Back Pain

Epidemiology and Etiology

Epidemiology

Back pain Pain An unpleasant sensation induced by noxious stimuli which are detected by nerve endings of nociceptive neurons. Pain: Types and Pathways is a common complaint among adults:

• A majority of adults will develop back pain Pain An unpleasant sensation induced by noxious stimuli which are detected by nerve endings of nociceptive neurons. Pain: Types and Pathways in their lifetime.
• The most common musculoskeletal problem globally
• A leading cause of disability Disability Determination of the degree of a physical, mental, or emotional handicap. The diagnosis is applied to legal qualification for benefits and income under disability insurance and to eligibility for social security and workman’s compensation benefits. ABCDE Assessment

Risk factors

• Obesity Obesity Obesity is a condition associated with excess body weight, specifically with the deposition of excessive adipose tissue. Obesity is considered a global epidemic. Major influences come from the western diet and sedentary lifestyles, but the exact mechanisms likely include a mixture of genetic and environmental factors. Obesity
• Age
• Women
• Smoking Smoking Willful or deliberate act of inhaling and exhaling smoke from burning substances or agents held by hand. Interstitial Lung Diseases
• Occupation (e.g., strenuous activity, sedentary work)
• Psychological (e.g., somatization Somatization Somatic Symptom Disorder, anxiety Anxiety Feelings or emotions of dread, apprehension, and impending disaster but not disabling as with anxiety disorders. Generalized Anxiety Disorder, depression)

