MRI could not identify the pathology. A study
conducted by Maigne et al.,[9] in 32 patients with sacroiliac
joint syndrome, revealed that bone scan has a poor sensitivity
but appears to have a good specificity (90%) for detecting the
pathology. There was a 50% reduction (based on VAS) in pain
in patients undergoing sacroiliac joint injection. Pulisetti and
Ebraheim[10] in a prospective evaluation of sacroiliac joint
injection procedure reported a 75% relief of pain following
the injection therapy.
Preprocedural SPECT, which was used in this study to rule
out facet syndrome and sacroiliac joint syndrome, was helpful
in localizing the pathology and aided in determining the
injection site; this finding was also observed in a study by
Pneumaticos et al.[11]
In our study, on administering corticosteroid injection into
the facet joint in our patients with facet syndrome, there was
a significant improvement that was evident on comparison
of the pre‑ and postprocedural values of pain scores. Similar
result was seen in the study conducted by Carette et al.,[12]
that included both the placebo and facet injection groups and
demonstrated considerable improvement in function and pain
relief at 1, 3, and 6 months. However, statistically significant
differences in pain relief were observed only at 6 months.
During the 6‑month follow‑up of patients who underwent
facet joint injection therapy, none of the patients required a
second injection indicating the efficacy of a single injection
block in our study. This result was contradictory to the study
by Schütz et al.,[13] which concluded that a single articular facet
block was often not useful and that multiple blocks were
often required. They conducted a triple crossover study and
concluded that facet joint blocks were of no diagnostic value
as there were no reliable clinical and radiological parameters
for diagnosing a facet joint syndrome. The significant pain
relief during the 6‑month follow‑up period in our study
included patients who had undergone a facet joint block;
none of these patients had undergone a medial branch block.
Ackerman et al.,[14] conducted a prospective double‑blind
study on 46 patients who were positive for facet joint
syndrome on SPECT and also concluded that intraarticular
955
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Chandra, et al.: An algorithmic approach to low back pain
lumbar facet injection were more effective than medial branch
blocks, as assessed by the pain scores.
Both steroids and lidocaine were used for facet injections
in our study and brought about a significant pain relief.
Revel et al., in a finding similar to ours, compared facet joint
injections using a combination of lidocaine and corticosteroid
with facet joint injections using a combination of saline and
corticosteroid and found that the lidocaine group had a
significant pain relief.[15]
All the patients who underwent epidural injections with
steroids and local anesthetics had a better pain relief when
assessed objectively utilizing the various pain scores. In a
study conducted by Benyamin et al.,[16] the primary outcome
measures were pain relief and the secondary outcome
measures were improvement in the functional status, the
psychological status, and the return to work. In a finding
similar to ours, they also noticed in their evidence‑based
systematic review that lumbar epidural injections with
steroids and local anesthetics resulted in a better pain
relief.
In our patients, who had undergone epidural injections, there
was immediate pain relief. On following up these patients for
6 months, it was found that these patients were comfortable
and had significant pain relief, which was evident by the
decrease in the pain scores. Similarly, in a controlled study
by Bush and Hiller,[17] it has been reported that patients who
underwent epidural injections with steroid (triamcinolone)
and procaine had better pain relief compared to the saline
group. In the latter study, the patient’s pain assessment was
carried out utilizing the straight leg raising test.
Limitations
The major drawback of the present study is its small sample
size and a single, short term, follow‑up visit. Furthermore,
a comparative analysis with other similar studies was not
performed.
Conclusions
The mean age of patients who presented with low back
pain was 41.3 years. Female subjects predominated in the
study (there was 57.5% female and 42.5% male patients). The
causes of chronic back pain in subjects having no significant
radiological findings included the sacroiliac joint syndrome
or the facet syndrome. Indices such as VAS and ODI were
helpful in assessing the efficacy of spinal injections. The
pre‑ and postoperative disability and pain scales showed
a statistically significant difference which correlated with
956 Neurology India / September 2016 / Volume 64 / Issue 5
clinically significant pain relief. SPECT imaging is helpful in
diagnosing the sacroiliac joint syndrome and facet syndrome.
Epidural injections were a better choice in cases of low back
pain, where clinically, the patient had no signs of sacroiliac
joint syndrome and facet syndrome. Spinal injections utilizing
a combination of a steroid and local anesthetic contributed to
a better pain relief. The demonstration of radiotracer uptake
at the pain generating area proved to be a good predictor
of outcome. Image‑guided spinal injection improved the
accuracy of the injection.
Financial support and sponsorship
Nil.
Conflicts of interest
There are no conflicts of interest.
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