THE MANAGEMENT OF INTRACTABLE- LOW BACK PAIN : RECENT ADVANCES
DR. NEERAJ JAIN
Interventional Pain Specialist ,Spine & Pain Clinic. RU-23 Pitampura,
& Consultant Incharge, Pain Clinic, Sri Balaji Action Medical Institute, New Delhi,
& Sant Parmanand Hospital, Delhi.
LOW BACK PAIN (LBP) is a pandemic disease having 80% of lifetime prevalence,affecting 15-20% population at any point of time, being one of the commonest reason for visit to a doctor & young age morbidity/disability/work absenteeism.
AETIOLOGY OF LBP:
LBP is not just a disease but a symptom, syndrome with combination of multiple possible abnormalities of anterior & posterior longitudinal ligaments, vertebral body, synovia / chondropathy/osteoarthritis of articulating facets joints, sacroiliac joint, nerve roots & foramen, paraspinal muscles, related connective tissues eg.- ligamentum flavum , spinal canal, intervertebral disc at annulus ring. It may be due to mechanical, nonmechanical, referred pain, psychological & failed back surgery (FBSS).
PERCUTANEOUS LEAST INVASIVE INTERVENTIONAL
PAIN MANAGEMENT OF LBP:-
It has both diagnostic & therapeutic relevance(as there are significant false positive & negative imaging studies not correlating to symptoms)
Better results are obtained if treatment is started early.
*  LESI-lumbar epidural steroid injections::
*  interlaminar and transforaminal or caudal approach
*  SNRB- selective nerve root block
*  Epidural neurolysis or percutaneous decompressive neuroplasty
*  Trigger point injection
*  Botox paraspinal muscle injection
*  Facet joint or pericapsular injection
*  Spine Prolotherapy & manipulation
*  Facet RF thermal neurolysis
*  SI joint injection or denervation
*  Piriformis  muscle block
*  Diagnostic provocative discography
*  Intradiscal procedures:-Ozone Discolysis/ Chemonucleolysis
-  Dekompressor disc debulking
-  IDET-intradiscal electrothermal therapy
-  Coblation nucleoplasty
-  Laser percutaneous discectomy
*  Vertebroplasty & kyphoplasty
*  Intrathecal pump neuraxial implants
*  Augmentation or neuromodulation spinal cord stimulation
ONCE THE CONSERVATIVE TREATMENT FAILS:-
Early aggressive treatment plan of pain has to be implemented to prevent peripherally induced CNS changes that may intensify or prolong pain making it a complex pain syndrome. Only 5% of total LBP patients would need surgery & 20% of discal rupture or herniation would need surgery. Nonoperative treatment is sufficient in most of the patients, although patient selection is important even then.
Depending upon the diagnosis one can perform & combine properly selected percutaneous fluoroscopic guided procedures with time spacing depending upon pt`s pathology & response to treatment.
Using precision diagnostic & therapeutic blocks in chronic LBP , isolated facet joint pain in 40%,discogenic pain in 25%(95% in L4-5&L5S1) ,segmental dural or nerve root pain in 14% & sacroiliac joint pain in 15% of the patients. This article describes successful interventions of these common causes of LBP after conservative treatment has failed.
LESI : LUMBAR EPIDURAL STEROID INJECTION
Indicated in  - Acute radicular pain due to irritation or inflammation.
- Symptomatic herniated disc with failed conservative therapy
- Acute exacerbation of discogenic pain or pain of spinal stenosis
-  Neoplastic infiltration of roots
-  Epidural fibrosis
-  Chronic LBP with acute radicular symptoms
ESI  TREATMENT PLAN:
Compared to interlaminar approach better results are found with transforaminal approach where drugs (steroids LA/saline+/- hyalase) are injected into anterior epidural space & neural foramen area where herniated disc or offending nociceptors are located. Whereas in interlaminar approach most of drug is deposited in posterior epidural space.Drugs are injected total 6-10 ml at lumbar, 3-6 ml at cervical & 20+ mlif caudal approach is selected. Lumbar ESI is performed close to the level of radiculopathy, often using paramedian approach to target the lateral aspect of the epidural space on involved side. Cervical epidural is performed at C7-T1 Level .
SNRB-SELECTIVE NERVE ROOT BLOCK.
Fluoroscopically performed it is a good diagnostic & therapeutic procedure for radiculopathy pain if
*  There Is minimal or no radiological finding.
* Multilevel imaging abnormalities
* Equivocal neurological examination finding or discrepancy between clinical & radiological signs
* Post Op patient with unexplainable or recurrent pain
* Combined canal & lateral recess stenosis.