Etiology

• Nonspecific back pain Pain An unpleasant sensation induced by noxious stimuli which are detected by nerve endings of nociceptive neurons. Pain: Types and Pathways (most common): lacks an underlying condition
• Mechanical:
  • Muscle strain
  • Vertebral compression Compression Blunt Chest Trauma fracture Fracture A fracture is a disruption of the cortex of any bone and periosteum and is commonly due to mechanical stress after an injury or accident. Open fractures due to trauma can be a medical emergency. Fractures are frequently associated with automobile accidents, workplace injuries, and trauma. Overview of Bone Fractures
  • Disk herniation Herniation Omphalocele
  • Spondylolisthesis ( displacement Displacement The process by which an emotional or behavioral response that is appropriate for one situation appears in another situation for which it is inappropriate. Defense Mechanisms of a vertebra forward in relation to the vertebra below)
  • Scoliosis Scoliosis Scoliosis is a structural alteration of the vertebral column characterized by a lateral spinal curvature of greater than 10 degrees in the coronal plane. Scoliosis can be classified as idiopathic (in most cases) or secondary to underlying conditions. Scoliosis and hyperkyphosis
  • Sacroiliac joint Sacroiliac Joint The immovable joint formed by the lateral surfaces of the sacrum and ilium. Pelvis: Anatomy dysfunction
• Degenerative:
  • Spondylosis Spondylosis A degenerative spinal disease that can involve any part of the vertebra, the intervertebral disk, and the surrounding soft tissue. Central Cord Syndrome (a nonspecific term for degenerative changes Degenerative Changes Spinal Stenosis of the spine Spine The human spine, or vertebral column, is the most important anatomical and functional axis of the human body. It consists of 7 cervical vertebrae, 12 thoracic vertebrae, and 5 lumbar vertebrae and is limited cranially by the skull and caudally by the sacrum. Vertebral Column: Anatomy)
  • Osteoarthritis Osteoarthritis Osteoarthritis (OA) is the most common form of arthritis, and is due to cartilage destruction and changes of the subchondral bone. The risk of developing this disorder increases with age, obesity, and repetitive joint use or trauma. Patients develop gradual joint pain, stiffness lasting < 30 minutes, and decreased range of motion. Osteoarthritis
  • Radiculopathy Radiculopathy Disease involving a spinal nerve root which may result from compression related to intervertebral disk displacement; spinal cord injuries; spinal diseases; and other conditions. Clinical manifestations include radicular pain, weakness, and sensory loss referable to structures innervated by the involved nerve root. Rheumatoid Arthritis (dysfunction of the spinal nerve root from inflammation Inflammation Inflammation is a complex set of responses to infection and injury involving leukocytes as the principal cellular mediators in the body’s defense against pathogenic organisms. Inflammation is also seen as a response to tissue injury in the process of wound healing. The 5 cardinal signs of inflammation are pain, heat, redness, swelling, and loss of function. Inflammation, compression Compression Blunt Chest Trauma, or damage)
  • Spinal stenosis Stenosis Hypoplastic Left Heart Syndrome (HLHS)
  • Cauda equina Cauda Equina The lower part of the spinal cord consisting of the lumbar, sacral, and coccygeal nerve roots. Spinal Cord Injuries compression Compression Blunt Chest Trauma
• Infections Infections Invasion of the host organism by microorganisms or their toxins or by parasites that can cause pathological conditions or diseases. Chronic Granulomatous Disease:
  • Epidural abscess Epidural abscess Circumscribed collections of suppurative material occurring in the spinal or intracranial epidural space. The majority of epidural abscesses occur in the spinal canal and are associated with osteomyelitis of a vertebral body; analgesia, epidural; and other conditions. Clinical manifestations include local and radicular pain, weakness, sensory loss, urinary incontinence, and fecal incontinence. Cranial epidural abscesses are usually associated with osteomyelitis of a cranial bone, sinusitis, or otitis media. Retropharyngeal Abscess
  • Discitis
  • Vertebral osteomyelitis Vertebral Osteomyelitis Osteomyelitis
• Malignancy Malignancy Hemothorax:
  • Spinal tumors
  • Metastatic cancer
• Rheumatologic:
  • Ankylosing spondylitis Ankylosing spondylitis Ankylosing spondylitis (also known as Bechterew’s disease or Marie-Strümpell disease) is a seronegative spondyloarthropathy characterized by chronic and indolent inflammation of the axial skeleton. Severe disease can lead to fusion and rigidity of the spine. Ankylosing Spondylitis
  • Reactive arthritis Arthritis Acute or chronic inflammation of joints. Osteoarthritis
  • Psoriatic arthritis Psoriatic Arthritis A type of inflammatory arthritis associated with psoriasis, often involving the axial joints and the peripheral terminal interphalangeal joints. It is characterized by the presence of hla-b27-associated spondyloarthropathy, and the absence of rheumatoid factor. Psoriasis
  • Enteropathic spondyloarthropathy Spondyloarthropathy Ankylosing Spondylitis
  • Fibromyalgia Fibromyalgia Fibromyalgia is a chronic pain syndrome characterized by widespread body pain, chronic fatigue, mood disturbance, and cognitive disturbance. It also presents with other comorbid symptoms such as migraine headaches, depression, sleep disturbance, and irritable bowel syndrome. Fibromyalgia
• Extraspinal causes:
  • Psychological stress Psychological stress Stress wherein emotional factors predominate. Acute Stress Disorder
  • Pancreatitis Pancreatitis Inflammation of the pancreas. Pancreatitis is classified as acute unless there are computed tomographic or endoscopic retrograde cholangiopancreatographic findings of chronic pancreatitis. The two most common forms of acute pancreatitis are alcoholic pancreatitis and gallstone pancreatitis. Acute Pancreatitis
  • Nephrolithiasis Nephrolithiasis Nephrolithiasis is the formation of a stone, or calculus, anywhere along the urinary tract caused by precipitations of solutes in the urine. The most common type of kidney stone is the calcium oxalate stone, but other types include calcium phosphate, struvite (ammonium magnesium phosphate), uric acid, and cystine stones. Nephrolithiasis
  • Pyelonephritis Pyelonephritis Pyelonephritis is infection affecting the renal pelvis and the renal parenchyma. This condition arises mostly as a complication of bladder infection that ascends to the upper urinary tract. Pyelonephritis can be acute or chronic (which results from persistent or chronic infections). Typical acute symptoms are flank pain, fever, and nausea with vomiting. T Pyelonephritis and Perinephric Abscess
  • Abdominal aortic aneurysm Aortic aneurysm An abnormal balloon- or sac-like dilatation in the wall of aorta. Thoracic Aortic Aneurysms
  • Herpes zoster Herpes Zoster Varicella-zoster virus (VZV) is a linear, double-stranded DNA virus in the Herpesviridae family. Shingles (also known as herpes zoster) is more common in adults and occurs due to the reactivation of VZV. Varicella-Zoster Virus/Chickenpox

Clinical Presentation

Classification

Back pain Pain An unpleasant sensation induced by noxious stimuli which are detected by nerve endings of nociceptive neurons. Pain: Types and Pathways is classified based on the duration of symptoms:

• Acute: symptoms < 4 weeks
• Subacute: symptoms 4–12 weeks
• Chronic: symptoms > 12 weeks

