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Table of Contents    
ORIGINAL ARTICLE
Year : 2016  |  Volume : 64  |  Issue : 5  |  Page : 950-957

An algorithmic approach for clinical management of low back pain


1 Department of Neurosurgery, Sri Venkateswara Institute of Medical Sciences, Chittoor, Andhra Pradesh, India
2 Department of Nuclear Medicine, Sri Venkateswara Institute of Medical Sciences, Chittoor, Andhra Pradesh, India
3 Department of Anaesthesiology, Sri Venkateswara Institute of Medical Sciences, Chittoor, Andhra Pradesh, India
4 Department of Radiology, Sri Venkateswara Institute of Medical Sciences, Chittoor, Andhra Pradesh, India

Date of Web Publication12-Sep-2016

Correspondence Address:
C Krishna Mohan
Department of Neurosurgery, Sri Venkateswara Institute of Medical Sciences, Alipiri Road, Tirupati, Chittoor, Andhra Pradesh
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/0028-3886.190252

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 » Abstract 


Background: Low back pain is caused by a variety of conditions. When conventional imaging failed, single-photon emission computed tomography (SPECT) was superior to scintigraphy in identifying the pathology. Injection therapies are often helpful in treating the pathology.
Aim: To determine the cause of chronic low backache in individuals with normal conventional imaging (radiographs, computed tomography and magnetic resonance imaging), to determine the specific pathology using scintigraphic studies and diagnostic blocks; and, to treat the individuals with various spinal injection techniques and determine their efficacy.
Material and Methods: All the patients having chronic back pain on presentation in the outpatient clinic from April 2013 to October 2014 were prospectively evaluated.
Results: The 40 patients included in the study were followed up pre- and post operatively with various pain scales (visual analogue scale [VAS], Oswestry disability index [ODI] and short form health survery 36 [SF36]). The mean age at presentation was 41.3 years. Female patients formed the predominant subgroup in the study (57.5% female and 42.5% male patients). Pain indices like VAS and ODI were helpful in assessing the efficacy of spinal injections. Preoperative and postoperative pain scale assessment, supplemented by a SPECT evaluation of the sacroiliac and facet joints, showed a statistically significant difference, which correlated with clinically significant pain relief.
Conclusions: SPECT imaging is helpful in diagnosing sacroiliac joint syndrome and facetal syndrome. Epidural injections were a better choice in cases of low backache, where clinically, the patient had no signs of sacroiliac joint syndrome and facetal syndrome. Spinal injections with steroid and local anaesthetic had better relief. Radiotracer uptake at the pain generating area is a good predictor of outcome. Image guided spinal injection improves the accuracy of the injection.


Keywords: Chronic back pain; epidural injection; mental component summary; Oswestry disability index; physical component summary; single-photon emission computed tomography; sacroiliac joint block; visual analog scale


How to cite this article:
Ramesh Chandra V V, Prasad B, Mohan C K, Kalawat T C, Satyanarayana V, Lakshmi A Y. An algorithmic approach for clinical management of low back pain. Neurol India 2016;64:950-7

How to cite this URL:
Ramesh Chandra V V, Prasad B, Mohan C K, Kalawat T C, Satyanarayana V, Lakshmi A Y. An algorithmic approach for clinical management of low back pain. Neurol India [serial online] 2016 [cited 2019 Oct 17];64:950-7. Available from: http://www.neurologyindia.com/text.asp?2016/64/5/950/190252





 » Introduction Top


Low back pain is a very common presenting complaint in the general population. No age group is completely immune.[1] Low back pain may be caused by a variety of conditions including musculoligamentous disorders, bone and joint disorders, and neurological disorders.[2] According to the available literature, when conventional imaging fails, single-photon emission computed tomography (SPECT) is superior to scintigraphy in identifying the pathology.[3] The aim of this study was to determine the cause of low back pain by using clinical and advanced imaging methods (SPECT) and to manage such pathologies with various interventional techniques such as facet injections, sacroiliac joint injections, and diagnostic nerve root blocks.


