Oh, my aching back:

A Case Study on Lower Back

Pain Diagnosis and Treatment

Chronic Pain Lecture Series

Department of Anesthesiology
May 9th, 2018
Alexander Pitts-Kiefer, MD
 Chronic Pain Lecture Series

• Introduction to Chronic Pain Medicine

• Pharmacology of Pain Medicines, Part 1
• Pharmacology of Pain Medicines, Part 2
• Diagnosis and Treatment of Low Back Pain, Part 1
• Diagnosis and Treatment of Low Back Pain, Part 2
• Diagnosis and Treatment of Cancer Pain / Chronic
Regional Pain Syndrome
• Advanced Pain Therapies
 Lecture Outline
• Epidemiology
• Overview of clinical evaluation
• Case introduction
• Case History and Physical
• Imaging
• Differential Diagnosis
• History
• Physical Exam
• Potential Interventional Treatments
• Outcome of case
 Learning Objectives
• Become familiar with a focused pain history

• Become familiar with a focused

musculoskeletal/neurologic physical exam
for lower back pain

• Be able to form a differential diagnosis for

lower back pain

• Achieve a basic understanding of treatment

modalities for lower back pain
 Why is this important?
• Most common chronic pain condition
• Most common cause of missed days from work
• Highest prevalence in 45 to 64 years
• Return to work rates for pain >6 months is low
• Estimated that up to 80% of the population will
experience low back pain
– 70% will resolve in a few weeks
– 85% will recur
– 7% will have chronic pain
• Economic costs
– $200 Billion Annually (1/3 direct cost)
It’s 4:15pm on a Friday, Dr. Net asks you see the
last new patient of the day…

“A 56-year-old woman with a PMH of lung CA,

colon cancer, depression presents to the pain
clinic with lower back pain, which she states she
has had for the past three years after a MVC.”
What do you want to know?
 You conduct an HPI focused on pain symptoms…

- Located bilateral lower back

- Severity is 8 out of 10
- Quality is sharp, shooting, throbbing, cramping and
burning.
- Timing is intermittent and mostly in the morning, but
gets better through the course of the day
- Exacerbated by sitting, standing, lying down and
driving
- Alleviated by rest and heat
- Accompanied by numbness and paresthesia in L.
leg to above the knee.
- Works as a yoga instructor and an office
administrator, and the pain does not limit her ability
to perform her job.
 You complete the history…

Previous Surgeries:
– L4-L5 Laminectomy and posterior interbody fusion (2/13)
– L. lower lobectomy and lymph node dissection (4/13)
– R. Laparoscopic colectomy for hyperplastic polyp

Pain Medications:
– Naproxen 440mg PO Daily
– Tumeric Supplement Daily
– Trazadone 50mg PO QHS
– Fish Oil Capsules Daily
– MVI
 You complete the history…

Previous Pain Interventions:

-SIJ injections with corticosteroids, unclear number
-Right GTB (greater trochanteric bursa) injections,
unclear number

Physical Therapy:
-No history of physical therapy

Complementary:
-Yoga
-Tumeric
 You perform a physical exam…

• General: Fit woman in no acute distress

• HEENT: Normocephalic, atraumatic
• Eyes: EOMI, pupils equal round and reactive
• Cardiac: RRR
• Lungs: CTAB
• Abdomen: Soft
• Skin: No rashes, lesions or alopecia noted.
• Extremities:
– Walks with a non-antalgic gait.
– No pain with internal and external rotation of hips.
– Full flexion at knee.
 You examine her back…
• While standing no asymmetry.
• Evidence of prior surgeries.
• No tenderness over spinous processes.
• Multiple trigger points palpated in R. quadratus lumborum.
• Full lumbar flexion without reproduction of pain.
• Full range of extension, axial rotation and lateral rotation.
• Axial and lateral rotation reproduce pain primarily on R.
lower back.
• Point tenderness over bilateral SI joints and bilateral
lumbar facet joints and bilateral GTBs (L>R).
• Patrick's test (FABER) negative b/l.
• Straight leg raise negative.
You conduct a focused neuro exam…

• Alert and oriented x 3

• CN III-XII intact
• Strength: 5/5 in UE and LE
• Reflexes: 1+ b/l biceps, triceps, knees, ankles,
negative babinski
• Sensation to light touch (STLT) intact in b/l UE
and LE
• No allodynia or hyperalgesia noted
• Coordination within normal limits
What other data would you want to review?