History

• Pain Pain An unpleasant sensation induced by noxious stimuli which are detected by nerve endings of nociceptive neurons. Pain: Types and Pathways characteristics:
  • Location
  • Onset and duration
  • Timing
  • Pain Pain An unpleasant sensation induced by noxious stimuli which are detected by nerve endings of nociceptive neurons. Pain: Types and Pathways quality Quality Activities and programs intended to assure or improve the quality of care in either a defined medical setting or a program. The concept includes the assessment or evaluation of the quality of care; identification of problems or shortcomings in the delivery of care; designing activities to overcome these deficiencies; and follow-up monitoring to ensure effectiveness of corrective steps. Quality Measurement and Improvement
  • Severity
  • Radiation Radiation Emission or propagation of acoustic waves (sound), electromagnetic energy waves (such as light; radio waves; gamma rays; or x-rays), or a stream of subatomic particles (such as electrons; neutrons; protons; or alpha particles). Osteosarcoma
  • Exacerbating and relieving factors
• Associated symptoms:
  • Radiating pain Pain An unpleasant sensation induced by noxious stimuli which are detected by nerve endings of nociceptive neurons. Pain: Types and Pathways
  • Referred pain Referred Pain Spinal Disk Herniation
  • Numbness
  • Paresthesia
  • Claudication
  • Muscle spasm
  • Muscle weakness
  • Gait instability Gait Instability Lateral Medullary Syndrome (Wallenberg Syndrome)
  • Bowel/ bladder Bladder A musculomembranous sac along the urinary tract. Urine flows from the kidneys into the bladder via the ureters, and is held there until urination. Pyelonephritis and Perinephric Abscess dysfunction
• Review of systems (list is not exhaustive):
  • Unintentional weight loss Weight loss Decrease in existing body weight. Bariatric Surgery → malignancy Malignancy Hemothorax
  • Fever Fever Fever is defined as a measured body temperature of at least 38°C (100.4°F). Fever is caused by circulating endogenous and/or exogenous pyrogens that increase levels of prostaglandin E2 in the hypothalamus. Fever is commonly associated with chills, rigors, sweating, and flushing of the skin. Fever or chills Chills The sudden sensation of being cold. It may be accompanied by shivering. Fever → infection
  • Rash Rash Rocky Mountain Spotted Fever → herpes zoster Herpes Zoster Varicella-zoster virus (VZV) is a linear, double-stranded DNA virus in the Herpesviridae family. Shingles (also known as herpes zoster) is more common in adults and occurs due to the reactivation of VZV. Varicella-Zoster Virus/Chickenpox
  • Bowel or bladder Bladder A musculomembranous sac along the urinary tract. Urine flows from the kidneys into the bladder via the ureters, and is held there until urination. Pyelonephritis and Perinephric Abscess incontinence → spinal cord Spinal cord The spinal cord is the major conduction pathway connecting the brain to the body; it is part of the CNS. In cross section, the spinal cord is divided into an H-shaped area of gray matter (consisting of synapsing neuronal cell bodies) and a surrounding area of white matter (consisting of ascending and descending tracts of myelinated axons). Spinal Cord: Anatomy compression Compression Blunt Chest Trauma
  • Flank pain Flank pain Pain emanating from below the ribs and above the ilium. Renal Cell Carcinoma and urinary symptoms → urinary tract Urinary tract The urinary tract is located in the abdomen and pelvis and consists of the kidneys, ureters, urinary bladder, and urethra. The structures permit the excretion of urine from the body. Urine flows from the kidneys through the ureters to the urinary bladder and out through the urethra. Urinary Tract: Anatomy infection or nephrolithiasis Nephrolithiasis Nephrolithiasis is the formation of a stone, or calculus, anywhere along the urinary tract caused by precipitations of solutes in the urine. The most common type of kidney stone is the calcium oxalate stone, but other types include calcium phosphate, struvite (ammonium magnesium phosphate), uric acid, and cystine stones. Nephrolithiasis
• Recent trauma
• Past medical history Past Medical History Adult Health Maintenance:
  • History of back pain Pain An unpleasant sensation induced by noxious stimuli which are detected by nerve endings of nociceptive neurons. Pain: Types and Pathways
  • IV drug use
  • Malignancy Malignancy Hemothorax
  • Rheumatologic disease
  • Osteoporosis Osteoporosis Osteoporosis refers to a decrease in bone mass and density leading to an increased number of fractures. There are 2 forms of osteoporosis: primary, which is commonly postmenopausal or senile; and secondary, which is a manifestation of immobilization, underlying medical disorders, or long-term use of certain medications. Osteoporosis
  • Corticosteroid use and immunosuppression
  • Recent bacterial infection
  • Spinal or epidural procedure
  • Disability Disability Determination of the degree of a physical, mental, or emotional handicap. The diagnosis is applied to legal qualification for benefits and income under disability insurance and to eligibility for social security and workman’s compensation benefits. ABCDE Assessment
  • Social or psychological distress

Mnemonic

Important, open-ended questions to ask when evaluating an individual with pain Pain An unpleasant sensation induced by noxious stimuli which are detected by nerve endings of nociceptive neurons. Pain: Types and Pathways can be remembered with OPQRST mnemonic:

