Low Back Pain

Published on 31/05/2015 by admin

Filed under Obstetrics & Gynecology

Last modified 22/04/2025

Print this page

rate 1 star rate 2 star rate 3 star rate 4 star rate 5 star
Your rating: none, Average: 0 (0 votes)

This article have been viewed 1680 times

Chapter 34 Low Back Pain

INTRODUCTION

Description: Pain located in the lower portion of the back (generally between the level of the iliac spines and the lower ribs) with radiation to the abdomen, pelvis, legs, or trunk. In women, gynecologic processes are often implicated (correctly or incorrectly) in this complaint. Low back pain is especially common during pregnancy.
Prevalence: Common (80% suffer some form of low back pain during their lifetime).
Predominant Age: 25 to 45 years.
Genetics: No genetic pattern.

ETIOLOGY AND PATHOGENESIS

Causes: Normal aging aggravated by trauma, injury, or pregnancy.
Risk Factors: Obesity, poor posture, improper lifting, age, sedentary lifestyle, osteoporosis, psychosocial factors (secondary gain), and trauma.

CLINICAL CHARACTERISTICS

Signs and Symptoms

• Pain and discomfort between the level of the iliac spines and the lower ribs, generally sudden in onset after an injury or gradually over the subsequent 24 hours
• Radiation of pain to buttocks or posterior thighs (stopping at the knees); referred pain, not radicular; back pain greater than leg pain
• Pain aggravated by back motion, lifting, coughing, straining, bending, or twisting; relieved by rest
• Normal sensory, motor, and reflex findings;, decreased range of motion

DIAGNOSTIC APPROACH

Differential Diagnosis

• Gynecologic disease (pregnancy, endometriosis, pelvic inflammatory disease)
• Gastrointestinal disease (duodenal ulcer, pancreatitis, irritable bowel syndrome, diverticulitis)
• Urinary tract disease (pyelonephritis, nephrolithiasis)
• Disc herniation or degenerative disease
• Osteoporotic fracture
• Fibromyalgia
• Spinal stenosis
• Spondylolisthesis
• Ankylosing spondylitis
• Arthritis (hip or back)
• Neoplasia (primary or metastatic)
• Fictitious complaint (somatization, secondary gain)

Associated Conditions: Chronic pain states (pelvic pain, headaches), radiculopathy, obesity, and psychosocial disease. Secondary gain often complicates both the diagnosis and treatment of low back pain. Warning signs of significant secondary gain include pending litigation or compensation, depression, hostility, and prolonged use of potent analgesics.

Workup and Evaluation

Laboratory: No evaluation indicated unless suggested by nonmechanical symptoms or atypical patterns of pain.
Imaging: Generally not required. When indicated (persistent pain, atypical symptoms)—anteroposterior, lateral, and spot films of L5–S1 area. Bone scan if tumor, trauma, or infection is suspected.
Special Tests: Computed tomography, magnetic resonance imaging, or myelography only for specific cause.
Diagnostic Procedures: History and physical examination (with special attention to the back and hips).

Pathologic Findings

Based on cause.

MANAGEMENT AND THERAPY

Nonpharmacologic

General Measures: Bed rest, short-term analgesics or anti-inflammatory agents, massage, or manipulation.
Specific Measures: Muscle relaxants, Williams’ flexion exercises, physical therapy, topical low-level continuous heat therapy, transcutaneous electrical nerve stimulation (TENS).
Diet: No specific dietary changes indicated. Weight reduction, if appropriate.
Activity: Restricted activity for 3 to 6 weeks, then a gradual return to normal activity as tolerated. Patients should begin Williams’ flexion exercises as prevention for future injuries.
Patient Education: Posture and activity counseling, home back exercises; American College of Obstetricians and Gynecologists Patient Education Pamphlet AP115 (Easing Back Pain During Pregnancy).

Drug(s) of Choice

Nonsteroidal anti-inflammatory drugs, muscle relaxants—cyclobenzaprine (Flexeril) 10 mg PO three times daily, diazepam (Valium) 5 to 10 mg PO two times daily.
Contraindications: See individual agents. Aspirin-sensitive asthma for most agents.
Precautions: See individual agents. Ulcer or renal disease for most agents.
Interactions: See individual agents.

FOLLOW-UP

Patient Monitoring: Normal health maintenance.
Prevention/Avoidance: Muscle-strengthening exercises, care in lifting, maintenance of reasonable weight. Avoid tasks that aggravate (heavy lifting, bending, twisting, sudden movements). Weight reduction, if appropriate.
Possible Complications: Chronic low back pain, pain medication dependence, and dependency state resulting from secondary gain.
Expected Outcome: Gradual improvement with analgesics, muscle relaxants, massage, and exercise (1 to 6 weeks).

image

MISCELLANEOUS

Pregnancy Considerations: No effect on pregnancy, although pregnancy (and the postural changes brought about by it) may worsen existing low back pain. Some relief is gained when the fetus descends into the pelvis in the last days of the gestation, but the sudden return to upright and the constant bending to care for a newborn make this improvement short-lived.
ICD-9-CM Codes: Based on cause.

