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20 May 2010
Low Back Pain
Low back pain is the most common musculoskeletal problem that requires medical attention, and is the fifth most common reason for a physician visit (1). The “lumbar” spine, which is the Latin and medical term for low back, is made of five lumbar vertebra (L1-L5). The low back bones (vertebrae) hold the intervertebral discs. The lumbar vertebrae connect to soft tissue (muscles, ligaments, and tendons), and allow five lumbar spinal nerves to exit. The spinal cord runs through the middle of the vertebrae in the spinal canal, but the spinal cord typically ends in the high lumbar area (L1-L2) in most adults.
There are two initial categories of low back pain: acute low back pain and chronic low back pain. Acute low back pain has a sudden onset and generally does not last longer than 3-4 weeks. Chronic low back pain is when the pain persists longer than 4 weeks after an acute injury, or pain lasts greater than 3 months with no history of an acute injury. Low back pain can be further divided into the source or pain.
Common causes of low back pain
- Muscle strain or tear
- Ligament strain or tear
- Myofascial syndrome is pain and inflammation from muscles and their connections. It is often associated with trigger points.
- Spondylosis or wear and tear from arthritis.
- Disc related pain
- Discogenic pain, including disc tears, bulging discs, herniated discs, disc protrusion, disc extrusion, and degenerative disc disease.
- Radiculitis (irritation of a lumbar nerve root).
- Radiculopathy (an abnormality of a lumbar nerve root).
- Facet joint arthritis or facet syndrome.
- Central spinal stenosis or narrowing of the spinal canal.
- Neuroforaminal stenosis or narrowing of the nerve-exiting canal.
- Diffuse Idiopathic Skeletal Hyperostosis (DISH Syndrome) which is a syndrome with calcifications in the ligaments and tendonsalong the lumbar spine.
- Vertebral body fracture.
Dr. Tory McJunkin explains the sources of low back pain. Low back pain can come from a variety of sources and cause different types of pain. It is very important to seek proper care for treatment.
Low back pain is diagnosed by a history of pain from a patient and a physical exam by a physician. Conservative measures are often taken first if pain is the primary complaint and the patient is lacking from new neurological abnormalities such as: weakness, loss of balance, and/or bladder dysfunction. Conservative measures such as rest, heat packs, and anti-inflammatory medications are often attempted first. Should these prove ineffective, diagnostic measures such as x-rays, CT scans, and MRIs are used for a diagnostic source of pain. Additional pain medications and more directed pain treatments such as physical therapy and/or chiropractic care are then initiated. If pain still persists, advanced pain practioners (pain doctors, surgeons, and other specialists) are typically utilized.
Even though the majority of low back pain is self-limiting, when low back pain is present in the following situations an individual should seek medical attention:
- History of a recent infection
- Fever or temperature over 100⁰ F
- IV drug use, which increases risk of an infectious cause.
- Low back pain worse at rest, which may be associated with an infectious cause or cancer.
- Unexplained weight loss, which may be associated with cancer.
- New or unexplained weakness or paralysis
- Loss of bowel or bladder control
- New changes with prior history of cancer
- Recent significant trauma such as a fall from a height or motor vehicle accident
Statistics: Incidence/Prevalence
In 2002, the National Health Interview Survey (NHIS) revealed that one in four adults (26.4%) in the U.S. had experienced low back within three months (2, 3). This estimate corresponds to approximately 54 million people in the U.S. who have experienced back pain in the past three months (3). Back pain was the most commonly reported pain documented in the NHIS and is more common in adults over the age of 45. Women were more likely to report back pain than men, however, this does not imply men have less incidence of low back pain, it may mean men are less likely to report it. The NHIS also looked at the distribution of back pain amongst racial groups. American Indians and Alaska Natives had the highest prevalence of back pain, while Asian Americans had the lowest prevalence. With greater levels of education, the prevalence of back pain decreased. Comparatively, back pain prevalence decreased with increasing family income (2,3).
Low back pain also has a major social impact. Back pain is the second leading cause of work absenteeism in the US. Spine symptoms account for approximately 25% of all lost work days (4). In 1998, it was estimated that $26.3 billion of health care costs were related to low back pain in the U.S. (4).
Pathophysiology of Low Back Pain
The pathophysiology or the mechanism of action of low back pain can be very complex and depends on the cause of the back pain. Therefore, a clear definition of acute vs. chronic pain must be established before an understanding of the mechanism and the cause of the pain can be developed.
