Back to basics

Healthcare Middle East reviews the common and vexing issue of nonspecific low back pain.

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By  Healthcare Middle East Published  December 6, 2006

|~|back2.jpg|~|“Early use of MRI or radiography during an episode of low back pain does not improve clinical outcomes or reduce costs of care.”|~|In recent decades, back pain has taken on the hallmarks of an epidemic. Low back pain is generally defined as pain, muscle tension, or stiffness localised below the costal margin and above the inferior gluteal folds, with or without leg pain (sciatica). An estimated two thirds of adults will endure a bout of moderate to severe lower back pain at some time, making it the fifth most common reason for physician visits. The symptoms also extend far beyond pain and inconvenience. In American alone, low back pain is responsible for US $50 billion annually in medical costs and lost productivity. Low back pain is a regular feature in primary healthcare settings, yet the diagnostic and therapeutic management of patients varies considerably. This suggests there is some uncertainty amongst healthcare professionals about the optimal approach. Certainly within primary care, the specific pathoanatomical cause of back pain can be impossible to define with only a small percentage of patients presenting with an identifiable underlying cause. As a result, non-specific terms such as strain, sprain or degenerative processes, are often used and essentially refer to idiopathic lower back pain. The natural history of non-specific low back pain is favourable, and recovery is generally rapid. Most patients can be managed conservatively, with pain usually resolving within several weeks. Even among patients with back pain lasting more than three months, serious or persistent disability is uncommon. Recurrences however are frequent, affecting an estimated 40% of patients within six months, but most are not disabling and exhibit only low-grade symptoms. ||**||Diagnostic evaluation|~|back2.jpg|~||~|A comprehensive history and physical examination is helpful mainly in identifying the small percentage of patients with serious underlying diseases, such as fracture, tumour, infection or deformity, that require specific management (see At a glance: red flags). A commonly recommended approach is the so called “diagnostic triage”, where physicians address three questions, namely: - Is a systemic disease causing the pain? - Is there any social or psychological distress that may amplify or prolong the pain? - Is there neurological compromise that may require surgical evaluation? These questions can often be answered from history-taking and physical examination, but if symptoms are unusual or if pain is not improved within four to six weeks, a laboratory work-up may be useful to help rule out systemic disease. This may include a complete blood count, determination of erythrocyte sedimentation rate, urinalysis and other specific tests, as indicated by the clinical evaluation. More elaborate tests are rarely helpful for acute low back pain. As a guide, age-related degenerative processes in the intervertebral discs and facet joints account for almost 10% of lower back pain. Osteoporotic compression fractures account for a further estimated 4% of cases and, predictably, as osteoporosis is the culprit, are more common in women than men. In approximately 4% of cases, pain can be attributed to a disc herniation and in perhaps 3% to spinal stenosis. Neurologic involvement is usually suggested by the presence of sciatica or pseudoclaudication (leg pain after walking that mimics ischemic claudication), which is often associated with numbness or parasthesia. The presence of bowel or bladder dysfunction may be a symptom of cauda equina syndrome (severe compression of the cauda equina), which requires urgent treatment. The extrinsic pressure of a massive midline disc herniation or tumour usually causes this rare condition. In the great majority of patients with low back pain, imaging studies are not useful. Research has shown that early use of MRI or radiography during an episode of low back pain does not improve clinical outcomes or reduce costs of care, and consequently should be limited to patients with clinical findings suggestive of systemic disease or trauma. As before, failure of pain to improve after four to six weeks should prompt further investigation. Computed tomography (CT) and magnetic resonance imaging (MRI) are more sensitive than plain radiography for the detection of early spinal infections and cancers, and are also able to reveal herniated discs and spinal stenosis. CT is less valuable than MRI in the case of back pain, and in general should only be used when detailed imaging is necessary but MRIs cannot be performed. MRIs can be critically important for patients with warning signs or with pain that is prolonged or unusually severe. It is best used to rule out neurologic injury, infection or tumours. Suitable candidates for MRI include patients with low back pain who have associated neurologic or systemic symptoms or signs, risk cancers for infection, cancer or fracture or persistent pain after six weeks. It should be noted that disk abnormalities are common among asymptomatic adults and, even in those with low back pain, may be unrelated to pain. In three studies, subjects who were entirely free of back pain received MRIs of the spine. Of the study group, 46%–93% had degenerative discs, 24%–79% had bulging discs, and 22%–40% had herniated discs. Had these patients presented with low back pain, such incidental findings may have led to overdiagnosis, anxiety on the part of the patient, a conviction about the presence of serious disease and unnecessary, possibly invasive, tests and treatments. Should your patient have back pain, and their MRI show arthritis or disc disease, there is no assurance that the anatomic abnormality is actually responsible for the pain. When evaluating the older adult (those over 65 years of age), the incident of cancer, compression fractures, spinal stenosis become more common. Osteoporotic fractures may occur even in the absence of definable trauma. Consequently, the earlier use of imaging studies may be useful. ||**||Treatment|~|back2.jpg|~|“Pharmacological treatment of low back pain usually includes analgesics, anti-inflammatory drugs and muscle relaxants, but there is limited evidence for their efficacy.”