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low back pain (LBP)

Etiology: 1) myofascial a) muscle strain b) insertion tendonitis 2) discogenic, radiculopathy, sciatica a) herniated nucleus pulposus b) degenerative disc 3) osteoarthritis: including facet joints 4) spondylolisthesis - spondylolysis: pain on extension of lumbar spine, young athletes 5) spinal stenosis (see lumbar spinal stenosis) a) congenital b) acquired 6) fracture a) vertebral compression fracture) - traumatic - pathologic b) osteoporotic sacral fracture [8] 7) sacroiliac joint pain 8) inflammatory or rheumatologic disease a) ankylosing spondylitis b) lumbar adhesive arachnoiditis 9) infiltrative disease a) infection b) malignancy (see bone neoplasm) c) Paget's disease 10) psyschosocial component ? [49] 11) risk factors for chronic low back pain - obesity, female, age > 65 years, low educational status, demanding physical occupations, depression, anxiety [88] Epidemiology: - low back pain afflicts 90% of people over their lifetime; - 80% of cases resolve within 30 days with conservative management [45] - a precise diagnosis is found in <10% of cases - no association with rain [79] - Covid-19 lockdowns increased the prevalence & intensity of chronic low back pain [102] Clinical manifestations: 1) discogenic back pain a) relieved by back rest, aggravated by activity b) episodic attacks, generally resolving in 4 weeks c) minimal morning stiffness d) back movement limited only with acute flares 2) symptoms of sciatica 3) back pain due to muscle spasm generally worsens with sitting [8] 4) pain from the spine is poorly localized 5) pain from abdominal, thoracic & pelvic viscera may refer dorsally 6) signs/symptoms of serious etiologies (see complications) a) bowel & bladder incontinence b) saddle anesthesia c) pain that is worse in the supine than upright position 7) runners with low back pain 2.5 time more likely to have knee pain [102] 8) point tenderness over the lumbar spine suggests vertebral fracture 9) STarT Back Screening Tool may help stratify risk [32] * see Complications: for *red flags* Laboratory: 1) testing generally reserved for patients whose symptoms do not improve or worsen after 6 weeks of conservative therapy [3] 2) electromyelography: tests peripheral nerve function 3) blood tests a) ESR or CRP b) serologic tests for rheumatologic diseases Radiology: 1) radiographs a) routine imaging is not cost-effective [3,30] b) can reveal - fractures - spondylolysis - lytic lesions - degenerative disc disease [10] - loss of disc space height (61%) - facet degeneration (34%) c) along with neurologic exam can rule out most serious causes of low back pain, but does not by itself rule out cancer or infection d) indicated in: - trauma - major risk factors for cancer - neurologic deficits - 4-6 weeks of conservative management without improvement - adolescents, adults > 50 years of age (probably not) e) not indicated - within 6 weeks on onset in absence of red flags [78] - not necessarily indicated for referral [65] - monitoring of patient' progress [78] 2) bone scan a) can reveal - inflammatory processes - infiltrative processes - occult fractures - active spondylosis b) highly sensitive for ruling out serious pathology 3) computed tomography (CT) a) for red flags & patients who may require surgery b) MRI unavailable (MRI is superior to CT) 4) magnetic resonance imaging (MRI) [10] a) for red flags & patients who may require surgery b) disc bulges (61%) c) disc herniation (33%) d) spinal stenosis (20%) e) suspicion of osteomyelitis or bony metastases* f) LS spine abnormalities on MRI are often meaningless [37] g) no benefit for patients without pathologic features or red flags suggesting a need for surgery [51] h) MRI signal changes in the vertebral bone marrow known as Modic changes may be noted in patients with chronic low back pain - Modic type 1: edema - Modic type 2: fatty - Modic tyoe 3: sclerotic [90] i) spinal cord compression: - administer dexamethasone 1st, then MRI of entire spine [3] 5) symptoms & functional disability correlated poorly with objective anatomical tests 6) routine imaging in the evaluation of low-back pain - does not change outcomes regardless of age [26,48] - increases risk of lumbar surgery 13-fold [92] - increases risk of opioid prescription (RR=1.2) - slightly worsens, rather than improves pain scores [92] - increases health care costs [92] * more comon than primary bone cancers Complications: - early guideline non-concordant care associated with risk of transition from acute to chronic low back pain [94] === red flags === 1) cauda equina syndrome a) urinary retention is most common presentaton b) bowel & bladder incontinence c) saddle anesthesia (diminished perineal sensation) d) bilateral lower extremity motor deficits 2) cancer: a) pain that is worse in the supine