Understanding low back pain

Understanding low back pain

Low back pain is one of the most common reasons for seeking medical evaluation, thought to impact up to 84% of adults at some point in their life. It is one of the leading causes of disability globally and often results in lost workdays and decreased productivity.

Etiologies

There are a wide array of diagnoses that can present with symptoms of low back pain. The vast majority of patients seen in primary care (>85 percent) will have nonspecific back pain, or back pain in the absence of a specific underlying condition that can be reliably identified. Less than 1% will have a serious etiology such as a spinal infection or metastatic cancer, and almost all of these patients will have risk factors or other symptoms.

Nonspecific back pain

The most common etiology of low back pain in patients seen in the primary care clinic, many of whom have musculoskeletal pain. These patients have a lack of risk factors or other symptoms of another disease process, and typically improve within a few weeks.

Spinal stenosis

Lumbar spinal stenosis typically includes additional symptoms of pain in the calf and distal lower leg that is worse with walking and improved with sitting or leaning forward. Along with low back pain, patients may have weakness in the legs or sensory changes.

Radiculopathy

Radiculopathy refers to damage to a spinal nerve root that can cause pain, sensory changes or weakness to the area of the body served by the nerve root involved. A common example is a herniated disk causing impingement on the L5 nerve root, which may manifest as pain or numbness down the side of the leg and into the top of the foot.

Compression fracture

A vertebral compression fracture is a fracture of a vertebral body in the spinal column. It may be preceded by a traumatic fall with severe, localized acute back pain. Osteoporosis is a risk factor and vertebral compression fractures account for approximately 4 percent of patients presenting in the primary care setting with low back pain.

Cauda equina syndrome

Spinal cord compression of the cauda equina, which is the collection of nerve roots at the bottom of the spinal cord, can cause pain, weakness and incontinence. There are many potential causes of cauda equina syndrome, with a herniated lumbar disc the most common.

Infection

A spinal epidural abscess is a rare cause of back pain, that can cause fever, localized back pain and over time radiculopathy. Risk factors include immunocompromised state, injection drug use, infections leading to bacteremia (bacteria in the blood stream), recent spinal injection or epidural catheter placement.

Vertebral osteomyelitis is another type of infection that can cause low back pain that may gradually increase over a period of weeks to months, with or without fever. The clinical presentation may vary based on the extent of the infection, with risk factors including immunocompromised state and injection drug use.

Osteoarthritis

Most commonly presenting in patients over the age of 40, osteoarthritis of the facet joints of the spine may cause low back pain. It is typically worse with activity and improved with rest.

Ankylosing spondylitis

A rare cause of chronic low back pain, with studies ranging from 0.7 to 5 percent among patients with chronic low back pain. Most commonly diagnosed in males under the age of 40, with morning stiffness, improvement with activity, and worsening pain at night.

Metastatic cancer

Another rare cause of low back pain, with a history of cancer as the strongest risk factor for back pain from bone metastasis. Pain is the most common symptom, and patients in addition may have neurological symptoms from spinal instability or cord compression.

Referred pain

Referred pain refers to pain that is felt in a different part of the body than where the pain is actually coming from. Low back pain may be a symptom of a disorder that occurs outside of the spine, such as pancreatitis, kidney stones, or pyelonephritis, among others. Patients often have other accompanying symptoms as well.

Initial evaluation

A good history and physical examination should be performed to determine the need for immediate imaging and further evaluation. For most patients with acute onset of back pain ( < 4 weeks), imaging is not necessary in the initial evaluation.

Indications for imaging

The majority of patients with acute low back pain will not require imaging and will rapidly improve. The American College of Physicians recommends that “clinicians should not routinely obtain imaging or other diagnostic tests in patients with nonspecific low back pain”, and reserve imaging for patients with severe or progressive neurologic deficits, or when serious underlying conditions are suspected based on the history and physical examination. Approximately 95% of patients with acute back pain < 6 weeks will not require immediate imaging.

Red flags, or high risk findings

Certain findings or risk factors may indicate a potentially more serious cause of back pain and earlier imaging would be indicated. A history of cancer, older age, prolonged use of corticosteroids (like prednisone), severe trauma, and presence of a contusion or abrasion may warrant earlier imaging. Other “red flags” include urinary retention, fecal incontinence, lack of sensation in the buttocks, groin and inner thigh area (saddle anesthesia), progressive moderate or severe leg weakness.

Why not image everyone?

Early imaging for non-specific low back pain without risk factors is not associated with improved outcomes, and increases the use of invasive procedures and health care costs. A large systematic review and meta-analysis in 2009 compared immediate imaging with MRI, CT or x-ray with usual care for patients with acute and subacute low back pain without risk factors, and found no differences in short-term or long-term outcomes for measures of patient pain or function.

In adults without low back pain, imaging often shows abnormal findings which makes it challenging to determine which imaging findings are clinically significant. For example, disc herniations on MRI are seen in up to 67% of asymptomatic adults over age 60. Osteoarthritis is also commonly seen on imaging but with questionable clinical significance with many patients reporting no symptoms. Incidental imaging findings, unrelated to symptoms, may lead to unnecessary additional testing or interventions.

Ongoing monitoring

If patients did not undergo imaging on initial evaluation and subsequently develop muscle weakness or progressive sensory changes, imaging should be performed. After four to six weeks of conservative therapy without improvement, imaging should also be performed as part of an additional workup.

Management of nonspecific acute low back pain

Non-medication treatment with superficial heat and massage, along with medications such as NSAIDs (ibuprofen, naproxen, meloxicam, etc), muscle relaxants or acetaminophen are common approaches for providing symptomatic relief.

Importantly, bed rest is no longer advised after studies showed it was associated with increased pain and a slower recovery than patients who are ambulatory. For those with significant pain, activity modification may be necessary, but patients should gradually increase activity as tolerated and avoid prolonged periods of inactivity.

Outcomes

The prognosis for patients with acute nonspecific low back pain is excellent. Of those who present for evaluation, 70 to 90 percent improve within seven weeks. While recurrences are common and affect up to 50 percent of patients within six months, recurrences also have a favorable prognosis. A low percentage of patients (5-10 in some studies) will subsequently develop chronic low back pain.

Prevention strategies

Preventing low back pain involves adopting healthy lifestyle habits:

• Regular exercise: Engaging in regular physical activity can strengthen the core and back muscles.

• Proper ergonomics: Adjusting workstations and using proper lifting techniques can minimize strain.

• Weight management: Maintaining a healthy weight can reduce stress on the back.

Conclusion

Low back pain is a common yet manageable condition. If you’re experiencing persistent or severe pain, it’s essential to consult a physician for a proper evaluation and tailored treatment plan. Remember, early intervention and lifestyle modifications can significantly improve outcomes and help you maintain an active, fulfilling life.

Florida Direct Primary Care

At Florida Direct Primary Care, we develop individualized treatment plans that promote overall health and wellness, tailored to each patient’s unique health needs and goals. If you’re in the St. Augustine area and looking for a primary care, sports medicine, or obesity medicine doctor, contact us to learn more about the practice. Visit FloridaDPC.com, email us at info@FloridaDPC.com, or call 904-650-2882.

This web site is provided for educational and informational purposes only and does not constitute the provision of medical advice or professional services. The information provided should not be used for diagnosing or treating individual health problems or diseases. Those seeking medical advice should consult with a licensed physician.

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