Lower Back Pain Therapy

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Lower Back Pain Therapy

• Christine Mai, MD
• Department of Anesthesiology
• Boston University Medical Center

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Lower Back Pain

• 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

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Anatomy of Lumbar Spine

• Anterior components
• Vertebral bodies
• Intervertebral disks
• Anterior/Posterior longitudinal ligaments
• Posterior components
• 2 pedicles
• 2 transverse processes
• 2 lamina
• Spinous process
• Innervation
• 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

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Lumbar Facet Joint

• 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

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Lumbar Medial Branch Facet Injection

• Performed under fluoroscopy with patient in prone
  position
• Views AP and 30o oblique (Scotty dog view)
• Insert a 22 gauge spinal needle 5-6cm lateral to
  spinous process, directed medially to upper
  border of root of transverse process
• Insert at three levels (ie. L3-4, L4-5, L5-S1)
• Medication 40-80mg Triamcinolone or
  Methylprednisone and local anesthetic or
  perservative free NS

30 degree oblique view with needles in "eye of
Scotty dog"
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Radiofrequency Themocoagulation (RFTC)

• 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

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Lumbar Radiculopathy

• 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

MRI Lumbar Spine
Herniated disks
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Epidural Steroid Injections

• 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

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Translaminar Lumbar Epidural Steroid Injection
Epidural space highlighted by red arrows

• Performed under fluroscopic guidance
• Views AP and Lateral
• Maybe be left or right differentiated depending
  on patients 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

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Transforaminal Lumbar Epidural Steroid Injection
Spread of steroid injection
Needle entering transforaminal epidural space

• 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

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Risks of ESI

• Bleeding
• Infection
• Localized tenderness
• Post-dural puncture headache
• Paresthesia
• Anxiety-related sx lightheadedness, nausea

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Selective Nerve Root Block

• 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

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Lumbar Facet Injection
Can you visualize the Scotty Dog? At what levels
are the needles inserted?
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Lumbar ESI
At what level is the needle inserted? Where will
the patient get the most pain relief?
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Selective Nerve Root Block
Which nerve roots are being blocked?