Lumbalgia

Lumbalgia is the medical term for the more common lay description of low back pain or lower back pain. It is used to describe a symptom related to the lower section of the human spine. Persistent and recurring low back pain affects 60 - 80% of people at some stage in their life and is the most common reason for lost work.

Low back pain varies in intensity, frequency, duration, and quality depending on the cause and stage of injury or illness as well as the time of day and activity level. It is considered either acute (of recent origin) or chronic (longer term) in nature, though these give little insight as to a particular cause of the pain. The degree of pain ranges from a mild annoyance that comes and goes to constant and totally disabling.

Etymology

"Lumbalgia" derives from the Latin "Lumbaris" referring to the lower or loin region of the body and "algia" is from the Greek "algos" for pain.

Background

The low back performs two major functions; to act as a weight bearing column that supports upright posture and to act as a conduit that protects the spinal cord and the tender nervous system that transmits through it. As a supporting structure, it carries the weight of the upper torso including the head, arms, thorax, and abdominal contents. Impact forces from actions such as walking or jumping multiply these forces exponentially.

The structures of the adult low back consist of the lower five verterbae along with the ligaments, discs and muscles that support it. Together they are identified as the lumbar region of the spine and are frequently labeled L1 to L5. The range of movement that occurs at the lumbar level combined with flexion of the hips is responsible for the majority of the total range of motion necessary for bending. The lumbar spine sits atop the sacrum which is a wedge shaped bone that rests into a space formed by the left and right innominate bones. The innominates are divided into the ilium, ischium and pubis and, with its attached musculature, make up the pelvic girdle that acts to connect the leg to the torso. Together with the sacrum, the left and right innominates wrap around to the lower abdominal region, creating a "bowl" that supports the organs contained within the abdomen. The joint between the sacrum and each innominate (sacroiliac joint) allows for slight motion with walking and bending. The sacrum and innominates together with their supporting ligaments and muscles are referred to as the pelvis. The resulting circle-like formation is commonly called the pelvic ring. For the lay person, the combination of the lumbar and pelvic regions are effectively called the low back. Low back pain can be generated from injury to any or all of the joints, muscles, ligaments or nerves that make up the region as well as organs in the pelvic bowl that get their nerve supply from the low back.

For the purposes of understanding the causes of low back pain, it is important to note that all pain is a perception of the person that is experiencing it. These perceptions are the result of an intricate relationship between the nerve endings that monitor the condition of the tissues and send that information to the higher centers of the brain where the conscious perception actually occurs. The vast majority of the nerve endings are in the ligaments, muscle and outer layers of the disc tissues that support the boney structures. While bones have a thin 'skin' or periosteum that has a plentiful nerve supply, the bones themselves do not. This is also the case of the inner portions of the normal disc. However, in the degenerating disc, growing evidence suggests that nerves that are specific to the sympathetic nervous system infiltrate deep into the damaged disc resulting in a visceral-type pain that is not seen elsewhere in the musculoskeletal system. This may help us understand the central sensitisation that seems to occur with low back pain and explain why "stress" can play a role in chronic low back pain.

Causes

Radiographic abnormalities of the low back may occur in patients without pain. SPECT/CT can identify lesions in some patients and these patients may be more likely to have responses to treatment.

Serious causes of low back pain are uncommon. The majority of acute causes of low back pain are grouped as mechanical type injuries to the ligaments, muscles and joints that are responsible for the function of the vertebral column. The injury may be the result of one traumatic event or multiple, repetitive type traumas. If the cause of these mechanical conditions persist, the pain may develop into a chronic low back pain with a change in symptom quality and frequency depending on the type of structures that become affected, such as discs and nerves. These include diagnoses such as osteoarthritis, degeneration of the discs or a spinal disc herniation.

Some cases of low back pain are related to systemic conditions that affect other regions of the body such as rheumatoid arthritis or cardivascular disease, while a small percentage are caused by tumors (including cancer). There are psychological or emotional components of all disease and low back pain is no exception.

