Sumathi Reddy. (2019) No Drugs for Back Pain, New Guidelines Say - WSJ. Retrieved April 29, 2019, from https://www.wsj.com/articles/no-drugs-for-back-pain-new-guidelines-say-1487024168
Contents
Introduction
Pain in the back from the level of the lowest rib down to the gluteal fold, with or without radiation into the legs.
Leading cause of years lived with disability worldwide
LBP is a symptom and not a disease
Years lived with disability for low back pain | Vlaeyen, J. W. S., Maher, C. G., Wiech, K., Van Zundert, J., Meloto, C. B., Diatchenko, L., … Linton, S. J. (2018). Low back pain. Nature Reviews Disease Primers, 4(1), 52. https://doi.org/10.1038/s41572-018-0052-1
Classification
By duration:
Acute (< 6 weeks)
Sub-chronic (6-12 weeks)
Chronic LBP (CLBP) (> 12 weeks)
By underlying cause:
Mechanical
Non-mechanical
Referred pain
Aetiology
Musculoskeletal:
Mechanical (including muscle strain, muscle spasm, or osteoarthritis)
Herniated nucleus pulposus, herniated disk
Spinal stenosis
Compression fracture
Inflammatory:
HLA-B27 associated arthritis including ankylosing spondylitis, reactive arthritis, psoriatic arthritis, and inflammatory bowel disease
Malignancy:
Bone metastasis from lung, breast, prostate, thyroid, among others
Infectious:
Osteomyelitis
Abscess
Pathophysiology
Vertebral anatomy | Vlaeyen, J. W. S., Maher, C. G., Wiech, K., Van Zundert, J., Meloto, C. B., Diatchenko, L., … Linton, S. J. (2018). Low back pain. Nature Reviews Disease Primers, 4(1), 52. https://doi.org/10.1038/s41572-018-0052-1
Clinical features
Diagnosis
Red flags:
Red flag
Possible cause
Previous history of cancer
Cancer
Unintentional weight loss
Loss of bladder/bowel control
Cauda equina syndrome
Significant motor/sensory loss
Loss of sensation in buttocks (saddle anaesthesia)
Significant trauma related to age
Fracture
Chronic corticosteroid use
Osteoporosis
Severe pain after lumbar surgery in past year
Infection
Fever
Urinary tract infection
Immunosuppression
Intravenous drug use
Imaging
CT scan:
CT scan shows prolapsed lumbar disc | Nasser, M. J. (2005). How to approach the problem of low back pain: an overview. Journal of Family & Community Medicine, 12(1), 3–9. Retrieved from https://www.ncbi.nlm.nih.gov/pubmed/23012066
CT scan shows degenerative lumbar canal stenosis | Nasser, M. J. (2005). How to approach the problem of low back pain: an overview. Journal of Family & Community Medicine, 12(1), 3–9. Retrieved from https://www.ncbi.nlm.nih.gov/pubmed/23012066
Sacrolitis: degenerated and sclerotic CT scan and pelvis plain x-ray | Nasser, M. J. (2005). How to approach the problem of low back pain: an overview. Journal of Family & Community Medicine, 12(1), 3–9. Retrieved from https://www.ncbi.nlm.nih.gov/pubmed/23012066
MRI:
MRI sagittal image showing an abnormal alignment of lumbar vertebrae; black discs (red arrow) are pathogenetic for discogenic pain; facet joint hypertrophy (yellow arrow) is pathogenetic for facet joint pain. | Allegri, M., Montella, S., Salici, F., Valente, A., Marchesini, M., Compagnone, C., … Fanelli, G. (2016). Mechanisms of low back pain: a guide for diagnosis and therapy. F1000Research, 5, F1000 Faculty Rev-1530. https://doi.org/10.12688/f1000research.8105.2
MRI axial image showing reduction in the size of the spinal canal (blue arrow), a pathogenetic finding in spinal stenosis; the red arrow shows radicular compression that can cause radicular pain. | Allegri, M., Montella, S., Salici, F., Valente, A., Marchesini, M., Compagnone, C., … Fanelli, G. (2016). Mechanisms of low back pain: a guide for diagnosis and therapy. F1000Research, 5, F1000 Faculty Rev-1530. https://doi.org/10.12688/f1000research.8105.2
Management
Management of low back pain | Vlaeyen, J. W. S., Maher, C. G., Wiech, K., Van Zundert, J., Meloto, C. B., Diatchenko, L., … Linton, S. J. (2018). Low back pain. Nature Reviews Disease Primers, 4(1), 52. https://doi.org/10.1038/s41572-018-0052-1
Summary
Vlaeyen, J. W. S., Maher, C. G., Wiech, K., Van Zundert, J., Meloto, C. B., Diatchenko, L., … Linton, S. J. (2018). Low back pain. Nature Reviews Disease Primers, 4(1), 52. https://doi.org/10.1038/s41572-018-0052-1