than upright position &/or no relief with bedrest b) history of cancer$ &/or unexplained weight loss c) pain lasting 1 month or not improving after 1 month of therapy d) age > 50 years 3) osteomylelitis a) fever b) preceding urinary tract infection c) skin infection d) injection drug use 4) vertebral fracture a) long-term corticosteroid use b) age > 50 years, osteoporosis c) presence of contusions or abrasions# (trauma) [41] 6) herniated disk: symptoms of sciatica 7) lumbar spinal stenosis: age > 50 years 8) ankylosing spondylitis or other rheumatologic disorder a) morning stiffness b) pain not relieved with supine c) pain persisting > 3 months d) involvement of other joints 9) other progressive motor weakness [3] * red flags need re-evaluation; predictive value low [41,82,111] # best predictive value for vertebral fracture (62%) [41] $ best predictive value for spinal malignancy (33%) [41] Management: 1) conservative initial approach [22] a) 90% of patients will be better in 4-6 weeks; most patients with be better in 3 months [3] b) nonpharmacologic therapies 1st line [68] - heat, massage, acupuncture, spinal manipulation [[68] c) heat, ice, ultrasound d) relative rest, early return to activity - bedrest not helpful [3] e) physical therapy - physical therapy for chronic low back pain (not acute pain) - combine with cognitive-behavorial therapy (CBT) best for benefit of physical function & alleviating fear of movement [100] - massage therapy may be helpful [3] (MKSAP17) - very little confidence that massage is an effective treatment [62]; update on Cochrane review cited by [3] - weekly massage for 10 weeks of marginal benefit [31] - early physical therapy of no benefit [52] - 30-60% of patients benefit with clinical improvement [66] - prolonged physical therapy not indicated unless in support of active treatment plan [78] f) exercise: benefit to risk ratio is favorable [3,98] - therapeutic aquatic exercise better than physical therapy [99] - long-term effect up to 12 months [99] - isometric & motor control trunk training most effective in patients < 40 years of age [102] - individualised, progressive walking & education intervention may reduce recurrence of low back pain [112] - a run-walk program may be suitable for adults with low back pain [114] g) yoga may be of benefit [17,80] - yoga equivalent to stretching [33] - yoga non-inferior to physical therapy [74] - yoga improves function but not pain [34] h) psychosocial interventions - resolution of pyschosocial stressors - cognitive-behavorial therapy (CBT) [27,59,80] - benefits persist after 2 years [69] - CBT combined with physical therapy best for benefit of physical function & alleviating fear of movement [100] - telephone-based interactive voice-response CBT noninferior to in-person CBT [72] - EaseVRx FDA-approved Nov 2021 - artificial intelligence driven cognitive behavioral therapy may be effective [108] - mindfulness meditation, mindfulness-based stress reduction - may be associated with sustained reductions in pain [59,80] - no sustained functional improvement [56] - functional improvement [59] - better than usual care, noninferior to CBT [59] - benefits not as persistent as CBT (< 2 years) [69] i) pharmaceutical agents 1] muscle relaxants & NSAIDs effective in reducing pain & disability for acute low back pain after about 1 week of use [104] 2] non-steroidal anti-inflammatory drugs (NSAIDs) a] 1st line for subacute or chronic low back pain not responsive to non-pharmacologic measures [68] b] only a small % of patients benefit [76] c] toradol 60 mg IM may be useful for acute, severe pain d] no benefit in ibuprofen + topical diclofenac vs ibuprofen alone [113] 3] muscle relaxants (cyclobenzaprine 10-20 mg TID) a] may have some benefit in 1/3 of patients [5] b) of modest short-term benefit at best [97] c) alternative to NSAID for subacute low back pain [68] d] of no benefit when added to NSAID [10,53] e] avoid long-term use [3] 4] acetaminophen - no better than placebo [3,47,50] - when combined with NSAIDs, better than NSAIDs alone [104] 5] antidepressants a] tricyclic antidepressants; 25 mg amitriptyline QD may be of some benefit [86] b] SSNRI: duloxetine (Cymbalta) [29], venlafaxine [103], tramadol - benefit unlikely to be clinically significant [93] - benefit for chronic back pain (moderate-certainty evidence) [103] c] antidepressants not effective [93] 6] opiates - opiates of no benefit when added to NSAID [53] - minimal benefit of opiates for chronic low back pain [19,63] - no better than placebo at 6 weeks [107] - long-term pain management contraindicated in absence of psychosocial assessment [78] - off-label epidural Depo-Medrol is increasing as doctors limit opioid prescribing [84] - tramadol no better than other opioids 7] cannabis reduces opioid use & improve both pain & function [102] - multiple routes