Low Back Pain And Sciatica: Management Of Non-s...
The pain may be constant or may come and go. Also, the pain is usually more severe in your leg compared to your lower back. The pain may feel worse if you sit or stand for long periods of time, when you stand up and when your twist your upper body. A forced and sudden body movement, like a cough or sneeze, can also make the pain worse.
Low back pain and sciatica: management of non-s...
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Within the framework of evidence-based medicine high-quality randomised trials and systematic reviews are considered a necessary prerequisite for progress in orthopaedics. This paper summarises the currently available evidence on surgical and other invasive procedures for low back pain. Results of systematic reviews conducted within the framework of the Cochrane Back Review Group were used. Data were gathered from the latest Cochrane Database of Systematic Reviews 2005, Issue 2. The Cochrane reviews were updated using the evidence summary on surgery and other invasive procedures from the COST B13 European Guidelines for the Management of Acute and Chronic Non-Specific Low Back Pain. Facet joint, epidural, trigger point and sclerosant injections have not clearly been shown to be effective and can consequently not be recommended. There is no scientific evidence on the effectiveness of spinal stenosis surgery. Surgical discectomy may be considered for selected patients with sciatica due to lumbar disc prolapses that fail to resolve with the conservative management. Cognitive intervention Combined with exercises is recommended for chronic low back pain, and fusion surgery may be considered only in carefully selected patients after active rehabilitation programmes during 2 years time have failed. Demanding surgical fusion techniques are not better than the traditional posterolateral fusion without internal fixation.
Low back pain causes more disability, worldwide, than any other condition. Episodes of back pain are usually transient with rapid improvements in pain and disability seen within a few weeks to a few months. Whilst the majority of back pain episodes resolve improve with initial primary care management, without the need for investigations or referral to specialist services, up to one third of patients report persistent back pain of at least moderate intensity one year after an acute episode requiring care and episodes of back pain often recur.
One of the greatest challenges remains the identification of risk factors that may predict the progression from a single back pain episode to a long term, persistent pain condition where quality of life is often very low and healthcare resource use high.
A complex and variable interplay between biological, psychological and social factors undoubtedly influences this progression and it is the modification of these factors that has become one of the mainstays of back pain research and treatment over the last decade or so.
As a general rule of thumb, if the back pain is bad enough that it wakes one up from deep sleep, one should consult a physician to rule out possible serious conditions, such as an infection, tumor or fracture.
The natural history of axial low back pain is that with time the symptoms get better, and about 90% of patients with axial low back pain recover within six weeks. If axial low back pain persists for more than six to eight weeks, then additional testing and/or injections may be useful in diagnosing and treating the source of the low back pain.
For patients with severe, chronic low back pain that impedes their ability to function in everyday activities, degenerative disc disease or other problems may be identified as the source of the pain and fusion, disc replacement surgery, or other surgical options may be considered.
It should be emphasized that laminectomy and discectomy surgery is rarely recommended for axial low back pain and is unpredictable as to its successful outcome. These types of back surgery are reserved for pain secondary to compression of the spinal nerve roots or sac.
The surgical and non-surgical treatment of chronic axial back pain (e.g. lasts more than six weeks), is somewhat controversial and beyond the scope of this article. More can be read about ongoing axial back pain in the degenerative disc disease and chronic pain sections of this site.
