Low back pain is the most common pain complaint. A vast majority of adults have low back pain at some time in their lives. The long-term outcome of low back pain is generally favorable, but persistent symptoms can affect millions of people. Acute to subacute low back pain is back pain lasting less than 3 months, whereas chronic low back pain persists for 3 months or longer.
Most patients who are seen have nonspecific low back pain, which is low back pain that cannot reliably be attributed to a specific diagnosis. Within the first month, one can have rapid improvement in pain and disability, return to work, and reach normal functionality. Continuing improvement generally occurs over three months with conservative treatments and improved exercise. However, a small portion of patients have worsening symptoms and back pain disability which contribute to most of the cost interventions associated with chronic low back pain.
Multiple treatment options for acute, subacute, and chronic low back pain exist. The options are divided into pharmacologic treatments, minimally invasive interventional treatments, and surgery. For acute pain the options incorporate increasing activity levels and utilizing physical therapy and stretching mechanics. The interventional options for subacute and chronic low back pain who have failed conservative management involve the injection of medications, local anesthetics and/or steroid, into the spinal structures, or destruction of nerves or other tissues with radiofrequency ablation.
The World Health Organizations estimates the lifetime incidence of Low Back Pain is nearly 65-70%. Meaning that most people will experience low back pain in life with increasing prevalence as one advances in age. A vast majority of low back pain is mechanical in nature and associated with Spondylosis (degeneration of the vertebral column) most frequently in the lumbar vertebrae (L1-L5) due supporting the weight of the upper body in conjunction with the hips. It can range from dull aching to sudden, sharp pain after trauma (falls, motor vehicle accidents, or heavy lifting) or can develop progressively over years of arthritis and age-related changes to the spine. Back pain that lasts for more than a couple of days can induce changes in how the muscle components of the back function leading to muscle spasm (Myalgia). Other causes of Spondylosis include sprains or strains from trauma, disc degeneration, herniation or protrusion of discs, Radiculopathy (nerve compression from disc protrusion or inflammation in tissues surrounding nerves), Sciatica, Spondylolisthesis (shifting of the vertebral bodies), or Spinal Stenosis (progressive narrowing of the internal components of the vertebral column leading to compression of nerve tissue). The most common risk factors for developing Low Back Pain are Age, Weight, Fitness Level, and Occupational Hazards (repeated heavy lifting, twisting, vibration of the spine or more sedentary work environments with prolonged sitting and poor posture).
Diagnosing Low Back Pain is typically done by history and physical exam by qualified healthcare practitioners in addition to radiographic studies (Xray, CT, or MRI). Treatment is dictated by severity of symptoms and can range from conservative therapy (Rest, Heat, Ice Treatments) to surgical intervention by an Orthopedic or Neurosurgical Spine Surgeon.
Treatment for low back pain includes Heat or Ice packs aimed at decreasing symptoms from inflammation and maintaining activity levels with stretching exercises and resumption of normal daily activities (avoiding movements that aggravate pain) as soon as possible. Clinical data has shown that bed rest can lead to worsening symptoms due to less flexibility and decreased muscle tone. Strength training exercises are not advised while symptoms persist, but supplementing with Yoga and Physical Therapy give the best evidence for returning to normal activity. Medication Management with NSAIDs (Ibuprofen, Naproxen) can help relieve pain and inflammation, in combination with Anticonvulsants (Gabapentin, Pregabalin, or Zonisamide) and Antidepressants (Duloxetine or Amitriptyline) that help with decreasing symptoms from neuropathic pain. Analgesic medication consists of NSAIDs and Acetaminophen, but sometimes needs the addition of opioid based medications. Opioids should only be used for short periods and only prescribed by a qualified Physician. Temporary benefit with opioids can be achieved; however, opioid medication (Tramadol, Hydrocodone, Oxycodone, Morphine and its derivatives) has been shown to lead to tolerance, addiction, and an actual increase or amplification of the pain response in the central nervous system (Opioid Induced Hyperalgesia). Minimally Invasive Procedures include Epidural Steroid Injections (Interlaminar or Transforaminal Approach), Vertebral Facet Injections, Median Branch Nerve Blocks, Selective Nerve or Nerve Bundle Injections, and Radiofrequency Ablation of Nerves or Nerve Bundles. At times, surgery could be indicated which involves the referral and consultation with an Orthopedic Spine or Neurosurgical Spine Surgeon. Surgical options range from conservative surgical techniques to more substantial stabilization of the spine with fusion and hardware implantation.
Minimally Invasive Procedures
- Epidural Steroid Injection
- Vertebral Facet Injection
- Median Branch Nerve Block
- Sacroiliac Joint Injection
- Major or Minor Joint Injection
- Radiofrequency Ablation
- Spinal Cord Stimulation
- Peripheral Nerve Stimulation
- Trigger Point Injection
- Intrathecal Drug Management
- Ketamine Infusion Therapy