Lower Back Pain: An Overview of the Most Common Causes

8. Grobler LJ, Robertson PA, Novotny JE, et al. Etiology of spondylolisthesis: assessment of the role played by lumbar facet joint morphology. Spine. 1993;18:80–91.

9. Merskey H, Bogduk N, editors. Classifi cation of chronic pain. Descriptions of chronic pain syndromes and defi nitions of pain terms. 2nd ed. Seattle: IASP Press; 1994.

10. Slipman CW, Derby R, Simeone FA, Mayer TG. Interventional spine an algorithmic approach.

Philadelphia: Saunders; 2008.

References and Suggested Further Reading

Chapter 3 Treatment of Acute Lower Back Pain

Acute lower back by defi nition is self-limited, lasting less than 4 weeks. While acute lower back pain may last up to 4 weeks, in fact it often only lasts less than 1 or 2 weeks. Because of its short duration and relative benign nature, acute lower back pain has received much less attention in the medical literature than chronic lower back pain. There are two very good reasons for this. First, it is very diffi cult to study something that is only going to last four weeks at most. To measure the effective-ness of any particular intervention would require massive amounts of patients in a study in order to detect whether that intervention was effective. Second, because of its limited duration, testing and treatments are of limited value. Diagnostic testing is rarely performed [ 1 ]. Treatments are used to take away symptoms and ideally speed recovery, but invasive treatments tend to be avoided because, again, the pain is going to go away anyway [ 2 ].

So understanding that the research is sparse in this arena, what is a physician to do when treating a patient who presents with acute lower back pain?

The fi rst thing to do with a patient with acute lower back pain is to make sure there are no red fl ag signs or symptoms. Red fl ag signs or symptoms may indicate a more serious underlying problem such as infection, fracture, spinal cord compres-sion, or underlying cancer. See Table 3.1 for red fl ag signs and symptoms. Assuming no red fl ags, how does one approach a patient with acute lower back pain?

Doctors are often asked in training and in board examinations: What is the fi rst diagnostic thing you do when a patient comes in presenting with lower back pain?

The answer is uniformly to take a comprehensive history and perform a thorough physical examination. After that, in a patient with simple acute lower back pain, no neurologic signs or symptoms and no red fl ag signs or symptoms, there is no need for diagnostic imaging studies.

When considering treatment for acute lower back pain, the fi rst thing to gauge is the severity. If the severity is mild to moderate, then recommendations generally include:

Advice to stay active and continue to move but not to do activities that directly increases pain.

Ice the lower back in the fi rst 48 h after an injury (20 min on, 20 min off) for a few times per day. Heat or ice, or a combination of both for symptom relief after that, with an emphasis on explaining to the patient that it really doesn’t “matter”

which they use—heat or ice—as neither will affect the long-term duration of the pain and problem and so the patient should use whichever she feels helps her symptoms most.

Over-the-counter pain medications within recommended dosages and assuming no contraindications.

Discussion of the biomechanics of activities of daily living, including education of limiting sitting and proper lifting techniques.

A prescribed topical NSAID (such as Flector patch , Voltaren Gel , of Pennsaid ) may be appropriate if the pain is felt to be due to a muscle strain, ligament sprain, or tendonitis.

The above recommendations are appropriate for most patients with acute lower back pain and may suffi ce for many patients. If the lower back pain is gauged to be moderate to severe, other interventions may be appropriate. Some prescription non-steroidal anti-infl ammatory drugs (NSAIDs) are (ironically) often safer on the gas-trointestinal system than over-the-counter NSAIDs and could be considered. Muscle relaxers could be considered, especially to help the patient sleep at night [ 3 ]. If the intensity of the pain is severe, then a short course of tramadol or an opiate may be indicated. The decision to use a short course of muscle relaxers, tramadol , or an opi-ate should be balanced with the potential side effects. Because they all can produce drowsiness, nighttime usage is generally better tolerated. It is always important to

Table 3.1 Red fl ag signs and symptoms Fever

Chills

Recent unintended weight loss of ten or more pounds Radiating leg pain

Leg numbness, tingling, or burning Weakness in the legs

Diffi culty with balance

Loss of control or bowel or bladder

History of recent and signifi cant trauma or repetitive trauma that precipitated the pain Immunodefi ciency disease

Immunosuppression such as with a history of prolonged corticosteroid usage Minor trauma precipitating pain in the setting of a patient with osteoporosis

Lower back pain and stiffness in a young male (20s–30s) who takes >30 min in the morning to be limber enough to get around and then pain that is much more mild during the day

NB : Chapter 14 will discuss the importance and meanings of the red fl ag signs and symptoms 3 Treatment of Acute Lower Back Pain

remember that as these medications can cause dizziness, they may be less appropri-ate in a geriatric population who may already have balance problems and bone den-sity loss. Recall too that in addition to acting on the opiate receptors, tramadol also has properties of serotonin and norepinephrine reuptake inhibition and may have an additive effect with other serotonin reuptake inhibitors such as antidepressants and therefore should be used with extreme caution or avoided altogether in these patients to avoid the potential for serotonin syndrome.

Physical therapy is often prescribed for acute lower back pain [ 4 ]. In physical therapy, passive modalities such as ultrasound, electrical stimulation, and soft tissue mobilization can be used. In addition, patients can be taught better biomechanics, and exercises can be performed to strengthen and stretch the appropriate muscles.

Physical therapy has an additional role in acute lower back pain in that it can help teach patients better ergonomics, biomechanics, and a home exercise routine . While acute lower back pain is self-limited, it also predisposes patients to further bouts of acute lower back pain that may ultimately lead to chronic lower back pain. Ideally, patients will look at acute lower back pain as warning signs to take better care of their backs. It may be useful to remind patients that the chance of acute lower back pain returning is signifi cant. The best way to prevent it is to learn better lifting bio-mechanics, overall ergonomics, and to learn and perform a short targeted set of exercises to help stretch and strengthen the appropriate muscles to prevent future pain cycles.

Many patients with acute lower back pain may also fi nd relief from massage therapy, chiropractic care, or acupuncture.

If the pain is severe and a trigger point is found on physical examination, then another option to consider is a trigger point injection [ 5 ]. A trigger point is defi ned as a taut muscle band that, when palpated, produces pain and also a referral pain pattern as well as restricted range of motion. When a trigger point is palpated, mas-saging or injecting that trigger point can be very helpful in breaking the pain cycle and releasing the muscle spasm.

A trigger point injection procedure may be done by anatomic palpation or by using an ultrasound for guidance in making sure the needle is placed in the muscle belly. The most important part of a trigger point injection is the mechanical break-ing up of the trigger point with the needle. However, the injection can be done usbreak-ing a dry needling technique (in which nothing is injected), using saline to be injected, lidocaine, or a combination of saline, lidocaine, and/or steroid. The advantage of the lidocaine is that the injection procedure is generally less painful. The advantage of the steroid in the injectate is that the steroid acts as an anti-infl ammatory and may help with reducing the infl ammation from the trigger point and also, perhaps, from reducing the infl ammation caused by the injection procedure itself. In this author’s experience, trigger point injections can be helpful, and lidocaine is generally good to inject as it makes the procedure less uncomfortable. Depending on the circum-stance, steroid may be helpful. However, it is important to understand that there is no proven benefi t of steroids, lidocaine, saline, or any other substance injected in trigger points. Indeed, whether or not trigger point injections provide any lasting relief is controversial and based more on clinical experience then compelling

In document Non-Operative Treatment of the Lumbar Spine. Grant Cooper (Page 25-29)