In most episodes of low back pain, a specific underlying cause is not identified or even looked for, with the pain believed to be due to mechanical problems such as muscle or joint strain.[1][4] If the pain does not go away with conservative treatment or if it is accompanied by "red flags" such as unexplained weight loss, fever, or significant problems with feeling or movement, further testing may be needed to look for a serious underlying problem.[5] In most cases, imaging tools such as X-ray computed tomography are not useful and carry their own risks.[9][10] Despite this, the use of imaging in low back pain has increased.[11] Some low back pain is caused by damaged intervertebral discs, and the straight leg raise test is useful to identify this cause.[5] In those with chronic pain, the pain processing system may malfunction, causing large amounts of pain in response to non-serious events.[12]
Initial management with non-medication based treatments is recommended.[6] NSAIDs are recommended if these are not sufficiently effective.[6] Normal activity should be continued as much as the pain allows.[2] A number of other options are available for those who do not improve with usual treatment. Opioids may be useful if simple pain medications are not enough, but they are not generally recommended due to side effects.[4][13] Surgery may be beneficial for those with disc-related chronic pain and disability or spinal stenosis.[14][15] No clear benefit of surgery has been found for other cases of non-specific low back pain.[14] Low back pain often affects mood, which may be improved by counseling or antidepressants.[13][16] Additionally, there are many alternative medicine therapies, including the Alexander technique and herbal remedies, but there is not enough evidence to recommend them confidently.[17] The evidence for chiropractic care[18] and spinal manipulation is mixed.[17][19][20][21]
In the common presentation of acute low back pain, pain develops after movements that involve lifting, twisting, or forward-bending. The symptoms may start soon after the movements or upon waking up the following morning. The description of the symptoms may range from tenderness at a particular point to diffuse pain. It may or may not worsen with certain movements, such as raising a leg, or positions, such as sitting or standing. Pain radiating down the legs (known as sciatica) may be present. The first experience of acute low back pain is typically between the ages of 20 and 40. This is often a person's first reason to see a medical professional as an adult.[1] Recurrent episodes occur in more than half of people[23] with the repeated episodes being generally more painful than the first.[1]
Other problems may occur along with low back pain. Chronic low back pain is associated with sleep problems, including a greater amount of time needed to fall asleep, disturbances during sleep, a shorter duration of sleep, and less satisfaction with sleep.[24] In addition, a majority of those with chronic low back pain show symptoms of depression[13] or anxiety.[17]
Low back pain is not a specific disease but rather a complaint that may be caused by a large number of underlying problems of varying levels of seriousness.[25] The majority of LBP does not have a clear cause[1] but is believed to be the result of non-serious muscle or skeletal issues such as sprains or strains.[26] Obesity, smoking, weight gain during pregnancy, stress, poor physical condition, and poor sleeping position may also contribute to low back pain.[26] There is no consensus as to whether spinal posture or certain physical activities are causal factors.[27] A full list of possible causes includes many less common conditions.[5] Physical causes may include osteoarthritis, degeneration of the discs between the vertebrae or a spinal disc herniation, broken vertebra(e) (such as from osteoporosis) or, rarely, an infection or tumor of the spine.[28]
Women may have acute low back pain from medical conditions affecting the female reproductive system, including endometriosis, ovarian cysts, ovarian cancer, or uterine fibroids.[29] Nearly half of all pregnant women report pain in the lower back or sacral area during pregnancy, due to changes in their posture and center of gravity causing muscle and ligament strain.[30]
The multifidus muscles run up and down along the back of the spine, and are important for keeping the spine straight and stable during many common movements such as sitting, walking and lifting.[12] A problem with these muscles is often found in someone with chronic low back pain, because the back pain causes the person to use the back muscles improperly in trying to avoid the pain.[33] The problem with the multifidus muscles continues even after the pain goes away, and is probably an important reason why the pain comes back.[33] Teaching people with chronic low back pain how to use these muscles is recommended as part of a recovery program.[33]
As the structure of the lumbago back is complex and the reporting of pain is subjective and affected by social factors, the diagnosis of low back pain is not straightforward.[5] While most low back pain is caused by muscle and joint problems, this cause must be separated from neurological problems, spinal tumors, fracture of the spine, and infections, among others.[3][1] The ICD 10 code for low back pain is M54.5.
There are a number of ways to classify low back pain with no consensus that any one method is best.[5] There are three general types of low back pain by cause: mechanical back pain (including nonspecific musculoskeletal strains, herniated discs, compressed nerve roots, degenerative discs or joint disease, and broken vertebra), non-mechanical back pain (tumors, inflammatory conditions such as spondyloarthritis, and infections), and referred pain from internal organs (gallbladder disease, kidney stones, kidney infections, and aortic aneurysm, among others).[5] Mechanical or musculoskeletal problems underlie most cases (around 90% or more),[5][36] and of those, most (around 75%) do not have a specific cause identified, but are thought to be due to muscle strain or injury to ligaments.[5][36] Rarely, complaints of low back pain result from systemic or psychological problems, such as fibromyalgia and somatoform disorders.[36] 041b061a72