User Tools

Site Tools


low_back_pain

Low back pain (LBP)

Common low back pain (LBP) is defined as pain between the costal margins and the inferior gluteal sulcus, which may be associated with pain referred down to the leg (“leg pain”), and is usually accompanied by painful limitation of movement.

Intermittent LBP is defined as a clinical condition in which pain is induced by standing or walking but is absent at rest.

The impact of low back pain on any modern healthcare system is well known. In industrialized countries, LBP is one of the main causes of health-related and social costs 1) 2).

Therefore, many attempts are being made to develop a systematic, evidence-based approach to dealing with this from a public health perspective.

Types

Epidemiology

Low back pain is the single most common cause for disability in individuals aged 45 years or younger and as a result carries tremendous weight in socioeconomic considerations.

In Western Europe, Low back pain (LBP) is considered to have the greatest burden of disease for society 3).

One of the countervailing issues is that epidemiologically, spinal degenerative disease and particular low back pain are most prevalent amongst musculoskeletal disease. Nearly 100% of all adults end up with spinal problems at least once during their lifetime, with a point prevalence of 4%-33% 4).

In the U.S., acute low back pain is the fifth most common reason for physician visits. About nine out of ten adults experience back pain at some point in their life, and five out of ten working adults have back pain every year.

Low back pain causes 40% of missed days of work in the United States.


A significant majority of patients discharged from hospitals in the US from 1998 to 2007 with a primary diagnosis of LBP were admitted through the emergency room (ER), with more patients being admitted via this route each year. These patients were less likely to be discharged directly home compared with patients with LBP who were not admitted through the ER. Uninsured and African American patients with LBP were more likely to be admitted through the ER than their counterparts, as were patients with more preexisting health problems. Interestingly, patients with LBP at the highest income levels were more likely to be admitted through hospital ERs. The findings suggest that socioeconomic factors may play a role in the utilization of ER resources by patients with LBP, which in turn appears to impact at least the short-term outcome of these patients 5).

Etiology

Diagnosis

In 85 % of cases no specific diagnosis can be made.

History

Work status

Typical job tasks

Educational level

Pending litigation

Workers compensation or disability issues

Failed previous treatments

Substance abuse

Depression.

Diagnosing common LBP implies that the pain is not related to conditions such as fractures, spondylitis, direct trauma, or neoplastic, infectious, vascular, metabolic, or endocrine-related processes 6) 7).

Physical examination

Fever

Vertebral tenderness

Very limited range of spinal motion.

Radiculopathy

Weakness

Light touch sensation.

Straight leg raising

Imaging

Imaging is important in the evaluation of patients with degenerative disease and infectious processes. There are numerous conditions that can manifest as low back pain (LBP) or neck pain in a patient, and in many cases, the cause may be multifactorial. Clinical history and physical examination are key components in the evaluation of such patients 8).

However, physical examination has variable sensitivity and specificity.

Although studies have demonstrated that uncomplicated acute LBP and/or radiculopathy are self-limited conditions that do not warrant any imaging 9) 10) 11) , neuroimaging can provide clear anatomic delineation of potential causes of the patient's clinical presentation. Various professional organizations have recommendations for imaging of LBP, which generally agree that an imaging study is not indicated for patients with uncomplicated LBP or radiculopathy without a red flag (eg, neurological deficit such as major weakness or numbness in lower extremities, bowel or bladder dysfunction, saddle anesthesia, fever, history of cancer, intravenous drug use, immunosuppression, trauma, or worsening symptoms). Different imaging modalities have a complementary role in the diagnosis of pathologies affecting the spine 12).


Imaging, primarily with MRI and CT, is used to evaluate the source of both LBP and neck pain. These imaging modalities commonly identify disc degeneration, disc herniations, and posterior element arthopathy; however, the imaging findings of spine degeneration are present in a high proportion of asymptomatic individuals and increase with age 13) 14)


see Lumbar spine magnetic resonance imaging.

Treatment

Initial assesment is geared to detecting red flags.

see Low back pain treatment

Outcome

A standardized set of outcome measures for use in patients with back pain was proposed by a multinational group of experts 15).

The domains recommended for inclusion were pain, back-specific function, generic health status (well-being), work disability, social disability, and patient satisfaction.

Recommendations

RECOMMENDATION 1: Clinicians should conduct a focused history and physical examination to help place patients with low back pain into 1 of 3 broad categories: nonspecific low back pain, back pain potentially associated with radiculopathy or spinal stenosis, or back pain potentially associated with another specific spinal cause. The history should include assessment of psychosocial risk factors, which predict risk for chronic disabling back pain (strong recommendation, moderate-quality evidence).

RECOMMENDATION 2: Clinicians should not routinely obtain imaging or other diagnostic tests in patients with nonspecific low back pain (strong recommendation, moderate-quality evidence).