 » Materials and Methods Top


Study design

This was a prospective study of 243 patients with low back pain and normal imaging. These patients, who presented to our institution from April 2013 to October 2014, were evaluated for chronic back pain. Patient presenting with low back pain of more than 3 months duration and failing to respond to conservative treatment were primarily included in the study. An algorithm was designed in our institution as depicted in [Figure 1].
Figure 1: Study plan. LS: lumbosacral; SPECT CT: Single photon emission computed tomography; CT: Computed tomography

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Statistical analysis

All data sets were collected and entered into a spreadsheet (Microsoft Excel 2007) under various headings that included the pre- and postprocedural pain scale (VAS, ODI, SF36) assessment done after 6 months of treatment. Statistical analysis was performed using SPSS version 16.0 for windows (IBM Inc., Chicago, IL.). The analysis of these procedures was expressed in terms of means and standard deviation; the significance levels were expressed by using Student's paired sample t-test for comparison of variables before and after treatment.

Clinical evaluation and workup of patients

Prior to the procedure, neurological examination along with assessment of the functional status by using various disability and pain scales such as the visual analog score (VAS) chart, Oswestry disability index (ODI), and short form 36 (SF36) health survey scoring was done. All the patients were subjected to radiological investigations which included plain radiographs and magnetic resonance imaging (MRI) [Siemens, 1.5 Tesla, Germany 2002/2012]. If these investigations were found to be normal, the possibility of facet joint and sacroiliac joint pathology was suspected and the patients were evaluated by bone scintigraphy and SPECT-computed tomography (CT) [the bone SPECT study was performed on Symbia E dual-head gamma camera and SPECT images were fused with CT images performed on Biograph 06 PET-CT system, using multi-modality fusion software supplied by Siemens Ltd.], to accurately localize the scintigraphically detectable lesion in the spine. Based on the diagnosis, the patients were treated with various modalities ranging from therapeutic facet blocks, therapeutic sacroiliac joint blocks, and therapeutic epidural blocks. The patients were assessed using various pain scales (VAS, ODI, and SF36) and scintigraphy at the end of 6 months.

Procedure

Sacroiliac joint injections

This procedure was performed in prone position. The skin surface was marked exactly at the midpoint of the line drawn from the ipsilateral posterior superior iliac spine and S1 spinous process. A 22-G needle measuring 10–12 cm was placed at the infiltrated site at a lateral angle of 45° from the plane horizontal to the skin surface and was slowly advanced until it made bony contact with the posterior section of the sacroiliac joint. The position of the needle was confirmed using fluoroscopy and 3 ml of local anesthetic (1% lidocaine), along with steroids (triamcinolone), was injected.

Facet joint injections

This procedure was performed in a prone position. The surface marking for the procedure included a point at a distance of 2–2.5 cm lateral to the midline, exactly between the spinous processes of the corresponding vertebrae.


 » Results Top


Of the 243 patients with low back pain and normal imaging, forty patients were selected for therapeutic intervention and their disability and pain assessment was pre- and post-operatively carried out utilizing various pain scales (VAS, ODI, and SF36).

Demographics, outcome, and correlation

The age of the patients included in the study ranged from 20 to 66 years with the mean age group being 41.3 years [Table 1] and [Figure 2]. 57.5% of the subjects were female and 42.5% were male, with the male:female ratio being 1:1.3 [Table 2] and [Figure 3].
Table 1: The age distribution in the study

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Figure 2: Age distribution

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Table 2: The gender distribution in the study

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Figure 3: Sex distribution

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The patients included in this study were assessed based on their clinical examination as their imageology was normal. Sacroiliac joint syndrome and facet syndrome were further diagnosed based on the SPECT study. Other patients, who did not confirm to this inclusion criteria underwent epidural injections and diagnostic blocks and constituted nearly 50% of the subjects. Sacroiliac joint syndrome was present in 27.5%, and facet syndrome, in 22.5% of the patients [Table 3] and [Figure 4]. The preprocedural VAS ranged from 4 to 8 with a mean of 6.35. The postprocedural VAS ranged from 0 to 4 with a mean of 1.42. There was a significant decrease in the mean scale from the pre- to post-procedural period (P < 0.0001) indicating that the patients had a significant improvement after the procedure [Table 4] and [Figure 5]. The pre-procedural ODI ranged from 40.2 to 67.25 with a mean of 61.54. The postprocedural ODI ranged from 8.8 to 33.33 with a mean of 18.54. There is a significant decrease in the value of ODI in the postprocedural period (P < 0.0001) [Table 5] and [Figure 6]. The preprocedural physical component summary (PCS) of the SF-36 score ranged from 28.4 to 33.2 with a mean of 31.2. The postprocedural PCS ranged from 32.4 to 43.8 with a mean of 38.68. There was, therefore, a significant improvement in the mean scores (P < 0.0001) [Table 6] and [Figure 7].
Table 3: Various causes of low backache found in patients without radiological abnormalities

