Lower Back Pain Therapy Christine Mai, MD Department of Anesthesiology

Lower Back Pain
Therapy
Christine Mai, MD
Department of Anesthesiology
Boston University Medical Center
Lower Back Pain
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One of the most common problem seen by pain
specialists
Second to headaches as cause of chronic pain
Major cause of work disability worldwide
Multifactorial Causes: congenital, traumatic,
degenerative, myofascial syndrome, inflammatory,
infectious, metabolic, psychologic, cancerous, or
referred pain from retroperitoneal disease processes
Anatomy of Lumbar Spine
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Anterior components:
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Vertebral bodies
 Intervertebral disks
 Anterior/Posterior longitudinal
ligaments
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Posterior components:
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2 pedicles
 2 transverse processes
 2 lamina
 Spinous process
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Innervation:
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Sinuvertebral branches arises before
spinal nerve divides into anterior and
posterior rami, innervates posterior
longitudinal ligament, posterior
annulus fibrosis, periosteum, dura
and epidural vessels
 Posterior Rami innervates paraspinal
structures
Lumbar Facet Joint
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Paired facet joints connect
vertebrae in the spine
Important for both range of
motion and stability
Painful when become arthritic
Facet arthropathy can further
cause back spasm and referred
pain frequently indistinguishable
from sciatica or discogenic
radicular pain
Each facet joint is innervated by
medial branches of posterior
primary rami, above and below
the joint
Medial branch crosses upper
border of the lower transverse
process in groove between root of
transverse process and superior
articular process
Lumbar Medial Branch Facet Injection
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Performed under fluoroscopy with
patient in prone position
Views: AP and 30o oblique (Scotty
dog view)
Insert a 22 gauge spinal needle 56cm lateral to spinous process,
directed medially to upper border
of root of transverse process
Insert at three levels (ie. L3-4, L45, L5-S1)
Medication: 40-80mg
Triamcinolone or
Methylprednisone and local
anesthetic or perservative free NS
Radiofrequency Themocoagulation (RFTC)
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Ablates nerve branches utilizing heat current flows from
active electrode incorporated in special needle
Temperature 60-90oC for 1-3mins to ablate nerve without
excessive tissue damage
Performed under fluoroscopy-important to be exactly within
“eye of Scottie dog”
Electrical stimulation (2 Hz for motor response, 50 Hz for
sensory response) via electrode and impedence measure help
confirm correct position
Prolongs pain relief for 3-12 months
Utilized for medial branch facet rhizotomy, trigeminal
rhizotomy, dorsal root rhizotomy, lumbar sympathetomy
Lumbar Radiculopathy
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Lower back pain radiating down
lower extremities
Sensations of pain, paresthesia,
numbness
Associated with herniated disks,
DJD, nerve impingement
Sciatica-compression of lower
nerve roots producing pain along
sciatic nerve
Paracentral compression of cauda
equina in dural sac can cause
bilateral LLE pain, urinary
retension, fecal incontinence
Inflammation results from nerve
root compression
Epidural Steroid Injections
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Effective pain relief for radiculopathy
Relieves inflammation, edema and irritation by
reducing swelling of nerve root, blocking c-fibers,
stabilize nerve membranes, and decrease ectopic
discharge from inflamed tissue
Inflammatory mediators leak into epidural space
rather than subarachnoid space
Translaminar Lumbar Epidural Steroid
Injection
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Performed under fluroscopic guidance
Views: AP and Lateral
Maybe be left or right differentiated depending on patient’s pain location
20 gauge Touhy needle
Loss of resistance to air/saline technique
Medications: Triamcinolone 40-80mg or Methylprednisolone 40-80mg injected
with local anesthetic or with perservative free NS
Local anesthetic provides immediate pain relief until steroid inflammatory response
takes place in 12-48hr
Transforaminal Lumbar Epidural
Steroid Injection
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Performed when there is correlating lesion on MRI with radiculopathy
Alternative approach to epidural space when translaminar ESI fails to give
relief
22 G spinal needle directed under fluoroscopy into foramen of affect nerve
root and contrast is injected to confirm entry into epidural space prior to
steroid injection
Less volume of steroid/local anesthetic needed
Risks of ESI
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Bleeding
Infection
Localized tenderness
Post-dural puncture headache
Paresthesia
Anxiety-related sx: lightheadedness, nausea
Selective Nerve Root Block
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Performed when there is correlating lesion on MRI with radiculopathy
Used interchangeably with transforaminal epidural steroid injection
22 gauge spinal needle inserted under fluoroscopy lateral to spinous
process, directed medially to lower border of root of transverse process
Contrast is injected to confirm injection proximal to nerve root
Lumbar Facet Injection
Lumbar ESI
Selective Nerve Root Block