LBP

LLow ow B Back ack PPain ain
Aabeel Kouka, Aabeel Kouka, MD, DO, MBA MD, DO, MBA
www.brain101.info www.brain101.info
www.brain101.info 1
Epidemiology Epidemiology
ncidence of LBP: ncidence of LBP:
60 60- -90 % 90 % lifetime incidence
5 % 5 % annual incidence
90 % 90 % of cases of LBP resolve without treatment within 6 of cases of LBP resolve without treatment within 6- -12 12
weeks weeks
40 40- -50 % 50 % LBP cases resolve without treatment in 1 week LBP cases resolve without treatment in 1 week
75 % 75 % of cases with nerve root involvement can resolve in 6 of cases with nerve root involvement can resolve in 6
months months
LBP and lumbar surgery are: LBP and lumbar surgery are:
2nd 2nd and 3rd 3rd highest reasons for physician visits
5th 5th leading cause for hospitalization
3rd 3rd leading cause for surgery
www.brain101.info 2
Disability Disability
Age and LBP: Age and LBP:
0ading caus0 of disabiIity of aduIts < 45 < 45
y0ars oId
Third caus0 of disabiIity in thos0 > 45 > 45
y0ars oId
Prevalence rate: Prevalence rate:
ncr0as0d 140 % 140 % from 1991 to 2000 with
onIy125 % 125 % popuIation growth
N0arIy 5 miIIion 5 miIIion p0opI0 in th0 U.S. ar0 on
disabiIity for !
www.brain101.info 3
Lifetime Return to Work Lifetime Return to Work
Success of Success of if off work > 6 months if off work > 6 months
success rate if off work > 1 year success rate if off work > 1 year
0,7 0,7 success if return to work has not success if return to work has not
occurred in 2 years occurred in 2 years
www.brain101.info 4
Occupational Risk Factors Occupational Risk Factors
Low job satisfaction Low job satisfaction
Monotonous or repetitious work Monotonous or repetitious work
Educational level Educational level
Adverse employer Adverse employer- -employee relations employee relations
Recent employment Recent employment
Frequent lifting Frequent lifting
Especially exceeding 25 pounds
Utilization of poor body mechanics in
technique
www.brain101.info 5
Differential Diagnoses Differential Diagnoses
Lumbar Strain Lumbar Strain
Disc Bulge / Protrusion / Extrusion Disc Bulge / Protrusion / Extrusion
producing Radiculopathy producing Radiculopathy
Degenerative Disc Disease (DDD) Degenerative Disc Disease (DDD)
Spinal Stenosis Spinal Stenosis
Spondyloarthropathy Spondyloarthropathy
Spondylosis Spondylosis
Spondylolisthesis Spondylolisthesis
Sacro Sacro- -iliac Dysfunction iliac Dysfunction
www.brain101.info 6
Frequency oI Back Pain Types Frequency oI Back Pain Types
2 visceral
1 tumor,
inIection,
inIlammatory
arthritis
2 visceral
1 tumor,
inIection,
inIlammatory
arthritis
97%
"m0chanicaI"
www.brain101.info 7
r06u0nci0s of Caus0s of ! r06u0nci0s of Caus0s of !
Mechanical LBP 97% Mechanical LBP 97% Non-Mechanical 1%
Lumbar sprain Lumbago 70 Lumbar sprain Lumbago 70
Disk/facet degeneration 10 Disk/facet degeneration 10
Herniated disk 4 Herniated disk 4
Spinal Stenosis 3 Spinal Stenosis 3
Osteopor. Compre. Frx 4 Osteopor. Compre. Frx 4
Spondylolisthesis 2 Spondylolisthesis 2
Traumatic fractures < 1 Traumatic fractures < 1
Congenital < 1 Congenital < 1
Severe kyphosis Severe kyphosis
Severe Scoliosis Severe Scoliosis
Internal disk disruption Internal disk disruption
Neoplasia 0.7 Neoplasia 0.7
Multiple Myeloma Multiple Myeloma
Lymphoma/leukemia Lymphoma/leukemia
