An algorithmic approach for clinical management of low back pain

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.