Extract
The approach to the management of low back pain has undergone substantial
change in recent decades. Low back pain can often present as a difficult
problem to solve. It is a loosely defined diagnosis that may refer to multiple
patterns of pain with complex issues surrounding its pathoanatomical diagnosis
and treatment. There is a paucity of evidence from the health professional
literature regarding its cause, management, and prognosis. The difficulty of
managing patients with low back pain stems from the fact that there often is
very little association between any pathological physical findings and the
patient's pain and disability. The professional must then find ways of
clinically treating a syndrome that betrays the principles of basic
science.
The approach to the management of low back pain has undergone substantial
change in recent decades. Low back pain can often present as a difficult
problem to solve. It is a loosely defined diagnosis that may refer to multiple
patterns of pain with complex issues surrounding its pathoanatomical diagnosis
and treatment. There is a paucity of evidence from the health professional
literature regarding its cause, management, and prognosis. The difficulty of
managing patients with low back pain stems from the fact that there often is
very little association between any pathological physical findings and the
patient's pain and disability. The professional must then find ways of
clinically treating a syndrome that betrays the principles of basic
science.
In recent years, the advancement in diagnostic modalities and therapies has
led to the belief that there are precise and treatable organic causes of low
back pain. The quickly evolving worlds of radiology, electrodiagnostics, and
injection techniques have yielded advances in diagnostic reliability and more
directed treatment plans. Many who routinely treat axial low back pain favor
the idea that identification of a particular pain generator should be
aggressively pursued and identified. Only after a thorough attempt has been
made to provide a focused pathoanatomical diagnosis should the diagnosis of a
nonspecific low back disorder be accepted by the patient or physician.
With the understanding that there are still many difficulties in the
management of low back syndromes, this lecture will review some of the
available nonoperative modes of low back pain treatment, which can be applied
regardless of whether a particular pain mediator has been identified.
Currently, low back pain is epidemic in the United States. Its annual
incidence has been projected to be 5% per year, with an associated prevalence
of 60% to 90%1. The
one-month prevalence of low back pain is estimated to be 43% of the
population2. Only
visits for the common cold have outnumbered presentations of low back pain to
primary care
physicians3. The
medical costs and vocational disabilities that occur with low back pain are
substantial. The length of time that a patient is absent from work because of
low back pain correlates with a decreasing chance of return to work. A patient
who has missed work for more than six months has a 50% chance of returning to
work, one who has missed more than a year has a 25% chance of returning, and
one who has missed two years or more has a <5% chance of
returning4. Low back
pain is the leading cause of disability in the largest working
population—that is, persons younger than forty-five years of age.
In addition to causing substantial morbidity, low back pain is expensive.
It has been estimated that between $33 and $55 billion is spent yearly in
direct medical costs for the treatment of low back
pain5,6.
The indirect costs to society, such as lost work-days and productivity are
even higher. Indirect costs for musculoskeletal diseases as a group have been
estimated to be $90
billion7, and low
back pain is the major contributor to this cost. This problem is not isolated
to the United States. Seitz et al. estimated that, in Germany in 2001, low
back pain led to 5 billion euro in direct medical costs and 13 billion euro in
indirect costs8.
Both direct and indirect costs continue to rise.
Most studies have suggested that low back pain is usually a self-limited
disease, with dramatic improvement in one to several weeks. Improvement can be
seen in up to 80% of people in the first two
weeks9. Furthermore,
many studies have shown that observation is as good as active treatment of low
back pain. Thus, it behooves the physician to manage this syndrome effectively
to limit its negative impact.
Low back pain has many different causes. Frymoyer suggested that nearly 85%
of low back conditions cannot be diagnosed on the basis of the history,
findings of the physical examination, or diagnostic
testing10. In fact,
the rapid resolution of most back pain often prevents a diagnosis from ever
being made. Confounding the problems with diagnosis is the difficulty in
understanding the motive of the patient seeking help. Psychological and
emotional factors, particularly depression, can play a
role11. There may
be unknown social pressures, and it may not be possible or effective to
manipulate work accommodations.
