Step by Step Approach in

Patient with Low Back Pain

Dr. dr. Rizaldy Pinzon, MKes, SpS

RS Bethesda/ FK UKDW Yogyakarta
Email: drpinzon17@gmail.com
Curiculum vitae
• S1 : FK UGM
• S2 : FK UGM
• Spesialis FK UGM
• S3 : FK UGM
• Pengajar S2 UGM dan FK UKDW Yogyakarta
• Dokter spesialis saraf RS Bethesda Yogyakarta
Mechanism of Pain

Transduction: convert stimuli (thermal, mechanic,

chemical) into electrical activity at peripheral
sensory of nociceptor nerve.

Conduction: conduct action potential from

peripheral terminal axon to terminal nociceptor
at CNS.

Transmission: transfer among synapse &

modulate inputs among neuron.

Modulation: inhibit & facilitate from brain which

modulate nociceptive transmission at spinals.

Perception: impulse is ‘translated’ at higher

structures (CNS)

5
 Mechanism of Pain
Mediators of Inflammation and Pain1-4
Tissue injury Nerve injury Disc injury
Types of
Cell membrane phospholipids
injury
Bradykinin
Interlukin-1
Serotonin, Phospholipases
Norepinephrine

Arachidonic acid
Mediators

Cyclooxygenase 5-Lipoxygenase

Leukotrienes
COX-1 COX-2
*Vasoconstriction
Increase vascular
Prostacyclin (PGI2) Prostaglandin E2 (PGE2)
Prostaglandin G2 (PGG2) permeability

Prostaglandin D2(PGD2) Prostaglandin H2 (PGH2) ThromboxaneA2 (TXA2)

*Vasodilation, *Vasodilation, increased *Vasoconstriction Inflammation

Effects inhibits platelet vascular permeability, promotes platelet
and pain
aggregation hyperalgesia aggregation

COX, cyclooxygenase; PG, prostaglandin; TxA2, thromboxane A2. *Red text indicates involvement in inflammation.
1McLain et al. Spine J 2005;5:191-201; 2Funk CD. Science 2001;294:1871-5; 3Miller SB. Semin Arthritis Rheum 2006;36:37-49;
4Khanapure et al. Curr Top Med Chem 2007;7:311-40.
Types of Pain
Pain

Acute Chronic

Injury
Post-operative Nociceptive Visceral Neuropathic Mixed
pain
Osteoarthritis
Rheumatoid arthritis Internal organ Lower Back
Lower back
involvement
Gout Cancer
IBS
Ankylosing spondylitis Fibromyalgia

Dysmenorrhea

Central Peripheral

Post-stroke Spinal cord injury Post-herpetic Diabetic

HIV-related neuralgia neuropathy
Migraine
neuropathic pain

HIV, human immunodeficiency virus; IBS, inflammatory bowel syndrome. 7

1Melnikova I. Nat Rev Drug Discov 2010;9:589-90.
Classification of Pain
Acute vs Chronic Pain

Acute Pain Chronic Pain

• Pain lasting >3 months1
• Pain lasting <30 days1 • Persists although the original cause is not
• Sudden onset clearly present2
• Severe in intensity • May be the result of inadequately treated
• Pain plus anxiety acute pain2

• Arises as a result of tissue injury that • May recur due to the presence of noxious
stimulates nociceptors and generally stimuli or repeated exacerbation of injury1
disappears when the injury heals1 • Affects lifestyle, attitudes, and behavior2

• Treatment includes NSAIDs (mainstay of

• Treatment includes acetaminophen, NSAIDs,
therapy), opioids, and local anesthetic
selective COX-2 inhibitors, opioids3
analgesics3

NSAIDs, non-steroidal anti-inflammatory drugs; COX-2, cyclooxygenase-2.

1WHO guidelines on the pharmacological treatment of persisting pain in children with mental illnesses. 2012; 2Thomas

MA. Oschner J 2003;5:15-21; 2http://www.npcnow.org/system/files/research/download/Pain-Current-Understanding-of-

Assessment-Management-and-Treatments.pdf. Accessed July 15, 2015; 3Breivik H et al. Br J Anaesth 2008;101:17-24. 8
Step by step
approach
Low Back Pain: Epidemiology

 A debilitating, recurrent, and highly prevalent condition1

- Lifetime prevalence, 84%
- 1-year prevalence, 50%
- Point prevalence, 25%

 Incidence peaks in the third decade of life2

 Prevalence increases until age 60-65 years, and then
gradually declines2
 Mixed pain is common
Classification of lower back pain, by
duration3:
Acute: Lasts <4 weeks
Sub-acute: Lasts 4-12 weeks
1Morlion
2Golob
B. Nat Rev Neurol 2013;9:462-73; Chronic: Lasts > 12 weeks
A and Wipf JE. Med Clin N Am 2014;98:405-28;
3Chou R. Ann Intern Med 2014;ITC1-16.
Etiology

