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INTRODUCTION:
 
Low back pain can be described as an unpleasant experience characterised by discomfort felt in the lower back and with possible irradiation to the hips, the buttocks and the legs.
 
This experience is, in most cases, self limiting with significant improvement of the acute symptoms within days.
 
Back pain is one of the most common forms of musculoskeletal complaints to affect the human race.
 
Most Authors agree that over 80% of individuals during their life time would experience back pain at some stage.
 
A very large majority would not require medical treatment and would continue to live a relatively normal life with no need for any modifications or restrictions.
 
Back pain, however, does recur and it is important, therefore, to realise that although self limiting, this unpleasant experience is not a one off phenomenon.
 
Back pain is not a disease.  A number of studies have suggested that individuals disabled by back pain for long periods are more likely to suffer from mental illness (especially depression), being engaged in litigation (especially workers’ compensation) or suffer from other medical illnesses which do not allow them to cope with this otherwise benign problem.
 
Individuals with back pain, therefore, should be encouraged to look after their physical and mental health as it is highly likely that they will be able to cope satisfactorily with their back pain experience with no need for medical intervention.
 

ETIOPATHOGENESIS OF LOW BACK PAIN

 
 
Individuals experiencing acute and disabling back pain are likely to suffer from painful irritation of one or more of the components of the spinal motion segments.  In most cases, this may be represented by the outer fibres of the annulus fibrosis of the intervertebral disc (fig. 1) or the facet joint (fig. 2).  Ligaments, tendons and muscles are unlikely to be responsible for sustained experiences of pain although may, at times, give origin to short lived pain.
 
Nerve pain, such as sciatica, by definition would affect the leg more than the lower back and may be associated with tingling, numbness and/or weakness in the leg which is generally not present in a vast majority of patients with prevalent back pain.
 
It is extremely rare for back pain to be due to a more sinister cause, such as Cancer, infection, vascular impairment or fractures.  It is important, however, to exclude the possibility of medical illness being associated with and/or being responsible for the pain and it is, therefore, essential that in the presence of ongoing back pain, a Doctor be involved to carry out a comprehensive clinical examination and consider the possibility of blood tests and/or other investigations which may allow to achieve a diagnosis.  A risk, therefore, exists in individuals seeking alternative treatment in the presence of acute back pain to either delay or miss altogether, a very important possible diagnosis.  In general terms, however, the possibility of an underlying sinister condition being responsible for the back pain is extremely rare.  Some of the possible signs which may be associated with Cancer may be represented by weight loss, change in bowel and/or bladder habits, unremitting and continuous pain present at night and not relieved by rest or oral analgesia, the presence of generalised illness with vomiting, nausea, night sweats, etc and generalised weakness.  In the presence of significant injury such as a serious fall, a car accident or a direct blow to the lower back, the possibility of a fracture would need to be excluded by adequate imaging.
 

DIAGNOSIS

 
A more specific diagnosis in back pain can be extremely difficult to achieve as pain, as such, can not be identified in either clinical examinations, imaging or even surgery.  The pain, in fact, is at present an experience that cannot be shared and, therefore, remains identifiable only by hypothesis and/or educated guess.  In order to exclude possible other causes of pain, however, it is important that individuals suffering from acute and disabling back pain be properly examined by a Medical Practitioner and that a thorough history be obtained to identify any possible risk factors and/or associated circumstances which may lead to a more specific diagnosis.  In most cases, however, the diagnosis would be consistent with what is referred as non-specific or "mechanical" low back pain.  This, as mentioned in the previous paragraph, is likely to stem from irritation of the disc or the facet joints and would be expected to settle within days.
 
Plain x-rays are unlikely to allow any more precise indication of the origin of the pain.  Whilst x-rays can be used to exclude fractures and/or obvious bony lesions which may be due to established infections or Cancer, in the vast majority of individuals they are unlikely to influence the decision for future treatment.  The presence of more or less degenerative changes in the joints and the discs of the spine would not influence the principles of management which are based on re-assurance, encouragement for regular exercise and prevention of high risk situations.
 

PRINCIPLES OF MANAGEMENT

 
Non-specific low back pain is not a medical disease and as such, does not generally require medical treatment. 
 
Individuals with non-specific back pain should be encouraged to stay away from medically driven treatment and to use their own resources to cope with their experience.  Individuals that have experienced back pain and are, therefore, likely to continue to experience it intermittently are encouraged to perform regular exercise which would include swimming, walking, the use of pushbikes or exercise bikes and any other form of general sport.
 
No evidence exists that specific medically driven exercises would lead to any better outcome than general fitness routines.  As pain is always a combination of physical and psychological factors, it is paramount that individuals suffering from back pain are allowed to choose a form of exercise that is considered by them more suitable not only in terms of their body tolerance, but also gratification and social interaction.  It is inappropriate to prevent individuals with back pain from playing golf, tennis and/or other sports which they enjoy on the basis of their possible aggravating effects on the pain.  It is also extremely important to identify possible risk factors which may be represented by anxiety, depression and industrial issues which may be central to the chronicity of symptoms.  More aggressive intervention may be indicated when the pain does not allow the individual to participate in regular exercise.
 
It is in these cases that facet joint injections, facet rhyzolysis, (see sub-headings Facet Injections, Facet Rhyzolysis), thermal disc therapy, extraforaminal injections and stronger medications may be used to break the vicious circle of pain and inactivity and to allow individuals to gradually return to a normal lifestyle.
 

SURGERY

 
Surgery for back pain is, in general terms, an inappropriate approach based on a misunderstanding of the real reasons for the disability of the patient and/or an overestimation of the technical merits of the operation.
 
Surgery may be indicated however in the presence of neural compression with the pain affecting mainly the leg (see sub-heading Lumbar Surgical Decompression) and/or when back pain is due to a life threatening or specific condition with major anatomical disruption, such as Cancer, infection or unstable fractures.  The results of surgery for non-specific back pain, when a compensation claim is present in general terms, is unfavourable.   
 

CORSETS/BRACES

 
Lumbar corsets can be employed in individuals with recurrent back pain when they engage in repetitive physical tasks.  It has been proven in occupational studies that  individuals  suffering from disabling back pain and who engage in repetitive manual handling, by using  a lumbar corset have a lower risk of recurrence of symptoms.  Pain medications (analgesics) can be useful, especially to help regaining a normal sleeping pattern and as a way of continuing with regular exercise.
 
PROGNOSTIC FACTORS
 
A major sleeping pattern disturbance should alert the Doctor and the patient to the possibility of underlying depression and is considered a relatively unfavourable early prognostic indicator after a compensable injury, such as motor vehicle accidents or work-related incidents.  Other additional unfavourable prognostic indicators are represented by co-morbidities (the presence of other illnesses) and other psychosocial factors such as long absence from work, long term reliance on opioid analgesia (Morphine, etc) and mental illness (especially depression/anxiety).  The presence or otherwise of radiological abnormalities (disc protrusion, disc degeneration, scoliosis, facet osteoarthritis, etc.) is generally much less significant for the long term prognosis.



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