Smoking deserves mention. There is an increased incidence of both low back
pain and disc herniations in
smokers1,12,13.
An et al. found a threefold higher risk of lumbar disc herniations and a
3.9-fold higher risk of cervical disc herniations in
smokers14. Nicotine
appears to interfere with bone metabolism through induced calcitonin
resistance and decreased osteoblastic
function15,16.
Disc nutrition is impaired by a decreased exchange capacity, with progressive
disc
degeneration17. An
autoimmune response may also be involved in progressive disc degeneration in
smokers14.
Furthermore, oxygen levels are reduced in smokers, leading to hyalinization
and necrosis of the nucleus
pulposus18.
Outcomes of treatment, operative or nonoperative, are less successful in
patients who smoke than they are in those who do not smoke. There is a higher
incidence of persistent back pain after treatment and of progressive
osteoporosis with associated complications, and surgical healing rates are
lower19-23.
Therefore, cessation of smoking is an important aspect of the treatment of
patients with low back pain.
In the past, there has been variability in the understanding of the
clinical presentation of lumbar disc disease. Low back pain with radiation to
one or both buttocks and posterior aspects of the thighs in combination with
exacerbation while coughing or sneezing is suggestive of lumbar disc disease.
A positive straight-leg-raise test or a decreased Achilles reflex is a
characteristic finding associated with disc herniation. Radicular sensory
deficits, unilateral pain, and tension signs with or without reflex
alterations all suggest nerve root impingement. Paraspinous muscle tenderness
probably indicates a myofascial component to the pain. Pain with standing that
improves with short walks and pain with back flexion and with no substantial
muscle tenderness suggest a discogenic etiology. Focal night pain without
associated tenderness may be consistent with a tumor. Nonspinal causes of low
back pain may include systemic diseases, intraperitoneal lesions, and
particularly retroperitoneal lesions. Low back pain also could be a physical
manifestation of a psychological malady.
Psychosocial and occupational risk factors often cloud the diagnosis and
make it difficult to establish an explainable organic cause of low back pain.
Smoking, as stated earlier, as well as obesity may contribute to the incidence
of low back pain24.
Repetitive bending and twisting can increase the risk of low back pain and
disc herniation25.
Additionally, job dissatisfaction or involvement in a Workers' Compensation
lawsuit portends a poorer prognosis for
recovery26.
Non-musculoskeletal causes of low back pain should be considered during the
work-up phase. The most common causes are renal and vascular pathology, such
as a kidney stone or an abdominal aortic aneurysm. Tenderness and pain with
percussion over the dorsal twelfth rib region, lateral to the midline, suggest
kidney involvement. Laboratory studies, including urinalysis and a blood
metabolic panel, should be performed. A patient with cardiovascular disease
who has back pain that is unresponsive to early treatment and no back
tenderness should have an abdominal examination to palpate for an aneurysm. An
aneurysm may also be detected on magnetic resonance imaging or computed
tomography scans of the lumbar spine made to look for spinal pathology.
Lastly, tumors may manifest as back pain. Pain at night and without response
to activity or rest, unexplained weight loss, and fatigue should be "red
flags" during the work-up for low back pain.
A diagnosis can be confirmed with radiographic imaging. Anteroposterior and
lateral plain radiographs of the lumbar spine are conventionally the first
radiographic images made, and they are useful for the evaluation of osseous
anatomy and alignment (Fig. 1).
Benefits of myelography include the dynamic assessment of nerve compression
with the ability to obtain standing flexion and extension views. With the
refinement of magnetic resonance imaging, however, myelography is performed
less frequently, but it has a useful application when it is followed by a
computed tomography scan. The computed tomography scan adds the clarity of
osseous anatomy and the ability to reformat in sagittal and coronal planes.
Computed tomography is helpful for the assessment of fractures and
spondylolysis or in preoperative planning, and it is an important alternative
for assessing a patient with instrumentation in place.
Magnetic resonance imaging has had a dramatic impact on the diagnosis and
treatment of spinal disease (Fig.
