Low Back Pain Disease

BASICS

DESCRIPTION

Mechanical low back pain is a diagnosis of exclusion. It is generally a self-limiting condition of the aging spine, responsive to conservative measures including rest and pain management. Patients typically present with pain at the posterior belt line with occasional referred pain to the buttocks and/or posterior thighs. These injuries often are the result of the mechanical stresses and functional demands placed on the low back area by everyday activities. The condition, for the vast majority of patients, is of short duration and complete recovery is the general rule. The primary goal of the clinician is to rule-out other more serious etiologies. It must be remembered that low back pain is a symptom, not a disease, and that the pathological basis of the pain frequently lies outside the spine.

System(s) affected: Musculoskeletal, Nervous
Genetics: N/A
Incidence/Prevalence in USA:
- 80% of Americans experience mechanical low back pain sometime in their lifetime
- One of the most common complaints for primary care visits
- Repetitive episodes are common
Predominant age: 25-45 years
Predominant sex: Male = Female

SIGNS AND SYMPTOMS

History
- Onset of low back pain begins either suddenly after an injury or gradually over the next 24 hours
- Variable pain at posterior belt-line, typically bilateral
- Occasional radiation of pain to buttocks, and/or posterior thighs stopping at knees
- Pain pattern referred rather than radicular
- Back pain worse than leg pain
- Pain aggravated by back motion, sitting, standing, lifting, bending and twisting
- Pain relieved by rest (recumbency)
- Bowel and bladder function preserved
Physical findings
- Normal motor, sensory, and reflex examinations
- Decreased lumbar range of motion, tenderness to palpation, paraspinous musculature spasm common
- Nerve root stretch tests are commonly negative
- Straight leg raise and other tests causing spinal motion may increase low back pain, but not leg pain

CAUSES

Normal aging process of musculoskeletal system aggravates an acute event

RISK FACTORS

Age
Activity
Smoking
Obesity
Vibration, e.g., driving motor vehicles
Sedentary lifestyle
Psychosocial factors

DIAGNOSIS

LABORATORY

Generally negative and not typically indicated with initial presentation
Indications
- Age > 50 years
- Nonmechanical nature of pain
- Atypical pain pattern or distribution
- Persistent symptomatology remittent to conservative treatment measures
Screening laboratory studies
- CBC with differential
- Sedimentation rate
- Alkaline and acid phosphatase
- Serum calcium
- Serum protein electrophoresis

Drugs that may alter lab results: N/A
Disorders that may alter lab results: N/A

PATHOLOGICAL FINDINGS

N/A

SPECIAL TESTS

System directed investigation

IMAGING

Plain radiographs
- Not indicated to initiate conservative management program
- Indicated for persistent symptoms > 1 week, patient age > 50 years, or suggestive history
- Radiographs utilized to rule-out tumor or identify other disease process
- Anteroposterior, lateral, spot lateral of L5-S1 and oblique x-rays are included in routine lumbo-sacral series
Bone scan (scintigraphy)
- Technetium-99m labeled phosphorus indicates active mineralization of bone
- Rule-out tumor, trauma or infection

DIAGNOSTIC PROCEDURES

MRI, CT/myelography only indicated with persistent symptoms, sciatica or the development of neurologic abnormalities

TREATMENT

APPROPRIATE HEALTH CARE

Outpatient for majority

GENERAL MEASURES

Initial short-term bedrest 2-3 days
Short-term analgesics
NSAIDs 10 day course initially, then prn
Muscle relaxants 10 day course
Physical therapy
Manipulation

SURGICAL MEASURES

N/A

ACTIVITY

Restricted activities for 3-6 weeks
Resume activities of daily living as tolerated

DIET

Weight reduction - if appropriate

PATIENT EDUCATION

Home based exercise program
Posture and body mechanics training
"Back school" for chronic mechanical low back pain

FOLLOW UP

PREVENTION/AVOIDANCE

Smoking cessation
Weight reduction
General physical condition
Avoid aggravating tasks, e.g., heavy lifting, bending, twisting, sudden unexpected movements or combination of above

POSSIBLE COMPLICATIONS

Incorrect diagnosis
Chronic low back pain
Narcotic addiction
Persistent psychosocial impairment

EXPECTED COURSE AND PROGNOSIS

Resumption of normal activity without residual symptoms in most cases
May be hindered by secondary gain issues

MISCELLANEOUS

ASSOCIATED CONDITIONS

Deconditioning
Obesity
Psychosocial disease

AGE-RELATED FACTORS

Pediatric: Thorough work-up imperative
Geriatric: Tumors, degenerative conditions, fractures and stenosis more common
Others: N/A

PREGNANCY

Commonly associated with low back pain and/or sciatica. Treatment is conservative.

OTHER NOTES

Adverse psychosocial factors to resolving back pain:
- Pending litigation or compensation
- Depressed or hostile patient
- Prolonged use of narcotics or alcohol

ABBREVIATIONS

N/A

Clinical Investigations

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