Spinal cord tumors Spinal cord tumors
Primary vertebral tumors Primary vertebral tumors
Retroperitoneal tumors Retroperitoneal tumors
INFECTION (0.01) INFECTION (0.01)
Osteomyelitis Osteomyelitis
Paraspinal abscess Paraspinal abscess
Herpes Zoster Herpes Zoster
Spondyloarthropathy (0.3) Spondyloarthropathy (0.3)
Ankylosing Spondylitis Ankylosing Spondylitis
www.brain101.info 8
80 80
Anterior Anterior
20 20
Posterior Posterior
The 80 The 80 20 rule of Spine loading 20 rule of Spine loading
Biomechanics Biomechanics
www.brain101.info 9
''Biggest challenge is to identify the Biggest challenge is to identify the
pain generator pain generator""
Diagnosis Diagnosis
www.brain101.info 10
Diagnostic Tools Diagnostic Tools
1. Laboratory: 1. Laboratory:
Performed primarily to screen for other disease etiologies
nfection
Cancer
Spondyloarthropathies
No evidence to support value in first 7 weeks unless with
red flags
Specifics:
WBC
ESR or CRP
HLA-B27
Tumor markers: Kidney Breast Lung Thyroid Prostate
2. Radiographs: 2. Radiographs:
Pre-existing Degenerative Joint Disease
(Osteoarthritis) is most common diagnosis
Usually 3 views adequate with obliques only if
equivocal findings
ndications:
History of trauma with continued pain
< 20 years or > 55 years with severe or
persistent pain
Noted spinal deformity on exam
Signs / symptoms suggestive of spondylo-
arthropathy
Suspicion for infection or tumor
a vertebral body
d rt. pedicle, en face
i interfacetal joint
o rt. superior articular
process
r rt. inferior articular mass
& facet
rrow absent pars =
spondylolysis
o1 rt. superior articular
process & facet, subjacent
vertebra
d1 rt. pedicle, suprajacent
vertebra
p1 rt. subjacent intact pars
3. Electromylogram (EMG): 3. Electromylogram (EMG):
Measures muscle function
Can demonstrate radiculopathy or peripheral nerve
entrapment, but may not be positive in the extremities
for the first 3-6 weeks and paraspinals for the first 2
weeks
Would not be appropriate in clinically obvious
radiculopathy
4. Bone Scan: 4. Bone Scan:
Very sensitive but nonspecific
Useful for:
Malignancy screening
Detection for early infection
Detection for early or occult fracture
5. Myelogram: 5. Myelogram:
Procedure of injecting contrast material into the spinal
canal with imaging via plain radiographs versus CT
n past, considered the gold standard for evaluation of
the spinal canal and determining the cause of
pressure on the spinal cord or spinal nerves.
With potential complications, as well as advent of MR
and CT, is less utilized:
More common: Headache, nausea / vomiting
Less common: Seizure, pain, neurological
change, anaphylaxis
Myelogram alone is rarely indicated.
Hitselberger study 1968 Journal of Neurosurgery:
24 % 24 % of asymptomatic subjects with defects
QuickTime and a
TFF (Uncompressed) decompressor
are needed to see this picture.
1 SpinaI cord
2 Contrast in
subarachnoid
spac0
3 nt0rv0rt0braI
disc
4 N0rv0 rootI0ts
of cauda 06uina
QuickTime and a
QuickTime and a
6. CT with Myelogram: 6. CT with Myelogram:
Can demonstrate much better anatomical
detail than Myelogram alone
Utilized for:
Demonstrating anatomical detail in multi-
level disease in pre-operative state
Determining nerve root compression
etiology of disc versus osteophyte
Surgical screening tool if equivocal MR or
