Low back pain

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Low back pain
Classification and external resources
ICD-10	M54.4-M54.5
ICD-9	724.2
MedlinePlus	003108
eMedicine	pmr/73
MeSH	D017116

Low back pain (sometimes referred to generally as lumbago) is a common symptom of musculoskeletal disorders or of disorders involving the lumbar vertebrae and related soft tissue structures such as muscles, ligaments, nerves and intervertebral discs. It can be either acute, subacute or chronic in its clinical presentation. Most often, the symptoms of low back pain show significant improvement within a few days to a few weeks from onset. In a significant number of individuals, low back pain can be recurrent in nature with a waxing and waning quality to it. In a small proportion of individuals this condition can become chronic. Population studies show that back pain affects most adults at some stage in their life and accounts for more sick leave and disability than any other single medical condition.^[1]

An acute lower back injury may be caused by a traumatic event, like a car accident or a fall. It occurs suddenly and its victims will usually be able to pinpoint exactly when it happened. In acute cases, the structures damaged will more than likely be soft tissue. With a serious accident, osteoporosis or other causes of weakened vertebral bones, vertebral fractures in the lumbar spine may also occur. At the lowest end of the spine, some patients may have tailbone pain (also called coccyx pain or coccydynia). Others may have pain from their sacroiliac joint at the bottom of the lumbar spine, called sacroiliac joint dysfunction (see sacroiliac joint for more information). Chronic lower back pain usually has a more insidious onset, occurring over a long period of time. Physical causes may include osteoarthritis, rheumatoid arthritis, degeneration of the discs between the vertebrae, or a spinal disc herniation, a vertebral fracture (such as from osteoporosis), or rarely, a tumor (including cancer) or infection.

Contents 1 Classification 2 Causes 3 Diagnosis 3.1 Imaging 3.2 Red flags 4 Treatments 4.1 Conservative treatment 4.2 Acute back pain 4.3 Chronic back pain 4.4 Other therapies that might have some benefit 4.5 Surgery 5 Prognosis 6 See also 7 References 8 External links

[edit] Classification

One method of classifying lower back pain is by the duration of symptoms: acute (less than 4 weeks), subacute (4–12 weeks), chronic (greater than 12 weeks).

[edit] Causes

Most cases of lower back pain are due to skeletal degeneration or musculoligamentous injury and are referred to as non specific low back pain. The full differential diagnosis however includes many other less common conditions.

[edit] Diagnosis

Diagnosing the underlying cause of low back pain is usually done by a medical doctor, osteopathic physician, physical therapist (physiotherapist) or by a chiropractor. Often, getting a diagnosis of the underlying cause of low back pain and/or related symptoms is quite complex. A complete diagnosis is usually made through a combination of a patient's medical history, physical examination, and, when necessary, diagnostic testing, such as an MRI scan or x-ray.

[edit] Imaging

X-rays are not required in lower back pain except in the cases where "red flags" are present.^[2] If the pain is of a long duration X-rays may increase patient satisfaction.^[3]

[edit] Red flags

• Recent significant trauma or milder trauma if age is > 50 years

• Unexplained weight loss

• Unexplained fever

• Immunosuppression

• Previous or current cancer

• Intravenous drug use

• Osteoporosis

• Chronic corticosteroid use

• Age < 20 or > 55 (first complains)

• Focal neurological deficit

• Thoracic pain

• Pain nonmechanical

• Structural deformity

^[4]

[edit] Treatments

[edit] Conservative treatment

For the vast majority of patients, low back pain can be treated conservatively. A systematic review of randomized controlled trials made a number of recommendations^[5]:

[edit] Acute back pain

• Analgesics (pain medications), such as NSAIDs or acetaminophen.^[6][7]
• Muscle relaxants for acute^[6] or chronic^[7] pain. There are, however, concerns with side effects, and their general use is discouraged.^[8]
• Stay physically active.^[6]
• Exercise is no more effective than no treatment or other conservative treatments for acute low back pain.^[9]
• There is continuing conflict of opinion on the efficacy of spinal manipulation (SM) therapy for nonspecific (i.e., unknown cause) low back pain; methods for formulating treatment guidelines differ significantly between countries, casting some doubt on the guidelines' reliability.^[10] A 2007 U.S. guideline weakly recommended SM as one alternative therapy for spinal low back pain in nonpregnant adults when ordinary treatments fail,^[11] whereas the Swedish guideline for low back pain was updated in 2002 to no longer suggest considering SM therapy for acute low back pain for patients needing additional help, possibly because the guideline's recommendations were based on a high evidence level.^[10] A 2008 review found strong evidence that SM is similar in effect to medical care with exercise, and moderate evidence that SM is similar to physical therapy and other forms of conventional care.^[12] As SM is one procedure physical therapists perform this review confounds the evidence to a degree. A 2007 literature synthesis found good evidence supporting SM and mobilization for low back pain and exercise for chronic low back pain.^[13] Of four systematic reviews published between 2000 and May 2005, only one recommended SM, and a 2004 Cochrane review^[14] stated that SM or mobilization is no more or less effective than other standard interventions for back pain.^[15] A 2008 systematic review found insufficient evidence to make any recommendations concerning medicine-assisted manipulation for chronic low back pain.^[16]

[edit] Chronic back pain

Chronic back pain is defined as back pain that has been present for over six months. The following measures have been found to be effective for chronic non-specific back pain

• Exercise appears to be slightly effective for chronic low back pain.^[9] The Schroth method, a specialized physical exercise therapy for scoliosis, kyphosis, spondylolisthesis, and related spinal disorders, has been shown to reduce severity and frequency of back pain in adults with scoliosis.^[17]

• Tricyclic antidepressants are recommended in a 2007 guideline by the American College of Physicians and the American Pain Society. ^[18]
• Acupuncture may help chronic pain^[7]; however, a more recent randomized controlled trial suggested insignificant difference between real and sham acupuncture.^[19]
• Intensive multidisciplinary treatment programs may help subacute^[6] or chronic^[7] low back pain.
• Behavioral therapy^[7]
• Arch support^{[citation needed]}
• The Alexander Technique was shown in a UK clinical trial to have long term benefits for patients with chronic back pain.^[20]
• Back schools have shown some effect in managing chronic back pain.^[21]
• Prolotherapy, facet joint injections, and intradiscal steroid injections have not been found to be effective.^[22]

[edit] Other therapies that might have some benefit

Additional treatments have been more recently reviewed by the Cochrane Collaboration:

• Massage therapy may benefit some patients.^[23]

• Ice and/or heat application (or moist heat) has uncertain benefit.^[24]

Individual randomized controlled trials, thus interpretation may be subject to publication bias, also confounded by absence of double blinding have shown benefit for:

• Viniyoga,^[25] Iyengar,^[26] and Hatha yoga (small trial).^[27]

• Correcting leg length difference may help.^[28] To correct leg length difference, insert a hard rubber or cork heel pad into the shoe of the short leg if the difference between the two legs is 3/8ths inch or less. If more, have a shoe repairman build up the sole and heel. Taper the toe to avoid tripping. If more than 3/4 inch, start with 1/2 of what you need so that your body can adjust.

• Muscle Energy Technique (MET) may help (small study).^[29]

Other treatments that were not reviewed are

• Education and attitude adjustment (TMS)
• Increasing internal hip rotation
• Increase internal hip rotation with stretching or connective tissue massage
• Medical cannabis

Because of variations in clinical study methodology, a review of clinical studies in any one area is not necessarily conclusive.

For any one condition, it may be necessary to try a variety of treatments in order to find the best one (or combination) to best manage the pain. In almost all cases, physical therapy and/or a regular exercise program that includes stretching, strengthening and low impact cardio conditioning will be part of the treatment and rehabilitation program.

