Description
The way primary care doctors and even spine specialists handle patients with low back pain (LBP) varies greatly, and little is known about the best course of treatment. Back pain is typically self-limited, going away in 4 to 8 weeks for over 50% of patients; nevertheless, 85% of patients experience recurrences. Due to the high rate of early, spontaneous remission and the complexity of the neurological, muscular, ligamentous, and skeletal components, there is a lack of specificity. This does not apply to people with a history of recent trauma, red flags, or a chronic, unrelenting course. Numerous therapeutic approaches have been tried, such as physical therapy, medication therapy, ultrasound, heat therapy, local injection, and surgery, but the majority of trials have inconsistent outcomes.
Résumé
- Lower back pain is a common complaint, affecting 65-80% of individuals at some point in their lives. Determining if the pain is acute, subacute, or chronic is crucial, as it helps narrow down the potential causes, such as disc prolapse, infection, tumor, degenerative changes, or spinal stenosis.
- Key aspects of the patient's history include the onset of pain, its location (midline or paraspinal), character, radiation, and aggravating or relieving factors. Red flags include unexplained weight loss, fever, night sweats, history of cancer, and neurological deficits in the legs.
- Physical examination begins by observing the patient's gait and posture. Palpation of the spine can reveal tenderness, gaps, or misalignments. Range of motion assessment helps determine muscle spasm or mechanical instability. A thorough neurological examination is crucial, including assessment of power in key myotomes (hip, knee, ankle, big toe) and reflexes.
- Investigations are warranted if the patient doesn't improve with conservative treatment. X-rays can reveal bone abnormalities like spinal alignment, fractures, and reduced disc space, but MRI scans are needed to definitively diagnose disc herniations and nerve compression. CT scans are useful for detailed bone anatomy, while DEXA scans are used to assess bone density in suspected osteoporosis. Lab tests like CBC, ESR, and CRP are used to rule out infection, and multiple myeloma screening may be necessary.
- Conservative management, including physical therapy, rest, and patient education, is the primary approach for most back pain patients. Educating patients about proper posture, lifting techniques, and the importance of core and back strengthening exercises is essential to prevent recurrence.
- Referral to a spine surgeon is indicated in certain situations. These include routine cases that don't improve with conservative treatment, sciatica with radiating leg pain, osteoporosis, spinal degeneration with stenosis or disc herniation, spondylolisthesis, tumors, infections, and spinal deformities like scoliosis or kyphosis.
- Immediate referral to a spine surgeon is necessary for severe worsening back or neck pain with fever, weight loss, history of cancer or HIV, significant trauma with neurological deficits, persistent sciatica with neurological deficits, urinary or bowel incontinence, sexual dysfunction, and progressive unsteadiness of gait.
- Urgent conditions requiring immediate referral include cauda equina syndrome, metastatic spinal cord compression, unstable fractures, and spinal infections resulting in cord compression. Cauda equina syndrome presents with saddle anesthesia, bowel and bladder dysfunction, and leg weakness. Metastatic spinal cord compression is a tumor that has spread to the spine and compresses the spinal cord. Unstable fractures involve damage to all three spinal columns. Spinal infections can cause neural damage with weakness in the legs.
- Management of these urgent conditions often involves surgical intervention to decompress the spinal cord, stabilize the spine, and prevent further neurological damage. A thorough clinical examination, imaging, and collaboration with other specialists, such as oncologists, are crucial for optimal patient care.
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