Comprehensive Management of Low Back Pain- A Neurosurgical Perspective Presenter- -Dr Abdulhafedh Ahmed - Date23-10-2025-.pptx

How to manage low back pain

1. Comprehensive Management of Low Back Pain: A Neurosurgical Perspective Presenter: [Dr Abdulhafedh Ahmed ] Date23-10-2025]

2. Title: Comprehensive Management of Low Back Pain: Beyond the Operative Table · Subtitle: A Guide for the Modern Neurosurgeon · Logo:

3. Introduction & The Scale of the Problem · Epidemiology: · Lifetime prevalence: 60-80% · Leading cause of disability worldwide (Global Burden of Disease Study). · Enormous socioeconomic impact (healthcare costs, lost productivity). · The Neurosurgeon's Role: · We are often the "last stop" for complex cases. · Crucial to be a gatekeeper for surgery and a guide for comprehensive care. · Goal: Provide the right treatment to the right patient at the right time.

4. The Initial Triage: A Systematic Approach · Critical First Step: Categorize the pain. · 1. Mechanical Axial Low Back Pain (>90%): · Pain localized to lumbosacral spine, buttocks, and posterior thighs. · Worsens with activity, improves with rest. · E.g., Muscular strain, facet arthropathy, degenerative disc disease. · 2. Radicular Pain (Sciatica): · Radiating pain in a dermatomal distribution. · Often due to nerve root compression (HNP, stenosis). · 3. Red Flags: Prompt Further Investigation · Cauda Equina Syndrome: Saddle anesthesia, bowel/bladder dysfunction, severe leg weakness. · Infection: Fever, night sweats, IV drug use, recent infection. · Malignancy: History of cancer, unexplained weight loss, night pain. · Fracture: Major trauma, minor trauma in elderly/osteoporotic. · AAA: Pain with pulsatile mass

5. Diagnostic Workup · History & Physical Exam: The Cornerstone. · History: OPQRST (Onset, Provoking/Palliating, Quality, Radiation, Severity, Timing), red flags, psychosocial factors ("yellow flags"). · Physical: Inspection, palpation, ROM, neurologic exam (sensation, motor, reflexes), special tests (Straight Leg Raise, Femoral Nerve Stretch Test). · Imaging: · X-Ray: Good for alignment, instability (flexion/extension views), gross fractures. Not for soft tissue. · MRI (Gold Standard): Excellent for discs, nerves, thecal sac, ligaments, bone marrow. Essential for pre-op planning. · CT: Superior for bony anatomy. Best for fractures, fusion planning, stenosis in patients who cannot have MRI. · CT Myelogram: For patients with contraindications to MRI or with extensive hardware. · Electrodiagnostic Studies (EMG/NCS): · Useful to confirm radiculopathy, differentiate from peripheral neuropathy, and assess chronicity.

6. Comprehensive Management: The Treatment Pyramid · Visual: A pyramid diagram. · Base (Majority of Patients): Non-Interventional & Conservative Care · Middle: Interventional Pain Procedures · Apex (Minority): Surgical Intervention

7. Tier 1 - Non-Interventional & Conservative Management · Patient Education & Reassurance: Set expectations. Most acute LBP is self-limiting. · Activity Modification: Avoid heavy lifting, twisting; NOT strict bed rest. · Physical Therapy (Core of Conservative Care): · Acute Phase: Modalities (ice/heat), gentle stretching. · Subacute/Chronic Phase: Core strengthening (McGill Big 3), stabilization, aerobic conditioning, McKenzie exercises. · Pharmacological Management: · First Line: Acetaminophen, NSAIDs. · Second Line: Muscle relaxants (short-term for spasms). · Neuropathic Agents: For radicular pain (Gabapentin, Pregabalin, Duloxetine). · Opioids: Severe acute pain only. Short-term, strict monitoring. Avoid for chronic non-cancer pain. · Multidisciplinary Rehabilitation: For chronic pain with significant psychosocial components.

8. Tier 2 - Interventional Pain Management · Indications: Failed conservative management, diagnostic clarity, therapeutic bridge. · Epidural Steroid Injections (ESI): · Interlaminar: Good for central/canal stenosis. · Transforaminal: Targets specific nerve root. Higher diagnostic and therapeutic value for radiculopathy. · Facet Joint Interventions: · Medial Branch Blocks (MBB): Diagnostic. · Radiofrequency Ablation (RFA): Therapeutic; can provide 6-12 months of pain relief. · Sacroiliac (SI) Joint Injections: For suspected SI joint dysfunction. · Intradiscal Procedures (e.g., Biacuplasty): For carefully selected discogenic pain.

9. Tier 3 - Surgical Management: INDICATIONS ARE KEY · Absolute Indication: · Cauda Equina Syndrome (Surgical Emergency). · Strong Relative Indications (The "Big 3"): 1. Progressive Neurologic Deficit: Worsening motor weakness. 2. Refractory Radicular Pain: Failure of >6-12 weeks of structured conservative care. 3. Symptomatic Spinal Stenosis with Neurogenic Claudication: Significantly impaired quality of life. · Other Considerations: · Spinal instability (spondylolisthesis). · Deformity (e.g., scoliosis). · Intractable axial pain from a specific, correctable source (less common).

10. Surgical Options: A Brief Overview · Discectomy: · Microdiscectomy (Gold Standard): For herniated nucleus pulposus. Minimally invasive, excellent outcomes for leg pain. · Decompression: · Laminotomy/Laminectomy: For central/lateral recess stenosis. · Fusion: · Indications: Instability, spondylolisthesis, deformity, correction of sagittal balance, post-corpectomy for fracture/tumor. · Approaches: PLIF, TLIF, ALIF, LLIF. Often combined with instrumentation. · Motion Preservation: · Artificial Disc Replacement (ADR): Primarily for axial discogenic pain in a well-selected patient. Preserves motion. · Minimally Invasive Surgery (MIS): · Tubular retractors, percutaneous screws. Benefits: less tissue damage, reduced blood loss, faster recovery.

11. The Failed Back Surgery Syndrome (FBSS) · Definition: Persistent or recurrent pain following spine surgery. · Common Causes: · Inadequate initial diagnosis/decompression. · Recurrent disc herniation. · Post-operative fibrosis (epidural fibrosis). · Instability (pseudoarthrosis). · New pathology (adjacent segment disease). · Management: Requires meticulous re-evaluation (MRI with contrast, CT). Often best managed with multidisciplinary pain management before considering re-operation.