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PubMed1987

Low back pain.

Low back pain is a frequent medical complaint that is often the result of a conflict between a compressed or degenerated disc and the inflamed nerve root. The discoradicular conflict is best treated with dual modality therapy: mechanical treatment to relieve disc compression and anti-inflammatory treatment for the congested root. Almost all cases of acute low back pain can be treated with conservative therapy, including the use of non-steroidal anti-inflammatory drugs (NSAIDs), and surgery should be used only as a last resort. Results of a study comparing oral administration of piroxicam with indomethacin and diclofenac for reduction of spontaneous low back pain indicated that the three drugs are nearly identical in efficacy. In other investigations, intramuscular piroxicam (one injection of 40 mg/d for two days, then 20 mg/d) performed favorably in terms of pain relief and tolerance as compared with higher doses of intramuscular ketoprofen and diclofenac administered in two daily doses.

Anti-Inflammatory Agents, Non-Steroidal↗

PubMed1995

Low back pain.

Low back pain is a common reason for physician visits and is associated with enormous costs to health care and industry. Radiographic abnormalities of the lumbar spine, including disk protrusion, are common in asymptomatic subjects and only loosely associated with symptoms and neurologic examination. Therefore, highly selective evaluation is required to avoid subjecting patients with back pain to unnecessary tests and surgical procedures. Reassurance about the favorable prognosis of low back pain is an important component of therapy. Most patients with simple back pain recover with symptomatic treatment. Plain radiographs are indicated for evaluation of patients with radiculopathy and those with risk factors for underlying medical conditions. The majority of patients with back pain, even those with radiculopathy, improve with conservative management and surgery is unnecessary. Surgical consultation and CT or MR imaging scans are indicated for patients with persistent or progressive neurologic deficits or persistent sciatica with nerve root tension signs. Acute radiculopathy with bilateral neurologic deficits, saddle anesthesia, or urinary symptoms is suggestive of cord compression or cauda equina syndrome and requires urgent surgical referral.

Ambulatory Care↗

PubMed2002

[Contribution of psychosocial factors in chronic low-back pain].

Low back pain (LBP) is a highly prevalent and costly cause of disability. In spite of a large amount of research in this field, there is still controversy about which factors are more important to determine chronicity in low back pain. Recent results have shown that LBP becomes a chronic condition mainly because of the relationship between psychosocial factors and pain. This relationship would explain the resistance of chronic LBP to classical medical treatment, which results in absenteeism and high economical costs. In this study we review recent results, including our own, that elucidate the contribution of psychosocial factors to chronic LBP. A biopsychosocial approach to these patients is highly recommended.

Chronic Disease↗

PubMed2001

A nonsurgical approach to low back pain.

Low back pain, a leading cause of disability in the United States, has a significant economic impact not only on lost productivity but also on healthcare expenditures. Approximately a fifth of patients will see multiple physicians in their quest for relief of low back pain. Primary care physicians therefore play a crucial role in the initial approach to these patients. A thorough history and physical examination directed toward the neurologic, orthopedic, and osteopathic evaluation are essential. This article reviews the diagnosis and assessment of pain levels and a triad system of therapy involving cortical, spinal, and peripheral levels. Options include antidepressants, neuroleptics, neurostimulants, and osteopathic manipulative treatment (OMT) (cortical level); opiates, tramadol hydrochloride, and transcutaneous electrical nerve stimulators (spinal level); and nonsteroidal anti-inflammatory drugs, epidural injections, spinal blocks, antispasmodics, physical therapy, muscle relaxants, exercise, and OMT (peripheral level), By choosing a modality directed at each level, the clinician may provide the patient with a pain management program that will maximize the chosen mode of therapy and restore function and mobility.

Analgesics↗

PubMed2006

A randomized, single blind placebo controlled clinical trial on the effect of continuous ultrasound on low back pain.