• O: onset
• P: provocation and palliation
• Q: quality Quality Activities and programs intended to assure or improve the quality of care in either a defined medical setting or a program. The concept includes the assessment or evaluation of the quality of care; identification of problems or shortcomings in the delivery of care; designing activities to overcome these deficiencies; and follow-up monitoring to ensure effectiveness of corrective steps. Quality Measurement and Improvement of the pain Pain An unpleasant sensation induced by noxious stimuli which are detected by nerve endings of nociceptive neurons. Pain: Types and Pathways
• R: radiation Radiation Emission or propagation of acoustic waves (sound), electromagnetic energy waves (such as light; radio waves; gamma rays; or x-rays), or a stream of subatomic particles (such as electrons; neutrons; protons; or alpha particles). Osteosarcoma (or region)
• S: severity
• T: timing

Physical examination

General examination:

• Inspection Inspection Dermatologic Examination:
  • Posture
  • Deformities
  • Erythema Erythema Redness of the skin produced by congestion of the capillaries. This condition may result from a variety of disease processes. Chalazion
  • Rash Rash Rocky Mountain Spotted Fever
• Palpation Palpation Application of fingers with light pressure to the surface of the body to determine consistency of parts beneath in physical diagnosis; includes palpation for determining the outlines of organs. Dermatologic Examination of the spine Spine The human spine, or vertebral column, is the most important anatomical and functional axis of the human body. It consists of 7 cervical vertebrae, 12 thoracic vertebrae, and 5 lumbar vertebrae and is limited cranially by the skull and caudally by the sacrum. Vertebral Column: Anatomy and paraspinal muscles:
  • Tenderness
  • Muscle tone Muscle tone The state of activity or tension of a muscle beyond that related to its physical properties, that is, its active resistance to stretch. In skeletal muscle, tonus is dependent upon efferent innervation. Skeletal Muscle Contraction
  • Swelling Swelling Inflammation
  • Asymmetry Asymmetry Examination of the Upper Limbs
  • Masses
• Range of motion Range of motion The distance and direction to which a bone joint can be extended. Range of motion is a function of the condition of the joints, muscles, and connective tissues involved. Joint flexibility can be improved through appropriate muscle strength exercises. Examination of the Upper Limbs (ROM):
  • Flexion Flexion Examination of the Upper Limbs
  • Extension Extension Examination of the Upper Limbs
  • Side bending
  • Rotation Rotation Motion of an object in which either one or more points on a line are fixed. It is also the motion of a particle about a fixed point. X-rays
• Neurological examination Neurological examination A neurological exam is a systematic assessment of cognitive, sensory, and motor responses to identify pathologies of the nervous system. A neurological exam allows for the localization of neurologic lesions to narrow the differential diagnosis and focus on subsequent laboratory and imaging examinations. The exam should include assessments of the subject’s mental status, speech, cranial nerves, motor system, deep tendon reflexes, sensation, balance, and coordination. Neurological Examination to assess the entire spinal cord Spinal cord The spinal cord is the major conduction pathway connecting the brain to the body; it is part of the CNS. In cross section, the spinal cord is divided into an H-shaped area of gray matter (consisting of synapsing neuronal cell bodies) and a surrounding area of white matter (consisting of ascending and descending tracts of myelinated axons). Spinal Cord: Anatomy:
  • Deep tendon reflexes Deep Tendon Reflexes Neurological Examination (DTR)
  • Strength testing (myotomal distribution)
  • Sensation ( dermatomal Dermatomal Dermatologic Examination distribution)
  • Gait Gait Manner or style of walking. Neurological Examination

Specific maneuvers:

• Straight leg-raising test (also known as the Lasègue test Lasègue Test Spinal Disk Herniation):
  • Lay the individual supine and test both legs.
  • The extended leg Leg The lower leg, or just “leg” in anatomical terms, is the part of the lower limb between the knee and the ankle joint. The bony structure is composed of the tibia and fibula bones, and the muscles of the leg are grouped into the anterior, lateral, and posterior compartments by extensions of fascia. Leg: Anatomy is passively raised with the foot Foot The foot is the terminal portion of the lower limb, whose primary function is to bear weight and facilitate locomotion. The foot comprises 26 bones, including the tarsal bones, metatarsal bones, and phalanges. The bones of the foot form longitudinal and transverse arches and are supported by various muscles, ligaments, and tendons. Foot: Anatomy dorsiflexed.
  • Result: increased lower-lumbar tension and high sacral-dural tension
  • A positive test elicits worsening radicular pain Radicular Pain Spinal Disk Herniation down the raised leg Leg The lower leg, or just “leg” in anatomical terms, is the part of the lower limb between the knee and the ankle joint. The bony structure is composed of the tibia and fibula bones, and the muscles of the leg are grouped into the anterior, lateral, and posterior compartments by extensions of fascia. Leg: Anatomy.
  • Evaluates for lumbosacral radiculopathy Radiculopathy Disease involving a spinal nerve root which may result from compression related to intervertebral disk displacement; spinal cord injuries; spinal diseases; and other conditions. Clinical manifestations include radicular pain, weakness, and sensory loss referable to structures innervated by the involved nerve root. Rheumatoid Arthritis (sciatica)
• Patrick test (also known as the FABERE test or figure 4 test):
  • Lay the individual supine and instruct to place 1 foot Foot The foot is the terminal portion of the lower limb, whose primary function is to bear weight and facilitate locomotion. The foot comprises 26 bones, including the tarsal bones, metatarsal bones, and phalanges. The bones of the foot form longitudinal and transverse arches and are supported by various muscles, ligaments, and tendons. Foot: Anatomy on the opposite knee.
  • The contralateral hip is supported by the examiner and downward pressure is placed on the flexed knee.
  • A positive test elicits pain Pain An unpleasant sensation induced by noxious stimuli which are detected by nerve endings of nociceptive neurons. Pain: Types and Pathways in the sacroiliac joint Sacroiliac Joint The immovable joint formed by the lateral surfaces of the sacrum and ilium. Pelvis: Anatomy.
  • Indicative of potential sacroiliac joint Sacroiliac Joint The immovable joint formed by the lateral surfaces of the sacrum and ilium. Pelvis: Anatomy pathology