Acute pain is defined by an observable and distinct cause with a short duration (less than 3-4 weeks). Acute pain generally occurs in response to tissue injury from trauma, lack of blood flow, or inflammation. Trauma cases range in cause and can be simple, such as lifting a heavy object to more severe, like a motor vehicle accident. Tissue injury stimulates peripheral pain receptors (nociceptors) that in turn lead to sharp or dull pain in the injured area. A sprained ankle is a classic example of acute pain as local tissue inflammation, swelling, and bruising typically occur along with pain. The pain related to a sprained ankle typically resolves as the ligaments and tendons begin to heal.
Chronic pain is defined by a symptomatic experience of pain extending beyond the normal time frame for healing; generally lasting more than 3 months or pain that persists greater than one month after resolution of an acute injury. Chronic pain is thought to be a result from ongoing tissue injury that activates pain fibers for a prolonged period of time. This can cause a dull or sharp pain that lasts for an extended length of time. Chronic pain can also indicate damage or dysfunction of the nervous system (i.e. spinal cord or a single nerve) which is generally experienced as neuropathic pain. Neuropathic pain is described as a shooting pain and can also be felt as burning, numbness, or tingling. If the pain does not resolve from a sprained ankle and the pain continues and even worsens with time a chronic pain condition such as CRPS (complex regional pain sydrome) or RSD (reflex sympathetic dystrophy) must be suspected. This is a classic example of a chronic pain condition or a neuropathic pain condition.
Pain is a complicated symptom and often presents with a mixture of acute and chronic pain. For instance, a patient could have arthritis in their back which causes them chronic pain and then suffer from a muscle strain which would cause acute pain. Due to the complexity of low back pain, it can be difficult for physicians to pinpoint the exact cause or nature a patient's back pain.
Causes of Low Back Pain
Muscle Strain
The most common cause of acute low back pain. The strain can occur immediately after some type of strenuous physical activity or can be delayed and occur a few hours after physical activity. Muscle strain means the muscle underwent an abnormal elongation while being used, resulting in stretching or even tearing small fibers that make up a muscle. The back is supported by a large number of muscles, but the most common muscles to be strained are the paraspinous muscles, located next to the spine. These muscles provide support for the spine and aid in the movement of the spine.
Ligamentous Strain
Similar to a muscle strain. A ligament attaches one bone to another bone to form a joint. Ligaments support the bones and keep them in a proper position during movement. A strain of a ligament occurs when the ligament is stretched beyond its normal range (such as twisting). Both strains can vary in symptoms from dull to sharp pain, or an aching feeling. Patients can also experience muscle cramping or spasms as well. Generally this type of back pain is reduced when lying down (5).
Lumbar Spondylosis
A type of arthritis that occurs in the small joints in the back, known as the facet joints. This is also called lumbar facet syndrome and can be associated with degenerative disc disease. Besides the spine, arthritis can occur in the knees, feet, hips, and fingers. It is often caused by "wear and tear" on a joint. When one vertebrae begins to rub on another vertebrae, the joints connecting them (called facet joints) can become irritated or inflamed, leading to back pain. People with spondylosis of the spine may also develop bone spurs or osteophytes, which can also cause low back pain (5, 6, 7).
Herniated Disc
Called many different things, including: bulging disc, disc extrusion, “slipped disc,” and sequestered disc. The spinal backbone is comprised of 33 individual bones called vertebrae. Between each vertebrae there is a cushion called an intervertebral disc. The intervertebral disc provides support to the backbone and helps cushion stress placed on the vertebrae. The center of the disc is a gel-like substance called the nucleus pulposus. The outer disc ring is more fibrous and is called the annulus fibrosus. As a person ages, each disc loses its strength and elasticity. There are several types of disc herniations.
- Herniated Disc- a contained herniation or bulging disc is when the nucleus pulposus (center disc portion) bulges out into the annulus fibrosis (outer ring) but does not rupture the annulus fibrosis.
- Extruded Disc- a disc extrusion is when the nucleus pulposus (center material) ruptures the annulus fibrosus (outer ring), but is still attached to the rest of the disc.
- Sequestered Disc- is when the nucleus pulposus (center material) breaks through the annulus fibrosus (outer ring) and is no longer attached to the disc.