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Figure 4: Low back pain and frequency

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Table 4: The comparison between the pre-and postprocedural visual analogue scale (VAS)

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Figure 5: Visual analog scale

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Table 5: The comparison between the pre-and postprocedural Oswestry disability index (ODI)

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Figure 6: Oswestry disability index scores

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Table 6: The comparison between the pre-and postprocedural physical component summary (PCS) of short form-36 scale

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Figure 7: Physical component summary

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The pre-procedural mental component summary (MCS) of the SF-36 score ranged from 32.4 to 40.7 with a mean of 36.68. The postprocedural MCS ranged from 32.7 to 38.7 with a mean of 36.43. There was only a slight decrease in the mean levels of MCS in the postprocedural period, and the difference was not statistically significant (P < 0.486) [Table 7] and [Figure 8].
Table 7: The comparison between the pre-and postprocedural mental component summary (MCS) of short form-36 scale

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Figure 8: Mental component summary

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 » Discussion Top


Our study was intended to evaluate the cause of low back pain using an algorithmic approach and to determine the efficacy of injection therapies for various causes of low back pain. The injection therapies included in the study were facet injection (n = 9), sacroiliac joint injection (n = 11), epidural injection (n = 13), and diagnostic block (n = 7) [Figure 9], [Figure 10], [Figure 11], [Figure 12], [Figure 13], [Figure 14], [Figure 15]. On using the algorithmic approach to assess various pain pathologies, it was noticed that the sites capable of causing low back pain in the presence of a normal radiological imaging included the facet joints, sacroiliac joints, and nerve roots; similar findings were noticed in a study by Kuslich et al.,[4] who conducted a study on 193 patients prospectively. In all the patients in the latter study, local anesthesia was used and various pain generating structures in and around the disc were stimulated, and the patients were asked to define their pain. In our study, we used various clinical tests to identify the probable pain generating pathology and then proceeded with the conventional imaging techniques (radiographs/MRI), which were then followed by advanced imaging techniques such as the SPECT-CT.
Figure 9: The pre- and post-treatment single-photon emission computed tomography images in the facet syndrome (axial view)

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Figure 10: The pre- and post-treatment single-photon emission computed tomography images in the sacroiliac joint syndrome (axial view)

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Figure 11: Surface marking for facet injection

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Figure 12: External positioning of the spinal needle

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Figure 13: Confirmation of spinal needle position under C-arm in facet injection

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Figure 14: Confirmation of spinal needle position under C-arm in sacroiliac joint injection

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Figure 15: (a and b) Surface markings for an interforaminal epidural injection

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A male:female ratio of 1:1.3 was observed in the study. A similar female predominance was noted in the study by Von Korff et al.[5] In our study, when radiological assessment of the patients done with roentgenograms and MRIs did not reveal any significant abnormality, these patients were subjected to a SPECT study, which was able to identify the presence of either a facet syndrome or a sacroiliac joint syndrome; the same findings were observed in a study by Chung et al.[6]

Different provocative tests were used to diagnose the sacroiliac joint syndrome (Patrick/Gaenslen/Yeoman/Gillet). Among these tests, Patrick's (flexion, abduction, external rotation at the hip joint) test was found to be effective in most of the cases; however, we could not unequivocally differentiate the sacroiliac joint pathology from the hip joint pathology using this test. Lanslett et al.,[7] in their study quoted that most of the provocative maneuvers also cause stress at other pain sensitive structures, including the intervertebral discs, facet joints, muscles, and hip joint at the same time, and therefore, do not clearly diagnose the sacroiliac joint as being the back pain generator. Thus, sacroiliac pain provocation tests do not definitely demonstrate the presence of sacroiliac joint pain.

The efficacy of various injection therapies was assessed by various pain scales (VAS, ODI, and SF-36). In our study, there was a significant decrease in the VAS scores from a preoperative mean of 6.35 to a postoperative mean of 1.42. There was a significant decrease in the ODI from a preoperative mean of 61.54 to a postoperative mean of 18.54, which was statistically significant (P < 0.0001). In the study by Maugars et al.,[8] there was a significant improvement in the ODI scores, which was similar to the findings found in our study.