Red flag signs Red Flag Signs Primary vs Secondary Headaches and symptoms

The following symptoms suggest serious pathology and should elicit an urgent evaluation:

• Neurologic deficits Neurologic Deficits High-Risk Headaches:
  • Muscle weakness
  • Gait Gait Manner or style of walking. Neurological Examination disturbance
  • Saddle anesthesia Anesthesia A state characterized by loss of feeling or sensation. This depression of nerve function is usually the result of pharmacologic action and is induced to allow performance of surgery or other painful procedures. Anesthesiology: History and Basic Concepts
  • Bowel or bladder Bladder A musculomembranous sac along the urinary tract. Urine flows from the kidneys into the bladder via the ureters, and is held there until urination. Pyelonephritis and Perinephric Abscess dysfunction
• Fever Fever Fever is defined as a measured body temperature of at least 38°C (100.4°F). Fever is caused by circulating endogenous and/or exogenous pyrogens that increase levels of prostaglandin E2 in the hypothalamus. Fever is commonly associated with chills, rigors, sweating, and flushing of the skin. Fever
• Unexplained weight loss Weight loss Decrease in existing body weight. Bariatric Surgery
• Severe nocturnal back pain Pain An unpleasant sensation induced by noxious stimuli which are detected by nerve endings of nociceptive neurons. Pain: Types and Pathways

Diagnosis

Imaging

The majority of individuals with back pain Pain An unpleasant sensation induced by noxious stimuli which are detected by nerve endings of nociceptive neurons. Pain: Types and Pathways do not require imaging.

Indications:

• Acute trauma
• Signs or symptoms of a red flag
• High clinical suspicion of infection or malignancy Malignancy Hemothorax:
  • Diagnosed or suspected cancer
  • Risk factors for infection:
    • Immunosuppression
    • IV drug use
    • Recent surgery
    • Penetrating trauma
    • Bacterial infection
• High clinical suspicion for life-threatening conditions:
  • Acute, tearing pain Pain An unpleasant sensation induced by noxious stimuli which are detected by nerve endings of nociceptive neurons. Pain: Types and Pathways in the upper or middle back
  • Abdominal aorta Abdominal Aorta The aorta from the diaphragm to the bifurcation into the right and left common iliac arteries. Posterior Abdominal Wall: Anatomy > 5 cm (especially if tender) or lower extremity pulse deficits
  • Gastrointestinal findings:
    • Peritoneal signs
    • Abdominal tenderness
    • Melena Melena The black, tarry, foul-smelling feces that contain degraded blood. Gastrointestinal Bleeding
    • Hematochezia Hematochezia Gastrointestinal Bleeding
• Disabling pain Pain An unpleasant sensation induced by noxious stimuli which are detected by nerve endings of nociceptive neurons. Pain: Types and Pathways

Imaging modalities:

• Plain radiograph:
  • Anteroposterior and lateral views are usually adequate.
  • Useful for assessing:
    • Osteoporotic or compression Compression Blunt Chest Trauma fractures
    • Lytic bone lesions Bone Lesions Multiple Myeloma ( malignancy Malignancy Hemothorax)
    • Spondylolisthesis
    • Malignment 
    • Osteoarthritis Osteoarthritis Osteoarthritis (OA) is the most common form of arthritis, and is due to cartilage destruction and changes of the subchondral bone. The risk of developing this disorder increases with age, obesity, and repetitive joint use or trauma. Patients develop gradual joint pain, stiffness lasting < 30 minutes, and decreased range of motion. Osteoarthritis
    • Loss of disk height
• MRI:
  • Best initial evaluation for individuals requiring advanced imaging
  • Helpful in evaluating:
    • Ligaments
    • Intervertebral discs
    • Nerve roots
    • Shape and size of the spinal canal Spinal Canal The cavity within the spinal column through which the spinal cord passes. Spinal Cord Injuries
    • Spinal cord Spinal cord The spinal cord is the major conduction pathway connecting the brain to the body; it is part of the CNS. In cross section, the spinal cord is divided into an H-shaped area of gray matter (consisting of synapsing neuronal cell bodies) and a surrounding area of white matter (consisting of ascending and descending tracts of myelinated axons). Spinal Cord: Anatomy
  • Specific and sensitive for malignancy Malignancy Hemothorax and infection
• CT scan is an option for those who cannot undergo MRI.