CT
QuickTime and a
QuickTime and a
CT-myelogram coronal 2D
reconstructed image shows the intraspinal
lipoma (arrows). Note the displaced nerve
roots to the leIt oI the conus. Tarlov cyst
(nerve root sleeve cyst or diverticulum) oI
leIt S3 is incidentally noted (arrowhead).
CT-myelogram sagittal 2D
reconstructed image shows the
expanding intraspinal low-density
mass (arrow) surrounding by
myelogram contrast.
7. CT: 7. CT:
Best for bony changes of spinal or
foraminal stenosis
Also best for bony detail to determine:
Fracture
Degenerative Joint Disease (DJD)
Malignancy
SW Wiesel study 1984 Spine:
36 % 36 % of asymptomatic subjects had "HNP
at L4-L5 and L5-S1 levels
8. Discography (Diagnostic disc injection) 8. Discography (Diagnostic disc injection)
Less utilized as initial diagnostic tool due to high
incidence of false positives as well as advent of MR
Utilizations:
Diagnose internal disc derangement with normal MR /
Myelogram
Determine symptomatic level in multi-level disease
Criteria for response:
Volume of contrast material accepted by the disc, with
normals of 0.5 to 1.5 cc
Resistance of disc to injection
Production of pain - MOST SIGNIFICANT MOST SIGNIFICANT
Usually followed by CT to evaluate internal
architecture, but also may utilize MR
As outcome predictor (CouIhoun study 1988 JJS):
89 % 89 % of those with pain response received
benefit from surgery
52 % 52 % of those with structural change received
surgical benefit
Discography Discography
Clinical pain provocation test
Test is positive only if:
The disc is abnormal in appearance
AND
Patient's clinical pain is provoked
during injection
QuickTime and a
QuickTime and a
9. MR 9. MR
0st diagnostic tooI for:
Soft tissue abnormalities:
nfection
Bone marrow changes
Spinal canal and neural foraminal contents
Emergent screening:
Cauda equina syndrome
Spinal cored injury
Vascular occlusion
Radiculopathy
Benign vs. malignant compression fractures
Osteomyelitis evaluation
Evaluation with prior spinal surgery
QuickTime and a
QuickTime and a
Has essentially replaced CT and Myelograms for initial
evaluations
Boden study 1990 JBJS:
20 % 20 % of asymptomatic population < 60 years with "HNP
36 % 36 % of asymptomatic population of 60 years
Jensen study 1995 NEJM:
52 % 52 % of asymptomatic patients with disc bulge at
one or more levels
27 % 27 % of asymptomatic patients with disc protrusion
1 % 1 % of asymptomatic patients with disc extrusion
MR with Gadolinium contrast: MR with Gadolinium contrast:
Gadolinium is contrast material allowing
enhancement of intrathecal nerve roots
Utilization:
Assessment of post-operative spine - 2ost 2ost
frequent use frequent use
dentifying tumors / infection within /
surrounding spinal cord
Diagnosis of radiculitis
Post-operatively can take 2-6 months for reduction
of mass effect on posterior disc and anterior
epidural soft tissues which can resemble pre-
operative studies
Only indications in immediate post-operative
period:
Hemorrhage
Disc infection
10. Psychological tools: 10. Psychological tools:
Utilized in case scenarios where psychological or
emotional overlay of pain is suspected
Symptom magnification
Grossly abnormal pain drawing
Non-responsive to conservative interventions but with
essentially normal diagnostic studies
ncludes:
Pain Assessment Report, which combines:
McGill Pain Questionnaire
Mooney Pain Drawing Test
MMP
Middlesex Hospital Questionnaire
Cornell Medical ndex
Eysenck Personality nventory
isc 0g0n0ration: indings? isc 0g0n0ration: indings?
Narrowing
EndpIat0 scI0rosis
Ost0ophyts
0g0n0ration & T0ars 0g0n0ration & T0ars
isc CIassification isc CIassification
Protrus|on
Extrus|on
6ana|
0|sc
ony
Endp|ate
Norma|
u|ge
uIging uIging
!rotrusion !rotrusion
!rotrusion !rotrusion
Extrusion Extrusion
Extrusion Extrusion
Extrusion Extrusion
CIassification of N0rv0 Roots CIassification of N0rv0 Roots
Normal
Contacted
Displaced
Compressed
NormaI N0rv0 Roots NormaI N0rv0 Roots
Contact0d N0rv0 Root Contact0d N0rv0 Root
Contact0d N0rv0 Root Contact0d N0rv0 Root
ispIac0d N0rv0 Root ispIac0d N0rv0 Root
Compr0ss0d N0rv0 Root Compr0ss0d N0rv0 Root
ispIac0d & Compr0ss0d ispIac0d & Compr0ss0d
N0rv0 Root N0rv0 Root
ispIac0d and Compr0ss0d ispIac0d and Compr0ss0d
N0rv0 Root N0rv0 Root
'Every thing doctors do is to 'Every thing doctors do is to
help patients to avoid surgery" help patients to avoid surgery"
Tr0atm0nt Tr0atm0nt
Tr0atm0nt Tr0atm0nt
!harmacoIogicaI !harmacoIogicaI
NSADS
Muscle relaxents:
Re-establish sleep patterns
More useful in myofascial/muscular pain
Membrane stabilizers
TCA / Neurontin
Re-establish sleep pain
Reduce radicular dysesthesias
Narcotics: rarely indicated
Morphine, Oxy/hydrocodone, Oxymorphone,
Hydromorphone, Fentanyl, Methadone
Steroids: more useful for radiculitis
Non-narcotic analgesics: Ultram (Tramadol)
!hysicaI Th0rapy !hysicaI Th0rapy
Modalities
Electrical Stimulation/TENS
Postural Education / Body Mechanics
Massage / Mobilization / Myofascial Release
Stretching / Body Work
Exercise / Strengthening
Traction
Pre-conditioning / Work-conditioning
nj0ctions (N0uraI bIockad0 nj0ctions (N0uraI bIockad0
Epidural blocks
Facet blocks
Trigger point
S joint
Ost0opathic ManipuIation Ost0opathic ManipuIation
Var|pu|al|or & Voo|||zal|or
Cerlra| & ur||al PAs, Trarsverse
3pec|l|c Pass|ve Prys|o|og|ca| Rxs
3evera| lqs perlorred dur|rg 1 Rx
sess|or
9 Rxs over 3 W|s
Rev|eW ol 2Z 3VT lr|a|s lor acule N3L8P
3VT produces oeller oulcores lrar p|aceoo, ro Rx,
& rassage.
3VT vs p|aceoo: -18rr (-21 lo -13)
3VT vs ro Rx: -1Zrr (-2 lo -8)
[Pa|r reducl|or, 100rr vA3, <1/52|
3VT & 'usua| prys|olrerapy', & 'usua| red|ca| care'
appear lo produce s|r||ar oulcores.
3VT vs red|ca| care: -1rr (-11 lo )
[Pa|r reducl|or, 100rr vA3, <1/52|
!sychoIogicaI th0rapy !sychoIogicaI th0rapy
Behavioral treatments (chronic LBP)
Biofeedback
It0rnativ0 Th0rapy It0rnativ0 Th0rapy
Acupuncture
MuItidiscipIinary approach0s MuItidiscipIinary approach0s
Sympath0tic Sympath0tic
Diagnostic
Therapeutic
Neurolytic
St0roid inj0ctions St0roid inj0ctions
mpIantation t0chnoIogy mpIantation t0chnoIogy
ntrathecal pumps
Neuromodulation
Spinal cord stimulation
Peripheral nerve stimulation
nt0rv0ntionaI Th0rapy nt0rv0ntionaI Th0rapy
Surg0ry Surg0ry
Laminectomy
Hemilaminectomy
Discectomy
Fusion
nstrumented
Non-instrumented fusion
MinimaIIy nvasiv0 Spin0 Surg0ry (MSS MinimaIIy nvasiv0 Spin0 Surg0ry (MSS
yphopIasty yphopIasty
!0rcutan0ous isc 0compr0ssion (! !0rcutan0ous isc 0compr0ssion (!
Spin0 rthropIasty Spin0 rthropIasty
(usion w/ (usion w/isc !rosth0sis isc !rosth0sis
ndications
Chronic low back pain +/- leg pain