2). It is the most accurate and sensitive modality for the
diagnosis of subtle spinal pathology, making it the test of
choice27.
Bone scanning with SPECT (single-photon-emission computed tomography)
allows physiologic assessment of bone by identifying increased osteoblastic
activity. It is a highly sensitive study with a low specificity, making it a
good screening test for degenerative changes or metastatic disease. It may be
useful for localizing a pain generator when multiple radiographic
abnormalities are identified.
Discography is an invasive, provocative, painful procedure done under
fluoroscopic guidance. Contrast medium is injected to pressurize the disc and
mimic the pressure of prolonged sitting or
standing28. While
an abnormal appearance, with fissuring and leakage of the contrast medium, is
seen on fluoroscopy and computed tomography scanning, the patient's pain
response is the most important determinant of the result. Discography, while
possibly the best study for identifying the pain generator in some patients,
remains a subjective study and should be thought of as a part of the whole
diagnostic work-up. It should not be given excessive importance.
The best strategy for nonoperative management of low back pain combines
active intervention with education and rehabilitation. The patient should be
an active participant in the healing process. There are many treatment options
for patients with low back pain, but, although there is a plethora of
literature, there is very little conclusive evidence for any of them. The
treatment options are often used in combination.
Bed Rest
Bed rest is a common treatment for low back pain. As is the case for many
of the other treatment options discussed below, there are conflicting reports
in the literature regarding the benefits. While some authors have shown that
bed rest can provide a benefit with regard to alleviating overall pain, others
have shown a quicker return to work with little or no bed
rest29-31.
The general consensus seems to be that bed rest should be short-term (two
days) if used at all.
Medications
Although no analgesic should be promoted as a cure for pain or a
replacement for non-pharmacological interventions, medications are frequently
used in the nonoperative care of low back pain. The different pharmacologies
of various medicines can be applied more effectively when a particular pain
generator has been diagnosed.
Nonsteroidal anti-inflammatory drugs are commonly used to treat
inflammation, but they also have a role as
analgesics32. They
are recognized for their ability to limit inflammation by interfering with
prostaglandin synthesis and cyclooxygenase (COX) activity. Dyspepsia is
common, and complications such as gastric erosion, ulceration, and hemorrhage
can develop. COX-1 regulates constitutive cellular processes, whereas COX-2
activity is induced by mediators of inflammation. Newer, selective COX-2
inhibitors have anti-inflammatory benefits while limiting the disruption of
cellular homeostasis and thus decreasing some adverse effects on the
gastrointestinal system. Other risks, such as renal toxicity, are associated
with COX-1 and COX-2-regulating nonsteroidal anti-inflammatory drugs.
Prescribing nonsteroidal anti-inflammatory drugs on an as-needed basis is more
likely to take advantage of its analgesic effect than to provide the
anti-inflammatory benefit that comes with scheduled
administration33.
Acetaminophen and opioids are commonly used analgesics but they are
associated with substantial risks. While hepatotoxicity is a risk with
overdosing, acetaminophen is generally very well tolerated. Although opioid
use is on the rise and can be effective for symptom control, these drugs do
not work over the long term and they can lead to other problems. They often
have side effects including drowsiness, dizziness, fatigue, nausea,
respiratory depression, and constipation. Tolerance to some side effects
occurs within days after the initiation of therapy. Others, like constipation,
may persist longer. Tolerance to the analgesic effect of opioids begins to
occur when the drugs have been continuously used for longer than several
weeks. However, tolerance to respiratory and sedative effects occurs much more
quickly. Opioids produce analgesia by binding to receptors that are normally
bound by endogenous compounds in the central nervous system. Short-acting
narcotics can cause sleep deprivation despite their use to help people with
pain to sleep. They are also more likely to encourage overuse. Long-acting
opioids have less addictive potential and are, therefore, better
tolerated34.
Combining acetaminophen with oxycodone yields analgesia superior to that
produced by either drug
alone35. All
narcotics are best avoided if possible.