In our study, patients who were suspected to have sacroiliac joint syndrome underwent a SPECT study, which was helpful in localizing the pathology. In all these patients, plain X-rays and MRI could not identify the pathology. A study conducted by Maigne et al.,[9] in 32 patients with sacroiliac joint syndrome, revealed that bone scan has a poor sensitivity but appears to have a good specificity (90%) for detecting the pathology. There was a 50% reduction (based on VAS) in pain in patients undergoing sacroiliac joint injection. Pulisetti and Ebraheim [10] in a prospective evaluation of sacroiliac joint injection procedure reported a 75% relief of pain following the injection therapy.

Preprocedural SPECT, which was used in this study to rule out facet syndrome and sacroiliac joint syndrome, was helpful in localizing the pathology and aided in determining the injection site; this finding was also observed in a study by Pneumaticos et al.[11]

In our study, on administering corticosteroid injection into the facet joint in our patients with facet syndrome, there was a significant improvement that was evident on comparison of the pre- and postprocedural values of pain scores. Similar result was seen in the study conducted by Carette et al.,[12] that included both the placebo and facet injection groups and demonstrated considerable improvement in function and pain relief at 1, 3, and 6 months. However, statistically significant differences in pain relief were observed only at 6 months.

During the 6-month follow-up of patients who underwent facet joint injection therapy, none of the patients required a second injection indicating the efficacy of a single injection block in our study. This result was contradictory to the study by Schütz et al.,[13] which concluded that a single articular facet block was often not useful and that multiple blocks were often required. They conducted a triple crossover study and concluded that facet joint blocks were of no diagnostic value as there were no reliable clinical and radiological parameters for diagnosing a facet joint syndrome. The significant pain relief during the 6-month follow-up period in our study included patients who had undergone a facet joint block; none of these patients had undergone a medial branch block. Ackerman et al.,[14] conducted a prospective double-blind study on 46 patients who were positive for facet joint syndrome on SPECT and also concluded that intraarticular lumbar facet injection were more effective than medial branch blocks, as assessed by the pain scores.

Both steroids and lidocaine were used for facet injections in our study and brought about a significant pain relief. Revel et al., in a finding similar to ours, compared facet joint injections using a combination of lidocaine and corticosteroid with facet joint injections using a combination of saline and corticosteroid and found that the lidocaine group had a significant pain relief.[15]

All the patients who underwent epidural injections with steroids and local anesthetics had a better pain relief when assessed objectively utilizing the various pain scores. In a study conducted by Benyamin et al.,[16] the primary outcome measures were pain relief and the secondary outcome measures were improvement in the functional status, the psychological status, and the return to work. In a finding similar to ours, they also noticed in their evidence-based systematic review that lumbar epidural injections with steroids and local anesthetics resulted in a better pain relief.

In our patients, who had undergone epidural injections, there was immediate pain relief. On following up these patients for 6 months, it was found that these patients were comfortable and had significant pain relief, which was evident by the decrease in the pain scores. Similarly, in a controlled study by Bush and Hiller,[17] it has been reported that patients who underwent epidural injections with steroid (triamcinolone) and procaine had better pain relief compared to the saline group. In the latter study, the patient's pain assessment was carried out utilizing the straight leg raising test.

Limitations

The major drawback of the present study is its small sample size and a single, short term, follow-up visit. Furthermore, a comparative analysis with other similar studies was not performed.


 » Conclusions Top


The mean age of patients who presented with low back pain was 41.3 years. Female subjects predominated in the study (there was 57.5% female and 42.5% male patients). The causes of chronic back pain in subjects having no significant radiological findings included the sacroiliac joint syndrome or the facet syndrome. Indices such as VAS and ODI were helpful in assessing the efficacy of spinal injections. The pre- and postoperative disability and pain scales showed a statistically significant difference which correlated with clinically significant pain relief. SPECT imaging is helpful in diagnosing the sacroiliac joint syndrome and facet syndrome. Epidural injections were a better choice in cases of low back pain, where clinically, the patient had no signs of sacroiliac joint syndrome and facet syndrome. Spinal injections utilizing a combination of a steroid and local anesthetic contributed to a better pain relief. The demonstration of radiotracer uptake at the pain generating area proved to be a good predictor of outcome. Image-guided spinal injection improved the accuracy of the injection.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.

