Low Back Pain
Low Back Pain
Low back pain (LBP) is one of the most common complaints and the second most common reason for physician visits. At least 60-90% of U.S. adults will have LBP at some time during their lifetime and up to 50% have back pain within a given year. Although symptoms are usually acute and self-limited, recurrent episodes are common and as many as 30% develop chronic LBP.
There are many different sources of low back each of which maybe more prominent in certain populations and age groups. By far the most common cause is due to injury or wear and tear of the intervertebral disc. The disc is the gelatinous shock absorber between each vertebral body which provides for motion of the low back. As we age the discs can develop small fissures which can progress to include tears, protrusions, and frank disc herniation; these changes can also be the result of trauma or work injury. The disc itself can be painful (discogenic back pain) or it can compress nearby nerves causing radicular leg pain (sciatica). Other common causes of back pain include spondylolysis, spondylolisthesis, lumbar stenosis, fracture, sagittal malalignment, kyphosis and rarely infection, tumor, or inflammatory conditions. Pain referred from visceral organs (pelvic, renal, vascular and GI) must also be considered, especially in patients with chronic pain that hasn’t responded to standard treatment.
The diagnosis of low back pain begins with a detailed history and physical examination with an experienced spine specialist. Most cases of acute low back pain are self limited and respond to a short period of rest, NSAIDs, activity modification, and gradual resumption of activities. Pain that does not respond to these efforts or pain with “red flag” symptoms (severe pain, non mechanical pain, fever, neurologic changes, h/o trauma, cancer or weight loss) should prompt a more detailed evaluation including possible imaging with MRI. Do not accept a “trash can diagnosis” which can not be confirmed such as muscle sprain or myofascial pain as this is one of the most common reasons for delay of diagnosis and treatment.
The appropriate treatment ultimately depends on an accurate diagnosis. However, most cases of acute low back pain (2-4 weeks) are related to discogenic sources, are self limited and may not require a definitive clinical diagnosis (with imaging confirmation). In these situations a short period of bedrest (1-2 days) with gradual return to activities as symptoms allow is most appropriate. Longer periods of bedrest and inactivity are more likely to lead to chronic pain. NSAIDs (ibuprofen, naproxen, aspirin) are helpfully especially for tor or herniated discs which are filled with inflammatory chemicals. A local steroid injections are also helpful for similar reasons while muscle relaxants are appropriate in the presence of significant muscle spasm. Narcotic medications (Tramadol, hydrocodone, oxycodone) are helpful if there is more severe pain but should be used sparingly over a short period as they are prone to abuse and dependency. Once pain has improved patients should return to normal activities as their pain allows. Rehabilitation with an exercise regimen that includes trunk and lower extremity range of motion, strengthening, and aerobic condition is key to long term improvement. Patients with risk factors for back pain (genetic predisposition, manual labor, smoker, or structural lesion, osteoporosis, or psychiatric diagnosis) would benefit from a structured exercises regimen with physical therapist. The role of other modalities including acupuncture, chiropractic care, traction are less clear although some patients may find them helpful. Surgical treatment maybe a consideration in a small percentage of patients who fail an adequate course of non operative treatment and have a structural lesion and or neurologic injury (microdiscectomy, laminectomy, spinal fusion PLFI, TLIF, XLIF cervical disc arthroplasty).
Preventative measures are essential for long term function and to minimize the chance of recurrent back pain. These include participating in a regular exercise regimen, activity modification (avoid or employ proper spine mechanics when bending, lifting twisting, or prolonged sitting), proper posture, smoking cessation, and weight reduction.