 Non-mechanic potential:
 Mechanic non-specific: • Neoplasm,
• Infections,
• Lumbar strain/sprain, • Arthritis.
• Ligament strain
• Lumbago
• Facet joint syndrome,
sacroiliac syndrome,
• Myofascial syndrome  Nerve compression, visceral organs
disorders (referred pain)

McCarberg, 2010; Swarm et al, 2004

Kasus
• Ibu Wati, 44 tahun, nyeri punggung bawah tidak menjalar ke
tungkai,karakteristik: kemeng/pegal, nyeri intensitas ringan-sedang,
NPS: 3-4, memberat bila membungkuk, nyeri bertambah saat bekerja,
membaik bila istirahat, sejak 2 minggu lalu, tidak memberat
• Tidak ada riwayat trauma yang signifikan
• Tidak ada kelemahan anggota gerak
• Apa yang harus saya tanyakan ?
• Apakah saya harus menyingkirkan penyakit yang serius ?
Esesmen nyeri pada LBP
Assessment of Pain: intensitas nyeri
Pain Scales
Valid and reliable assessment of pain is essential for effective pain management1

0-10 Numeric Pain Intensity Scale2 Visual Analog Scale2

0 10
No pain Highest imaginable
pain

Verbal Pain Intensity Scale2 Faces Pain Scale2

Due to variability in purpose, content, method of administration, respondent and administrative burden,
and evidence to support the psychometric properties of each measure, no single pain measure can be
recommended for use in all situations3

1Breivik H et al. Br J Anaesth 2008;101:17-24; 2Hague M and Shenker N. Best Pract Res Clin Rheum 2015; [Epub ahead
17
of print]; 3Hawker GA et al. Arthritis Care Res 2011;63:S240-52..
Penyebab
Kasus
Bu Wati: nyeri akut, non
spesifik, ringan-sedang, red
flags (-)
Benefits and Risks of Pharmaceutical Therapy
in pain management
Drug treatment choices
Paracetamol – risk but no evidence of benefit1-3
• No good evidence of efficacy in any chronic pain condition
• Increased risk of liver damage compared with NSAIDs

NSAIDs – risk, with evidence of benefits4-9

• Largest known risk with traditional NSAIDs is gastrointestinal
• Cardiovascular risk is modestly elevated in RCTs, but not in longitudinal studies
• Other risks include renal failure; therefore, NSAIDs should be avoided in patients with low eGFR
• 49-59% of patients on NSAIDs have moderate pain improvement
• 39-44% of patients on NSAIDs have substantial benefit

Opioids – risk, but doubtful evidence of benefit10-13

• Tramadol has marginal benefits and side-effects may be limiting in OA
• NSAIDs and coxibs have lower rates of significant harm than opioids in large matched cohorts
• No trials of traditional opioids have shown benefits in chronic non-cancer pain
• Drop-out rates can be high, up to 65% in 12-week studies
eGFR, estimated glomerular filtration rate; NSAIDs, non-steroidal anti-inflammatory drugs; OA, osteoarthritis; RCTs, randomized controlled trials.
1Towheed TE et al. Cochrane Database Syst Rev 2006;CD004257; 2Machado GC et al. BMJ 2015;350:h1225; 3Moore RA et al. Eur J Pain 2014; [Epub ahead of print];
4Moore RA. BMC Musculoskel Dis 2007;8:73; 5Rodriguez LAG et al. Arthritis Res Ther 2001;3:98-101; 6Coxib and traditional NSAID Trialists’ (CNT) Collaboration.

Lancet 2013;382:769-79; 7Mangoni AA et al. Br J Clin Pharmacol 2010;69:689-700; 8Gutthann SP et al. Arch Intern Med1996;156:2433-9; 9Moore RA et al. Ann
Rheum Dis 2010;69:374-9; 10Cepeda MS et al. Cochrane Database Syst Rev 2006;CD005522; 11Solomon DH et al. Arch Int Med 2010;70:1968-78; 12Moore RA et al.
Pain 2013;154:S77-86; 13Lange B et al. Adv Ther 2010;27:381-99.
20
 Inadequate Pain Management
Substantial number of patients who receiving pain treatment still reported having moderate-to-severe pain,
20% of patients did not receive analgesic treatment despitemoderate-to-severe pain

Patients who experienced any employed were also more likely to

common AE weremore likely to find their treatment inadequate
find their pain treatments compared with those who were
inadequate than those who did unemployed (31.7%).
not (32.4%). p < 0.0001 p = 0.007

Effective chronic pain management aims to

restore function and reduce pain intensity

The present analysis was conducted on the data from 1305 patients. The median duration of CNCP was 24 (interquartile range [IQR], 39) months.
The mean pain level on the BS-11 scale was 6.0 (SD 1.9), with the majority of patients reporting moderate (44.4%) or severe pain (44.9%) at the
time of the survey. The most common causes of pain were arthritis (33.3%) and poor posture(27.6%).