Each disc is located near nerve roots that branch off the spinal cord and exit between the vertebrae. When a disc herniates, it can compress one or more of these nerve roots, leading to pain in the back or legs. A herniated disc can occur during trauma (heavy lifting, fall, car accident) or can happen after long periods of strain and degeneration (weakening of the disc with age). Symptoms often associated with a slipped disc are back pain that occurs suddenly but is often preceded by several months of aching pain. The pain can be localized in the lower back or may travel down the legs depending on where the herniation occurred in the spinal column (5).
Discogenic Pain
Pain that comes from the disc itself. The intervertebral disc provides support and cushions stress placed on the vertebrae. The center of the disc is a gel-like substance called the nucleus pulposus. The outer disc ring is more fibrous and is called the annulus fibrosus. As a person ages, each disc loses its strength and elasticity. Usually discogenic pain implies some injury to the disc itself as the disc has a nerve supply and can be a source of pain. Many times discogenic pain is associated with annular (the outer part of the disc) tears or disc tears.
Degenerative Disc Disease (DDD)
Also known as disc break down is a natural part of aging, and most people will exhibit some disc degeneration over time. With age, the intervertebral discs lose fluid. This fluid loss can decrease their ability to absorb shock and they become less flexible. It also causes the disc to shrink, making the distance between the vertebrae shorter. All of these changes can produce chronic low back pain. Degenerative disc disease can occur anywhere in the spine but most commonly occurs in the lumbar spine, or lower back. The loss of fluid in the discs can lead to small tears or cracks in the disc, and can increase the risk of disc herniation (5, 6, 7).
Spondylolisthesis
Classified as occuring when one or more vertebrae slip forward causing the spinal column to be misaligned. This is usually due to degenerative disc disease or can be genetic. This leads to chronic low back pain and instability with pain that is increased with activity or bending (5, 6, 7).
Central Spinal Stenosis
A narrowing of the center part of the spinal canal. The vertebrae protect the spinal cord and/or nerve roots located in the spinal canal. Central spinal stenosis occurs when the spinal canal narrows, and is typically found in middle-aged or elderly people. When the spinal canal narrows it begins to compress nerve roots or the spinal cord near the narrowing. This leads to back pain that often travels to the buttocks and legs. Patients may also have numbness or weakness in their legs. Generally, the pain is worse with standing or walking and improves by bending forward (6).
Neuroforaminal Stenosis
A narrowing of the side part of the spinal canal where the nerve roots exit the spinal column. Neuroforaminal stenosis occurs when the neuroforamen or the nerves exiting area is narrowed. At each of the 33 vertebrae a nerve root branches off the spinal cord and exits the spinal canal between the vertebrae. When this area narrows it begins to compress nerve roots that are exiting the spinal canal near the narrowing. This can lead to pain that often travels to the buttocks and legs. Patients also may also have numbness or weakness in their legs (6).
Vertebral Compression Fracture (VCFs)
Occurs when a bone of the spine (vertebrae) breaks or collapses. A severe trauma could cause a compression fracture in a healthy adult. However, elderly patients with osteoporosis can have vertebral compression fractures with minimal or no trauma. Osteoporosis occurs when the bone weakens and becomes less dense, thereby increasing the risk of fracture. Elderly women are more prone to osteoporosis than elderly men. Compression fractures produce localized pain at the site of the fracture, with pain that radiates across the back and around the trunk (7).
Sacroiliac Joint Pain
Can be a source of low back pain, although the sacrum is below the lumbar vertebrae. The last lumbar vertebrae connects to the sacrum which is a fused segment made up of five bones. The sacrum connects to the iliac bones, which connect to the hips. The sacroiliac joint is a large joint on either side of the sacrum that transmits the weight from the lumbar spine to the legs.
Anklyosing spondylitis
Related to a specific gene, meaning most patients will have a family history of this disease. A chronic inflammatory disease of the spine and the sacroiliac joints, this disease may cause the patient to start exhibiting symptoms as young as age 15. The sacrum is the last portion of your spine and the iliac bones are part of your hip bones. The sacroiliac joint is where the sacrum and the right and left iliac bones connect and are held together by ligaments. Symptoms of this disease include morning stiffness, aching pain, decreased range of motion in the back and tenderness over the sacroiliac joints (6).