REFERENCES

Level I

Donzelli S, Di Domenica E, Cova AM, et al. Two different techniques in the rehabilitation treatment of low back pain: a randomized controlled trial. Eura Medicophys. 2006;42:205.

Gale GD, Rothbart PJ, Li Y. Infrared therapy for chronic low back pain: a randomized, controlled trial. Pain Res Manag. 2006;11:193.

Goins ML, Wimberley DW, Yuan PS, et al. Nucleus pulposus replacement: an emerging technology. Spine J. 2005;5(6 Suppl):317S-.

Katz J, Pennella-Vaughan J, Hetzel RD, et al. A randomized, placebo-controlled trial of bupropion sustained release in chronic low back pain. J Pain. 2005;6:656.

Kovacs F, Abraira V, Santos S, et alSpanish Back Pain Research Network. A comparison of two short education programs for improving low back pain-related disability in the elderly: a cluster randomized controlled trial. Spine. 2007;32:1053.

Linde K, Witt CM, Streng A, et al. The impact of patient expectations on outcomes in four randomized controlled trials of acupuncture in patients with chronic pain. Pain. 2007;128:264. Epub 2007 Jan 25

Mayer JM, Mooney V, Matheson LN, et al. Continuous low-level heat wrap therapy for the prevention and early phase treatment of delayed-onset muscle soreness of the low back: a randomized controlled trial. Arch Phys Med Rehabil. 2006;87:1310.

Mayer JM, Ralph L, Look M, et al. Treating acute low back pain with continuous low-level heat wrap therapy and/or exercise: a randomized controlled trial. Spine J. 2005;5:395.

Tavafian SS, Jamshidi A, Mohammad K, Montazeri A. Low back pain education and short term quality of life: a randomized trial. BMC Musculoskelet Disord. 2007 Feb 28;8:21.

Warke K, Al-Smadi J, Baxter D, et al. Efficacy of transcutaneous electrical nerve stimulation (TENS) for chronic low-back pain in a multiple sclerosis population: a randomized, placebo-controlled clinical trial. Clin J Pain. 2006;22:812.

Ximenes A, Robles M, Sands G, Vinueza R. Valdecoxib is as efficacious as diclofenac in the treatment of acute low back pain. Clin J Pain. 2007;23:244.

Level II

Allan L, Richarz U, Simpson K, Slappendel R. Transdermal fentanyl versus sustained release oral morphine in strong-opioid naive patients with chronic low back pain. Spine. 2005;30:2484.

Demoulin C, Crielaard JM, Vanderthommen M. Spinal muscle evaluation in healthy individuals and low-back-pain patients: a literature review. Joint Bone Spine. 2007;74:9-13. Epub 2006 Nov 13.

Farasyn A, Meeusen R. Validity of the new Backache Index (BAI) in patients with low back pain. Spine J. 2006;6:565.

Katz JN. Lumbar disc disorders and low-back pain: socioeconomic factors and consequences. J Bone Joint Surg Am. 2006;88(Suppl 2):21.

Rivero-Arias O, Gray A, Frost H, et al. Cost-utility analysis of physiotherapy treatment compared with physiotherapy advice in low back pain. Spine. 2006;31:1381.

Level III

American Academy of Orthopedic Surgeons. Clinical Policy; Low Back Musculoligamentous Injury (Sprain/Strain). AAOS Bulletin 3638. Rosemont, Ill: AAOS, 1991.

American College of Obstetricians and Gynecologists. Chronic Pelvic Pain. ACOG Practice Bulletin 51. Washington, DC: ACOG, 2004.

International Association for the Study of Pain. Classification of chronic pain, descriptions of chronic pain syndromes and definitions of pain terms. Pain. 1986;3(suppl):S1.

Shelerud RA. Epidemiology of occupational low back pain. Clin Occup Environ Med. 2006;5:501. v.

Smith RP, Ling FW. Back examination. In: Procedures in Women’s Health Care. Baltimore: Williams & Wilkins; 1997:367.

Yelland MJ, Schluter PJ. Defining worthwhile and desired responses to treatment of chronic low back pain. Pain Med. 2006;7:38.

Related posts:

Cervical Incompetence Bartholin’s Gland: Abscess/Infection Pre-Eclampsia and Eclampsia (Toxemia of Pregnancy) Sexually Transmitted Infections: Human Immunodeficiency Virus Breast: Galactocele Sheehan’s Syndrome