Steroids should play a minimal role in the treatment of low back pain. They
are associated with substantial gastrointestinal risks. Long-term use is known
to lead to osteopenia and an increased risk of infection. Concerns about
osteonecrosis of the proximal part of the femur and humerus should prompt
judicious use.
Muscle relaxants play a role in acute back pain and appear to be more
effective than a placebo alone. Paraspinous muscle spasm is commonly
associated with acute back injuries of various etiologies and can respond well
to these medications. Muscle relaxants work for only a limited period of time
and should be considered for the acute treatment of back pain rather than for
long-term treatment.
Antidepressants also have a role in the management of low back pain,
especially when there is a comorbid mood disorder. Their concomitant effects
as analgesics and antidepressants are particularly useful for individuals in
whom back pain would otherwise be increased by depression. Likewise, when
anxiety predominates, the threshold for pain perception is
lowered36. While
antidepressants may be effective when used alone, they may be extremely
effective, compared with a placebo, when they are part of combination
therapy.
Antiseizure medications are useful in the treatment of neurological pain,
particularly in the lower extremities. Their effectiveness in the treatment of
low back pain is in question.
Recommendations with regard to the use of medications for the treatment of
low back pain are fairly individualized. We tend to treat acute low back pain
with a nonsteroidal anti-inflammatory drug, starting with an inexpensive
generic medication or one with which the patient has had prior success. If the
patient has a history of gastritis or ulcer disease, a COX-2-selective
nonsteroidal anti-inflammatory drug is chosen. We occasionally prescribe
muscle relaxants for a short duration as well. For subacute or more chronic
low back pain, we often add an antidepressant along with other treatment
modalities, as outlined below. Muscle relaxants and opioids should be avoided
by patients with chronic pain.
Physical Therapy
Physical therapy can be used as a broad term to refer to
stretching and strength training, back school for the education of patients,
and other modalities to address low back pain. It has been shown to be better
than medical care alone over a six-month period, especially when the program
is medically
supervised37,38.
It is also better than chiropractic manipulation for the treatment of chronic
pain39. Specific
types of back flexion and extension stretching have been thought to have
beneficial effects for patients with low back
pain40.
Flexion-based isometric exercises appear to have the most support in the
literature, although extension-based exercises, progressive-resistance
exercises, and dynamic stabilization training are useful
adjuncts30,41.
They may offer benefit by decreasing local muscle spasm and stabilizing the
spine. Stand-alone strengthening programs have also shown
benefit42.
Currently, however, it is unclear whether one form of exercise therapy is more
effective than another, but all seem to provide
benefit43. A
comparison of McKenzie extension exercises with an intensive strengthening
program showed no difference in the reduction of disability or pain at the
time of
follow-up44. In a
systematic review of the available literature on the effectiveness of massage
in the management of low back pain, massage was shown to decrease symptoms and
improve function in patients with nonspecific low back pain, especially when
the massage was coupled with exercise and
education45. The
ultimate goal should be to involve patients in their back pain management.
Exercise can be supplemented with other modalities, such as transcutaneous
electrical nerve stimulation (TENS), which is electrotherapy applied to the
low back. Hypotheses to explain how this treatment works have ranged from the
suggestion that there is a release of endogenous analgesic endorphins to the
implication of a central nervous system process in which a control center is
altered to block transmission of
pain46. The best
study to date showed that transcutaneous electrical nerve stimulation is no
different from a
placebo47.
Traction is another modality used during therapy. The goal of lumbar
traction is to distract the lumbar vertebrae. There are many potential
effects, such as enlargement of the intervertebral foramen, creation of a
vacuum to reduce herniated discs, placement of the posterior longitudinal
ligament under tension to aid in reduction of herniated discs, relaxation of
muscle spasm, and freeing of adherent nerve
roots48.
Intradiscal pressure can be decreased by 20% to
30%49. Prospective
studies have shown, however, that traction is not a means with which to
definitively manage low back pain and that it does change its natural
history30.