Infection of the Spine (Veterbral osteomyelitis)
An infection in one of the vertebrae that makes up the back bone. The source of infection is usually from a urinary tract infection, an abscess on the skin, a catheter such as an epidural catheter, or from intravenous drug abuse. This can occur at any age and the infection is commonly located in the lumbar spine or sacrum. The infection causes sharp pain, fever, tenderness over the infection, and may cause weakness or decreased range of motion (6).
Cancer in the Spine
Also could be a source of pain. Malignancies (cancers) can have an initial source in the vertebral bodies, or more likely are from another source which metastatic cancer has spread to the spine. Breast, lung, prostate, kidney, and thyroid cancer are the most common cancers to metastasize or spread to the spine. The pain is often described as a dull or throbbing pain, which progressively gets worse over time. The pain may wake the patient up at night. Pain can be increased by lying down or coughing. There may also be some tenderness over the affected vertebra and neurologic problems like weakness, decreased reflexes, urinary or stool incontinence (5, 6, 7).
Risk Factors
- Obesity
- Smoking
- Poor overall health
- Lumbar Injury
- Certain occupations that involve heavy physical work particularly involving long periods of static work postures, heavy lifting, twisting, and vibration.
- Current psychological stress
- Depression
- Other chronic pain conditions
- Job dissatisfaction
- Severe scoliosis (8).
Diagnosis of Low back Pain
Physical Exam Findings
In patients with acute back pain, the initial history is used to identify those who are at increased risk for serious underlying conditions, such as fracture, infection, tumor, or major neurologic deficit. The presence of any of the above factors suggests earlier evaluation with imaging and labs than patients without these factors. After completion of a proper question and answer session about the pain, the physician will perform a physical exam specifically focusing on the patient's muscles, bones, and nervous system. To assess muscles and bones, the physician will perform several strength tests and have the patient move their extremities to assess range of motion. The physician will examine the patient for any tenderness to touch over the area of pain. Reflexes of the extremities, sensation, and the patient's walk will also be examined. Common maneuvers a physician can perform to determine the location or the source of the patient’s pain, are explained below (8):
Straight Leg Raise Test
The patient will lie on their back and the doctor will raise the patient’s leg up in an attempt to reach a ninety degree angle. Patients with sciatica (compression of the sciatic nerve) will often feel a sharp pain shooting down the leg that is extended, while patients with a herniated disc may feel pain in the opposite leg.
Lasegue Test: is a variation of the straight-leg test. The patient will lie on their back and the leg on the side of the pain will be flexed to ninety degrees at the hip and knee. Then the physician will slowly extend the knee to determine if this replicates the pain indicating a nerve root compression located at the fifth lumbar vertebrae or the first sacral nerve root.
Faber Test
The patient will lie on their back with the foot relating to the painful side is placed on the opposite knee. The patient's bent knee will be slowly rotated externally (outwards). If pain is felt during the rotation, this indicates the pain may be caused by a problem in the hip or sacroiliac joint.
Prone Straight Leg Raise Test
This test is performed with the patient lying on their stomach. The Leg relating to the painful side will be slowly extended at the hip by the doctor. If the patient experiences pain during this maneuver, it may suggest a nerve compression higher in the lumbar spine near L2 or L3.
Valsalva Test
Also know as bearing down as if having a bowel movement. Pain during valsalva can indicate nerve compression.
Gaenslen Test: This test is performed with the patient lying on their back with their buttocks and legs extending past the edge of the exam table. The leg on the side without pain will be bent at the hip and knee and brought to the patient's chest. Then the physician will apply slight downward pressure to the other leg (the side with pain) that is extended out. Pain that is localized to the lower back and buttocks during this test suggests sacroiliac inflammation or disease.
Imaging
In 90% of patients, low back pain will improve within one month. Therefore, conservative treatment is generally recommended before diagnostic imaging is performed. If the patient is at high risk for a serious underlying condition, an imaging study of the spine is commonly utilized earlier than in those patients who exhibit lower risk factors. Patients who have persistent pain after 4-6 weeks of conservative management should be re-evaluated, and will likely undergo further testing. An MRI is the best tool to confirm a herniated disc and is indicated when a patient's pain has failed to respond to conservative treatment and has persisted for at least 3 months. Plain radiography or x-rays of the spine can show fractures and signs of osteoarthritis, ankylosisng spondylitis, and spondylolisthesis. CT scan can be utilized when MRIs can not be used or for suspected malignancy or infection (5, 6, 7, 8).