RECOMMENDATION 3: Clinicians should perform diagnostic imaging and testing for patients with low back pain when severe or progressive neurologic deficits are present or when serious underlying conditions are suspected on the basis of history and physical examination (strong recommendation, moderate-quality evidence).

RECOMMENDATION 4: Clinicians should evaluate patients with persistent low back pain and signs or symptoms of radiculopathy or spinal stenosis with magnetic resonance imaging (preferred) or computed tomography only if they are potential candidates for surgery or epidural steroid injection (for suspected radiculopathy) (strong recommendation, moderate-quality evidence).

RECOMMENDATION 5: Clinicians should provide patients with evidence-based information on low back pain with regard to their expected course, advise patients to remain active, and provide information about effective self-care options (strong recommendation, moderate-quality evidence).

RECOMMENDATION 6: For patients with low back pain, clinicians should consider the use of medications with proven benefits in conjunction with back care information and self-care. Clinicians should assess severity of baseline pain and functional deficits, potential benefits, risks, and relative lack of long-term efficacy and safety data before initiating therapy (strong recommendation, moderate-quality evidence). For most patients, first-line medication options are acetaminophen or nonsteroidal anti-inflammatory drugs.

RECOMMENDATION 7: For patients who do not improve with self-care options, clinicians should consider the addition of nonpharmacologic therapy with proven benefits-for acute low back pain, spinal manipulation; for chronic or subacute low back pain, intensive interdisciplinary rehabilitation, exercise therapy, acupuncture, massage therapy, spinal manipulation, yoga, cognitive-behavioral therapy, or progressive relaxation (weak recommendation, moderate-quality evidence).

Guidelines

1) , 6)
Airaksinen O, Brox JI, Cedraschi C, et al. European guidelines for the man- agement of chronic nonspecific low back pain. European Spine Journal 2006;15(Suppl. 2):S192–300 [chapter 4].
2) , 7)
National Collaborating Centre for primary care low back pain: early man- agement of persistent non-specific low back pain. Full guideline May 2009 http://www.nice.org.uk/cg88 [accessed 14.07.12].
3)
Murray CJ, Vos T, Lozano R, Naghavi M, Flaxman AD, et al. (2012) Disability-adjusted life years (DALYs) for 291 diseases and injuries in 21 regions, 1990–2010: a systematic analysis for the Global Burden of Disease Study 2010. Lancet 380: 2197–2223
4)
Woolf AD, Pfleger B. Burden of major musculoskeletal conditions. Bull World Health Organ. 2003;81:646–656.
5)
Drazin D, Nuño M, Patil CG, Yan K, Liu JC, Acosta FL Jr. Emergency room resource utilization by patients with low-back pain. J Neurosurg Spine. 2016 Jan 29:1-8. [Epub ahead of print] PubMed PMID: 26824585.
8)
van der Wurff P, Buijs EJ, Groen GJ. A multitest regimen of pain provocation tests as an aid to reduce unnecessary minimally invasive sacroiliac joint procedures. Arch Phys Med Rehabil. 2006 Jan;87(1):10-4. PubMed PMID: 16401431.
9)
Ren XS, Selim AJ, Fincke G, et al. Assessment of functional status, low back disability, and use of diagnostic imaging in patients with low back pain and radiating leg pain. J Clin Epidemiol. 1999;52(11):1063–1071.
10)
Jarvik JG, Deyo RA. Diagnostic evaluation of low back pain with emphasis on imaging. Ann Internal Med. 2002;137(7):586–597.
11)
Jarvik JG, Hollingworth W, Martin B, et al. Rapid magnetic resonance imaging vs radiographs for patients with low back pain: a randomized controlled trial. JAMA. 2003;289(21):2810–2818.
12)
Shah LM, Ross JS. Imaging of Degenerative and Infectious Conditions of the Spine. Neurosurgery. 2016 Sep;79(3):315-35. doi: 10.1227/NEU.0000000000001323. PubMed PMID: 27352276.
13)
Brinjikji W, Luetmer PH, Comstock B, et al. Systematic literature review of imaging features of spinal degeneration in asymptomatic populations. AJNR Am J Neuroradiol. 2015;36(4):811–816.
14)
Boden SD, Davis DO, Dina TS, Patronas NJ, Wiesel SW. Abnormal magnetic-resonance scans of the lumbar spine in asymptomatic subjects: a prospective investigation. J Bone Joint Surg Am. 1990;72(3):403–408.
15)
Deyo RA, Battie M, Beurskens AJHM, Bombardier C, Croft P, Koes B, Malmivaara A, Roland M, Korff M, Waddell G. Outcome measures for low back pain research: a proposal for standardized use. Spine. 1998;23:2003–2013. doi: 10.1097/00007632-199809150-00018.
low_back_pain.txt · Last modified: 2019/05/28 21:46 by administrador