Chiropractic Manipulation
Chiropractic manipulation is the most common "alternative"
therapy for managing low back pain. It has been estimated that nearly 15% of
the United States population seeks chiropractic help each
year50. The
majority of visits are for the treatment of neck and low back pain. How
chiropractic manipulation provides relief is not fully understood, but it has
been shown to have a role in the treatment of acute low back pain.
Chiropractic manipulation and physical therapy have equivalent success in the
management of acute low back pain, and both are better than medical care
alone37. Skargren
et al. compared cost and effectiveness of chiropractic and physical therapy
and found chiropractic treatment to be more effective for acute low back pain
(less than one week in duration) and physical therapy to be more effective for
pain of longer
duration51. More
patients in the chiropractic group had recurrent symptoms and repeat
treatments for low back pain. There is no evidence to support the use of
long-term manipulation for the treatment of chronic back pain.
Lumbosacral Orthotic Devices
The purpose of a lumbosacral orthosis is to stabilize or immobilize.
Conditions such as vertebral body fracture and spondylolysis with
spondylolisthesis as well as the need for postoperative support are all
possible indications for prescribing an orthosis. There is no evidence in the
literature to support longterm use of orthotics for the treatment of low back
pain. Reasons for not prescribing orthoses may include concerns about a lack
of compliance on the part of the patient, creating psychological dependence,
and validating the disability. Although weakening of postural back and
abdominal muscles has also been a concern, it has been shown not to occur to
any substantial
extent52. The
ability of orthoses to limit motion is in doubt, with conflicting reports in
the literature. Axelsson et al. found no limitation of sagittal translation in
patients who wore a thoracolumbosacral
orthosis53.
Corset-type orthoses have been shown to decrease intersegmental motion at all
levels by 30%54.
While they are commonly prescribed, orthoses do not appear to change the
natural history of low back pain.
Selective Injections
Selective spinal injections produce focused and controlled anesthesia of
particular anatomic structures to help define loci of pain. In addition to
this diagnostic benefit, the addition of the potent anti-inflammatory effects
of glucocorticoids to the local anesthetic offers a therapeutic potential as
well. The epidural space is probably the most common location for selective
injections. With fluoroscopic guidance, an interlaminar, caudal, or
transforaminal approach can be used (Fig.
3)55.
Epidural steroid injections are most useful in the treatment of nerve root
irritation. Their benefit in the treatment of low back pain is in doubt,
although they are possibly useful for the treatment of low back pain secondary
to sacroiliac joint dysfunction. An injection into the sacroiliac joint may
provide both diagnostic information and some therapeutic
benefit56. The
joint is a difficult pain generator to implicate because it has diffuse
regional innervation. Schwarzer et al. reviewed the results of intraarticula
injections in patients who, when their history had been elicited, had
localized their pain specifically to the sacroiliac joint
region56. Only 30%
of the patients had substantial relief, indicating that the sacroiliac joint
was probably not the source of the pain in the majority of the patients.
Positive findings on physical examination, with pain in the medial aspect of
the buttock reproduced with the Patrick test, are suggestive. Treatment should
focus on physical therapy.
Facet or zygapophyseal joints can be generators of low back pain with
referred buttock and lower-limb pain. Use of a controlled injection technique
has shown that facet joints can produce low back
pain57. The
patient's history, physical examination, and imaging studies have each been
shown to be unreliable when used alone for the diagnosis of symptomatic facet
joints. Computed tomography scans of the lumbar spines of asymptomatic
individuals over the age of forty years frequently show degenerative changes
of the facet joints, so such studies alone are not
diagnostic58.
Extension-based back pain, as opposed to worse pain with flexion, along with
radiographic evidence of arthropathy suggests the presence of facet-mediated
pain. A bone scan may be used to help to confirm the presence of facet
arthritis. Correlating radiographic evidence of contrast medium-laden local
anesthetic injected into a facet joint with pain relief may be considered
diagnostic evidence of a pathologic facet joint.
An alternative to injecting the facet joint directly is addressing the
medial branch nerve, which carries afferent pain fibers from the facet joint.