Diagnostic Interventions
Selective Nerve Root Blocks for low back pain
A local injection procedure used for diagnostic and therapeutic purposes. It has also been used when the clinical exam and imaging studies fail to correlate.
Medial Branch Blocks (MBBs) for low back pain
May be therapeutic and/or diagnostic. If there is no pain relief after a MBB, then the pain is likely not coming from the facet joint. If the pain gets >50% better for a few hours, the pain may be caused by the facet joints.
Sacroilac Joint Injection (SI Joint) for low back pain
May be therapeutic and/or diagnostic. If there is no pain relief after a SI joint injection, then the pain is likely not coming from the sacroiliac joint. If the pain gets >50% better for a few hours, the pain may be caused by the sacroilac joints.
Discography for low back pain
Used to determine whether or not pain is coming from a disc and for identifying abnormalities in the disc. Abnormalities can include disc herniations, tears and fissures. This procedure involves the injection of contrast dye into the center of a disc under x-ray guidance. It is strictly a diagnostic procedure. An x-ray will be taken so the physician can see if the dye is leaking from the disc, which would indicate disc degeneration or a weakening in the annulus fibrosus. A few discs will be examined that correlate to the location of the patient's pain, and each disc is examined for the amount of pain that is produced during the dye injection, the volume (amount) of dye injected, the pressure within the disc, and any findings seen on x-ray. This procedure is repeated for each disc that needs to be examined (9).
Trigger Point Injections (TPIs) for low back pain
Can diagnose if muscles are the source of pain.
Hardware Injections for low back pain
Can diagnosis if hardware implanted in the low back is a source of pain.
Treatment for low back pain
Initially for acute low back pain, conservative treatment will be suggested. Conservative treatment consists of rest, physical therapy, and non-steroidal anti-inflammatory drugs (NSAIDs) such as aspirin or ibuprofen. Strict bed rest can actually worsen the pain and prolong the healing process, so bed rest should be limited to no more than 2-4 days. Continuation of normal activities is advised as long as the patient remains within the limits permitted by their pain. Physical therapy will help improve range of motion and safely increase the strength of the back muscles (10, 11).Medications for Low Back Pain by Class
(11, 12)Non Steroidal Anti-Inflammatory Drugs (NSAIDs) for back pain
Ibuprofen, Advil ®, Aleve®, Nuprin®, Motrin® and others are anti-inflammatory medications. These medications provide good short-term relief of Neck Pain and can be used as an adjunct for long-term pain conditions. Because of the risk of ulcers, gastrointestinal bleeding, and decreased kidney function talk with your doctor before using these medications.
Acetaminophen (Tylenol®) for back pain
Acetaminophen is a slighter weaker analgesic (pain reliever) than aspirin but it is generally more cost efficient and has a better safety profile. Both aspirin and acetaminophen are considered first line medications for low back pain. This medication is often added to other pain medications because of its synergistic effect with these medications. This medication must be taken as directed and care should be taken when taken regularly as excessive use can cause liver dysfunction.
Muscle Relaxants for back pain
Including cyclobenzaprine (Flexeril®), metaxalone (Skelaxin®), methocarbamol (Robaxin), tizanadine (Zanaflex), baclofen (Lioresal), and carisoprodol (Soma) treat painful muscle spasms. The most common side-effects include drowsiness, dizziness, drug interactions, and abuse (most commonly with Soma).
Anti-Convulsants for back pain
Considered membrane stabilizing medications as they are believed to “calm down irritated or hyperexcited nerves” which are responsible for neuropathic pain. These medications include gabapentin (Neurontin), pregabalin (Lyrica®), topiramate (Topamax), and others. Many have the side-effect of weight gain (excluding topiramate), drowsiness, dizziness, and trouble concentrating.
Anti-Depressants for back pain
Considered membrane stabilizing medications as they are believed to “calm down irritated or hyperexcited nerves” which are responsible for neuropathic pain. Within these medications are multiple tricyclic anti-depressant (TCAs) medications, which include the commonly used pain medications amitryptiline (Elavil) and nortriptyline (Pamelor). Newer anti-depressant pain medications are in the serotonin norepinephrine reuptake inhibitor(SNRI) category. These medications include duloxetine (Cymbalta®) and milnacipran (Savella).