15
You review her past imaging…

• Lumbar X-ray: AP and lateral

• Lumbar MRI w/o contrast
Transitional anatomy at
lumbosacral junction.

Grade 2 anterolisthesis
of L4 and L5.

Bones are osteopenic.

Posterior fusion from

L4 to L5.
 Lumbar MRI

L3-L4 Disc
Protrusion
Bilateral L4-
L5 foraminal
Stenosis
You tell the patient you’ll discuss her case with
your attending and will return in about 5
minutes.

What’s your differential diagnosis?

What do you think is the most likely diagnosis?

What course of treatment will you recommend?

 Differential Diagnosis

• Myofascial Pain
• Facetogenic Pain
• Sacroiliac Pain
• Piriformis Syndrome
• Radicular Pain

21
 Myofascial Pain: Diagnosis
• Thought to be caused by trigger points
• Trigger points are discrete areas defined by a tight band of muscle,
tenderness to palpation, and a reference pain zone
 Latent vs. Active
 Tender point
• When palpating trigger points, steady pressure should be applied until
hyperalgesic points are found
 Twitch response
• No clear mechanism (overuse, trauma, secondary to other
musculoskeletal injuries)
• Often, the muscles used to maintain body posture are affected (i.e.
muscles in neck, shoulders, and pelvic girdle)
Marked trigger points with areas of reference
 Myofascial Pain: Treatment
• NSAIDs
• Muscle relaxants
• Dry needling
• Trigger point injections (TPI)
– 25G ¾ inch needle for superficial muscles
– 25G 1.5 inch needle for deep muscles
– 1% Lidocaine and 0.25% bupivacaine
• TPIs can provide days to months of relief and may be curative
Trigger point injection

25
 You examine her back…
• While standing no asymmetry.
• Evidence of prior surgeries.
• No tenderness over spinous processes.
• Multiple trigger points palpated in R. quadratus lumborum.
• Full lumbar flexion without reproduction of pain.
• Full range of extension, axial rotation and lateral rotation.
• Axial and lateral rotation reproduce pain primarily on R.
lower back.
• Point tenderness over bilateral SI joints and bilateral
lumbar facet joints and bilateral GTBs (L>R).
• Patrick's test (FABER) negative b/l.
• Straight leg raise negative.
Facetogenic Pain: Anatomy
 Facetogenic Pain: Diagnosis
• Facet Joints also known as zygapophyseal joints are paired synovial joints
• Connect vertebrae posterolateral
• Function to assist discs in resisting compressive forces with stress occurring
during extension and rotation (facet loading)
• Pain observed during lumbosacral extension
 Facetogenic Diagnosis Cont.
• Normal ROM 20-35 degrees
• Weakness usually not seen
• Radiation does not extend
beyond knee
• Symptoms improved by walking
• Evidence of degenerative
changes on radiologic studies
• The only reliable method of
diagnosing facet pain is by
double diagnostic interventional
blocks.
– Single block false positive
30%
– False negative 8%
 Facetogenic Pain: Treatment
• Physical therapy
• Intra-articular facet blocks
• Medial branch blocks (MBB) that
reduce pain by 50% are diagnostic
– Each lumbar facet is supplied by two
medial branches
• Medial branch radiofrequency ablation
– Needle warmed to 80 degrees Celsius
which ablates neural transmission
• Neuroablative facet denervation
– Cryotherapy
– Radiofrequency
 You examine her back…
• While standing no asymmetry.
• Evidence of prior surgeries.
• No tenderness over spinous processes.
• Multiple trigger points palpated in R. quadratus lumborum.
• Full lumbar flexion without reproduction of pain.
• Full range of extension, axial rotation and lateral rotation.
• Axial and lateral rotation reproduce pain primarily on R. lower
back.
• Point tenderness over bilateral SI joints and bilateral lumbar
facet joints and bilateral GTBs (L>R).
• Patrick's test (FABER) negative b/l.
• Straight leg raise negative.
Sacroiliac Joint Pain: Anatomy