Laboratory studies

• Most individuals do not require lab studies.
• Erythrocyte sedimentation rate Erythrocyte Sedimentation Rate Soft Tissue Abscess ( ESR ESR Soft Tissue Abscess), CRP, and CBC can be useful if an inflammatory or infectious etiology is suspected.

Management

Conservative measures

• Education and reassurance Reassurance Clinician–Patient Relationship
• Heat Heat Inflammation or cold packs
• Massage
• Exercise and physical therapy Physical Therapy Becker Muscular Dystrophy
• Posture improvement
• Acupuncture
• Spinal manipulation

Pharmacologic management

• Initial therapy:
  • NSAIDs NSAIDS Primary vs Secondary Headaches
  • Acetaminophen Acetaminophen Acetaminophen is an over-the-counter nonopioid analgesic and antipyretic medication and the most commonly used analgesic worldwide. Despite the widespread use of acetaminophen, its mechanism of action is not entirely understood. Acetaminophen
• Muscle relaxants (2nd-line therapy):
  • Controversial
  • Sedating (particularly in the elderly)
  • More helpful with an associated muscle spasm
  • Ideally only used for short-term therapy
• Severe or refractory pain Pain An unpleasant sensation induced by noxious stimuli which are detected by nerve endings of nociceptive neurons. Pain: Types and Pathways:
  • Opioids Opioids Opiates are drugs that are derived from the sap of the opium poppy. Opiates have been used since antiquity for the relief of acute severe pain. Opioids are synthetic opiates with properties that are substantially similar to those of opiates. Opioid Analgesics:
    • Only added to therapy when other analgesics fail or are contraindicated.
    • Can cause sedation, constipation Constipation Constipation is common and may be due to a variety of causes. Constipation is generally defined as bowel movement frequency < 3 times per week. Patients who are constipated often strain to pass hard stools. The condition is classified as primary (also known as idiopathic or functional constipation) or secondary, and as acute or chronic. Constipation, and dependence
    • Avoid long-term use.
  • Glucocorticoids Glucocorticoids Glucocorticoids are a class within the corticosteroid family. Glucocorticoids are chemically and functionally similar to endogenous cortisol. There are a wide array of indications, which primarily benefit from the antiinflammatory and immunosuppressive effects of this class of drugs. Glucocorticoids:
    • Steroid “burst and taper”
    • Often used for acute inflammation Acute Inflammation Inflammation or nerve root impingement as a bridge to more definitive therapy
    • Avoid long term use.

Interventional pain Pain An unpleasant sensation induced by noxious stimuli which are detected by nerve endings of nociceptive neurons. Pain: Types and Pathways procedures

• May be helpful when conservative therapy and analgesics have not been effective
• Injection options:
  • Epidural injections (in order of specificity to pain Pain An unpleasant sensation induced by noxious stimuli which are detected by nerve endings of nociceptive neurons. Pain: Types and Pathways generator):
    • Caudal
    • Interlaminar
    • Transforaminal
  • Facet joint injections
  • Sacroiliac joint Sacroiliac Joint The immovable joint formed by the lateral surfaces of the sacrum and ilium. Pelvis: Anatomy injections
  • Trigger Trigger The type of signal that initiates the inspiratory phase by the ventilator Invasive Mechanical Ventilation point injections
  • Peripheral nerve blocks Peripheral Nerve Blocks Anesthesiology: History and Basic Concepts
• Neuromodulation:
  • Spinal cord Spinal cord The spinal cord is the major conduction pathway connecting the brain to the body; it is part of the CNS. In cross section, the spinal cord is divided into an H-shaped area of gray matter (consisting of synapsing neuronal cell bodies) and a surrounding area of white matter (consisting of ascending and descending tracts of myelinated axons). Spinal Cord: Anatomy stimulation
  • Sacral stimulation
  • Dorsal root ganglion stimulation
• Advanced percutaneous interventions:
  • Sacroiliac joint Sacroiliac Joint The immovable joint formed by the lateral surfaces of the sacrum and ilium. Pelvis: Anatomy infusion
  • Interspinous spacing
  • Intradiscal nerve ablation
  • Kyphoplasty