Steroid Medications for back pain
A high-dose, fast-taper course of corticosteroids (ie. Medrol dose pack) can be used if there is a strong suspicion of nerve root impingement by disk protrusion or spondylosis. Systemic corticosteroids are used to reduce inflammation and swelling. Systemic means the medications affect your entire body, and not just the area of pain. Clinical guidelines released by the American College of Physicians and the American Pain Society in 2007 do not recommend systemic corticosteroids for low back pain. Several studies have found no clinically significant difference between systemic corticosteroids and placebo (no treatment). Long-term use of corticosteroids has been associated with causing osteoporosis, Cushing's syndrome, and weight gain.
Opioid Medications for back pain
Also called narcotic pain relievers. These include codeine, hydrocodone, morphine, oxycodone, oxymorphone, hydromorphone, meperidine, fentanyl, methadone, propoxyphene and other medications. These medications are used to treat severe pain. Side-effects commonly include nausea, drowsiness, dizziness, tolerance, constipation, and addiction.
- Tramadol (Ultram®): works on the central nervous system to produce analgesia (pain relief). Tramadol is sometimes considered an opioid, but has a slightly different mechanism of action so it is considered in its own class. Like opioids, tramadol can cause sedation, constipation, dizziness, and nausea.
Minimally Invasive Interventions for low back pain
Epidural Steroid Injections (ESIs) for low back pain
Commonly used to treat radicular pain symptoms or pain which radiates from an irritated nerve root. Epidural steroid injections are used for radicular pain in the lumbar spine. Radicular pain is pain that is caused by an inflamed or compressed nerve, leading to sharp pain that travels down to the hip or legs. The physician will guide the needle to the correct location by fluoroscopic guidance (x-ray). The most common conditions that benefit from epidural steroid injections are lumbar (lower back) disc herniation, spinal stenosis, and inflammation of a nerve root. Epidural steroid injections are usually reserved for patients with persistent severe pain that is non-responsive to conservative care. Patients may receive a series of injections, usually administered 3-4 weeks apart, depending on the type of corticosteroid injected. These injections are for temporary pain relief and may not resolve the underlying condition (13, 14). Often the goal of ESIs is to allow sufficient pain relief to permit more active physical therapy and greater functional recovery. The steroids act on the nerve roots as they branch from the spinal cord by decreasing inflammation and irritation.
Lysis of Adhesions (adhesiolysis) for low back pain
Also known as the "Racz procedure," as it was invented by Dr Gabor Racz. The procedure is similar to an epidural steroid injection, but is designed to dissolve scar tissue in the epidural space. It is used to treat post-laminectomy syndrome, radiculopathy, spinal stenosis, and disc disease.
Medial Branch Blocks (MBBs) for low back pain
Also known as facet injections and are used to treat neck pain that comes from the facet joints. The "blocks" work by blocking the nerves that innervate the facet joints, which are prone to arthritic changes.
Radiofrequency Ablation (RFA) for low back pain
A procedure that targets the same medial branch nerves, and thus, has similar indications to MBBs. Radiofrequency ablation uses electrical energy to cauterize or “burn” the nerves that innervate the joints. RFA blocks the ability of the facet joints to send painful signals to the brain.
Spinal Cord Stimulation (SCS) for low back pain
Known by many pain physicians as the “pacemaker for pain” is a minimally invasive procedure that involves implanting a device that applies low currents of electrical stimulation through thin wires. The leads or wires are placed under x-ray guidance into the epidural space, where they block pain signals.
Trigger Point Injections (TPIs) for low back pain
Can be an effective treatment for muscle spasms. The procedure involves injecting a local anesthetic and/or steroid into a hyperirritable area of muscle, called a trigger point.
Surgical Interventions for low back pain
There are several types of spine surgeries, depending on the diagnosis. Spine surgery is only an option after more conservative measures like medications, physical therapy, and injections have failed or if serious neurological deficits are present like weakness, or loss of bowel/bladder control.
Discectomy for low back pain
A procedure where the center of the disc, the nucleus pulposus, is removed from the intervertebral disc. This is utilized in serve cases of herniated discs that are causing pain by placing stress on the spinal cord or nerve roots (15).
Foraminotomy for low back pain
Used to relieve a nerve root compression. The neural foramen is a space between each back bone where nerve roots that branch off the spinal cord exit the spinal canal. This space can become narrowed by bone spurs, ligaments that have become too large, and other material. When this occurs, it is called neuroforaminal stenosis. The surgeon will remove anything that is obstructing the neural foramen to allow ample room for the nerve root to exit the spinal canal without being compressed (15).