Iliac

PSIS
 Sacroiliac Pain: Diagnosis
• SI joint functions to dissipate shock
forces
• Can be bilateral or unilateral
• Pain can radiate to just below the knee
• Can present as groin pain
• No weakness or parathesias
• No single PE test that is highly
sensitive or specific
• Only true diagnosis can be made via
block
• CT or MRI not helpful
Sacroiliac Pain: Maneuvers
Gaenslens Test

35
Patrick/FABER(Flexion, Abduction, External
Rotation) Test

36
Fortin Finger Test

37
 Sacroiliac Pain: Risk Factors
• Ankylosing spondylitis
• Pregnancy
– Hormonal induced
ligamentous laxity
• True or apparent leg
length discrepancies
• Infection
• Tumors
• Among patients with
low back estimated
prevalence is 20-35%
 Sacroiliac Pain: Treatment
• PT
• NSAIDs
• Intraarticular block
– Will transverse thick and tough
SI ligament
• Lateral branch blocks (LBB)
• Then RFA of SI joint or LBB
– RFA of the L4 and L5 dorsal
Schematic showing S1-3 lateral
rami and lateral branches of S1 branches innervating the SI Joint
to S3 can provide long lasting
relief
 You examine her back…
• While standing no asymmetry.
• Evidence of prior surgeries.
• No tenderness over spinous processes.
• Multiple trigger points palpated in R. quadratus lumborum.
• Full lumbar flexion without reproduction of pain.
• Full range of extension, axial rotation and lateral rotation.
• Axial and lateral rotation reproduce pain primarily on R. lower
back.
• Point tenderness over bilateral SI joints and bilateral lumbar
facet joints and bilateral GTBs (L>R).
• Patrick's test (FABER) negative b/l.
• Straight leg raise negative.
 Piriformis Syndrome
• Myofascial pain disorder:
– Buttock pain
– Referred pain to the ipsilateral lower extremity
– Lower back pain
• Piriformis muscle inflammation, spasms, contracture,
anatomic anomalies, or irritation to the sciatic nerve.
• Controversial:
– Tender piriformis muscle 2/2 muscle spasms and
hypertrophy
– Compression of sciatic nerve
• 6-8% of LBP
• 0.33% - 6% incidence
 Piriformis Syndrome: Anatomy

• Origin:
– Anterior surface of S2-S4 vertebrae
– SIJ capsule
– Gluteal surface of ilium near the posterior
surface of the iliac spine.
• Joins with superior gemellus, inferior gemellus, and
obturator internus prior to insertion.
• Insertion:
– Superior border of the greater trochanter
• Action:
– Lateral rotator of hip joint
– Helps abduct hip joint if flexed
 Piriformis Syndrome: Sciatic Nerve
• Undivided
– Above
– Perforating through
– Below
• Divided
– Tibial & Common
peroneal
– Above and Perforating
through
– Above and below
– Perforating through
and below
• Most Common
– 84-98%: undivided
below
– 12%: divided through
and below
Piriformis Syndrome: Mechanism
Injury to piriformis

Histamine, serotonin,
prostaglandin, bradykinin
release

Muscle Spasms

Irritation of sciatic nerve

Piriformis Syndrome: Mechanism

Pain Spasm

Irritation Inflammation
Piriformis Syndrome: Mechanism

•Referred pain from trigger points

•Compression of sciatic nerve by

hypertrophied piriformis

•Taut band and trigger points may

contribute to compression of nerve

•Compression of motor nerve may

cause trigger points in the
innervated muscle.
 Piriformis Syndrome: Risk Factors
• Demographics:
– 30-40 years old
– Female (3-6 times more than males)
– Long distance truck drivers, cyclists, tennis players, ballet
dancers