* To find out the pathological dermatome for more invasive procedures , if needed
EPIDURAL NEUROLYSIS OR PERCUTANEOUS DECOMPRESSIVE NEUROPLASTY for EPIDURAL FIBROSIS OR ADHESIONS IN FAILED BACK SURGERY SYNDROME(FBSS)
A catheter is inserted in epidural space via caudal/ intralaminar/ transforaminal approach
After epidurography testing volumetric irrigation with normal saline/ L.A./ hyalase/ steroids/hypertonic saline in different combinations is then performed along with mechanical adenolysis with spring loaded or stellated catheters or under direct vision with EPIDUROSCOPY.
FACET SYNDROME:-  FACET JOINT INJECTION OR
RF MEDIAL BRANCH NEUROTOMY
It is due to mechanical stress on the Zygapophysial  joints or traumatic/anatomical derangement & degenerative facet arthropathy. It is commoner in male of younger age group during active careers . CT/ MRI/ Bone Scan show structural pathology, but diagnosis is confirmed by relief of pain with joint injection (1 ml of LA+ 20 mg triamcinolone) which has therapeutic therapeutic value.After effective facet joint block, fluoroscopic percutaneous radiofrequency(RF) thermal rhizotomy of two level medial branches of dorsal ramus  is a safe, effective & long term treatment.
SACROILIAC JOINT INJECTION & DENERVATION:
The only way to make a definitive diagnosis is pain relief with image guided joint injection of depo-steroid with L.A..This Can be followed by joint denervation of L4-5 S1-3 branches to this joint providing long term pain relief.
PROVOCATIVE DISCOGRAPHY: coupled with CT
A diagnostic procedure or prognostic indicator for surgical outcome is necessary in the evaluation of patients with suspected discogenic pain, its ability to reproduce pain(even with normal radiological finding), to determine type of disc herniation /tear,finding surgical options & in assessing previously operated spines
PERCUTANEOUS DISC DECOMPRESSION (PLDD)
After diagnosing the level of painful offending disc various percutaneous intradiscal procedures can be employed:
OZONE-DISCOLYSIS: Ozone Discectomy a revolutionary least invasive safe & effective alternative to spine surgery is the treatment of choice for prolapsed disc (PIVD) done under local anaesthesia in a daycare setting. This procedure is ideally suited for cervical & lumbar disc herniation with radiculopathy. Total cost of the procedure is much less than that of surgical discectomy. All these facts have made this procedure very popular at European countries. It is also gaining popularity in our country due to high success rate, less invasiveness, fewer chances of recurrences,remarkably fewer side effects meaning high safety profile, short hospital stay,no post operative discomfort or morbidity and low cost.
DEKOMPRESSOR:  A mechanical percutaneous nucleotomy cuts & drills out the disc material  somewhat like macerator debulking the disc reducing nerve compression.
INTRATHECAL(SPINAL) PUMP IMPLANTS:
Opted when oral narcotics provide insufficient pain relief or side effects are troublesome in intractable cancer & chronic pain patients. It delivers drug via an implanted catheter directly into CSF needing a very small dose (1/300 of oral dose). The programmable pump is implanted in ant. lower abdomen. It delivers the drug as per the patients needs. More powerful analgesia & spasticity control is achieved using lower doses, constant relief & fewer side effects as with oral doses eg. Somnolence, mental clouding, constipation, euphoria with decreased chances of drug addiction or misuse.
SPINALCORD STIMULATION (SCS) IMPLANTS :
Done for FBSS(failed back surgery syndrome) & CRPS(comlex regional pain syndromes) inUSA.In Europe it is done for chronic intractableangina &  pain of peripheral vasculardiseases (PVD). The indications are expanding further in chronic pain states. A Set of electrodes is placed in epidural space & connected to a pulse generator ( like a cardiac pacing device) that is implanted in upper buttock.Low level of electric impulses replace pain signals to the brain with mild tingling  sensation. A trial stimulation is done before permanent SCS lead implant.
PERCUTANEOUS VERTEBROPLASTY / KYPHOPLASTY:
A NEWER APPROACH TO MANAGEMENT OF VERTEBRAL BODY FRACTURES
As life expectancy is increasing so is the incidence of vertebral body (VB) # now being the commonest # of the body. PVP is an established interventional techniques in which PMMA bone cement is injected under L.A.via a needle into a # VB with imaging guidance providing increased bone strength, stability, pain relief, decreased analgesics, increased mobility with improved QOL and early return to work.