Laminectomy for low back pain
Used in cases of spinal stenosis (spinal canal narrowing) and in patients with narrowing and a herniated disc. This surgery removes a portion of the vertebra called the lamina which covers the spinal canal. By removing this part of the vertebra, the spinal canal is widened, relieving pressure placed on the spinal cord or nerve roots (15).
Lumbar Spine Fusion for low back pain
Most commonly performed at the fourth and fifth lumbar vertebral segments, but can be performed at any level. This surgery is used for a number of conditions including spinal instability, degenerative disc disease, scolosis, and spondylolisthesis. A bone graft may be taken from the patient's hip during the surgery and is then placed between the two vertebra to be fused, which causes them to grow together to form one bone. Screws and two metal rods will help hold the two vertebral bodies together (15).
Artificial Disc Replacement for low back pain
May be performed for degenerative disc disease or discogenic pain and is seen as an alternative to spinal fusion. The surgeon will remove the damaged disc and replace it with an artificial disc. The benefit of an artificial disc is that range of motion is expected to be better with the disc replacement than with spinal fusion (15).
Complementary and Alternative Treatment Options for low back pain
Physical Therapy for low back pain
Beneficial in both rehabilitation from an injury and prevention of future injury. Passive physical therapy involves: heat/ice packs, TENS, ultrasound. Active physical therapy includes: stretching, strengthening exercises, spinal manipulation, and low-impact aerobic conditioning. According to the clinical guidelines from the American College of Physicians and the American Pain Society released in 2007, superficial heat was the only non-pharmacologic therapy with good evidence for effectiveness in acute back pain (16).
Chiropractic Manipulations for low back pain
When done correctly as targeted adjustments, these treatments may significantly reduce neck pain when combined with other modalities of treatment. Spinal manipulation has been shown to be slightly better than placebo in one study for acute low back pain (16).
Exercise for low back pain
Physical activity is encouraged and works similar to physical therapy by increasing strength, and also releases endorphins. For chronic low back pain, it has been shown that exercise, rehabilitation and spinal manipulation have moderately efficacious results (16).
Acupuncture for low back pain
This treatment involves placing small needles into the skin, causing release of hormones called “endorphins,” the body’s natural pain reliever. Acupuncture has been used for several thousand years to treat pain and other maladies. Acupuncture has been shown to be very helpful at relieving symptoms in those with chronic pain. Additionally, acupuncture, massage and yoga have been found to provide some mild relief in chronic low back pain (16).
Biofeedback and Cognitive Behavioral Therapy (CBT) for low back pain
These treatments teach a patient to become aware of his/her body processes that are normally thought to be involuntary, such as temperature regulation, heart rate, and muscle tension. A better awareness of one’s body teaches one to effectively relax and can help to relieve pain. Cognitive behavioral therapy (CBT) is based on the idea that the mind affects the body and how each person perceives pain. CBT provides relaxation techniques, stress management, and other ways to appropriately cope with pain (16).
Transcutaneous Electrical Nerve Stimulation (TENS) for low back pain
A technique that relieves pain by applying mild electric current to the skin at the site of the pain. The use of TENS unit technology has been in the medical community for over 30 years. It is a relatively safe, non-invasive device that is easy to use. Some acknowledge that the electrical current delivered inhibits or blocks the pain receptors on nerves that send a signal to your central nervous system, where the body translates these signals into the sensation of pain. By blocking these receptors, the body cannot interpret the sensation of pain. It is also shown that the electrical stimulation increases the body's production of endorphins which are natural painkillers. There are studies that report significant pain relief with the TENS unit and other studies that report no significant pain relief compared to a placebo group (17).
Massage for low back pain
Massage of the tender areas may help relieve muscle spasms or contractions and provide pain relief. Additionally, massage has been found to provide some mild relief in chronic low back pain (16).
Yoga for low back pain
A program of exercises to help improve flexibility. Yoga leads to a decrease in stress and maintains health. The basic components of yoga are proper breathing, stretching, and posture. Yoga has been found to give relief to those with chronic back pain (16).
Prolotherapy for low back pain
Also known as Regenerative Injection Therapy, is a technique of injecting irritant solution into the painful areas of the body. The irritant causes a local inflammatory reaction and one’s body regenerates or heals the pain generating tissue. Prolotherapy is generally used in pain causing tendons and/or ligaments with the aim of strengthening weakened connective tissue and alleviating pain.
References
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