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Lbp with radiculopathy
- 1. RECENT GUIDELINE FORRADICULOPATHY AND BACK PAIN DR. VINOD SINGH JATAV SR NEUROLOGY GMC KOTA
- 2. • Up to84 percent of adults have low back pain at some time in their lives • >85 percent will have nonspecific low back pain. • Acute back pain upto four weeks. • Subacute back pain lasting between 4 and 12 weeks • And chronic back pain lasting >12 weeks Hoy D, Bain C, Williams G, et al. A systematic review of the global prevalence of low back pain. Arthritis Rheum 2012;
- 4. Congenital Spinal bifida occulta Tetheredspinal cord ;
- 5. Causes of lowerback pain without leg pain • Ligamentous strain • Muscle strain • Facet pain • Bony destruction • Inflammation from many causes Causes of lower back plus lower limb pain include: • Spinal stenosis • Radiculopathy • Plexopathy Leg pain without low back pain • Peripheral mononeuropathies • polyneuropathies • Plexopathies • Vascular claudication
- 12. Acute low backpain imaging consideration
- 13. Acute low backpain imaging consideration
- 15.
- 16. Treatment of acutelow back pain NONPHARMACOLOGIC THERAPIES • Heat • Massage- no evidence that massage offers clinical benefits for acute low back pain. increased patient satisfaction • Spinal manipulation • Exercise and physical therapy- in patients with acute low back pain, exercise therapy was not more effective, patient education programs, and/or advice to stay active evidence to support exercise therapy for patients with subacute and chronic low back pain • Lumbar supports No evidence to support 1.Qaseem A, Wilt TJ, McLean RM, et al. Noninvasive Treatments for Acute, Subacute, and Chronic Low Back Pain: A Clinical Practice Guideline From the American College of Physicians. Ann Intern Med 2017;.
- 17. PHARMACOTHERAPY • NSAIDS andacetaminophen • Second-line therapy- Muscle relaxants (Cyclobenzaprine, methocarbamol, carisoprodol, baclofen, chlorzoxazone, tizanidine) • Refractory or severe pain- Opioids and tramadol do not advise bed rest for patients with acute low back pain. (Patients who are treated with bed rest have more pain and slower recovery than ambulatory patients) If activity is painful or increases pain, advise gradually increase activity as tolerated
- 18. Subacute and chroniclow back pain: Nonpharmacologic • Self-care advice • Maintain activity as tolerated • Heat • Exercise therapy- core strengthening, aerobic exercise, yoga and Tai Chi. • Psychological and mind-body therapies cognitive behavioral therap, mindfulness-based stress reduction MBSR • Spinal manipulation • Acupuncture • Yoga
- 19. Pharmacologic treatment • NSAIDSand acetaminophen • second-line therapy- Muscle relaxant • Duloxetine and tramadol • Tricyclic antidepressants
- 20. Surgical Management INDICATIONS • severeor progressive motor weakness • signs and symptoms of cauda equina syndrome • persistent disabling symptoms of low back pain and significantly impaired quality of life • not responded to adequate trials of nonsurgical approaches • persistent (>1 year) disabling non-radicular low back pain with discussion of its risks and benefits
- 21. • Spinal fusion-(chronicnonspecific low back pain with lumbar disc degenerative changes) • Lumbar disc replacement. (approved by the FDA for patients who are in good health and ≤60 years old, with disease limited to one disc between L3 and S1 and no associated deformity, spondylolisthesis, or neurologic deficit)
- 22. LUMBAR DISC PROLAPSE •Traditional open discectomy with laminectomy • Microdiscectomy • Minimally invasive procedures- percutaneous manual nucleotomy, percutaneous discectomy, laser discectomy, endoscopic discectomy, microendoscopic discectomy, and radiofrequency nucleoplasty (inferior due to recurrent disc herniation) Spinal cord stimulation- in patients with persistent and disabling radicular pain following surgery complication, including electrode migration, infection or wound breakdown, generator pocket-related complications, and lead problem)
- 23. Approach to acutelumbosacral radiculopathy
- 24. Approach to acutelumbosacral radiculopathy
- 25. Approach to Acutelumbosacral radiculopathy Recommend urgent imaging • Acute radiculopathy with progressive neurologic deficits • Radiculopathy with urinary retention, saddle anesthesia, or bilateral neurologic symptoms or signs • Suspected neoplasm • Suspected epidural abscess If imaging is negative or equivocal, • nerve conduction studies (NCS) and electromyography (EMG) identify nonstructural causes. • A lumbar puncture and cerebrospinal fluid (CSF) analysis suspected inflammatory or infectious cause of lumbosacral radiculopathy
- 26. Acute lumbosacral radiculopathy:Treatment and prognosis • Initial conservative treatment- NSAIDs or Acetaminophen and activity modification • Physical therapy-in the first one to two weeks not recommended because mild symptoms are likely to improve on their own very severe symptoms cannot participate in exercise therapy. delay physical therapy until symptoms have persisted for three weeks. bed rest is ineffective for treating sciatica as well as back pain. • Systemic glucocorticoids- who do not respond well to analgesic and activity modification, With rapid taper over 7 to 14 days
- 27. • Opioids –exceptfor severe intractable pain unresponsive to other therapies • Benzodiazepines and antispasmodic agents • Epidural glucocorticoids- Which not improved with conservative treatment over six weeks EXERCISE: • Walking • Aerobic exercise- bicycling, swimming, treadmill walking, and elliptical trainers • Stretching exercises • Yoga • Tai Chi • Graded activities exercise/functional restoration • Multidisciplinary (interdisciplinary) rehabilitation
- 29. Surgical management • Anteriorcervical discectomy and fusion • Posterior lamino-foraminotomy • Artificial disc replacement • Cervical medial branch blocks • intermittent cervical traction • Percutaneous radiofrequency neurotomy Cervical collar- Routine use discouraged
- 32. REFERENCES • Dahm KT,Brurberg KG, Jamtvedt G, Hagen KB. Advice to rest in bed versus advice to stay active for acute low-back pain and sciatica. Cochrane Database Syst Rev. 2010 Jun 16;(6):CD007612 • Bradely’s Neurology In Clinical Practise, 8th Edition • Harrison’s Principle Of Internal Medicine,20th Edition • Low back pain and sciatica © NICE 2021. • Chou R, Qaseem A, Snow V, et al. Diagnosis and treatment of low back pain: a joint clinical practice guideline from the American College of Physicians and the American Pain Society. Ann Intern Med 2007; 147:478. • Chou R, Fu R, Carrino JA, Deyo RA. Imaging strategies for low-back pain: systematic review and meta-analysis. Lancet 2009; 373:463. • Friedman BW, Irizarry E, Solorzano C, et al. A Randomized, Placebo-Controlled Trial of Ibuprofen Plus Metaxalone, Tizanidine, or Baclofen for Acute Low Back Pain. Ann Emerg Med 2019
- 33.
Editor's Notes
- #17 systematic review including six studies of low back pain found moderate evidence that a heat wrap may reduce pain and disability for patients with pain of less than three months’ duration, although the benefit was small and short-lived)
- #18 bed rest should be avoided for relief of severe symptoms or kept to a day or two at most. Several randomized trials suggest that bed rest does not hasten the pace of recovery. In general, the best activity recommendation is for early resumption of normal physical activity, avoiding only strenuous manual labor. Possible advantages of early ambulation for ALBP include maintenance of cardiovascular conditioning, improved bone, cartilage, and muscle strength, and increased endorphin levels