Download Low back pain

Low Back Pain
Mr. Harish Kurup
Consultant in Orthopaedics
Pilgrim Hospital, Boston
1.
General Information
Back pain is a common condition and it is the largest cause of work-related absence. Back pain
can be very uncomfortable, but it is not usually serious. Lower back pain, also known as
lumbago, affects 7 out of 10 people at some time in their lives.
Pain in lower back is usually a symptom of stress or damage to ligaments, muscles, tendons or
discs. In some cases, if a spinal nerve root is irritated, the pain can spread to buttocks and thighs
and is known as sciatica.
Most cases of back pain resolve spontaneously, and staying active and continuing with usual
activities will normally promote healing. Back pain will usually last from a few days to a few
weeks. Treatment for back pain will usually depend on the underlying cause of the condition.
2.
Incidence/Prevalence
Back pain can affect anyone, regardless of age, but it is more common in patients between 35
and 55 years of age.
3.
Causes and Risk Factors
Most cases of lower back pain are known as 'non-specific' because they are not caused by serious
damage or disease, but by sprains, muscle strains, minor injuries or a pinched or irritated nerve.
Back pain can also be triggered by everyday activities at home or work, and by poor posture.
4.
History/symptoms
Back pain can be associated with pain down the legs and below the knees (sciatica). This does
not as such change management plan.
If any of the following symptoms are associated with lower back pain, examine the patient for
underlying serious pathology and refer for appropriate investigations..

fever
6.

weight loss

constant back pain that doesn't ease after lying down or resting

pain that travels to the chest or pain high up in back

pain down the legs and below the knees

a recent trauma or injury to back

loss of bladder control

inability to pass urine

loss of bowel control

Numbness around the genitals, buttocks or anus.

under 20 years old or over 55 years

on steroids

history of intravenous drug abuse

history of cancer

low immunity due to chemotherapy or AIDS
Physical signs
Examination of back pain includes examination of both lumbar spine and lower limb neurology.
In Lumbar spine, look for step which may be due to listhesis (one vertebra slipping over
another). Pain on spine extension indicates facet joint arthritis.
Examine lower limb sensations and motor power in muscles. Commonest level of disc prolapse
is L4-5 which causes L5 symptoms with numbness in 1st web space and weakness of extension
of big toe. Straight leg raising restricted to less than 45 degrees usually indicates a disc prolapse,
look for pain radiating below the knee as hamstring tightness may give false positive result.
Absence of perianal sensations or loss of motor tone indicates cauda equina syndrome and urgent
referral is indicated.
8.
Investigations
Most patients with back pain do not need any investigations. Patients with trauma or who are
elderly, osteoporotic may need an X-ray to rule out fractures. If back pain persists for longer than
6 weeks or if associated with any red flag symptoms, an MRI scan is usually required.
9.
Treatment
Bed rest is no longer advised for acute back pain. Conservative treatment is usually indicated and
carried out by physiotherapists. Many patients do take alternate measures such as chirpractic or
osteopathic treatment or acupuncture. For these complementary therapies, clinical studies have
not shown conclusive evidence as to their safety and effectiveness.
Chiropractic treatment tends to involve a more ‘direct’ approach, with an emphasis on
adjustments of the spinal joints. Chiropractors also rely on X-rays, blood and urine tests and MRI
scans for diagnosis.
The osteopathic approach involves mobilisation (slow, rhythmic stretching), pressure or
‘indirect’ techniques and manipulations on the muscles and joints.
Acupuncture is a form of traditional Chinese medicine which involves the insertion of very fine
needles at key points in the body. This can help encourage the body to release its natural form of
painkillers, known as endorphins.
Physiotherapists are trained to diagnose problems in the joints and soft tissues of the body.
Physiotherapy for back pain provides a wide range of treatments to relieve pain, promote
relaxation and restore movement. They include manipulation, mobilization and massage.
Exercise may also be used to increase general fitness or to strengthen muscles that support the
spine.
Analgesic may be used in acute phase or during physiotherapy. Most use oral forms some
chronic cases may benefit from patches.
Surgery is reserved for continuing pain beyond 6 weeks or cauda equina syndrome or for specific
diagnoses. The options are
10.

Injections – epidural or facet joint injections are useful adjuncts.

Discectomy - herniated disc that is pressing on nerve root is removed.

Fusion surgery – for instability, fuse adjacent vertebrae.

Disc replacement – degenerated disc is replaced.
When to refer
Suspected cauda equina syndrome, back pain not responsive to routine analgesics and requiring
parenteral forms or epidural injections, back pain persisting beyond 6 weeks may require referral
to Spine specialist.
12.
Prevention
For persistent, recurring bouts of back pain, the following advice may be useful:

Loose any excess weight

Wear flat shoes as these can reduce the stress on back.

Avoid sudden movements or muscle strain.

Try and reduce any stress, anxiety and tension

Practice good posture ( standing, sitting, driving, sleeping)

Regular exercises

Careful lifting and handling