Back Pain Algorithm Initial assessment

1) Screen for potential emergencies with RED FLAGS Constitutional symptoms of fever or weight loss Progressive neurological deficit Bowel or urinary incontinence History of significant trauma History of osteoporosis, heavy alcohol consumption or use of steroid Other medical causes eg: zoster, aneurysms, etc.

2) Screen for risk factors for long-term disability and work loss with YELLOW FLAGS Negative belief that pain is harmful or potentially severely disabling Fear avoidance behaviour, with reduced activity An expectation that passive, rather than active treatment is beneficial Excessive focus on pain Depressed mood, low morale and social withdrawal Low self- efficacy Co-existing social or financial problem Poor job satisfaction

Suggested methods of assessment: a. Screening questions: -Have you had time off work in the past with back pain? -What do you understand is the cause of your back pain? -What are you expecting will help you? -How is your employer responding to your back pain? Your co-workers? Your family? -What are you doing to cope with back pain? -Do you think that you will return to work? When? b. Questionnaires: -Pain intake form -Pain catastrophising scale -Pain self efficacy scale 3) Delineate somatic symptoms and its impact on patients function

4) For lower limb pain, differentiate referred pain from radiculopathy Nature of pain Location Neurological Referred pain Dull, aching, expanding Above knee > below knee Better defined Superficial and deep Normal Radiculopathy Shooting, electrical Below knee > above knee Ill defined Deep only May have weakness / reduced reflexes

4) Current treatment (including surgery) 5) Current coping skills 6) Examination for muscloskeletal, neurological and non-organic signs 7) Formulate plan of management

Flowchart for Management of Back Pain at Combined Neurosurgery Pain Clinic:

Red flags? No Note Yellow flags Yes MRI

Potential surgical candidate?

Yes

No

MRI

Eligible for block? Yes

Eligible for block? No

Regional block No Yes No Eligible for surgery?

Significant cognitive behavioural issue? No Yes

Yes

Regional block

Medication

Cognitive behavioural therapy

Surgery

Explanatory notes
3

I. Surgery:
-Decompression -Stabilization Potential surgical candidates for MRI: 1) Red flags 2) New onset of neurological impairment 3) Severe pain with disability persists after non-operative treatment > 6 weeks Contra-indications: patient refusal, significant psychiatric co-morbidities, on-going substance abuse Indication of discogram: 1) Persistent pain in whom disc abnormality is suspected 2) Assessment of disc and disc level in patients in whom fusion is considered 3) Confirm a contained disc herniation when minimally invasive discectomy is considered Contraindications: patient refusal, contraindication for surgery

II. Pharmacology
1) First line: NSAID / paracetamol 2) Second line: Tramadol 50-100 mg tds 3) Radiculopathy: Tricyclic antidepressants (eg: Amitriptyline 10-25 mg nocte) 4) Consider strong opioids (in opioid-nave patients) only if: Chronic pain > 2 years, AND Failed all other pharmacological / interventional management, AND No history of substance abuse, AND Good compliance with treatment and agree for long term FU, AND Good insight on functional rather than symptomatic goal, AND Informed consent

III. Intervention
-May be considered if duration of back pain> 6/52 -Diagnostic: to decide on operative treatment together with MRI -Therapeutic a. trigger point injection 1) For patients with identifiable trigger points only 2) Can be done at OPD straight, depend on staff and patient preference 4

3) Consider repeat if pain is responsive (> 2 weeks) up to 6 times per year for maximum of 1 year Contraindications: local sepsis, coagulopathy, patient refusal b. epidural steroid 1) For radiculopathy only (regardless of pathology, eg: spinal stenosis, PID, Post-spine surgery, etc.) 2) Consider repeat if pain is responsive (> 6 weeks) up to 6 times per year 3) Trans-foraminal approach (i.e. nerve root block) preferred especially with documented root compression or previous surgery. Other approaches include caudal and interlaminer approach. 4) X-ray with contrast is required for caudal and trans-foraminal approaches, and is recommended for interlaminar approach. Contraindications: coagulopathy, local sepsis, bleeding tendencies, immunodeficient, patient refusal c. Facet or SI joint 1) For paramedian spinal tenderness +/- referred pain only, esp. when provoked by extension 2) Joint or nerve injection will depend on anatomy upon fluoroscopy. In general the median branch block is preferred to joint injection 3) Consider repeat joint blocks if pain is responsive (> 4 weeks) up to 6 times per year. 4) Consider radiofrequency lesioning of median branch if nerve block is positive (immediate) up to 4 times per year Contraindications: same as for epidural steroid

Discharge
1) Symptomatic and functional improvement, without maintenance treatment: home 2) Condition optimised with simple maintenance pharmacology (NSAID, Amitriptyline, etc.): GOPD 3) Condition optimised with more elaborate medications (Gabapentin, Tramadol, etc.): FM clinic or other specialty clinics if agreeable to all parties 4) Static condition with significant cognitive-behavioral issues amenable to CBT: consider COPE 5) Defaults: review condition on CMS. Call back patients with medical reasons (eg: proven sick, hospitalized). Call back once only for non-medical reasons. No medication refill during defaults unless withdrawal is a concern and loss of medication is beyond doubt.

References 5

1) Adult low back pain. Institute for Clinical Systems Improvement (ICSI); 2004. National Guideline Clearinghouse. www.guideline.gov 2) Back pain. Australian Family Physician June 2004 Vol. 33; 6 3) Australian management strategies for oral opioid use in non-malignant pain Goucke. European Journal of Pain 2001; 5(Supp. A): 99-101 4) Evidence based practice guidelines for interventional techniques in the management of chronic spinal pain. American Society of Interventional Pain Physicians. Pain Physicians 2003; 6: 3-81 5) Chronic pain management: a paradigm. Chen. The Hong Kong Pracitioner 2004; 26:277-284 6) Guide to assessing psychosocial yellow flags in acute low back pain: Risk factors for long-term disability and work loss. National Advisory Committee on Health and Disability. January 1997 edition 7) Lumbar discography. Position statement from the North American Spine Society Diagnostic and Therapeutic Committee. Guyer. Spine 1995; 15;20(18):2048-59