• PMH
– Recent history of trauma to buttocks (>50%)
– Exacerbated by activity intensity
– Changes in low back, pelvis, or lower extremity
biomechanics
– Leg length discrepancy
– h/o TKA
– h/o laminectomy (scar tissue impinged nerve roots and
“shortens” nerve)
– Gait disturbances
– Pregnancy
 Piriformis Syndrome: History

• Buttock pain
– With or without
radiation
– To the ipsilateral
lower extremity
– To or below knee.
• Exacerbated by
– Prolonged sitting
– Intercourse
– Bowel movement.
 Piriformis Syndrome: Physical Exam

• Tenderness at buttock region

overlying piriformis muscle or greater
sciatic notch.
• Taut muscle band (+/- TP)
• Sensory deficits in lower leg or foot
• Due to depth, proper palpation of
piriformis can only be done via pelvic
or rectal exam
• FADIR test
– Flexion of hip
– ADduction
– Internal Rotation
FADIR (Flexion, Adduction, Internal Rotation) Test

50
 Piriformis Syndrome: Treatment
• Conservative Therapy
– Physical therapy
– Stretching
– NSAIDS
– Muscle Relaxants

• Injections
– Fluoroscopically- or
ultrasound- guided
– Local Anesthetics
– Adjuvants
(clonidine)
– Corticosteroids
– Botox
Piriformis Syndrome: Treatment
 You examine her back…
• While standing no asymmetry.
• Evidence of prior surgeries.
• No tenderness over spinous processes.
• Multiple trigger points palpated in R. quadratus lumborum.
• Full lumbar flexion without reproduction of pain.
• Full range of extension, axial rotation and lateral rotation.
• Axial and lateral rotation reproduce pain primarily on R. lower
back.
• Point tenderness over bilateral SI joints and bilateral lumbar
facet joints and bilateral GTBs (L>R).
• Patrick's test (FABER) negative b/l.
• Straight leg raise negative.
 Radicular Back Pain
• Radiculitis
– Neuropathic pain in a dermatomal distribution
• Radiculopathy
– Neurologic deficits (motor or sensory) in the
distribution of a spinal nerve

• Irritation of the spinal cord (myelopathy) or a spinal

nerve (radiculitis/radiculopathy) secondary to:
– Disc herniation (HNP)
– Neural foraminal stenosis
– Spinal canal stenosis
– Neurogenic claudication
 Radicular Pain: Inflammatory Model
• Mechanical compression considered most common reason for sciatica
• 36% of patients with compression on MRI remain asymptomatic
• Nucleus pulposis contains:
– Phospholipid A2 (PLA 2)
– Metalloproteases
– Nitric oxide.
• PLA 2 generates inflammatory mediators in experimental models.
 Radicular Pain: Inflammatory Model
• Compression surgery causes numbness and parathesias
• Injection of autologous nucleus pulposis into epidural space of dogs
 Inflammatory changes in the dural sac, spinal cord, and nerve roots

• Similar study in pigs resulted in decrease of conduction velocities

 Disc Herniation: Nomenclature

• Localized displacement of disc material

beyond the limits of the intervertebral disc
space.
• Circumferential bulge
– Disc material bulging out >50% of the edges of
the vertebral body (not a herniation)
• Localized herniated disc material (<50%):
– Focal herniation – <25%
– Broad-based herniation – 25-50%
 Disc Herniation: Nomenclature

• Protrusion
– Herniation that has a base wider than furthest
extent of apex
• Extrusion
– Herniation where the diameter of the disc
fragment from base to apex is wider than the
width of the fragment at the base
• Sequestration
– Material completely separated from parent disc
Straight Leg Raises

60
 Lumbar MRI

L3-L4 Disc
Protrusion
 Foraminal Stenosis

Caused by a reduction in the space available for the exiting root within its canal
(neural foramina) by osseous and/or ligamentous hypertrophy.
Bilateral L4-
L5 foraminal
Stenosis
Spinal Canal Stenosis
Spinal Canal Stenosis
 Neurogenic Claudication

• Central canal stenosis:

– Radicular pain
– Neurogenic claudication
– Both

• Symptoms
– Pain
– Paresthesia
– Cramping of one or both legs
– Brought on by walking
– Relieved by sitting.
 Neurogenic Claudication

• Exaggerated when the spine is

extended (upright stance)
• Eased when the spine is flexed
(stooping forwards or sitting).
• Likely caused by stenotic
changes
– Neural and microvascular
compromise of the cauda
equina and lumbosacral
nerve roots.
 Epidural Steroid Injections: Indications

• Radiculitis
• Radiculopathy
• Lumbar disc displacement without
myelopathy
• Axial pain
• Diagnostic for vague symptoms or
multilevel pathology
• Post-laminectomy with recurrent
pain
• Central canal stenosis
• Neural foraminal stenosis
 Epidural Steroid Injections

• Contraindications
– Patient refusal
– Bleeding disorders
– Elevated coagulation studies

• Medications
– Corticosteroids
• Triamcinolone
• Methylprednisolone
• Dexamethasone
– Local Anesthetics
Epidural Steroid Injections: Techniques
Epidural Steroid Injections: Techniques
 Assessment

• Chronic lower back pain s/p L4/5 laminectomy

and fusion
• Multifactorial etiology, including:
– Facetogenic pain
– B/L Sacroiliitis
– Lumbar paraspinal myofascial pain
– Possible contribution from post-laminectomy
syndrome
 Plan
• Diagnostic
– Lumbar diagnostic MBB injections
• Pharmacologic
– Discussed NSAIDS, acetaminophen, and muscle relaxants
– Patient declined
• Interventions
– If Lumbar MBB effective, proceed to RFL of MB
– In future, SIJ injections
– Trigger point injections
• Rehabilitation
– PT for stretching exercises
• Complementary
– Continue yoga and HEP
 Conclusion

• Patient reported 80% pain relief following MBB

• Progressed to lumbar RFL
• Received 4 months of analgesia
• Very satisfied with progress of her lower back pain
• Following, underwent SIJ injections
• Has returned periodically for repeat procedures
• Continues good function with limited effects on daily
activities.
 References:

• Alvarez, D., Rockwell, P. Trigger Points: Diagnosis and Management Am Fam Physician. 2002 Feb
15;65(4):653-661.
• Nieves RA, Shah RV. Nieves R.A., Shah R.V. Nieves, Ricardo A., and Rinoo V. [Link] Point
Injections. In: Diwan S, Staats PS. Diwan S, Staats P.S. Eds. Sudhir Diwan, and Peter S. [Link].
Atlas of Pain Medicine Procedures. New York, NY: McGraw-Hill; 2015.
[Link] Accessed
January 04, 2017.
• Schofferman J. Failed Back Surgery. In: Bajwa ZH, Wootton R, Warfield CA. eds. Principles and Practice
of Pain Medicine, 3e. New York, NY: McGraw-Hill; 2016.
[Link]
Accessed February 03, 2017.
• Gray DP, Simopoulos TT. Facetogenic Pain. In: Bajwa ZH, Wootton R, Warfield CA. eds. Principles and
Practice of Pain Medicine, 3e. New York, NY: McGraw-Hill; 2016.
[Link]
Accessed February 03, 2017.
• Sudhir Diwan, Peter S. Staats. Atlas of Pain Medicine Procedures, 2015 Sacroiliac Joint Injections. 2015
Accessed January 4, 2017
• Patil S, Benzon HT, Diwan S. Sacroiliac Joint Injections. In: Diwan S, Staats PS. eds. Atlas of Pain
Medicine Procedures. New York, NY: McGraw-Hill; 2015.
[Link] Accessed
February 02, 2017.
References:

• Lee AC, Cohen SP, Abdi S. Low Back Pain. In: Bajwa ZH, Wootton R, Warfield CA. eds. Principles and
Practice of Pain Medicine, 3e New York, NY: McGraw-Hill;
. [Link]
bookid=1845&sectionid=133686960. Accessed March 19, 2017.
• Images taken from a google images