BACK PAIN PROF DESSY.pdf

BACK PAIN, WHAT ARE THE POSSIBILITIES? Prof. Dr. dr. Dessy R. Emril, Sp.S(K) Pain and Headache Division Neurology Department, Medical Faculty Universitas Syiah Kuala  INTRODUCTION Pain is a complex unpleasant phenomenon composed of sensory experi...

BACK PAIN, WHAT ARE THE POSSIBILITIES? Prof. Dr. dr. Dessy R. Emril, Sp.S(K) Pain and Headache Division Neurology Department, Medical Faculty Universitas Syiah Kuala  INTRODUCTION Pain is a complex unpleasant phenomenon composed of sensory experiences that include time, space, intensity, emotion, cognition, and motivation The yearly prevalence of low back pain varies from 5% to as high as 65%1-5 the lifetime prevalence can range up to 84% 2,4,5 and the monthly prevalence has been placed between 35% and 37% Back pain has a high rate of disability associated with it, which has led to an escalation in the medical based costs as a result of back pain  DEFINITION Acute back pain occurs suddenly and generally lasts for several weeks or months. It is usually caused by a Back pain is a condition characterized by physical injury, incorrect movement, or pain or discomfort in the back region of the too much weight on the back. body, which includes the spine, muscles, ligaments, or nerves around the back. Back pain can be divided into two main types: Chronic back pain, on the other hand, acute back pain and chronic back pain. lasts longer than 12 weeks and can be caused by an underlying medical condition, such as a spinal hernia, osteoarthritis, or a nerve disorder.  THREE SYSTEMS INTERACT USUALLY TO PRODUCE PAIN Sensory Motivational Cognitive discriminative system affective system evaluative system processes information determines the overlies the individuals about the strength, individual´s approach- learned behaviour intensity, quality and avoidance behaviours concerning the temporal and spatial experience of pain. It aspects of pain may block, modulate, or enhance the perception of pain  ETIOLOGY EXTRASPINAL STRUCTURAL ETIOLOGIES ETIOLOGIES NEUROGENIC ETIOLOGIES  STRUCTURAL ETIOLOGIES Vertebral Bodies Sacroilliac Joint a. Vertebral Zygapophysial Joints fractures and Capsules Lumbar a. SI joint b. Spondylolysis, Intervertebral Disc arthropathy spondylolisthesis, a. Facet joint b. SI joint instability and pars defects a. High-intensity degeneration zones and annular b. Facet hypertrophy tears c. Capsular b. Degenerative disc derangement and disease calcification c. Diskitis  STRUCTURAL ETIOLOGIES Pelvic Insufficiency Ligamentum Flavum Fracture Duramater And Arachnoid Structures Iatrogenic Etiologies Musculoligamentous Structures  NEUROGENIC ETIOLOGIES 1. Spinal stenosis b. Congenital and developmental a. Central and foraminal spinal Incomplete vertebral arch closure stenosis (degenerative) Segmentation failure Degenerative disc disease Achondroplasia Facet hypertrophy and arthropathy Shortened pedicles Ligamentum flavum hypertrophy Spina bifida Vertebral fractures Thoracolumbar kyphosis Neoplastic Apical vertebral wedging Abscess formation Osseous exostosis Hematoma formation Iatrogenic because of leaked vetebro or kyphoplasty residue EXTRASPINAL ETIOLOGIES Gastrointestinal. Pelvic and Neoplasms gynecological Psychological Vascular Rheumatologic Infection conditions MECHANISMS-BASED CLASSIFICATIONS 03 02 CENTRAL 01 PERIPHERAL SENSITISATIO N (CS) NEUROPATHIC NOCICEPTIVE PAIN PAIN (NP) SYMPTOMS AND SIGNS OF NOCICEPTIVE PAIN IN PATIENTS WITH LOW BACK (LEG) PAIN Pain localised to the area of injury/dysfunction Clear, proportionate mechanical/anatomical nature to aggravating and easing factors Usually intermittent and sharp with movement Or mechanical provocation SYMPTOMS AND SIGNS OF PERIPHERAL NEUROPATHIC PAIN IN PATIENTS WITH LOW BACK (LEG) PAIN Pain referred in a dermatomal or cutaneous This cluster was found Two symptoms and distribution, history of nerve injury, pathology or to have high levels of one sign associated classification accuracy with a clinical mechanical compromise and pain/symptom provocation (sensitivity 86.3%, 95% classification of PNP CI: 78.0e 92.3; with mechanical/movement in patients with low tests specificity 96.0%, 95% back (leg) pain CI: 93.4e97.8; diagnostic odds ratio e.g. Active/Passive, Neurodynamic 150.9, 95% CI: that move / load 69.4e328.1) / compress neural tissue SYMPTOMS AND SIGNS OF CENTRAL SENSITISATION (CSP) IN PATIENTS WITH LOW BACK (LEG) PAIN Three symptoms and one sign predictive of CSP, including: Disproportionate, non-mechanical, unpredictable pattern of pain provocation in response to multiple/non-specific aggravating/easing factors Pain disproportionate to the nature and extent of injury or pathology Strong association with maladaptive psychosocial factors (e.g. negative emotions, poor self-efficacy, maladaptive beliefs and pain behaviors) Diffuse/nonanatomic areas of pain/tenderness on palpation This cluster was found to have high levels of classification accuracy (sensitivity 91.8%, 95% confidence interval (CI): 84-96.4; specificity 97.7%, 95% CI: 95-99.0)  NOCICEPTIVE AND NEUROPATHIC PAIN MAY CO-EXIST IN LOW BACK PAIN CONDITIONS Nociceptive pain component Neuropathic pain component 1. Freynhagen R, Arevalo Parada H, Calderon-Ospina CA, Chen J, Rakhmawati Emril D, Franco H et al. Current understanding of the mixed pain concept: A brief narrative review. Manuscript submitted for publication.  MIXED PAIN “Mixed pain is a complex overlap of the different known pain types (nociceptive, neuropathic nociplastic) in any combination, acting simultaneously and/or concurrently to cause pain in the same body area. Either mechanism may be more clinically predominant at any point of time. Mixed pain can be acute or chronic.” Freynhagen, Arevallo Parado, Dessy Emril, et al. (2018) it is clinically more challenging to distinguish predominantly neuropathic pain from predominantly nociceptive pain within a mixed pain context2 1. Freynhagen R, Arevalo Parada H, Calderon-Ospina CA, Chen J, Rakhmawati Emril D, Franco H et al. Current understanding of the mixed pain concept: A brief narrative review. Manuscript submitted for publication.  DIAGNOSTIC PROCEDURES FOR LBP  ANAMNESIS Spesicic Radicular Phatologogic pain or spinal condition stenosis Non Spesific LBP  Red Flags IDENTIFICATION Yellow Flags RED FLAGS YELLOW FLAGS PHYSICAL EXAMINATIONS  DISC HERNIATION SPINAL STENOSIS FACET JOINT PAIN SLR positiVe: Sens 91%, 20% no symptom Degeneration process Spec 26% Diagnosis base on history Spine injury crossed SLR: Sens 29%; and PE Fracture Spec 88% Neurogenic claudicatio Tear ligamentum Centralisasi phenomen : (pseudoclaudicatio) Disc problem increase Transient neurology No disc herniation in deficits MRI: decrease Decrease sensibility, muscle weakness wide-based gait or Romberg sign (pseudocereberal presentatation) SACROILLIACA JOINT PAIN distraction test, Uji provokasi compression test Akurasi terbatas thigh thrust test Kombinasi beberapa uji provokasi lebih bermanfaat Patrick’s sign Gaenslen’s test  SI join Spesifisitas dan Moderat Block validitas Radiologi Tidak terbukti diagnostik akurat Bone scan Sensifitifitas Rendah/limitied  MYOFASCIAL LOW BACK PAIN Quadratus Lumborum, Gluteus medius, Para iliopsoas, Abdominis rektus. DIAGNOSTIC IMAGING FOR LBP Abnormal radiology pattern is not the role of LBP causes Asymptomatic patients, > 60 yr: 36 % have disc herniation 21% have spinal stenosis >90% have disc degeneration INDICATIONS OF RADIOLOGY STUDY FOR LBP  PHARMACOLOGIC TREATMENT PAIN PATHWAY AND PHARMACOLOGICAL INTERVENTIONS ▪ At the site of injury, local anaesthetics, antihistamines, and anti-inflammatory agents can be used for direct pain relief. ▪ Opioids and non-opioid drugs including morphine, cannabinoids, COX-2 inhibitors, α2 agonists, gabapentin, acetaminophen, and tricyclic anti-depressants (TCAs) act both peripherally as well as centrally, hence attenuating the transmission of pain signaling. PHARMACOLOGIC TREATMENT  INTERVENTIONAL TECHNIQUES Steroid Injection and Neural Deep Brain Stimulation Blockade (DBS) Percutaneous Spinal cord stimulation neuromodulation therapy (PENS) Neuroablative Procedures Transcranial and Epidural and Stimulation of DRG and Stimulation the Peripheral Nerve or Nerve Field SUMMARY LBP must always be addressed as a complex disease in which it is mandatory that an accurate diagnosis of pain generators is determined before starting any treatment. All the guidelines currently avalaible stress the importance of a multimodal and multidisciplinary approach in order to determine a strategy to solve the problem and not simply alleviate symptomatic pain. A careful follow up is important to adapt our therapeuthic strategies to dynamic clinical manifestations of CLBP. THANKS YOU