Possible causes of low back pain:

Mechanical: Apophyseal osteoarthritis Ankylosing hyperostosis Scheuerman's osteochondritis Herniated disk Spinal stenosis Spondylolysis Postural strain Facet sprain Muscle strain Spondylolisthesis congenital abnormalities Fractures Inflammatory: ankylosing spondylitis Rheumatoid arthritis Psoriatic arthritis Reiter's Syndrome Infection

Neoplastic: Bone tumors (primary or metastatic) Spinal tumors Metabolic: Osteoporotic fractures Osteomalacia Ochronosis Chondrocalcinosis Paget's disease Referred pain: Pelvic/abdominal disease Cardiovascular disease Tension myositis syndrome Depression

Diagnosis

Often, getting a diagnosis of the underlying cause of low back pain and/or related symptoms, such as sciatica, is quite complex. A complete diagnosis is usually made through a combination of a patient's medical history, physical examination, and, when necessary, diagnostic testing, such as an magnetic resonance imaging or x-ray. However, a randomized controlled trial of routinely obtaining an MRI scan in back pain showed no benefit but increased costs.

History and physical examination

The goal of the history and physical examination is to place the patient into one of three categories of back-related etiology, or identify the pain as coming from a source outside the back:

• "nonspecific low back pain"
• "Back pain potentially associated with radiculopathy or spinal stenosis (suggested by the presence of sciatica or pseudoclaudication)" These patients may have a positive straight leg raise sign.
• Other specific spinal causes

"Back pain potentially associated with another specific spinal cause. The latter category includes the small proportion of patients with serious or progressive neurologic deficits or underlying conditions requiring prompt evaluation (such as tumor, infection, or the cauda equina syndrome), as well as patients with other conditions that may respond to specific treatments (such as ankylosing spondylitis or vertebral compression fractur).".

Diagnostic imaging

"MRI or CT is recommended in patients who have severe or progressive neurologic deficits or are suspected of having a serious underlying condition (such as vertebral infection, the cauda equina syndrome, or cancer with impending spinal cord compression)". Obtaining imaging for lesser reasons may lead to increased costs of unnecessary tests, unnecessary follow-up, and possibly even unnecessary treatment of incidental findings without benefit.

Electrodiagnosis

Nerve conduction studies and electromyography may be useful.

Laboratory studies

Hematological and biochemical tests are rarely needed, except when ruling out specific etiologies. Urinalysis and renal function tests may be useful if there is a suspicion of genitourinary system causation, especially in an exacerbation. Complete blood count (CBC) and erythrocyte sendimentation rate (ESR) are appropriate when fever is present, or if an abscess or osteomyelitis is being considered; ESR is a nonspecific screening test.

Treatment

Clinical practice guidelines American College of Physicians and American Pain Society are available to guide treatment choices; however, 2 years after their publication physicians do not reliably follow the guidelines. Increasingly, health care providers are not following guidelines for the management of low back pain.

Listed alphabetically, some of those evaluations include:

Home or Outpatient

Nondrug treatments

Acupuncture

Acupuncture has uncertain benefit for chronic back pain. While acupuncture may be better than usual care, acupuncture does not seem to be better than sham acupuncture which questions whether it has benefit beyond placebo.

Exercise

Clinical practice guidelines are available.

Back-mobilizing exercises in acute settings are helpful for acute and chronic pain. Over the long-term, the amount of exercise is more important than the type of exercise.

'Back schools', in an occupational setting, can help.

Heat therapy

Heat therapy is useful for back spasms or other conditions in acute or subacute situations.

Massage

Massage has shown some benefit for patients with subacute and chronic non-specific low-back pain, especially when combined with exercises and education..

Pilates

A randomized controlled trial found benefit of Pilates for chronic low back pain.

Psychological treatments

Respondent-cognitive therapy and progressive relaxation therapy can reduce chronic pain as well as exercise therapy..

Spinal manipulation

The role of spinal manipulation is difficult to assess.

• Randomized controlled trials report both benefit and lack of benefit.
• Systematic reviews of spinal manipulation conclude that it has similar benefit to other usual care therapies for both acute and chronic low back pain, but does not clearly add to usual care according the Cochrane Collaboration, the American College of Physicians, and the Agency for Healthcare Research and Quality.

Though considered safe, spinal manipulation is not without risk.

The patients most likely to benefit have at least four out of the following five criteria: 1) symptoms for less than 16 days, 2) no symptoms below the knee, 3) low fear of engaging in work or physical activity, 4) at least 1 hypomobile lumbar joint, and 5) at least 1 hip with more than 35° of internal rotation.

Spinal mobilization

Spinal mobilization does not seem to add to standard treatment of acute lumbalgia and is less effective than manipulation.

Work place modifications

Work place and home habit modifications help most people through assessing any ergonomic or postural factors that may contribute to their back pain, such as improper lifting technique, poor posture, or poor support from their bed or office chair, etc..

