algorithmic diagnosis of back pain.

1. Back Pain Algorithm
Ravi shankar
sharma

2. Low back pain
• Low back pain is defined as lumbar spinal pain
or sacral spinal pain or any combination of the
two.

3. Idea of pain generator
A structure/tissue can
be a source of pain
only when it will have
nociceptive nerve
Local anesthetic
injection in those
nerves and/or those
tissue should relieve
pain

4. Pain Generators
• Facet joints
• Deg. Disc
• Sensitized ms
• S.I. Joints
Not a Pain
Generator
• Normal muscle
• Normal Disc

5. Major causes
1. Facet joint arthropathy 15-45% (M.C.Cz in elderly)
2. Interval disc disruption 25-40% (M.C.Cz in young)
3. Sacro-Iliac joint arthropathy 15-30%
4. Disc prolapse/ herniated disc/ slipped disc-2-5%
5. CRPS/ RSD 2-8%
Causes of Low Back Pain

6. Other causes of Low Back Pain
Osteoporotic Compression fracture 3-5%
Other fracture <1%
Fibromyalgia & Myofascial Pain 2-5%
Spinal canal stenosis 2-3%
Spondylolisthesis 2-3%
Tumor <1%
Infection <1%
Others: like FBSS <1%

7. Low Back Pain :
RED FLAGS
• Possible FRACTURE
• Possible TUMOR OR INFECTION.
• BLADDER OR BOWEL DYSFUNCTION.
• Severe or PROGRESSIVE NEUROLOGIC
DYSFUNCTION in the legs.
• MAJOR MOTOR WEAKNESS in quadriceps,
plantar flexors, evertors, and dorsiflexors.

8. History
Chief complain/s
H/O Present
illness
Site
Onset
Intensity
Radiation
Aggravating &
relieving factors
Diurnal variation
Family history Medical history Personal history
Occupational
history

9. Examination
• Inspection
• palpation
• Range of movements
• Special tests

10. Facet Joints
Commonest cause of back pain in elderly.

11. Facet Joint pain
Back pain > leg pain
Paramedian pain
Pain on extension, rotation, lateral bending
Tenderness over facet joints
Non dermatomal distribution

12. Management of Facet Arthropathy
• Confirmation by dual diagnostic
block (L.A.’s)
• I/Articular Depo-steroid inj.
• Radio-frequency Rhizotomy of
Medial branch

13. Radio-frequency Rhizotomy of Medial branch

16. Degenerative Disc Disease

17. Grading:-

18. Disc Prolapse

19. DISC PROLAPSE

20. TYPES OF DISC PATHOLOGY
Degenerated Disc/
IDD/Discogenic Pain
No nerve root compression
Non-dermatomal
distribution of pain
Back pain > leg pain
Incidence: 40%
Herniated Disc/
Prolapsed/Slipped D
Nerve root compression
Dermatomal distribution
of pain
Back pain < leg pain
Incidence: 4%

21. Types of disc pathology
Degenerated Disc
Axial pain, SLR –ve
Neuro-deficits -ve
Provocative
discogram/ HIZ in
MRI correlates with
pain
Herniated Disc
Lateral pain,SLR+ve
Neuro-deficits +
Clinical + MRI

22. Internal disc disruption
• IDET/ Posterior annuloplasty
• Neucleoplasty
• Laser Discectomy
• Conventional radio-frequency lesioning
• Pulsed radio-frequency lesioning
• Percutaneous Discectomy
• Ozone Nucleolysis/ ozone Discectomy
• Surgery: Fusion, Disc replacement

23. Ramus communicans block via c-arm (AP/lateral )

24. DISC PROLAPSE
Epidural steroid inj
Ozone Nucleolysis & Transforaminal Ozone
injection.
Epidural neuroplasty
Percutaneous discectomy
Surgery: Discectomy/ laminectomy/
Fenestration

26. Sacro-iliac Joint Arthropathy
FABER test

27. S.I.joint RF ablation –Needle
Placement

28. Myofascial Pain Syndrmoes:

29. Vertebral compression #

30. Vertebroplasty

31. Interspinous ligament sprain

32. Low back pain
Back pain >leg
pain
Axial pain Paramedian pain

33. Axial pain
Aggravated by sitting
-No tenderness
-No other signs except
painful deep percussion
M.R.I showing HIZ
I.D.D
R.Com.block
Epidurals
M.R.I showing #
with edema
Vertebral
compression #
Vertebroplasty
Local tenderness +
b/w spinous area
I.S. ligament sprain
Over coccyx
Coccydynia
Steroid inj.

34. Axial pain
↓on sitting
No local tenderness
Neurogenic claudication +
Extension ↑ leg pain
MRI- canal dia. <10 mm
b/l p/median tenderness+
Extension↑ back pain
Neurodeficit/leg pain -
Canal stenosis
Epidurals/Sx
Diagnostic facet jnt. inj.+ve
I/Articular steroid/ R.F of medial branch

35. Paramedian pain↑ on sitting
Tenderness over
Q.L.
Trigger point inj. + ve
Tenderness over
buttock+
FAIR +ve
Piriformis T.P. inj.+
Tenderness over S.I. jnt.
FABER + ve
Diag. S.I. jnt.inj .+ ve
Repeat T .P. inj./Botox
Repeat T . P.inj./Botox I/A steroid /R.F.

36. Paramedian pain ↓ on sitting
Deep tenderness of paraspinal
muscle+
Extension ↑ pain
Diag. Psoas T.P. inj.+ ve
Repeat T.P.inj./Botox
Local tenderness over facet+
Extension ↑pain
Diagnostic facet jnt. inj.+ve
I/Articular steroid/ R.F of
medial branch