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Low back pain ( or lumbago) is a common musculoskeletal disorders affecting 80% of people at some point in their life. It accounts for more sick leave and disability than any other medical condition.^[1] It can be either acute, subacute or chronic in duration. Most often, the symptoms of low back pain show significant improvement within a few weeks from onset with conservative measures.

The causes of lower back pain are varied. A traumatic event may result in either muscular pain or a vertebral fractures. 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, where the spinal column attaches to the pelvis, called sacroiliac joint dysfunction. 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, an infection or tumor.

[edit] Classification

One method of classifying lower back pain is by the duration of symptoms: acute (less than 4 weeks), sub acute (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

Acute back pain is defined as pain less than 6 weeks while chronic back pain is defined as pain that has been present for over three months. The intermediate time period is known as sub acute back pain.^[2] Determination of the underlying cause is usually made through a combination of a medical history, physical examination, and, when necessary, diagnostic testing, such as an x-ray, CT scan, or MRI.

[edit] Imaging

X-rays and CT scans are not required in lower back pain except in the cases where "red flags" are present.^[3] If the pain is of a long duration X-rays may increase patient satisfaction.^[4]

[edit] Red flags

[edit] Management

[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^[6]:

[edit] Acute back pain

Medications

Pain medications, such as NSAIDs or acetaminophen can help with the symptoms of lower back pain.^[7][8] Muscle relaxants for acute^[7] and chronic^[8] pain have some benefit, however, there are concerns with side effects, and their routine use is discouraged.^[9]

Activity

Staying physically active as opposed to bed rest leads to faster recovery.^[7][10] Structured exercise in acute low back pain however lead to neither improvement or harm.^[11]

Spinal manipulation

Most reviews and guidelines have found that spinal manipulation (SM) therapy for low back pain of unknown cause is of no benefit beyond standard conservative management.^[12][13] A 2007 U.S. guideline weakly recommended SM as one alternative therapy for spinal low back pain in nonpregnant adults when ordinary treatments fail,^[14] well the Swedish guideline for low back pain in 2002 does not recommend considering SM therapy for acute low back pain in patients needing additional help, possibly because the guideline's recommendations were based on a higher evidence level.^[12] A 2008 review found that SM is similar to other forms of conventional care.^[15] A 2007 literature synthesis found good evidence supporting SM and mobilization for low back pain and exercise for chronic low back pain.^[16] Of four systematic reviews published between 2000 and May 2005, only one recommended SM, and a 2004 Cochrane review^[17] stated that SM or mobilization is no more or less effective than other standard interventions for back pain.^[18] A 2008 systematic review found insufficient evidence to make any recommendations concerning medicine-assisted manipulation for chronic low back pain.^[19]

[edit] Chronic back pain

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.^[11] 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.^[20]

• Tricyclic antidepressants are recommended in a 2007 guideline by the American College of Physicians and the American Pain Society.^[21]
• Acupuncture may help chronic pain^[8]; however, a more recent randomized controlled trial suggested insignificant difference between real and sham acupuncture.^[22]
• Intensive multidisciplinary treatment programs may help subacute^[7] or chronic^[8] low back pain.
• Behavioral therapy^[8]
• The Alexander Technique was shown in a UK clinical trial to have long term benefits for patients with chronic back pain.^[23]
• Back schools have shown some effect in managing chronic back pain.^[24]
• Prolotherapy, facet joint injections, and intradiscal steroid injections have not been found to be effective.^[25]

[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.^[26]

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.

A medical review in March 2009 found the following. Four randomised clinic trials showed the benefits of spinal surgery are limited when treating degenerative discs with spinal pain (no sciatica). Between 1990-2001 there was a 220% increase in spinal surgery despite there being no changes, clarifications or improvements in the indications for surgery or improved effectiveness of spinal surgery. The review also found that higher spinal surgery rates are sometimes associated with worse outcomes and the best surgical outcomes occurred where surgery rates where lower. It also found that use of surgical implants increased the risk of nerve injury, blood loss, overall complications, operating times and repeat surgery while only slightly improved solid bone fusion rates. There was no added improvement in pain levels or function.^[27]

[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.^[28]

• Heat application may have a modest benefit. The evidence for cold therapy is limited.^[29]

• Yoga has been found beneficial.^[30][31]

• Correcting leg length difference may help by inserting a heel lift or building up the shoe.^[32]

• The role of narcotics for chronic low back pain is uncertain.^[33]

• A 2008 review found antidepressants ineffective in the treatment of chronic back pain^[34] even though some previous studies did find them helpful.^[8]

[edit] Prognosis

Most patients with acute lower back pain recover completely over a few weeks regardless of treatments.^[35][36]

[edit] Epidemiology

Over a life time 80% of people have lower back pain,^[36] with 26% of United States adults reporting pain of at least one day in duration every three months.^[37]

[edit] See also

[edit] References

[edit] External links

• Back and spine at the Open Directory Project