Cheung Chi Way et al. SN Comprehensive Clinical Medicine. 2019;1:442–450 21

21
Treatment Low Back Pain

Pharmacological Intervention Pain Spine Surgery

Management

• Paracetamol: First-line therapy • Epidural steroid injections • Spinal decompression

for acute LBP and CLBP
• Facet joint interventions surgery
• NSAIDs: Non-selective (aspirin)
and selective COX-2 inhibitors • Spinal fusion surgery
- Oral NSAIDs as first-line • Disc arthroplasty
therapy for CLBP
• Opioids
• Antidepressants: Duloxetine
• Anticonvulsants: Gabapentin
and pregabalin
Muscle relaxants: Benzodiazepines

COX-2, cyclooxygenase-2; CLBP, chronic low back pain; LBP, low back pain; NSAIDs, non-steroidal anti-inflammatory drugs.
Morlion 23
B. Nat Rev Neurol 2013;9:462-73.
Diclofenac: mekanisme kerja perifer dan sentral
Van der gaag WH, Roelofs PD, Enthoven WT, Van tulder MW, Koes BW.
Non-steroidal anti-inflammatory drugs for acute low back pain.
Cochrane Database Syst Rev. 2020;4:CD013581.
• 1 in 14 reduction in pain intensity
• 1 in 12 reduction in disability
• 1 in 13 global improvement
• NNT: jumlah pasien yang harus
mendapat terapi untuk
mendapatkan pengurangan nyeri
> 50% pada 1 pasien
• NNT kecil: semakin efektif
Selectivity of NSAIDs to COX2/COX1

• The ideal NSAID is more selective for

COX-2 than COX-1, and achieves levels
of COX-2 inhibition required to achieve
pain relief while minimizing the harm
• Low-dose NSAIDs with short half-lives
and dosing intervals of up to 8 hours
could permit the recovery of
vasoprotective COX-2 dependent
prostaglandins

Diclofenac : preferentially COX2

inhibitor
Impact Selectivity of NSAIDs COX2/COX1
• Favour NSAIDs with favourable
tissue distribution and short
plasma half-lives
• Each patient’s clinical
background, including
gastrointestinal and
cardiovascular risk factors,
should be taken into account
when selecting appropriate
NSAIDs.

Diclofenac dan ibuprofen

waktu paruh pendek
Methods: We enrolled lumbar facet syndrome patients treated at Srinagarind Hospital. Enrolled patients were randomly assigned
to receive 100 mg/day oral diclofenac, an 80 mg injection of methylprednisolone into each symptomatic facet joint, or both.
Endpoints were the Oswestry disability index (ODI) and visual analogue scale (VAS) before treatment, and at four and 12 weeks
after treatment.

Results: Of the 99 patients, the mean age was 46.4 years and 48 were men. The initial ODI (mean ±SD) for the diclofenac,
methylprednisolone and combined treatment was 45.1± 9.3, 42.9± 15.6, and 42.2± 11.5, respectively.
Lumbar Facet Syndrome
cause of Low Back Pain
Diclofenac Effective Reducing Pain in Lumbar Facet Syndrome Patients

Lumbar facet joint

syndrome is thought to be
an important cause of low
back pain. The prevalence
of this condition ranges
between 15 and 40 %.

Initial visit 4 weeks 12 weeks

This prospective randomized trial is to determine the effectiveness of treating lumbar facet syndrome with oral diclofenac, methylprednisolone facet joint injection or both. We enrolled
lumbar facet syndrome patients, were randomly assigned to receive 100 mg/day oral diclofenac, an 80 mg injection of methylprednisolone into each symptomatic facet joint, or both.
Endpoints were the Oswestry disability index (ODI) and visual analogue scale (VAS) before treatment, and at four and 12 weeks after treatment.

Sae-Jung S., Jirarattanaphochai K. International Orthopedics (SICOT) (2016) 40:1091–1098. 31

Lumbar Facet Syndrome
cause of Low Back Pain
Diclofenac effective improve Oswestry disability index (ODI) in
lumbar facet syndrome patients

Oral diclofenac alone or

methylprednisolone facet
injection alone can relieve facet
joint inflammation, resulting in
pain reduction.

The combination of oral diclofenac and

methylprednisolone facet injection
produces a better result (which showed
significantly better function and pain
relief results) than each treatment
alone.

