discogenic pain

Dr Nagaraju MorubagalFCARCSI, Diploma in Pain Management

Consultant in Pain and Palliative careE mail : mlnagaraj@gmail.com

Low back pain (LBP) is a common disorder involving the muscles, nerves, and bones of the back. Pain can vary from a dull constant ache to a sudden sharp feeling

Radicular pain : Pain radiates to lower extremity along the distribution of the spinal nerve root. Usually sharp, shocking,

burning like pain

Radiculopathy : Pain associated with sensory or motor change in distribution of

nerve root

Second most frequent reason to visit a physician for a chronic condition,

The fifth most common cause for hospitalization

The third most frequent reason for a surgical procedure.

The socioeconomic impact of CLBP is massive.

LBP

Acute <6 weeks Sub acute6-12 weeks

Chronic > 6 months

LBP

MechanicalNon Mechanical

Referred

LBP

Mechanical Non Mechanical Referred

PlainParticulate VS

Systemic review conclusions NNT is 3 for short term(1 day to 3 months) NNT is 13 for long term pain relief (3mts-

1yr)

Ref: Mc Quay et al. epidural steriod for sciatica1998, oxford university press Chor R , et al. Non surgical interventional therapies for low back pain: a review of the evidence for an American pain

society guidelines.. Spine 2009:34:1078-1093

Three high quality , placebo controlled trials Showed benefit 1yr, Double blind ,randomised study LA with Steroid Vs LA only LA with steroid group 20/28 did not undergo

surgery as 9/27 (LA only), at follow up (13-28mts)

avoided surgery for 5 yrs

Riew et al. Nerve rot blocks in the treatment of lumbar radicular pain. A minimum five year follow up. J Bone joint surg am 2000,,2006;88:1722-1725 Karppinen et al. periradicular infiltration for sciatica . A randomised controlled trial. Spine 2001;26: 1059-1067 Ng L , Chaudhary et al. The efficacy of cortico sterids in periradicular infiltraton

ifor chronic radicular pain. Randomised , double blind,controlled trial.Spine 2005; 30:857-862

Disc herniation-extruded vs contained Extruded herniation group benefit for 3months Rebound effect after 3-6 months in this group Serious Complications: Anterior spinal artery

syndrome Retro peritoneal haematoma. Dural puncture,

discitis, transient blindness, cauda equine syndrome

Artery of Adamikiewacz in 80% T9-L1 Minority : T7-L4

Below L3, Real time imaging, LA first. Pain On injection DSA

O’Donnell C, Cano W, Eramo G. Comparison of triamcinolone to dexamethasone in the treatment of low back pain and leg pain via lumbar transforaminal epidural steroid injection. Spine J. 2008;8:65S.

Four placebo controlled , none high quality Mixed results

Retrospective study Radicular syndrome Disc herniation (NNT :1.38) Spinal canal stenosis (NNT : 1.19) FBSS ( NNT: 6.5)

Abejon et al. PRF in lumbar radicular ppain, clinical effects in various etiological groups . Pain practice 2007; 7:21-26

R/O Red & Yellow flags before interventions 95% LBP is self limiting Disc ( 25-40%) Facet (8-15%), and SIJ (1-

8%) SLR is sensitive ,Cross SLR specific test Trans foraminal route is the preferred

choice for subacute LS Radicular Pain DRG PRF is the preferred choice for Chronic

LS Radicular Pain