Low back pain (LBP) is a very common problem in primary care and a major cause of disability. There is no evidence for the efficacy of therapeutic modalities such as ultrasound in LBP In a randomized, single blind placebo controlled clinical trial, we aimed to evaluate the effect of continuous ultrasound (US) in patients with non specific LBP Of the fifty eight patients recruited, 10 patients (8 women and 2 men) randomly allocated to ultrasound (n=5) or placebo controlled (n=5) groups. The patients were treated by either US or sham-US for ten sessions, three days per week, every other day. The outcome measures were Functional Rating Index (FRI), Hmax/Mmax ratio and range of motion (ROM), which were measured at baseline, after 5 treatment sessions and at the end of treatment. To analyze the data, The Mann Whitney U test and Wilcoxon Signed Rank test were used. After treatment, both US and placebo groups showed statistically significant decrease in FRI scores indicating improvement in functional ability (p = 0.042 and p = 0.043, respectively). The mean changes of FRI during the second five treatment sessions and after the end of treatment was significantly better in the US group than in the placebo group (p = 0.016 and p = 0.032, respectively). Before and after treatment, the mean H reflex latency and Hmax/Mmax ratio, right and left side were similar in the groups (p > 0.05), and no significant changes were observed in the treatment groups (p > 0.05). After treatment, the extension and lateral flexion range of motion significantly increased in the US group (p = 0.04), but the back movements in the placebo group did not show significant changes (p > 0.05). The present study supports the significant effect of US on LBP, and suggests that US may improve the functional ability of patients with non specific low back pain.

Adult↗

PubMed1985

Low back pain.

Low back pain is one of the most common and costly afflictions of our Society. The majority of adults will have at least one episode of acute low back pain that will likely resolve regardless of treatment. Lumbar spine radiographs are overused and there is little scientific support for many of the therapeutic interventions advocated. Even for those patients with symptomatic herniated disc, only a small fraction will ultimately require surgical intervention.

Arthritis↗

PubMed1988

Office management of low back pain.

Low back pain, with or without sciatica, is a very common medical problem. Since a great majority of patients can be successfully treated with nonoperative methods, office management of these patients is a very important issue for all clinicians. Patients with low back pain can be divided into three major groups: 1) the first group with acute (initial onset or very occasional recurrent) symptoms, 2) the second group with chronic (frequent intermittent recurrent or persistent) symptoms and 3) the third group with resistant symptoms. For the first group with acute symptoms, establishment of a specific diagnosis is rarely necessary. An active nonoperative treatment program (brief rest, protection, physical therapy modalities, medication, exercises, and reconditioning) provides a high rate (nearly 90 to 95 per cent) of success (return to normal activities and work) within 8 to 12 weeks. For the second group, with chronic symptoms, establishment of a specific diagnosis and a comprehensive and specific history are essential. Diagnostic procedures for specific pathologic conditions are outlined. A clear and specific treatment goal should be established and communicated to all the parties involved. Nonoperative treatment for this group includes back school, postural exercises, bracing, exercises for strength and endurance, work-site modification, vocational counseling, and pain management. For the third group with resistant symptoms, the role of the orthopedic or neurosurgeon is as a consultant to a pain management team for evaluation and treatment of missed diagnosis or complications of previous treatments.

Acute Disease↗

PubMed1989

Radiologic investigation of low back pain.

Low back pain is one of the commonest disorders, yet is the most confusing. The cost in work-time lost and in the search for and treatment of its many causes amounts to billions of dollars annually. The traditional techniques for anatomic visualization have been plain-film radiography and myelography, but they have limitations. The development of computed tomography and magnetic resonance imaging have substantially improved anatomic imaging. However, invasive procedures, such as discography, percutaneous nerve-root blocking and percutaneous facet injection, may be helpful in patients with disabling pain in whom noninvasive methods give negative findings, show abnormalities that do not correlate with the symptoms or identify multiple sites of disease. The invasive procedures are believed by some to be associated with too many complications. We have attempted to clarify the strengths and weaknesses of the currently available methods of investigating low back pain and the indications for their use.

Adult↗

PubMed1993

Diagnosis and treatment of discogenic low back pain.

