Low Back Pain and Sciatica. Introduction. Low back pain is an extremely common problem that is often poorly managed. Back pain is a particular challenge because it is so common, demanding of medical resources and a major cause of physical, psychological and social disability. Epidemiology.
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Introduction Low back pain is an extremely common problem that is often poorly managed. Back pain is a particular challenge because it is so common, demanding of medical resources and a major cause of physical, psychological and social disability.
Epidemiology • Back pain is extremely common, affecting 80%-90% of adult men and women between the ages of 30 and 50 years. • Back pain is second only to the common cold as a cause of lost days at work.
What is back pain? • Most backache (85-90%) will be so-called simple low back pain (or 'mechanical low back pain') in which the symptoms by definition cannot be ascribed to a particular pathology (infection, tumour, osteoporosis, fracture, radicular syndrome, caudaequina syndrome (CES)). Simple low back ache is also called uncomplicated or non-specific low back pain and will vary with posture, activity, time and treatment. • Radicular (or nerve root pain) may occur with low back pain. Sciatica is a lay term for pain extending into the leg (buttock, thigh, calf or heel). • The classification into acute (less than 6 weeks), sub-acute (6-12 weeks) and chronic (more than 12 weeks) • Recurrent low back pain has been defined as a new episode of pain after a symptom-free period of 6 months.1
Causes • Red flags may suggest spinal fracture, cancer, infection or serious pathology associated with prolapsed intervertebral disc.Other causes of back pain include: • Primary malignancy: • Reticulo-endothelial system (myeloma is the most likely) • Carcinoma of pancreas • Osteosarcoma (does not usually affect the spine) • Secondary cancers are usually from: • Bronchus • Breast • Prostate • Thyroid • Kidney • Bone disorders including: • Paget's disease of bone (affects the pelvis in 72% of cases and the lumbar spine in 58%) • Osteoporosis (leading to vertebral collapse) • Spinal stenosis
Inflammatory disease, for example: • Ankylosing spondylitis (AS) which tends to present: • Slowly in men under age 40 • With a rigid back • With aggravation by inactivity and relief with exercise • Psoriatic arthritis (rash or family history of psoriasis) • Reiter's syndrome (symptoms including urethritis) • Arthritis associated with inflammatory bowel disease (usually arthritis is peripheral) • Infection: • Never forget tuberculosis (osteomyelitis can occur) • HIV predisposes to infections (including tuberculosis) • Renal tract infection (pyelonephritis can also cause referred back pain) • Causes from outside the spinal column include: • Dissecting aortic aneurysm • A posterior duodenal ulcer presenting as back pain may be difficult to diagnose. If a gastric ulcer presents for the first time over the age of 40, malignancy needs to be excluded. • Nephrolithiasis • Pyelonephritis • Factors suggesting malignancy include age greater than or equal to 50 years, previous history of cancer, duration of pain greater than 1 month, failure to improve with conservative therapy, elevated ESR, and anaemia.8 Consideration of these associations can reduce the number of fruitless back X-rays without missing malignancy.
History What should the history include- • When did the pain start? • Was it sudden or gradual in onset? • Where is it? • Does it radiate anywhere else? • Are there any aggravating or relieving factors? • Has the patient had this problem before? • Ask about occupation, what it involves and hobbies or sport. • What does the patient think caused the pain? • Note past medical history. Steroid use predisposes to osteoporosis. Has there been malignancy that metastasises to bone (lung, breast, prostate, thyroid, kidney) or myeloma? • How has the patient been managing the condition? This includes analgesics taken, whether they have been adequate and attitude to the condition.
Red flags from history • Red flags for possible serious spinal pathology from the history are • Recent violent trauma (such as vehicle accident or fall from a height) • Minor trauma, or even just strenuous lifting, in people with osteoporosis • Age at onset less than 20 or over 50 years (new back pain) • History of: • Cancer • Drug abuse • HIV • Immunosuppression • Prolonged use of corticosteroids • Constitutional symptoms, e.g. fever, chills, unexplained weight loss • Recent bacterial infection, e.g. urinary tract infection • Pain that is: • Worse when supine • Severe at night time • Thoracic • Constant and progressive • Non-mechanical without relief from bed rest or postural modification • Unchanged despite treatment for 2-4 weeks • Accompanied by severe morning stiffness (rheumatoid arthritis and ankylosingspondylitis) • Severe and leaves patients unable to walk or self-care • Accompanied by saddle anaesthesia or recent onset of difficulty with bladder or bowels
Examination • A brief examination for acute back pain is recommended with the patient undressed, revealing spine, and standing. • The brief examination should incorporate: inspection, palpation, brief neurological examination and an assessment of function. • More detailed neurological examination will be necessary if the history suggests any red flags, e.g. confirming saddle anaesthesia and diminished anal tone if CES is suspected. • Passive straight leg raising is often used to assist diagnosis of nerve root pain but it is highly sensitive (90%) and not very specific (20%).7
Red flags from examination • Structural deformity • Severe or progressive neurological deficit in the lower extremities • Unexpected laxity of the anal sphincter • Perianal/perineal sensory loss • Major motor weakness: knee extension, ankle plantar eversion, foot dorsiflexion • Caudaequina syndrome should be suspected if: • Bladder dysfunction (usually retention, sometimes overflow) • Sphincter disturbance • Saddle anaesthesia • Lower limb weakness • Gait disturbance
Investigations • Note: if the diagnosis would appear to be simple back pain, then no investigation is required. • If other diagnoses are entertained, appropriate investigations are in order, depending upon the suspicion. • Imaging • X-rays- for fractures and osteoporosis • CT-scan-spondylolisthesis • MRI-soft tissues,disc and nerves. • Bloods • Full blood count, ESR, CRP, urine analysis if cancer, infection or inflammation suspected.9,10 • LFTs may be helpful. Alkaline phosphatase can be elevated in metastatic disease and Paget's disease of bone. • PSA will be raised particularly in carcinoma of the prostate.
Management • Initially rest - perhaps with a board under the bed - was recommended for back pain. The new guidelines recommended active rehabilitation. The new principles of management involve keeping the patient active and giving analgesia to facilitate this. • Give information, reassurance and advice. • DO NOT prescribe bed rest. • Advise to stay as active as possible. • Prescribe regular pain relief (paracetamol, non-steroidal anti-inflammatory drugs) and consider a short course of muscle relaxants.
Other treatment options • acupuncture – fine needles are inserted into your skin at certain points on the body • exercise classes – aerobic exercise, muscle strengthening and stretching • manual therapy – your back is massaged or manipulated • Chiropractor and osteopaths.
Referral guidance • If red flags suggest a serious condition, refer with appropriate urgency. This means immediately for CES. • If there is progressive, persistent or severe neurological deficit, refer for neurosurgical or orthopaedic assessment, preferably to be seen within 1 week. • If pain or disability remain problematic for more than a week or two, consider early referral for physiotherapy or other physical therapy. • If, after 6 weeks, sciatica is still disabling and distressing, refer for neurosurgical or orthopaedic assessment, preferably to be seen within 3 weeks. • If pain or disability continue to be a problem despite appropriate pharmacotherapy and physical therapy, consider referral to a multidisciplinary back pain service or a chronic pain clinic.
Summary of referral guidance • These can also still be thought of usefully as 'immediate', 'urgent' and 'soon' referrals: • Immediately: • CES • Urgently: • Serious spinal pathology suspected • Progressive neurological deficit • Nerve root pain not resolving after 6 weeks • Soon: • Inflammatory conditions suspected, e.g. AS • Simple back pain and not resuming normal activities after 2-3 months