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Back Pain (Main)

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Other Names

  • Low back pain
  • Lumbar Back Pain (LBP)
  • Acute Back Pain
  • Chronic Back Pain (CBP)
  • Chronic LBP (CLBP)

Background

  • This page is a general page for thoracic and lumbar back pain, all causes, chronic and acute
    • The majority of the page covers lumbar back pain as this is by far more common

Definitions

  • Lumbar back pain (Low back pain): defined as pain in the back from the level of the lowest rib down to the gluteal fold, with or without radiation into the legs[1]
  • Chronic back pain is typically described as pain lasting >12 weeks[2]
    • Other authors describe it as pain which lasts beyond the expected period of healing rather than a specific chronological definition
  • Nonspecific back pain: no clear causal relationship between the symptoms, physical findings, and imaging findings
  • Specific back pain: a patho-anatomical relationship can be demonstrated between the pain and one or more pathological processes

History

Epidemiology

  • Low back pain (LBP) is the most common musculoskeletal condition affecting the adult population
  • Prevalence
    • Up to 84%[3]
    • Estimated to range from 15 to 45% in French healthcare workers[4]
    • Chronic LBBP among US adults age 20-69 was estimated to be 13.1%[5]
    • In Italy, estimated to be 5.91%[6]
  • Economic Burden
    • 2006 review: the total costs associated with LBP in the United States exceed $100 billion per year[7]

Pathophysiology

Etiology

  • Many potential anatomic sources
    • Nerve roots
    • Muscle
    • Fascial structures
    • Bones
    • Foints
    • Intervertebral discs (IVDs)
    • Visceral etiology
  • It is estimated that
    • Only 15% of all instances of low back pain have a specific pathologic finding[8]
    • Ergo, >80% of cases of low back pain have no clear pathoanatomical correlate
  • In one study in which a specific cause of low back pain could be found[9]

Pathoanatomy


Risk Factors

  • Obesity
  • Age
  • Sedentary lifestyle
  • Physically/psychologically strenuous or sedentary work
  • Job dissatisfaction
  • Psychological illness (such as somatic symptom disorder, depression, or anxiety)

Differential Diagnosis


Clinical Features

Red and Yellow Flags

  • Red Flags[10]
    • Saddle anesthesia
    • Bowel or bladder dysfunction
    • Unexplained weight loss
    • Fevers, chills
    • Night sweats
    • History of violent trauma
    • History of cancer or immunocompromised state
    • Absence of relief after 4 weeks of treatment
    • History of IV drug use
  • Yellow Flags[11]
    • Predict poor response to basic treatment
    • Maladaptive beliefs
    • Poor sleep
    • Mood disorder
    • Job dissatisfaction
    • Poor social support
    • Compensation and/or litigation issues
    • Kinesiophobia

Clinical

  • History
    • Inquire about onset, course of pain
    • Prior episodes
    • Location and radiation of present
    • Quality, intensity
    • Provocative factors including activity, exercise
    • Relieving factors
    • Which times of the day it is worse (day, night, sleep, etc)
    • How it is affecting activities of daily living and sports
    • Stressors at home and work
  • Physical Exam: Physical Exam Back

Evaluation

  • In general, imaging findingss are often weakly related to symptoms
    • Boden et al: Among asymptomatic persons over 60, 36% had herniated disc, 21% had spinal stenosis and 90% had degenerative or bulging discs[12]
  • Imaging is necessary if any red flags are present

Radiographs

MRI

  • Indicated if suspected fracture, infection, radiculopathy

CT

Laboratory Evaluation

  • No general applications to back pain
  • Indicated based on suspected etiology (i.e. infection, autoimmune, etc)

Classification


Management

  • If no specific or serious cause of back pain is identified, the following should be shared with the patient[1]
    • Everyday activities should be continued or resumed as soon as possible
    • Bed rest should be avoided
    • The patient’s low back pain is benign and reversible
    • The pain may recur, but the patient can have an influence on his/her symptoms and their consequences
    • Imaging studies are of little use in this situation, and therefore not indicated
  • Exercise Therapy
    • Cochrane review from 2005[13]
    • Acute low-back pain, exercise therapy is as effective as either no treatment or other conservative treatments
    • Exercise therapy appears to be slightly effective at decreasing pain and improving function in adults with chronic low-back pain
    • subacute low-back pain there is some evidence that a graded activity program improves absenteeism outcomes
  • Cognitive Behavioral Therapy

Pharmacologic


Return to Play


Complications


See Also


References

  1. 1.0 1.1 Casser HR, Seddigh S, Rauschmann M. Acute Lumbar Back Pain. Dtsch Arztebl Int. 2016 Apr 1;113(13):223-34.
  2. Mostagi FQ, Dias JM, Pereira LM, et al.: Pilates versus general exercise effectiveness on pain and functionality in non-specific chronic low back pain subjects. J Bodyw Mov Ther. 2015; 19(4): 636–45.
  3. Balagué F, Mannion AF, Pellisé F, et al.: Non-specific low back pain. Lancet. 2012; 379(9814): 482–91.
  4. Cougot B, Petit A, Paget C, et al.: Chronic low back pain among French healthcare workers and prognostic factors of return to work (RTW): a nonrandomized controlled trial. J Occup Med Toxicol. 2015; 10: 40.
  5. Shmagel A, Foley R, Ibrahim H: Epidemiology of chronic low back pain in US adults: National Health and Nutrition Examination Survey 2009–2010. Arthritis Care Res (Hoboken). 2016.
  6. Juniper M, Le TK, Mladsi D: The epidemiology, economic burden, and pharmacological treatment of chronic low back pain in France, Germany, Italy, Spain and the UK: a literature-based review. Expert Opin Pharmacother. 2009; 10(16): 2581–92.
  7. Katz JN: Lumbar disc disorders and low-back pain: socioeconomic factors and consequences. J Bone Joint Surg Am. 2006; 88(Suppl 2): 21–4.
  8. Koes BW, van Tulder MW, Thomcaas S. Diagnosis and treatment of low back pain. BMJ. 2006;332:1430–1434
  9. Deyo RA, Weinstein JN. Low back pain. N Engl J Med. 2001;344:363–370.
  10. Downie A, Williams CM, Henschke N, et al. Red flags to screen for malignancy and fracture in patients with low back pain: systematic review. BMJ. 2013;347
  11. Airaksinen O, Brox JI, Cedraschi C, et al. Chapter 4. European guidelines for the management of chronic nonspecific low back pain. Eur Spine J. 2006;(Suppl 2):192–300
  12. Boden SD, Davis DO, Dina TS, et al.: Abnormal magnetic-resonance scans of the lumbar spine in asymptomatic subjects. A prospective investigation. J Bone Joint Surg Am. 1990; 72(3): 403–8.
  13. Hayden JA, van Tulder MW, Malmivaara A, Koes BW. Exercise therapy for treatment of non-specific low back pain. Cochrane Database Syst Rev. 2005 Jul 20;(3):CD000335. Review. PubMed PMID: 16034851.
Created by:
John Kiel on 17 June 2019 15:12:29
Authors:
Last edited:
20 December 2020 15:01:16
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