 
 » References Top

1.
National Institute of Neurological Disorders and Stroke – National Institutes of Health. Low back pain fact sheet for patients and the public. J Pain Palliat Care Pharmacother 2004;18:95-110.  Back to cited text no. 1
    
2.
Al-Janabi MA. Imaging modalities and low back pain: The role of bone scintigraphy. Nucl Med Commun 1995;16:317-26.  Back to cited text no. 2
    
3.
Strobel K, Burger C, Seifert B, Husarik DB, Soyka JD, Hany TF. Characterization of focal bone lesions in the axial skeleton: Performance of planar bone scintigraphy compared with SPECT and SPECT fused with CT. AJR Am J Roentgenol 2007;188:W467-74.  Back to cited text no. 3
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4.
Kuslich SD, Ulstrom CL, Michael CJ. The tissue origin of low back pain and sciatica: A report of pain response to tissue stimulation during operations on the lumbar spine using local anesthesia. Orthop Clin North Am 1991;22:181-7.  Back to cited text no. 4
    
5.
Von Korff M, Dworkin SF, Le Resche L, Kruger A. An epidemiologic comparison of pain complaints. Pain 1988;32:173-83.  Back to cited text no. 5
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6.
Chung CT, Wang CF, Chou CS, Wang SJ, Kao CH, Lan HC. Single photon emission computed tomography (SPECT) for low back pain induced by extension with no root sign. J Chin Med Assoc 2004;67:349-54.  Back to cited text no. 6
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7.
Lanslett M, Willams M. The reliability of selective pain provocative tests for sacroiliac joint pathology. Spine (Phila Pa 1976) 1994; 19:1243-9.  Back to cited text no. 7
    
8.
Maugars Y, Mathis C, Berthelot JM, Charlier C, Prost A. Assessment of the efficacy of sacroiliac corticosteroid injections in spondyloarthropathies: A double-blind study. Br J Rheumatol 1996;35:767-70.  Back to cited text no. 8
    
9.
Maigne JY, Boulahdour H, Chatellier G. Value of quantitative radionuclide bone scanning in the diagnosis of sacroiliac joint syndrome in 32 patients with low back pain. Eur Spine J 1998;7:328-31.  Back to cited text no. 9
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10.
Pulisetti D, Ebraheim NA. CT-guided sacroiliac joint injections. J Spinal Disord 1999;12:310-2.  Back to cited text no. 10
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11.
Pneumaticos SG, Chatziioannou SN, Hipp JA, Moore WH, Esses SI. Low back pain: Prediction of short-term outcome of facet joint injection with bone scintigraphy. Radiology 2006;238:693-8.  Back to cited text no. 11
    
12.
Carette S, Marcoux S, Truchon R, Grondin C, Gagnon J, Allard Y, et al. A controlled trial of corticosteroid injections into facet joints for chronic low back pain. N Engl J Med 1991;325:1002-7.  Back to cited text no. 12
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13.
Schütz U, Cakir B, Dreinhöfer K, Richter M, Koepp H. Diagnostic value of lumbar facet joint injection: A prospective triple cross-over study. PLoS One 2011;6:e27991.  Back to cited text no. 13
    
14.
Ackerman WE 3rd, Ahmad M. Pain relief with intraarticular or medial branch nerve blocks in patients with positive lumbar facet joint SPECT imaging: A 12-week outcome study. South Med J 2008;101:931-4.  Back to cited text no. 14
    
15.
Revel M, Poiraudeau S, Auleley GR, Payan C, Denke A, Nguyen M, et al. Capacity of the clinical picture to characterize low back pain relieved by facet joint anaesthesia. Proposed criteria to identify patients with painful facet joints. Spine 1998;23:1972-77.  Back to cited text no. 15
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16.
Benyamin RM, Manchikanti L, Parr AT, Diwan S, Singh V, Falco FJ, et al. The effectiveness of lumbar interlaminar epidural injections in managing chronic low back and lower extremity pain. Pain Physician 2012;15:E363-404.  Back to cited text no. 16
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17.
Bush K, Hillier S. A controlled study of caudal epidural injections of triamcinolone plus procaine for the management of intractable sciatica. Spine (Phila Pa 1976) 1991;16:572-5.  Back to cited text no. 17
    


    Figures

  [Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5], [Figure 6], [Figure 7], [Figure 8], [Figure 9], [Figure 10], [Figure 11], [Figure 12], [Figure 13], [Figure 14], [Figure 15]
 
 
    Tables

  [Table 1], [Table 2], [Table 3], [Table 4], [Table 5], [Table 6], [Table 7]



 

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