Persisting > 6 months
Associated with degenerative disc
changes
Leg pain
Radicular
Pseudoradicular
Foraminal stenosis
Secondary to disc space height loss
may be relieved indirectly by
disc height restoration
yphopIasty yphopIasty
t is used to treat painful progressive vertebral body
collapse/fracture due to osteoporosis or the metastasis to the
vertebral body.
Accomplished by inserting a balloon into the center of the
vertebral body (See Figure 1). Then the balloon is inflated (See
Figure 2). This pushes the bone back towards its normal height
and shape. t also helps create a cavity. Then the cavity is filled
with the bone cement.
QuickTime and a
QuickTime and a
Benefits:
Outpatient procedure
Minimal to no epidural scarring
No general anesthesia
Spine stability preservation
Decreased cost
Low rate of complications:
nfection
Peripheral nerve injury
Percutaneous Disc Decompression (PDD) Percutaneous Disc Decompression (PDD)
Typ0s of ! Typ0s of !
Chemonucleolysis (w/Papain)
ntradiscal Electrothermy (DET
) or Spine CATH
Laser Disc Decompression (LASE
)
ntradiscal Coblation
Therapy (Nucleoplasty
)
Mechanical Nuclear Removal (DeKompressor
).
Endoscopic MSS Endoscopic MSS
%e Coa| of Endoscop|c H|88 %e Coa| of Endoscop|c H|88
"Less is Better, But Less is More
Spinal Motion Preservation
Non-fusion Technology
Dynamic Stabilization
Spinal Arthroplasty
Endoscopic MSS Endoscopic MSS
|nd|cat|ons for Endoscop|c H|88 |nd|cat|ons for Endoscop|c H|88
Patients with uncomplicated herniated
discs/degenerative spine disease accompanied by
the following:
Pain of back, neck, trunk, and limbs with
neurological deficit
Pain that has not responded to conventional
treatments,including physical therapy,
medication, exercise, rest for at least eight -
twelve weeks
A positive CT scan, MR scan, myelogram, and
positive discogram for disc herniation
Positive virtual 3D endoscopic findings, and
EMG findings are helpful
Contraindications for Endoscopic MSS Contraindications for Endoscopic MSS
Evidence of pathologies such as fracture-
dislocation, large spinal tumors, pregnancy, or
active infections
Clinical findings that suggest pathology other than
degenerative discogenic disease (e.g. multiple
sclerosis, vascular anomalies, degenerative
myelopathy)
Evidence of neurologic or vascular pathologies
mimicking a herniated disc
Evidence of acute or progressive spinal cord
disease
Cauda equina syndrome
Painless motor deficit
Possible Rx for chronic LBP
Cons0rvativ0 tr0atm0nts: Cognitive behavioural therapy, supervised
exercise therapy, brief educational interventions, multidisciplinary (bio-
psycho-social) treatment, back schools, manipulation/mobilisation,
heat/cold, traction, laser, ultrasound, short wave, interferential, massage,
corsets, TENS.
!harmacoIogicaI tr0atm0nts: NSADs, weak opioids, noradrenergic or
noradrenergicserotoninergic antidepressants, muscle relaxants, capsicum
plasters, Gabapentin.
nvasiv0 tr0atm0nts: Acupuncture, epidural corticosteroids, intra-articular
(facet) steroid injections,local facet nerve blocks, trigger point injections,
botulinum toxin, radiofrequency facet denervation, intradiscal
radiofrequency lesioning, intradiscal electrothermal therapy, radiofrequency
lesioning of the dorsal root ganglion, spinal cord stimulation, intradiscal