Yoga

Yoga either Viniyoga, Iyengar, or Hatha might help with the best evidence, albeit only fair-quality evidence, supporting Viniyoga. More recently, a randomized controlled trial supports the use of Viniyoga with supervision.

Medications

• Acetaminophen (paracetamol) may be as effective as non-steroidal anti-inflammatory agents or spinal manipulation for the short term treatment of acute low back pain. However, another randomized controlled trial found acetaminophen no better than placebo.
• Muscle relaxants are effective in the management of acute non-specific low back pain, but the adverse effects require that they be used with caution.
• Antidepressant medication does not help according to a meta-analysis by the Cochrane Collaboration This contradicts an older meta-analysis by the Cochrane Collaboration, a systematic review by Clinical Evidence, and a systematic review by the American College of Physicians.
• Non-steroidal anti-inflammatory drugs (NSAIDs/NSAIAs) are effective for short-term symptomatic relief in patients with acute low back pain. There does not seem to be a specific type of NSAID which is clearly more effective than others. Sufficient evidence for use of NSAIDS on chronic low back pain is still lacking.

Opioid analgesics

Opioid analgesics are also used. Opioids may benefit acute low back pain. Opioids may increase exercise test performance; however, in chronic benign pain, opioids may not clearly increase actual physical activity - at least in comparison to other medications. Patients that use opioid analgesics should be monitored.

Combination therapies

Difficulties in treating chronic back pain have to lead to investigations of combined modalities. One trial found some benefit from combining exercise with cognitive behavioral therapy.

Surgery

There are a number of different types of spine surgery to treat a variety of back conditions. Surgery should be considered if a patient has a significant neurological deficit, or if they fail non-surgical therapy. There is particular concern if back pain is associated with loss of bowel or bladder function and may indicate Cauda equina syndrome or Conus medularis syndrome. Urgent surgical considerations are necessary for these conditions.

Surgery has uncertain benefit for chronic pain.

Some of the more common forms of surgery are:

• Artificial disc replacement, a relatively new form of surgery in the U.S. but has been in use in Europe for decades, primarily used to treat low back pain from a degenerated disk.

• Discectomy/microdiscectomy, usually used to treat pain (especially pain that radiates down the arm or leg) from herniated disks.

• Kyphoplasty and Vertebroplasty, minimally invasive procedures designed to treat pain from osteoporotic compression fractures and sometimes other forms of fracture, such as a fracture caused by certain types of cancer.

• Laminectomy, removes a portion of the bone to relieve pressure on the spinal nerve from behind, may be used to treat spinal stenosis from a herniated disc.

• Spinal cord stimulation, where an electrical device is used to interrupt the pain signals being sent to the brain.

• Spinal fusion, sometimes with instrumentation using pedicle screws, usually to treat degenerative disc disease, spinal stenosis from degenerative spondylolisthesis, or deformity, such as from scoliosis.

Treatments with uncertain or doubtful benefit

• Injections, such as epidural steroid injections or facet joint injections, have uncertain benefit according to a meta-analysis by the Cochrane Collaboration and a more recent randomized controlled trial.
• Prolotherapy, which is 'injections of irritant solutions to strengthen lumbosacral ligaments,' has uncertain benefit. Injections with sclerosing agents do not help.
• Cold compression therapy is advocated for a strained back or chronic back pain and is postulated to reduce pain and inflammation, especially after strenuous exercise such as golf, gardening, or lifting. However, a meta-analysis of randomized controlled trials by the Cochrane Collaboration concluded "The evidence for the application of cold treatment to low-back pain is even more limited, with only three poor quality studies located. No conclusions can be drawn about the use of cold for low-back pain"
• Bed rest is rarely recommended as it can exacerbate symptoms , and when necessary is usually limited to one or two days.
• Electrotherapy, such as a Transcutaneous Electrical Nerve Stimulator (TENS) has been proposed. Two randomized controlled trials found conflicting results (PMID 10084439; PMID 2140432). This has led the Cochrane Collaboration to conclude that there is inconsistent evidence to support use of TENS (PMID 16034883).

Prognosis

40-50% of patients have functional impairment or pain 90 days after being seen in the emergency room for lumbalgia.

Criteria by the United States of America Social Security Administration for disability are available on line.

Prevention

In some setting, lumbar supports may be able to prevent back pain.