Lumbalgia

Low back pain is a generic term used to describe a symptom related to the lower section of the human spine. The pain varies in intensity, frequency, duration, and quality depending on the cause and stage of injury or illness as well as the time of day and activity level. It can be considered either acute (of recent origin) or chronic (longer term) in nature, though these give little insight as to a particular cause of the pain. The degree of pain can range from a mild annoyance that comes and goes to constant and totally disabling. Persistant and recurring low back pain affects 60 - 80% of people at some stage in their life and is the most common reason for lost work.

The majority of acute causes of low back pain can be grouped as mechanical type injuries to the ligaments, muscles and joints that are responsible for the function of the vertebral column whether the result of one traumatic event or multiple, repetitive type injuries. If the cause of these mechanical conditions persist, the pain may be develop into a chronic lower back pain and symptoms may change in quality and frequency depending on the types of structures, such as discs and nerves, that become affected. These include diagnoses such as osteoarthritis, degeneration of the discs or a spinal disc herniation.

Some cases of low back pain are related to systemic conditions that affect other regions of the body such as rheumatoid arthritis or cardivascular disease, while a small percentage are caused by tumors (including cancer). There are psychological or emotional components of all disease and low back pain is no exception.

Background

The low back performs two major functions; to act as a weight bearing column that supports upright posture and to act as a conduit that protects the spinal cord and the tender nervous system that tranmits through it. As a supporting structure, it carries the weight of the upper torso including the head, arms, thorax, and abdominal contents. Impact forces from actions such as walking or jumping multiply these forces exponentially.

The structures of the adult low back consist of the lower five verterbae along with the ligaments, discs and muscles that support it. Together they are identified as the lumbar region of the spine. The relationship between these five vertebrae and their discs allows for the majority of the total range of motion of the lower spine. The lumbar spine sits atop the sacrum which is a wedge shaped bone that rests into a space formed by the left and right innominate bones. This bone is divided into the ilium, ischium and pubis and makes up the pelvic girdle that acts to connect the leg to the torso. The left and right innominates wrap around to the lower abdominal region, creating a "bowl" that carries the organs contained within the abdomen. The joint between the sacrum and each innominate (sacroiliac joint) allows for slight motion with walking and bending. The sacrum and innominates together with their supporting ligaments and muscles are referred to as the pelvis. The resulting circle-like formation is commonly called the pelvic ring. For the lay person, the combination of the lumbar and pelvic regions are effectively called the low back.

For the purposes of understanding the causes of low back pain, it is important to note that all pain is a perception of the person that is experiencing it. These perceptions are the result of an intricate relationship between the nerve endings that monitor the condition of the tissues and send that information to the higher centers of the brain where the conscious perception actually occurs. The vast majority of the nerve endings are in the ligaments, muscle and outer layer of the disc tissues that support the boney structures. While bones have a thin 'skin' or periosteum that has a plentiful nerve supply, the bones themselves do not. This is also the case of the inner portions of the disc.

Causes

Possible causes of low back pain:

Mechanical: Apophyseal osteoarthritis Ankylosing hyperostosis Scheuerman's osteochondritis Spinal disc herniation Spinal stenosis Spondylolysis Postural strain Facet sprain Muscle strain Spondylolisthesis congenital abnormalities Fractures Inflammatory: ankylosing spondylitis Rheumatoid arthritis Psoriatic arthritis Reiter's Syndrome Infection

Neoplastic: Bone tumors (primary or metastatic) Spinal tumors Metabolic: Osteoporotic fractures Osteomalacia Ochronosis Chondrocalcinosis Paget's disease Referred pain: Pelvic/abdominal disease Cardiovascular disease 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 [1].

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.