Initial visit 4 weeks 12 weeks

This prospective randomized trial is to determine the effectiveness of treating lumbar facet syndrome with oral diclofenac, methylprednisolone facet joint
injection or both. We enrolled lumbar facet syndrome patients, were randomly assigned to receive 100 mg/day oral diclofenac, an 80 mg injection of
methylprednisolone into each symptomatic facet joint, or both. Endpoints were the Oswestry disability index (ODI) and visual analogue scale (VAS) before
treatment, and at four and 12 weeks after treatment.
Sae-Jung S., Jirarattanaphochai K. International Orthopedics (SICOT) (2016) 40:1091–1098.
Background: Low back pain is an important medical problem in Western industrialised countries. NSAIDs are one of the main options
for symptomatic pain relief in the early management of this painful condition.

Methods: A randomised, double-blind, parallel, active controlled, multicenter study that included 370 outpatients with acute low back
pain was conducted to compare the analgesic efficacy of dexketoprofen 50mg twice daily versus diclofenac 75mg twice daily
administered intramuscularly for 2 days.

Results: The median change in the RDQ was –6 points for both groups (p = 0.69), showing an overall improvement on the disability
scale. No significant differences between groups were observed regarding the percentage of patients needing rescue medication or in
the mean values of pain after repeated doses (SAPID0-last).
Acute Low Back Pain

Diclofenac Injection effective reducing pain in acute Low Back Pain

Acute episodes of low back pain lasting

<3 months (90% of cases) are usually
benign and self- limiting (90% of people
recover within 6 weeks), although 2–7%
of subjects develop chronic pain.

A randomised, double-blind, parallel, active controlled, multicenter study that included 370 outpatients with acute low back pain was conducted to compare the
analgesic efficacy of dexketoprofen 50mg twice daily versus diclofenac 75mg twice daily administered intramuscularly for 2 days. Efficacy outcomes were
assessment of pain intensity (PI) measured on a visual analogue scale, total PI scores from baseline to 6 hours after the first-dose administration (primary efficacy
endpoint; SAPID0-6), score on a physical disability scale using the Roland Disability Questionnaire (RDQ), and use of rescue medication. Tolerability and safety were
also assessed as secondary variables.

Zippel H and Wagenitz A. Clin Drug Invest. 2007;27(8):533-543. 34

Background: The vascular and gastrointestinal eff ects of non-steroidal anti-infl ammatory drugs (NSAIDs), including selective COX-2
inhibitors (coxibs) and traditional non-steroidal anti-infl ammatory drugs (tNSAIDs), are not well characterised, particularly in patients at
increased risk of vascular disease. We aimed to provide such information through meta-analyses of randomised trials.

Methods: We undertook meta-analyses of 280 trials of NSAIDs versus placebo (124 513 participants, 68 342 personyears) and 474
trials of one NSAID versus another NSAID (229 296 participants, 165 456 person-years).

Results: The proportional effects on major vascular events were independent of baseline characteristics, including vascular risk. Heart
failure risk was roughly doubled by all NSAIDs. All NSAID regimens increased upper gastrointestinal complications (coxibs 1·81, 1·17–
2·81, p=0·0070; diclofenac 1·89, 1·16–3·09, p=0·0106; ibuprofen 3·97, 2·22–7·10, p<0·0001; and naproxen 4·22, 2·71–6·56, <0·0001).

Business Use Only 35

 Gastrointestinal Risk
Diclofenac has equal GI risk compared to Coxibs and lower compared to
ibuprofen and naproxen.

Meta-analysis from 280 NSAID

Favors therapy Favors placebo
studies vs. placebo and 474 NSAID vs
Favors therapy Favors placebo
other NSAID. Meta-analyses included
are RCTs, duration of at least 4
weeks. Data analysis were done using
three methods: trial identifications,
feasibility evaluation, prespecified
analysis, and statistical analysis.
• Meta-analysis of individual subjects are taken from NSAID RCts of 4 weeks or longer duration. Almost all of the studies (~99%)
• CV risks were also evaluated. For full reference please refer to doi :0.1016/S0140-6736913)60900-9.
involves coxibs or high-dose NSAIDs
(diclofenac 150 mg/day, ibuprofen
2400 mg/day, or naproxen 1000
Favors therapy Favors placebo Favors therapy Favors placebo
mg/day).

Comparative ratio to Placebo (95%CI)

• Meta-analysis of individual subjects are taken from NSAID RCts of 4 weeks or longer duration.
• CV risks were also evaluated. For full reference please refer to doi :0.1016/S0140-6736913)60900-9.
Coxib and traditional NSAID Trialists' (CNT) Collaboration, Lancet. 2013;382(9894):769-779.
Kesimpulan
• Nyeri punggung bawah umum terjadi
• Proporsi terbesar adalah nyeri non spesifik
• NSAID adalah pilihan terapi farmaka utama
• Perhatikan 3 M:
• Multi disciplinary
• Multi mechanistic analgesia
• Multi modal analgesia
• Diclofenac adalah salah satu pilihan NSAID utama dengan profil
efektivitas dan keamanan yang baik