The role of narcotics for chronic low back pain is uncertain.^[30]

• A 2008 review found antidepressants ineffective in the treatment of chronic back pain ^[31] even though some previous studies did find them helpful.^[7]

[edit] Surgery

Surgery may be indicated when conservative treatment is not effective in reducing pain or when the patient develops progressive and functionally limiting neurologic symptoms such as leg weakness, bladder or bowel incontinence, which can be seen with severe central lumbar disc herniation causing cauda equina syndrome or spinal abscess.^{[citation needed]} Spinal fusion has been shown not to improve outcomes in those with simple chronic low back pain.^[32]

Other possible indications for surgery include:

• Severe Degenerative disc disease
• Spinal stenosis
• Spondylolisthesis
• Scoliosis
• Compression fracture
• Spinal instability
• Spinal trauma
• Spinal malignancy(cancer)
• Spinal hematoma
• Spinal Disc replacement

The most common types of low back surgery include microdiscectomy, discectomy, laminectomy, foraminotomy, or spinal fusion. Another less invasive surgical technique consists of an implantation of a spinal cord stimulator and typically is used for symptoms of chronic radiculopathy (sciatica). Lumbar artificial disc replacement is a newer surgical technique for treatment of degenerative disc disease, as are a variety of surgical procedures aimed at preserving motion in the spine.

[edit] Prognosis

Most patients with acute onset lower back pain recover completely over a few weeks.^[33]

[edit] See also

[edit] References

[edit] External links

• Back and spine at the Open Directory Project

v • d • e Dorsopathies / spinal disease (M40-M54, 720-724,737) Deforming dorsopathies Spinal curvature Kyphosis · Lordosis · Scoliosis Other Scheuermann's disease · Torticollis Spondylopathies Ankylosing spondylitis · Spondylosis (Spondylolysis, Spondylolisthesis)  · Spinal stenosis · Sacroiliitis · Discitis Pain Coccydynia · Back pain (Radiculopathy, Neck pain, Sciatica, Low back pain) Other Schmorl's nodes · Degenerative disc disease

v • d • e Pain and nociception Head and neck Jaw and mouth (Odynophagia )  • Ear (otalgia, otitis media, otitis externa)  • Eye (glaucoma)  • Head (headache, migraine, tension headache, cluster headache, cerebral aneurysm, sinusitis, meningitis)  • Neck (atypical myocardial infarction) Thorax Back (upper back, lower back, spinal disc herniation, degenerative disc disease, coccydynia)  • Breast (perimenstrual, breast cancer)  • Chest (myocardial infarction, gastroesophageal reflux disease, pancreatitis, hiatus hernia, aortic dissection, asymptomatic pulmonary embolism, Tietze's syndrome)  • Shoulder (right side - cholecystitis) Abdominal Left and right upper quadrant (peptic ulcer disease, gastroenteritis, hepatitis, pancreatitis, cholecystitis, atypical myocardial infarction, abdominal aortic aneurysm, asymptomatic gastric cancer)  • Left and right lower quadrant (appendicitis, ulcerative colitis, Crohn's disease, ectopic pregnancy, endometriosis, pelvic inflammatory disease, diverticulitis, urolithiasis, pyelonephritis, colorectal cancer) Limbs Arm (myocardial infarction, left arm)  • Leg (deep vein thrombosis, peripheral artery occlusive disease, claudication, spinal disc herniation, sciatica) Joints (arthralgia) Small joints (osteoarthritis, rheumatoid arthritis, systemic lupus erythematosis, gout, pseudogout  • Large joints (osteoarthritis, septic arthritis, hemarthrosis, osteonecrosis)  • Back joints (ankylosing spondylitis, inflammatory bowel disease)  • Other (psoriatic arthritis, Reiter's syndrome) Musculoskeletal Delayed onset muscle soreness, myalgia, physical trauma Other/unspecified cold pressor test, congenital insensitivity to pain, dolorimeter, HSAN (Type I, II congenital sensory neuropathy, III familial dysautonomia, IV congenital insensitivity to pain with anhidrosis, V congenital insensitivity to pain with partial anhidrosis), neuralgia, pain asymbolia, pain disorder, paroxysmal extreme pain disorder  • Allodynia, breakthrough pain, chronic pain, hyperalgesia, hypoalgesia, hyperpathia, phantom pain, referred pain Related concepts Anterolateral system, gate control theory of pain, pain management (anesthesia, cordotomy), pain scale, pain threshold, pain tolerance, posteromarginal nucleus, substance P, suffering, OPQRST