Low back pain

See also back pain

Low back pain is a common musculoskeletal disorder which affects the lumbar segment of the spine. It can be either acute, subacute or chronic in its clinical presentation. Typically, the symptoms of low back pain do show significant improvement within two to three months from its onset. In a significant number of individuals, low back pain tends to be recurrent in nature with a waxing and waning quality to it. In a small proportion of sufferers this condition can become chronic. Population studies show that back pain affects most adults at some stage in their life and accounts for more sick leave and disability than any other single medical condition.

An acute lower back injury may be caused by a traumatic event, like a car accident or a fall. It occurs suddenly and its victims will usually be able to pinpoint exactly when it happened. In acute cases, the structures damaged will more than likely be soft tissue like muscles, ligaments and tendons. With a serious accident or due to osteoporosis or other causes of weakened vertebral bones, vertebral fractures in the lumbar spine may also occur. 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 at the bottom of the lumbar spine, called sacroiliac joint dysfunction (see sacroiliac joint for more information) .

Chronic lower back pain usually has a more insidious onset, occurring over a long period of time. 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, a tumor (including cancer) or infection. The cause may also be psychological or emotional or due to other non-anatomical factors.^[1]

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Causes

Possible causes of low back pain:

• Mechanical:
  • Apophyseal osteoarthritis
  • Diffuse Idiopathic Skeletal Hyperostosis
  • Degenerative Discs
  • Scheuermann's kyphosis
  • Spinal disc herniation (slipped disc)
  • Spinal stenosis
  • Spondylolisthesis and other congenital abnormalities
  • Fractures
  • Non-specific muscular or ligamentous strains or sprains
  • Leg Length Difference
  • Restricted hip motion
  • Misaligned pelvis - pelvic obliquity, anteversion or retroversion

• Inflammatory:
  • Seronegative spondylarthritides (e.g. ankylosing spondylitis)
  • Rheumatoid arthritis
  • Infection - epidural abscess or osteomyelitis

• Neoplastic:
  • Bone tumors (primary or metastatic)
  • Intradural Spinal tumors

• Metabolic:
  • Osteoporotic fractures
  • Osteomalacia
  • Ochronosis
  • Chondrocalcinosis

• Psychosomatic
  • Tension myositis syndrome

• Paget's disease

• Referred pain:
  • Pelvic/abdominal disease
  • Prostate Cancer
  • Posture

• Depression
• oxygen deprivation

Diagnosis

Diagnosing the underlying cause of low back pain is usually done by a medical doctor, osteopathic physician, physiotherapist (physical therapist) or by a chiropractor. Often, getting a diagnosis of the underlying cause of low back pain and/or related symptoms is quite complex. A complete diagnosis is usually made through a combination of a patient's medical history, physical examination, and, when necessary, diagnostic testing, such as an MRI scan or x-ray. There are a number of health care professionals who may specialize in diagnosing and treating low back pain, including chiropractors, osteopathic physicians, physical therapists (physiotherapists), physiatrists, anesthesiologists/pain medicine physicians, and orthopedic surgeons or neurosurgeons.

Research shows that the presence of a leg length difference does not mean you will have back pain. Diagnosis of leg length difference is quite easy; just stand in front of a mirror in your underwear on a flat, level floor (a bathroom is usually good). Look at your hips to see if they are level. If one seems higher, put a magazine under the shorter leg. Keep adding magazines until your hips look level. Measure the height of the magazines. This is the difference in the length of your two legs. 90% of the population has a leg length difference; the same percentage that experiences lower back pain during their lifetime. A difference of only 1% would be ⅓ inch or more.

Diagnosis of restricted internal hip rotation is also easy. Lie on your stomach with your legs together. Bend your knees 90 degrees so that the soles of your feet point up toward the ceiling. Keeping your knees together, move your feet apart. Your lower legs will form a V. Have someone measure the angle of each lower leg in relation to a vertical line. The angle should be the same for both legs. Each leg should be a minimum of 45 degrees; 60 degrees if you play golf or tennis. Vad, et al, found restricted internal hip rotation on the lead hip associated with lower back pain in professional golfers.

Treatments

The course of treatment for low back pain will usually be dictated by the clinical diagnosis of the underlying cause of the pain.

Conservative treatment

For the vast majority of patients, low back pain can be treated with non-surgical care. For those with acute, short-term back pain, certain home remedies^[2] may be effective.^{[citation needed]} ClinicalEvidence.com has systematically reviewed randomized controlled trials published through April, 2004 and concluded:

Treatments likely to be beneficial

• Advice to stay active.^[3]
• Analgesics (pain medications), such as NSAIDs or acetaminophen.^[3][4]
• Spinal manipulation for acute^[3] or chronic^[4] pain. A clinical prediction rule can guide who is most likely to respond to manipulation.^[5]
• Muscle relaxants for acute^[3] or chronic^[4] pain.
• Antidepressants for chronic low back pain.^[4]
• Exercise for chronic pain.^[4]
• Intensive multidisciplinary treatment programs may help subacute^[3] or chronic^[4] low back pain.
• Behavioral therapy^[4]
• Acupuncture may help chronic pain^[4]; however, a more recent randomized controlled trial suggested significant difference between real and sham acupuncture.^[6]

Other treatments

Additional treatments have been more recently reviewed by the Cochrane Collaboration:

• Massage therapy may benefit some patients.^[7]

• Ice and/or heat application (or moist heat) has uncertain benefit.^[8]

Individual randomized controlled trials, thus interpretation may be subject to publication bias, also confounded by absence of double blinding have shown benefit for:

• Viniyoga,^[9] Iyengar,^[10] and Hatha yoga (small trial).^[11]

• Correcting leg length difference may help.^[12] To correct leg length difference, insert a hard rubber or cork heel pad into the shoe of the short leg if the difference between the two legs is 3/8ths inch or less. If more, have a shoe repairman build up the sole and heel. Taper the toe to avoid tripping. If more than 3/4 inch, start with 1/2 of what you need so that your body can adjust.

• Muscle Energy Technique (MET) may help (small study).^[13]

Other treatments that were not reviewed are

• Education and attitude adjustment (TMS)
• Increasing internal hip rotation
• Increase internal hip rotation with stretching or connective tissue massage
• Medical cannabis

Because of variations in clinical study methodology, a review of clinical studies in any one area is not necessarily conclusive.

For any one condition, it may be necessary to try a variety of treatments in order to find the best one (or combination) to best manage the pain. In almost all cases, physical therapy and/or a regular exercise program that includes stretching, strengthening and low impact cardio conditioning will be part of the treatment and rehabilitation program.

The role of narcotics for chronic low back pain is uncertain.^[14]

Surgery

Lumbar surgery is 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 lumbar disc herniation, spinal abscess or cauda equina syndrome. Other possible indications for surgery include:

• Severe Degenerative disc disease
• Spinal stenosis
• Spondylolisthesis
• Scoliosis
• Compression fracture
• Spinal instability
• Spinal trauma
• Spinal malignancy(cancer)
• Spinal hematoma

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 psine.

References

See also

• Back pain
• Upper back pain
• Chronic pain
• Lumbar disc herniation
• Degenerative disc disease
• Coccydynia (coccyx pain, tailbone pain)
• Sciatica
• Tension myositis syndrome
• Failed back syndrome
• Bertolotti's syndrome