injections, prolotherapy, percutaneous electrical nerve stimulation (PENS),
neuroreflexotherapy, surgery.
Europ0an Guid0Iin0s 2004 Europ0an Guid0Iin0s 2004
Recommended Treatments
Cons0rvativ0 tr0atm0nts: Cognitive behavioural therapy,
supervised exercise therapy, brief educational interventions,
multidisciplinary (bio-psycho-social) treatment, back schools, , back schools,
manipulation/mobilisation, heat/cold, traction, laser, ultrasound, manipulation/mobilisation, heat/cold, traction, laser, ultrasound,
short wave, interferential, massage, corsets, TENS. short wave, interferential, massage, corsets, TENS.
!harmacoIogicaI tr0atm0nts: NSADs, weak opioids, NSADs, weak opioids,
noradrenergic or noradrenergicserotoninergic antidepressants, noradrenergic or noradrenergicserotoninergic antidepressants,
muscle relaxants, capsicum plasters, Gabapentin. muscle relaxants, capsicum plasters, Gabapentin.
nvasiv0 tr0atm0nts: Acupuncture, epidural corticosteroids, intra Acupuncture, epidural corticosteroids, intra- -
articular (facet) steroid injections,local facet nerve blocks, trigger articular (facet) steroid injections,local facet nerve blocks, trigger
point injections, botulinum toxin, radiofrequency facet denervation, point injections, botulinum toxin, radiofrequency facet denervation,
intradiscal radiofrequency lesioning, intradiscal electrothermal intradiscal radiofrequency lesioning, intradiscal electrothermal
therapy, radiofrequency lesioning of the dorsal root ganglion, spinal therapy, radiofrequency lesioning of the dorsal root ganglion, spinal
cord stimulation, intradiscal injections, prolotherapy, percutaneous cord stimulation, intradiscal injections, prolotherapy, percutaneous
electrical nerve stimulation (PENS), neuroreflexotherapy, surgery. electrical nerve stimulation (PENS), neuroreflexotherapy, surgery.
Recommended under
some situation
Cons0rvativ0 tr0atm0nts: Cognitive behavioural therapy, supervised Cognitive behavioural therapy, supervised
exercise therapy, brief educational interventions, multidisciplinary (bio exercise therapy, brief educational interventions, multidisciplinary (bio- -
psycho psycho- -social) treatment, social) treatment, back schools, manipulation/mobilisation,
heat/cold, traction, laser, ultrasound, short wave, interferential, massage, heat/cold, traction, laser, ultrasound, short wave, interferential, massage,
corsets, TENS. corsets, TENS.
!harmacoIogicaI tr0atm0nts: NSADs, weak opioids, noradrenergic or
noradrenergicserotoninergic antidepressants, muscle relaxants, capsicum
plasters, Gabapentin. , Gabapentin.
nvasiv0 tr0atm0nts: Acupuncture, epidural corticosteroids, intra Acupuncture, epidural corticosteroids, intra- -articular articular
(facet) steroid injections,local facet nerve blocks, trigger point injections, (facet) steroid injections,local facet nerve blocks, trigger point injections,
botulinum toxin, radiofrequency facet denervation, intradiscal botulinum toxin, radiofrequency facet denervation, intradiscal
radiofrequency lesioning, intradiscal electrothermal therapy, radiofrequency radiofrequency lesioning, intradiscal electrothermal therapy, radiofrequency
lesioning of the dorsal root ganglion, spinal cord stimulation, intradiscal lesioning of the dorsal root ganglion, spinal cord stimulation, intradiscal