|~|Psychosocial factors can form a sizeable hurdle to recovery, strongly predicting future disability and reliance on healthcare services for low back pain. Data has shown that workers with lower job satisfaction are more likely to report back pain and to have an extended recovery. Equally, patients who are involved in litigation, disputed compensation claim, who have an affective disorder such as depression, or a history of substance abuse are more likely to have difficulties with pain resolution. These psychosocial factors should be routinely investigated in patients with low back pain and, as risk factors for chronicity, should influence any decisions regarding treatment. In the absence of specific pathoanatomical findings, recovery from nonspecific back pain is usually swift. In one study, 90% of patients seen within three days of onset recovered within three weeks, without intervention. However, in cross-sectional studies, results were less favourable. About 30% of patients substantially improved in a week, but another 60% took up to eight weeks to recover, and recurrences affected another 40% within six months of the first episode. The outlook for patients with herniated discs is favourable. Recovery is slower than in patients with back pain alone, but only about 10% of patients have enough pain after six weeks to warrant consideration of surgery. Subsequent MRI studies also show that in two-thirds of cases, the disc tends to regress with time, with partial or complete resolution within six months. In contrast, spinal stenosis is likely to cause persistent discomfort or to gradually worsen. As estimated 15% of patients improve over a four-year period, while 70% remain stable and 15% have deterioration. Overall, the outlook is good for patients who have low back pain but this news may seem like small comfort while they are enduring days or weeks of pain. Fortunately, a large variety of therapeutic interventions are available to reduce discomfort. Pharmacological treatment of low back pain usually includes analgesics, anti-inflammatory drugs and muscle relaxants, but there is limited evidence for their efficacy and international guidelines do not recommend any one pharmacological method over another. Research has shown nonsteroidal anti-inflammatory drugs (NSAIDS) and some muscle relaxants to be moderately effective for pain relief, but the absence of large, randomised trials mean recommendations are limited. Antidepressant drugs, namely tricyclic and tetracyclic drugs, have demonstrated small but consistent benefits in pain reduction for patients with chronic low back pain, without clinical depression. In one trial, antidepressants demonstrated a 20-40% greater pain reduction than placebo, but failed to show consistent or substantial functional improvement. Side effects were also reported by more than 20% of subjects. International guidelines for the treatment of low back pain consistently encourage patients to become active early and gradually. According to a Cochrane review of randomised trials, exercise therapy appears to be slightly effective at decreasing pain and improving function in adults with chronic low-back pain. In subacute low-back pain there is some evidence that a graded activity program decreases the amount of sick leave taken, though evidence for other types of exercise is unclear. In acute low-back pain, exercise therapy is as effective as either no treatment or other conservative treatments. Popular alternative therapies for low back pain include massage, spinal manipulation and acupuncture. Research suggests that both massage and spinal manipulation may be moderately more effective at reducing pain than a single treatment, and a Cochrane review concluded that acupuncture is more effective for pain relief and functional improvement than no treatment or sham treatment. This has been supported by a study published last September in the British Medical Journal that concluded acupuncture offered a “clinically relevant benefit” to sufferers of back pain. Patient education also plays a role in the road to recovery. Successful treatment involves the active participation of the patient in spine care, requiring the patient’s understanding of the disorder and their role in avoiding injury. Many hospitals offer rehabilitation programmes accompanied by a strong educational component on preventive care.||**||Conclusion|~|back2.jpg|~||~|Low back pain is a common although sometimes challenging problem. In the absence of any serious disease, patients should be reassured that the natural history of low back pain is favourable and encouraged to (within the context of diagnosis) resume daily activities as soon as possible. Due to the poor association between symptoms and findings, the role of imaging should be limited to patients with suspicious clinical findings or persistent pain. ||**||

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