of cannabis use more strongly associated with reduced opioid use [102] 8] diazepam of no benefit added to naproxen [70] 9] prednisone (oral glucocorticoid) of no benefit [64] 10] anticonvulsants of no benefit [83] - gabapentin marginally better than placebo [77,87] - prebabalin less effective than NSAID or antidepressant [77,87] - gabapentin & prebabalin associated with risk of drowsiness, dizziness, & nausea [83] - topiramate of no benefit but without adverse effects [83] 11) 3 months of amoxicillin of no benefit in patients with chronic low back pain & Modic changes (see Radiology .., MRI) 12] increased spending on pharmaceuticals has not resulted in corresonding improvement in functional status [25] 13] placebo of benefit even when people know its a placebo [67] 2) multidisciplinary rehabilitation better than usual care [6,49] a) physical therapy - heat, electrotherapeutic modalities, stretching, strengthening, manual therapy b) psychological assessment - addressing psychosocial factors of little benefit [14] (component of multidisciplinary rehabilitation) [49] c) social assessment d) vocational assessment e) multidisciplinary biopsychosocial rehabilitation program for patient who fail to show for physical therapy [49] f) person-specific motor skill training in functional activities limited because of chronic low back pain may improve function [96] 3) osteopathic or chiropractic manipulation (spondylolisthesis) - no evidence of clinically meaningful benefit or harm [43] - GSR8 interpretion: 'as effective as combination of analgesia, physical therapy & stretching' [8] - modest benefit for pain & function in adults with acute low back pain [71] - questionable benefit for low back pain [95] 4) other modalities [11] a) traction, transcutaneous electrical nerve stimulation (TENS), diathermy, acupuncture have no proven benefit b) acupuncture may be of benefit [18,73,80] - electroacupuncture of marginal benefit [91]; no benefit for pain c) facet joint &/or intradiscal corticosteroid injection not recommended [27] d) insufficient evidence to support use of injection therapy - specific subgroups of patients may respond to a specific type of injection therapy [46] e) an early feasibility study (20 patients, meeting abstract), hydrogel injected into spinal discs reduced chronic low back pain by 67% [102] f) one time subcutaneous injection of saline (lumbar) engages prefrontal- brainstem pathways linked to pain regulation & opioidergic function resulting in improvements in pain intensity, mood, & sleep at 1 month [116] 5) non-specific back pain persisting > 4 weeks a) see UK BEAM trial b) psychosocial evaluation for issues interfering with recovery 6) firmer mattress not necessarily better [12] 7) lumbar supports or braces not indicated for long-term treatment of low back pain [78] 8) surgery: a) indications: - persistent radiculopathy due to lumbar disk herniation - painful lumbar spinal stenosis - cauda equina syndrome [3] - neurologic deficits [3] - spinal cord compression [3] - 1st step is to administer dexamethasone, then MRI of entire spine [3] b) otherwise - spinal fusion surgery of uncertain value [9, 13] - outcomes at 1 year similar for surgery vs medical management [3] - complications more common with surgery vs medical management [110] 9) radiofrequency denervation - of no benefit in treatment of low back pain arising from facet joints, sacroiliac joints, &/or intervertebral disc disease [75] - lumbar facet blocks predict response to radiofrequency denervation [85] 10) implantation of a spinal cord stimulator for intractable back or leg pain [89] - FDA approves spinal cord stimulation devices for chronic low back pain in patients who have had surgery or are not eliible for surgery [106] 11) email discussion group participation improved symptoms [7] 12) some good results for individual herbal medicines in short-term individual trials, but no good pooled estimates of benefit [42] 13) prevention a) lumbosacral corset or lumbosacral orthosis may help prevent back injury [23] (not helpful for treatment) [3] - lumbar supports or braces not indicated for prevention of low back pain [78] b) exercise of benefit in preventing low back pain [55] c) general exercise better than back muscle exercises [15] d) motor control exercises which aim to strengthen deep trunk muscles through isolated contractions may be of benefit [54] e) weight loss f) modified workplace ergonomics g) lifelong fitness Notes: - adherence to guidelines for management of low back pain is suboptimal [39]

Related

causes of myofascial back pain indications for radiographs in patients with acute low back pain STarT Back Screening Tool United Kingdom back pain exercise and manipulation (UK BEAM) randomised trial

General

back pain nociplastic pain

References

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