injections, prolotherapy, injections, prolotherapy, percutaneous electrical nerve stimulation (PENS),
neuroreflexotherapy, surgery.
Not Recommended
Cons0rvativ0 tr0atm0nts: Cognitive behavioural therapy, supervised Cognitive behavioural therapy, supervised
exercise therapy, brief educational interventions, multidisciplinary (bio exercise therapy, brief educational interventions, multidisciplinary (bio- -
psycho psycho- -social) treatment, back schools, manipulation/mobilisation, social) treatment, back schools, manipulation/mobilisation,
heat/cold, traction, laser, ultrasound, short wave, interferential, massage,
corsets, TENS.
!harmacoIogicaI tr0atm0nts: NSADs, weak opioids, noradrenergic or NSADs, weak opioids, noradrenergic or
noradrenergicserotoninergic antidepressants, muscle relaxants, capsicum noradrenergicserotoninergic antidepressants, muscle relaxants, capsicum
plasters, plasters, Gabapentin.
nvasiv0 tr0atm0nts: Acupuncture, epidural corticosteroids, intra-articular
(facet) steroid injections,local facet nerve blocks, trigger point injections,
botulinum toxin, radiofrequency facet denervation, intradiscal
radiofrequency lesioning, intradiscal electrothermal therapy, radiofrequency
lesioning of the dorsal root ganglion, spinal cord stimulation, intradiscal
injections, prolotherapy, percutaneous electrical nerve stimulation (PENS), , percutaneous electrical nerve stimulation (PENS),
neuroreflexotherapy, surgery. neuroreflexotherapy, surgery.
Eff0ctiv0: Eff0ctiv0: Advice to Stay Active Advice to Stay Active, ,
NSs & MuscI0 R0Iaxants NSs & MuscI0 R0Iaxants
Not 0ff0ctiv0: Not 0ff0ctiv0: 0d R0st & Sp0cific 0d R0st & Sp0cific
Ex0rcis0s Ex0rcis0s
No consist0nt 0vid0nc0 No consist0nt 0vid0nc0 for for
cupunctur0 & umbar Supports cupunctur0 & umbar Supports
R0suIts: cut0 ! R0suIts: cut0 !
Eff0ctiv0: Eff0ctiv0: Ex0rcis0 Th0rapy, Ost0opathic Ex0rcis0 Th0rapy, Ost0opathic
ManipuIations, 0haviouraI Th0rapy & ManipuIations, 0haviouraI Th0rapy &
MuItidiscipIinary pain tr0atm0nt MuItidiscipIinary pain tr0atm0nt
programs programs
ik0Iy to b0 0ff0ctiv0: ik0Iy to b0 0ff0ctiv0: ack SchooIs & ack SchooIs &
Massag0 Massag0
Not 0ff0ctiv0: Not 0ff0ctiv0: TENS TENS
No consist0nt 0vid0nc0 for: No consist0nt 0vid0nc0 for: cupunctur0 cupunctur0
ac0t, EpiduraI & ocaI nj0ctions ac0t, EpiduraI & ocaI nj0ctions
umbar Supports umbar Supports
R0suIts: Chronic ! R0suIts: Chronic !
No diff0r0nc0 b0tw00n Micro No diff0r0nc0 b0tw00n Micro- - & &
Standard isc0ctomy Standard isc0ctomy
Ch0monucI0oIysis produc0d b0tt0r Ch0monucI0oIysis produc0d b0tt0r
cIinicaI outcom0s than !0rcutan0ous cIinicaI outcom0s than !0rcutan0ous
isc0ctomy & !Iac0bo isc0ctomy & !Iac0bo
SurgicaI isc0ctomy produc0d b0tt0r SurgicaI isc0ctomy produc0d b0tt0r
cIinicaI outcom0s than cIinicaI outcom0s than
Ch0monucI0oIysis with Ch0monucI0oIysis with Chy2opapain Chy2opapain
R0suIts: isc !roIaps0 Surg0ry R0suIts: isc !roIaps0 Surg0ry

LBP

Uploaded by

Document Information

Copyright

Available Formats

Share this document

Share or Embed Document

Sharing Options

Did you find this document useful?

Is this content inappropriate?

Copyright:

Available Formats

LBP

Uploaded by

Copyright:

Available Formats

LLow ow B Back ack PPain ain

You might also like