Low back pain (LBP) is very prevalent in the general population. Treatment of nonradicular back pain, in the absence of deformity, continues to be controversial. Recently, anatomic dissections, magnetic resonance imaging studies, and the use of provocative discograms (pain-related response during the injection similar to the typical pattern of pain reported prior to the procedure) have contributed to our understanding of the etiology of discogenic back pain. Various techniques of spine fusion, with and without instrumentation, have altered the natural history of LBP unresponsive to conservative treatment. This review discusses the etiology and diagnosis of discogenic back pain and the treatment options available to the spine surgeon.

Diagnosis, Differential↗

PubMed1993

Evaluation of impairment related to low back pain.

Low back pain is the leading cause of disability and expense from work-related conditions in the United States. Forty percent of the expense of the worker's compensation program is spent on claims involving the low back. There are several systems of impairment evaluation in use in the United States, but the most commonly used has been developed by the American Medical Association. Evaluation of impairment related to the low back is expressed as a percent impairment of the whole person and is calculated by combining values related to: (1) diagnostic based categories, (2) range of motion of the spine, and (3) neurologic deficits in the lower extremities. Using this system, and given a cooperative patient, a reproducible quantification of impairment can be obtained to help administrators of the worker's compensation system more fairly compensate injured workers for partial permanent disability.

Accidents, Occupational↗

PubMed2003

Low back pain.

Low back pain is a leading cause of disability. It occurs in similar proportions in all cultures, interferes with quality of life and work performance, and is the most common reason for medical consultations. Few cases of back pain are due to specific causes; most cases are non-specific. Acute back pain is the most common presentation and is usually self-limiting, lasting less than three months regardless of treatment. Chronic back pain is a more difficult problem, which often has strong psychological overlay: work dissatisfaction, boredom, and a generous compensation system contribute to it. Among the diagnoses offered for chronic pain is fibromyalgia, an urban condition (the diagnosis is not made in rural settings) that does not differ materially from other instances of widespread chronic pain. Although disc protrusions detected on X-ray are often blamed, they rarely are responsible for the pain, and surgery is seldom successful at alleviating it. No single treatment is superior to others; patients prefer manipulative therapy, but studies have not demonstrated that it has any superiority over others. A WHO Advisory Panel has defined common outcome measures to be used to judge the efficacy of treatments for studies.

Acute Disease↗

PubMed2006

Occupational low back pain.

Low back injury is one of the most common conditions in the workplace. The causes are multifactorial and must be sought during the physician's examination. Failure to perform a comprehensive history and physical examination ultimately can lead to treatment failure and injury recurrence. A comprehensive history and physical may help clinicians to differentiate organic and nonorganic causes of low back pain. Different diagnoses need specific rather than generalized treatment programs. Teaching clinicians the nuances of the history and physical examination in a setting with an injured worker is the goal of this article.

Humans↗

PubMed1996

Managing sports-related low back pain.

Low back pain is a common complaint among both the general and the athletic populations. A thorough evaluation and specific diagnosis is required before prescribing treatment. A complete rehabilitation program should include exercises to enhance strength, flexibility, endurance, and coordination. This article focuses on exercises to improve flexibility.

Athletic Injuries↗

PubMed2002

Low back pain.

Low back pain is a very common condition, with about 80% of people suffering from it at some point in their lives. It is usually self-limited, resolving in 4 to 8 weeks in more than 50% of patients, yet the recurrence rate is high, about 85%. Because of the complexity of the bony, muscular ligamentous, and neural elements of the back, a specific anatomic diagnosis often cannot be made. Evaluation should include a careful history and physical examination, paying particular attention to alarm symptoms or "red flags" mentioned in the text. Imaging procedures are usually not necessary because of the lack of specificity and the high rate of early, spontaneous remission. Exceptions to this include history of recent trauma, presence of red flags or chronic unremitting course. Many treatment modalities, including physical therapy, ultrasound, thermal therapy, and local injection have been tried, but most studies are inconclusive as to their effectiveness. Prolonged bed rest is not indicated. Nonsteroidal anti-inflammation agents, judicious use of muscle relaxers, and patient education about the cause and prognosis are justified.

