Lumbalgia

Low back pain can be either an acute or chronic disabling condition. It will affect most people at some stage in their life and accounts for more sick leave taken than any other single 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, vertebral fractures in the lumbar spine may also occur.

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, or tumors (including cancer). However, some causes are psychological or emotional, and have been diagnosed as TMS or tension myositis syndrome.[1][2]

Causes

Possible causes of low back pain:

• Mechanical:
  • Apophyseal osteoarthritis
  • Ankylosing hyperostosis
  • Scheuerman's osteochondritis
  • Spinal disc herniation
  • Spinal stenosis
  • Spondylolisthesis and other congenital abnormalities
  • Fractures
  • Non-specific

• Inflammatory:
  • Seronegative spondylarthritides (e.g. ankylosing spondylitis)
  • Rheumatoid arthritis
  • Infection

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

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

• Paget's disease

• Referred pain:
  • Pelvic/abdominal disease
  • Posture

• Tension myositis syndrome

• Depression

Diagnosis

Often, getting a diagnosis of the underlying cause of low back pain and/or related symptoms, such as sciatica, 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 [3].

Treatment

The management goals when treating back pain are to achieve maximal reduction in pain intensity as rapidly as possible; to restore the individual's ability to function in everyday activities; to help the patient cope with residual pain; to assess for side effects of therapy; and to facilitate the patient's passage through the legal and socioeconomic impediments to recovery.

Not all treatments work for all conditions or for all individuals with the same condition, and many find that they need to try several treatment options to determine what works best for them. Only a minority (most estimates are 1% - 10%) require surgery.

• Heat therapy is useful for back spasms or other conditions. A meta-analysis of randomized controlled trials by the Cochrane Collaboration concluded that heat therapy can reduce symptoms of acute and sub-acute low-back pain

• Medications, such as muscle relaxants, narcotics, non-steroidal anti-inflammatory drugs (NSAIDs/NSAIAs) or paracetamol (acetaminophen).

• Exercises can be done the patient individually, or under supervision of a professional such as a physical therapist. Generally, some form of consistent stretching and exercise is believed to be an essential component of most back treatment programs. However, a meta-analysis of randomized controlled trials by the Cochrane Collaboration found that exercises are effective for chronic back pain, but not for acute pain . One randomized controlled trial found that back-mobilizing exercises in acute settings are less effective than continuation of ordinary activities as tolerated .
  • Physical therapy and exercise, including stretching and strengthening (with specific focus on the muscles which support the spine), often learned with the help of a health professional, such as a physical therapist. Physical therapy, when part of a 'back school', can improve back pain .

• Massage therapy, especially from a very experienced therapist, may help. Acupressure or pressure point massage may be better than classic (Swedish) massage .

• Manipulation, as provided by an appropriately trained and qualified physical therapist, osteopath, physiatrist, or a chiropractor. Meta-analyses of the effect of manipulation suggest that manipulation has a small benefit similar to other therapies and superior to sham .

• Acupuncture has a small benefit for chronic back pain. The Cochrane Collaboration concluded that "for chronic low-back pain, acupuncture is more effective for pain relief and functional improvement than no treatment or sham treatment immediately after treatment and in the short-term only. Acupuncture is not more effective than other conventional and alternative treatments." . More recently, a randomized controlled trial found a small benefit after 1 to 2 years .

• Education, and attitude adjustment to focus on psychological or emotional causes (e.g. TMS). respondent-cognitive therapy and progressive relaxation therapy can reduce chronic pain .

• Most people will benefit from assessing any ergonomic or postural factors that may contribute to their back pain, such as improper lifting technique, poor posture, or poor support from their bed or office chair, etc. Although this recommendation has not been tested, this intervention is a part of many 'back schools' which do help .

Surgery

There are a number of different types of spine surgery to treat a variety of back conditions. Surgery should be considered if a patient has a significant neurological deficit, or if they fail non-surgical therapy. Regarding the role of surgery for failed medical therapy in patients without a neurological deficit, a [review http://www.cochrane.org/reviews/en/ab001352.html] by the Cochrane Collaboration concluded that "limited evidence is now available to support some aspects of surgical practice". The ongoing Spine Patient outcomes Research Trial (SPORT) is addressing the role of surgery . Some of the more common forms of surgery are:

• Artificial disc replacement, a relatively new form of surgery in the U.S. but has been in use in Europe for decades, primarily used to treat low back pain from a degenerated disc.

• Discectomy/microdiscectomy, usually used to treat pain (especially pain that radiates down the arm or leg) from spinal disc herniations.

• Kyphoplasty and Vertebroplasty, minimally invasive procedures designed to treat pain from osteoporotic compression fractures and sometimes other forms of fracture, such as a fracture caused by certain types of cancer.

• Spinal cord stimulation, where an electrical device is used to interrupt the pain signals being sent to the brain.

• Spinal fusion, usually to treat chronic, severe pain from degenerative disc disease, spondylolisthesis, or deformity, such as from scoliosis.

Treatments with uncertain or doubtful benefit

• Injections, such as epidural steroid injections, facet joint injections, or prolotherapy have limited, if any, benefit .

• Cold compression therapy is advocated for a strained back or chronic back pain and is postulated to reduce pain and inflammation, especially after strenuous exercise such as golf, gardening, or lifting. However, a meta-analysis of randomized controlled trials by the Cochrane Collaboration concluded "The evidence for the application of cold treatment to low-back pain is even more limited, with only three poor quality studies located. No conclusions can be drawn about the use of cold for low-back pain"

• Bed rest is rarely recommended as it can exacerbate symptoms , and when necessary is usually limited to one or two days.

• Electrotherapy, such as a Transcutaneous Electrical Nerve Stimulator (TENS) has been proposed. Two randomized controlled trials found conflicting results (PMID 10084439; PMID 2140432). This has led the Cochrane Collaboration to conclude that there is inconsistent evidence to support use of TENS (PMID 16034883).

See also

• Back pain
• Upper back pain
• Lumbar disc herniation
• Degenerative disc disease

External links

• Back Pain Medical Journal for Patients
• Low Back Pain - American Academy of Orthopedic Surgeons
• The treatment of low back pain with Acupuncture Includes several research articles on effectiveness.