Evaluation and Interventional Treatment of Axial Lumbar Back Pain (Podcast)

Approximately 80% to 85% of people will experience axial lumbar back pain at some point in their life, with about 20% of those individuals requiring the bulk of care delivered for low back pain.

“In axial lumbar back pain, the pain remains mostly in the spine, although it can be referred into the pelvis, hips or legs,” says physical medicine and rehabilitation spine specialist Alison Stout, DO, of Cleveland Clinic’s Center for Spine Health. “Compared with conditions like lumbar radiculopathy or neurogenic claudication, it involves a tougher workup and diagnosis and has more limited treatments.”

In the latest episode of Cleveland Clinic’s Neuro Pathways podcast, Dr. Stout outlines the essentials of managing this common but challenging condition. She touches on the following topics, among others:

• The epidemiology and impact of axial lumbar back pain
• The diagnostic workup, including key advice for history-taking and examination
• When and why to order various types of imaging
• Interventional treatment options, particularly radiofrequency ablation guided by diagnostic facet joint medial branch blocks
• Treatment response and need for follow-up
• Why surgery is considered a last resort for axial lumbar back pain

Click the podcast player above to listen to the 33-minute episode now, or read on for a short edited excerpt. Check out more Neuro Pathways episodes at clevelandclinic.org/neuropodcast or wherever you get your podcasts.

This activity has been approved for AMA PRA Category 1 Credit™ and ANCC contact hours. After listening to the podcast, you can claim your credit here.

Excerpt from the podcast

Podcast host Glen Stevens, DO, PhD: Who requires imaging, and what’s the typical approach to it?

Alison Stout, DO: X-rays typically rule out 80% to 90% of occult processes. They are not that helpful for discerning a pain generator, but they rule out the majority of really concerning findings. Many payers require them before you can move on to advanced imaging.

The utility of X-ray is that it helps sort out counting anomalies that can confuse us when doing interventions or surgery involving a transitional segment. If a patient is partially lumbarized in their sacrum, defining that on X-ray can be very helpful before you proceed to an MRI and before you get to a procedure room.

The other thing that X-ray reveals that can't be seen on other imaging is instability or changes in alignment in standing. From my perspective, I want to know if someone's unstable, if they have a spondylolisthesis. Standing X-rays often show that, whereas on a supine MRI or a CT scan, it resolves and you don't see it. Sometimes we add flexion extension to further evaluate for instability, which can't be seen on static advanced imaging.

For deciding on interventions and surgery, MRI is the gold standard. Sometimes we additionally need a CT scan to look at the bony anatomy. Typically, MRI is what we need at the interventional stage. More often than not, a CT scan is added in cases of surgical planning.

When ordering an MRI, it’s important to prepare the patient with information on what to expect — that we are going to see disc wear and tear and that disc degeneration is not a disease. That term can get medicalized, and some patients catastrophize about having degenerative disc disease. I tell them that having degenerative disc disease is simply kind of like having gray hair and wrinkles as you age. It’s important to emphasize the goal of the MRI — to identify whether the imaging findings match their symptoms — and that any findings of arthritis or disc wear and tear are typical and to be expected.

When reviewing an MRI, my job is matching its anatomic findings with the patient. That’s where the art comes in. For instance, the image may show profound facet arthritis at L4-5, but the patient's symptoms may not really be in that location or their pain might be all midline and not parasagittal along the facets. In a case like that, I need to be looking more at the disc and perhaps some endplate changes that may also be there. And I may need to discern things from their history. If their pain is worse with extension loading, that would point me toward looking at the facet joints more. The history and examination are always feeding my decision-making when I look at the MRI.