Surgical treatment

• Only required in a minority of individuals
• Indications:
  • Refractory, disabling symptoms
  • Severe or progressive weakness
  • Cauda equina syndrome Cauda Equina Syndrome Compressive lesion affecting the nerve roots of the cauda equina (e.g., compression, herniation, inflammation, rupture, or stenosis), which controls the function of the bladder and bowel. Symptoms may include neurological dysfunction of bladder or bowels, loss of sexual sensation and altered sensation or paralysis in the lower extremities. Ankylosing Spondylitis
  • Infection (e.g., epidural abscess Epidural abscess Circumscribed collections of suppurative material occurring in the spinal or intracranial epidural space. The majority of epidural abscesses occur in the spinal canal and are associated with osteomyelitis of a vertebral body; analgesia, epidural; and other conditions. Clinical manifestations include local and radicular pain, weakness, sensory loss, urinary incontinence, and fecal incontinence. Cranial epidural abscesses are usually associated with osteomyelitis of a cranial bone, sinusitis, or otitis media. Retropharyngeal Abscess)

Clinical Relevance

• Cauda equina syndrome Cauda Equina Syndrome Compressive lesion affecting the nerve roots of the cauda equina (e.g., compression, herniation, inflammation, rupture, or stenosis), which controls the function of the bladder and bowel. Symptoms may include neurological dysfunction of bladder or bowels, loss of sexual sensation and altered sensation or paralysis in the lower extremities. Ankylosing Spondylitis: compression Compression Blunt Chest Trauma of nerve roots of the lumbar spine Spine The human spine, or vertebral column, is the most important anatomical and functional axis of the human body. It consists of 7 cervical vertebrae, 12 thoracic vertebrae, and 5 lumbar vertebrae and is limited cranially by the skull and caudally by the sacrum. Vertebral Column: Anatomy. Intervertebral disk herniation Herniation Omphalocele is the most common cause. Other causes include ankylosing spondylitis Ankylosing spondylitis Ankylosing spondylitis (also known as Bechterew’s disease or Marie-Strümpell disease) is a seronegative spondyloarthropathy characterized by chronic and indolent inflammation of the axial skeleton. Severe disease can lead to fusion and rigidity of the spine. Ankylosing Spondylitis, lumbar puncture Lumbar Puncture Febrile Infant, trauma, malignant/ benign Benign Fibroadenoma tumor Tumor Inflammation, and infection. Individuals will have back pain Pain An unpleasant sensation induced by noxious stimuli which are detected by nerve endings of nociceptive neurons. Pain: Types and Pathways, lower extremity weakness, sensory Sensory Neurons which conduct nerve impulses to the central nervous system. Nervous System: Histology findings (such as saddle anesthesia Anesthesia A state characterized by loss of feeling or sensation. This depression of nerve function is usually the result of pharmacologic action and is induced to allow performance of surgery or other painful procedures. Anesthesiology: History and Basic Concepts), and bowel/ bladder Bladder A musculomembranous sac along the urinary tract. Urine flows from the kidneys into the bladder via the ureters, and is held there until urination. Pyelonephritis and Perinephric Abscess dysfunction. In addition to the physical examination, imaging will help to confirm the diagnosis. Surgery is required to relieve compression Compression Blunt Chest Trauma of the nerve roots.
• Metastatic cancer: Bones are common sites for metastases. Vertebral involvement may cause back pain Pain An unpleasant sensation induced by noxious stimuli which are detected by nerve endings of nociceptive neurons. Pain: Types and Pathways and sudden, severe pain Pain An unpleasant sensation induced by noxious stimuli which are detected by nerve endings of nociceptive neurons. Pain: Types and Pathways may indicate a pathologic fracture Pathologic Fracture Chondrosarcoma. Compression Compression Blunt Chest Trauma of the spinal cord Spinal cord The spinal cord is the major conduction pathway connecting the brain to the body; it is part of the CNS. In cross section, the spinal cord is divided into an H-shaped area of gray matter (consisting of synapsing neuronal cell bodies) and a surrounding area of white matter (consisting of ascending and descending tracts of myelinated axons). Spinal Cord: Anatomy or nerve root can occur. The diagnosis can be made with MRI. Management depends on the cancer, location, and severity of symptoms. Palliative care is often recommended.