The nerve branches from the dorsal ramus of the exiting nerve root, and it
innervates the immediately caudal two facets. For example, the L3 medial
branch nerve innervates the L3-L4 and L4-L5 facet joints. Relief of back pain
with selective blockade of this nerve can help to diagnose painful facet
joints, but it is rarely long-lasting. When a medial branch block is effective
but temporary, more permanent relief may be afforded by radiofrequency dorsal
rhizotomy. This technique denervates the facet joint by the localized
insertion of a probe that destroys the afferent fibers with a radiofrequency
current59. The
results of dorsal rhizotomy have been variable. Modest success has been shown
with single-level rhizotomy. Multilevel rhizotomy may have better
outcomes60. Studies
have yet to consistently show clinical efficacy, however.
Intradiscal Electrothermal Therapy
Intradiscal electrothermal therapy has become popular in recent years for
the treatment of low back pain thought to be of discogenic origin. Internal
disc derangement is used specifically for internal disc derangement, not
classic degenerative disc disease. Radiographic changes are not characteristic
of internal disc derangement, and radiculopathy is not typically associated
with it. It is diagnosed with discography and magnetic resonance imaging, the
latter of which often shows a high-intensity zone or internal tear in the
posterior portion of the anulus (Fig.
2). Pain is caused by chemical and mechanical mediation of
nociceptors. The procedure involves the posterolateral placement of a probe
around the inner circumference of the anulus followed by heating of the probe.
The exact mechanism by which intradiscal electrothermal therapy provides
relief is unknown. Alteration in collagen has been hypothesized, as has
neuronal deafferentation of the
anulus61,62.
However, studies of cadavera have suggested that there is no change in the
stability of the spine after intradiscal electrothermal
therapy63.
The indications for intradiscal electrothermal therapy are somewhat similar
to those for spine arthrodesis, although intradiscal electrothermal therapy is
performed for patients who, because of their age or other reasons, are not
ideal surgical candidates. The developers of the treatment suggested that the
indications should include persistent low back pain for more than six months
after failure of a program of back education, activity modification,
nonsteroidal anti-inflammatory medications, physical therapy, and progressive
intensive
exercises64.
Frequently, an epidural steroid injection has been tried and has failed. The
findings on physical examination should include normal results of a
neurological examination with a negative straight-leg-raise sign. The absence
of compressive lesions on magnetic resonance imaging and a positive concordant
discogram with negative findings at an asymptomatic control level
(Figs. 4-A and 4-B) are
essential for proper patient selection. Reports on the results of intradiscal
electrothermal therapy have been criticized because of the lack of a concrete
understanding of the mechanism of action of the therapy, the lack of peer
review, and the lack of long-term follow-up. Recent double-blinded randomized
sham-controlled trials have shown conflicting
outcomes6,65.
With further refinement of indications, outcomes may improve.
The treatment of low back pain is a challenge faced by most practitioners
in the medical community. Acute back pain is generally a self-limited process
that is likely to get better in the short term no matter what treatment is
undertaken. Supportive care is key to early pain relief, with therapeutic
stretching and strengthening exercises used to promote patient involvement in
the process and to allow resumption of normal activities. Chronic low back
pain is far more difficult to treat or even to define in terms of etiology.
Multiple diagnostic modalities and treatment options exist because of the very
nature of this problem.
A specific treatment program (Fig.
5) must be customized to the patient's specific findings, and all
patients must be active participants in their return to health and activity.
For the initial treatment of acute low back pain, we recommended use of a
nonsteroidal anti-inflammatory drug and a muscle relaxant combined with no
more than two days of bed rest. Use of the nonsteroidal anti-inflammatory drug
should be continued, and physical therapy should be started within a week if
possible. The therapy should include stretching, strengthening, and
trunk-stabilization exercises. Modalities to relieve symptoms should be used
only initially, if at all, to enable the patient to start the exercises.
Patient education is an integral part of this active treatment program. The
patient should be given the tools with which to continue long-term
self-treatment, with injury avoidance and a home therapeutic exercise program.
Empowering the patient with the responsibility for self-care is the most
effective means of treating low back pain.
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