Definition: This refers to pain that is located in or arises from the region of the lumbar spine. It is a symptom which is felt by a person and is difficult to measure or quantify. There are many potential causes of low back pain. Pain conditions are referred to as acute is the pain is present for less than 3 months and chronic if it persists for more than 3 months. A third category, subacute pain refers to pain that persists for 3 to 6 months.
Basic facts: Back pain is extremely common. Most cases get better no matter what the person does. Very few cases are do to serious conditions such as cancer or infection. The following are some facts about back pain:
- 60 – 90% of people experience low back pain at some time in their life
- 80 – 90% of people with back pain or sciatica recover within 6 weeks with or without treatment
- in 85% of cases no specific cause can be found
- serious conditions such as cancer and infection are found in less than 1% of people with back pain
- 2 to 5% of people visit a doctor or lose time from work each year because of back pain
- low back pain accounts for 15% of all sick leave
- low back pain is the most common cause of disability in people under 45 years of age
There is no good correlation between the occurrence of back pain and the presence of abnormalities on x-ray, CT or MRI of the spine. ie. people with normal a looking spine on imaging can be disabled by back pain while people with severe degenerative changes on imaging may have no back pain. It is important to ensure that the patients signs and symptoms match the findings on imaging studies before undergoing major surgical procedures.
Failed back surgery refers to people whose pain condition does not improve after an operation which was done to relieve their symptoms. It occurs in 5 – 25% of all spine surgery.
Red flags: Red flag signs and symptoms may indicate the presence of a serious cause for back pain including cancer, infection, fracture or cauda equina syndrome. Red flag conditions include:
- onset in people over 50 or under 20 years of age
- history of previous cancer
- unexplained weight loss
- pain that is not improved with rest or that wakes you up from sleep
- pain that persists for longer than 4 to 6 weeks
- weakness, numbness or bladder problems that are progressively getting worse
Causes: There are many structures that could be the source of low back pain. These include muscles, fascia, bone, cartilage, meniscus, ligaments, tendons, discs, facet joints, sacroiliac joints, nerves, arteries, veins, lymphatics, or even the skin. Any of these structures can be affected or inflicted in a variety of different ways. Stress, strain, sprain or direct trauma can lead to inflammation and pain. Structural abnormalities such as tears (ligament), fractures (bone) and ruptures (disc) may be the inciting cause. Degenerative changes in the discs, facet joints, and soft tissue can also be the source of pain.
Many of these conditions cannot be identified with any current laboratory or imaging technique while others are identified in people who do not have pain. This makes it difficult to identify the exact cause or source of a persons back pain in the majority of patients. It is estimated that the exact cause goes without identification in 85% of people. Fortunately the majority of causes improve or heal within 3 months and the pain resolves.
Testing: There are a number of diagnostic tests that can be used to investigate the cause or source of back pain. The initial test is a good history and physical examination by a medical practitioner. Other investigations should be reserved for people with “red flag” conditions that would suggest something serious that requires immediate treatment. Otherwise investigations are usually deferred for 6 to 12 weeks because most conditions improve or recover during that period of time. If pain persists beyond 3 months then investigations are warranted. x-rays will show fractures and should be performed initially if there is a history of trauma. CT and MRI scans are the most common investigation for back pain. They will identify serious conditions such as tumors or infections, which are uncommon, degenerative conditions such as arthritis and structural abnormalities such as disc herniations and spinal stenosis. Bone scans can identify focal areas of inflammation, infection or tumor infiltration. Laboratory tests can be used to help make the diagnosis of conditions such as infections, rheumatoid arthritis and ankylosing spondylitis. Diagnostic injection of local anesthetic can be used to help identify the source of pain such as a facet joint, sacroiliac joint, ligament, muscle or disc.
Treatment: There are a number of treatment options for back pain. Initially non-steroidal anti-inflammatory and analgesics are tried. Ibuprofen, acetaminophen, advil, robaxicet and similar over the counter medication are often effective. Bed rest is not recommended for more than 3 to 4 days. Remaining active leads to a more rapid recovery. Prescription medication such as narcotics, muscle relaxants and stronger anti-inflammatory medication are used for severe pain. Physiotherapy, massage therapy, chiropractic treatment and acupuncture are often beneficial. If symptoms persist beyond 6 to 12 weeks and investigations show a structural cause, such as a disc herniation then surgical intervention may be considered. However surgery has potential risks and required a period of time to recover. Therefore it is often viewed as a last resort form of treatment. Treatment should be individualized based on the persons symptoms and circumstances.
In addition to the physical experience of pain, there are a number of emotional and psychological factors that can be present and may need to be addressed. People with severe pain often fear the worst. They may believe that they have cancer or some severe structural abnormality that could get worse with continued activity or without treatment. Fear, catastrophization, depression and other emotional and psychological factors can interfere with the recovery process and be significant factors that contribute to the development of disability. These factors need to be identified and addressed in addition to treating the pain.
Back pain is very common and can become chronic. The longer it is present the more difficult it is to relieve. Therefore investigation and treatment should be initiated if the pain has not resolved within 6 weeks. The goal is to identify and relieve the cause when possible to prevent the condition from becoming chronic.
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