• Spinal epidural abscess Epidural abscess Circumscribed collections of suppurative material occurring in the spinal or intracranial epidural space. The majority of epidural abscesses occur in the spinal canal and are associated with osteomyelitis of a vertebral body; analgesia, epidural; and other conditions. Clinical manifestations include local and radicular pain, weakness, sensory loss, urinary incontinence, and fecal incontinence. Cranial epidural abscesses are usually associated with osteomyelitis of a cranial bone, sinusitis, or otitis media. Retropharyngeal Abscess: pus accumulation within the spinal epidural space Epidural space Space between the dura mater and the walls of the vertebral canal. Epidural Hemorrhage. Individuals may experience fever Fever Fever is defined as a measured body temperature of at least 38°C (100.4°F). Fever is caused by circulating endogenous and/or exogenous pyrogens that increase levels of prostaglandin E2 in the hypothalamus. Fever is commonly associated with chills, rigors, sweating, and flushing of the skin. Fever, malaise Malaise Tick-borne Encephalitis Virus, and localized back pain Pain An unpleasant sensation induced by noxious stimuli which are detected by nerve endings of nociceptive neurons. Pain: Types and Pathways (often worse laying down). If left untreated, neurologic deficits Neurologic Deficits High-Risk Headaches can occur due to compression Compression Blunt Chest Trauma of the spinal cord Spinal cord The spinal cord is the major conduction pathway connecting the brain to the body; it is part of the CNS. In cross section, the spinal cord is divided into an H-shaped area of gray matter (consisting of synapsing neuronal cell bodies) and a surrounding area of white matter (consisting of ascending and descending tracts of myelinated axons). Spinal Cord: Anatomy or nerve roots. Diagnosis is made with MRI. Treatment includes antibiotics and aspiration of the abscess Abscess Accumulation of purulent material in tissues, organs, or circumscribed spaces, usually associated with signs of infection. Chronic Granulomatous Disease. Surgery is necessary for individuals with neurologic dysfunction.
• Vertebral osteomyelitis Vertebral Osteomyelitis Osteomyelitis: vertebral infection occurring due to hematogenous Hematogenous Hepatocellular Carcinoma (HCC) and Liver Metastases spread, direct inoculation, or contiguous spread from adjacent soft tissue Soft Tissue Soft Tissue Abscess. The major clinical symptom is localized pain Pain An unpleasant sensation induced by noxious stimuli which are detected by nerve endings of nociceptive neurons. Pain: Types and Pathways exacerbated by physical activity or percussion Percussion Act of striking a part with short, sharp blows as an aid in diagnosing the condition beneath the sound obtained. Pulmonary Examination at the affected site. The preferred imaging modality for diagnosis is MRI. Treatment includes antibiotics. Surgery may be needed for spinal instability, neurological deficits, cord compression Compression Blunt Chest Trauma, or worsening/persistent infection.
• Vertebral compression Compression Blunt Chest Trauma fracture Fracture A fracture is a disruption of the cortex of any bone and periosteum and is commonly due to mechanical stress after an injury or accident. Open fractures due to trauma can be a medical emergency. Fractures are frequently associated with automobile accidents, workplace injuries, and trauma. Overview of Bone Fractures: often caused by trauma or osteoporosis Osteoporosis Osteoporosis refers to a decrease in bone mass and density leading to an increased number of fractures. There are 2 forms of osteoporosis: primary, which is commonly postmenopausal or senile; and secondary, which is a manifestation of immobilization, underlying medical disorders, or long-term use of certain medications. Osteoporosis. The presentation includes pain Pain An unpleasant sensation induced by noxious stimuli which are detected by nerve endings of nociceptive neurons. Pain: Types and Pathways, which is often radiating. Movement aggravates the pain Pain An unpleasant sensation induced by noxious stimuli which are detected by nerve endings of nociceptive neurons. Pain: Types and Pathways and may be accompanied by muscle spasms Spasms An involuntary contraction of a muscle or group of muscles. Spasms may involve skeletal muscle or smooth muscle. Ion Channel Myopathy. The diagnosis is made with imaging. Management is usually conservative ( physical therapy Physical Therapy Becker Muscular Dystrophy and analgesics) unless evidence of associated spinal cord Spinal cord The spinal cord is the major conduction pathway connecting the brain to the body; it is part of the CNS. In cross section, the spinal cord is divided into an H-shaped area of gray matter (consisting of synapsing neuronal cell bodies) and a surrounding area of white matter (consisting of ascending and descending tracts of myelinated axons). Spinal Cord: Anatomy injury exists.
• Spinal stenosis Stenosis Hypoplastic Left Heart Syndrome (HLHS): a narrowing of the central canal, the neural foramen, or the lateral recess Lateral Recess Spinal Stenosis. Degenerative changes Degenerative Changes Spinal Stenosis, spondylolisthesis, disk herniation Herniation Omphalocele, tumors, and fractures may cause spinal stenosis Stenosis Hypoplastic Left Heart Syndrome (HLHS). While some individuals are asymptomatic, others may experience back pain Pain An unpleasant sensation induced by noxious stimuli which are detected by nerve endings of nociceptive neurons. Pain: Types and Pathways, neurogenic claudication, weakness, and numbness. Diagnosis is clinical and confirmed with imaging. Management includes physical therapy Physical Therapy Becker Muscular Dystrophy and analgesics. Surgery is reserved for advanced cases.