Diagnosis, Differential↗

PubMed2006

Chronic low back pain.

Low back pain (LBP) is one of the most prevalent medical problems in society today. In addition to the profound effect LBP can have on patients, it has an exceedingly high societal cost. Although most acute episodes of back pain will ultimately resolve, this condition will become chronic for many. Those with chronic LBP are a challenge to treat. Nonetheless, with a better understanding of the underlying pathophysiology and treatment options, our management of these patients is gradually improving. Conservative therapy remains the mainstay treatment of chronic LBP. If this has failed, surgical options may be considered in the carefully selected patient. Fusion is the most established treatment option for this condition. Disc arthroplasty is being increasingly considered. Class I studies critically evaluating established and evolving technologies continue to help shape our understanding of the surgical options for this condition.

Chronic Disease↗

PubMed2005

Iatrogenic (para-) spinal abscesses and meningitis following injection therapy for low back pain.

Low back pain is often treated with paraspinal injections of analgesics and steroids. Infectious complications of these techniques are rare but they can potentially hold high risks for the patients. History and clinical data of all patients admitted to a neurological unit suffering from community acquired purulent meningitis were prospectively analyzed during an 8 year interval (1992 and 2000) with special regard to the previous medical history. One hundred and twenty eight patients were included in the study. Eight out of 128 patients (6.25%) had a history of single or repeated paravertebral (4/8), facet-joint (2/8), peridural (1/8) or spinal (1/8) injections 2-21 days before admission to the hospital. In six out of eight patients either Staphylococcus aureus (4/8) or coagulase-negative staphylococci (2/8) were found in the cerebro spinal fluid (CSF), in two patients no causative organism was detected. One patient died, three survived with sequel. Repeated paraspinal, peridural or spinal injections with analgesic drugs in combination with corticosteroids hold a risk for parameningeal inoculation of bacteria resulting in paraspinal, spinal, and epidural abscesses or meningitis. The absolute frequency of these complications may be rare but they are responsible for a considerable proportion of community acquired purulent CNS infections.

Adolescent↗

PubMed1983

Low back pain.

Low back pain probably always will be a problem because of the anatomic arrangement of the lower spine and posture in standing and walking. However, during recent years, new attempts at diagnosis and treatment of this difficult problem have occurred, and it is now possible, in most cases, with a good history, physical examination, and diagnostic work-up to determine the cause of the problem. The injuries are still difficult to treat in many cases, but often with a thorough explanation to the patient about the underlying problem and mechanism of pain, and with use of the "back school" and conservative measures, most of the patients can continue on with daily activities. Formal surgery is playing less of a role in the treatment of back problems, with the development of various injections and percutaneous techniques. Still to be addressed, and where considerable effort and energy should be spent, is in the prevention of back problems with changes in daily habits and in increased awareness of ways to avoid back injuries.

Acute Disease↗

PubMed2005

Intradiscal electrothermal coagulation and percutaneous neuromodulation therapy in the treatment of discogenic low back pain.

Low back pain (LBP) is a major physical and socioeconomic entity. A significant percentage of LBP is attributable to internal disc disruption. The management of internal disc disruption has traditionally been limited to either conservative treatment or spinal fusion. Intradiscal electrothermal coagulation (IDET) and percutaneous neuromodulation therapy (PNT) are now being performed as an alternative to these therapies. Scientific data regarding the pathophysiology, biologic effects, and clinical results are relatively scarce. Early biomechanical and histologic investigations into the effects of IDET are conflicting. However, in early prospective human trials, IDET seems to provide some benefit with little risk. PNT represents a new less invasive technique for the treatment of discogenic pain, but limited research is available to determine long-term clinical efficacy. IDET and PNT are potentially beneficial treatments for internal disc disruption in carefully selected patients as an alternative to spinal fusion. More basic science and clinical research with long-term follow-up evaluation is necessary.

Journal Article↗