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Explain Back Pain

Explain back pain is a great book written by David S. Butler and G. Lorimer Moseley in 2013. It is an evidence based book designed for therapists, patients and students. I have made some mind mapping about it. I hope you find it useful to review some concepts or study. For who don’t know, you have to read the mind map clockwise.

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Sciatica

Sciatica (also called radicular pain) is commonly used to describe radiating leg pain. It is caused by inflammation or compression of the lumbosacral
nerve roots (L4-S1) forming the sciatic nerve. Sciatica can cause severe discomfort and functional limitation.

People with sciatica usually describe aching and a sharp leg pain radiating below the knee and into the foot and toes. The pain can have a sudden or slow onset and varies in severity. Most people report coexisting low back pain. Disc herniations affecting the L5 or S1 nerve root are more common and cause pain at the back or side of the leg and into the foot and toes. If L4 root is affected, pain is localised to the front and lateral side of the thigh. Tingling or numbness and loss of muscle strength in the same leg are other symptoms that suggest nerve root involvement.

How common is sciatica?

In the UK about 60% of patients with back and leg pain were clinically diagnosed with sciatica.

How is sciatica diagnosed?

Sciatica is a clinical diagnosis based on the person’s symptoms and findings on examination. Symptoms and signs suggesting sciatica:

  • Unilateral leg pain more severe than low back pain;
  • Pain most commonly radiating posteriorly at the leg and below the knee;
  • Numbness and/or paraesthesia in the involved lower leg;
  • Neurological deficit associated with the involved nerve root (muscle weakness/absence of tendon reflexes/sensory deficit);
  • Positive neural tension test with provocation of pain in the affected leg (straight leg raise test/femoral nerve test/slump test).

Role of imaging

  • Routine imaging is not advised in people with non-specific low back pain with or without sciatica
  • Disc herniation is a common age related finding
  • Consider imaging if symptoms progress for more than 12 weeks, or if the person has progressive neurological deficits (signs of urinary retention or decreased anal sphincter tone ) or worsening pain

Conservative treatment

  • Encourage patients to remain active and avoid bed rest

What is the prognosis?

  • Most people experience an improvement in symptoms over time with either conservative treatment or surgery
  • For disabling symptoms lasting longer than 6 weeks with a lack of response to non-operative management, specialist referral (rheumatologist, rehabilitation physician, spinal surgeon) can also be considered
  • Laminectomy surgery for radiculopathy may shorten the duration of symptoms, but outcomes at 12 months are similar to non-operative treatment and surgery is associated with increased risk of further surgery
  • Decompression surgery for central lumbar canal stenosis may improve symptoms, but there is a lack of high -quality evidence for its superiority over non-operative management

References

  • Diagnosis and treatment of sciatica, bmj 2019;
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Low Back Pain: a major global challenge

The Lancet – 2018

Almost everyone will have low back pain at some point in their lives. It can affect anyone at any age, with the biggest increase seen in low-income and middle-income countries. Disability due to back pain has risen by more than 50% between 1990 and 2015.

For nearly all people with low back pain, it is not possible to identify a specific cause (non-specific low back pain). Only a small proportion of people have a well understood pathological cause – eg, a vertebral fracture, malignancy, or infection (specific low back pain).

Key messages:

  • Low back pain is an extremely common symptom.
  • Most episodes of low back pain are short-lasting with little or no consequence
  • People with physically demanding jobs, physical and mental comorbidities, smokers, and obese individuals are at greatest risk of reporting low back pain.
  • Disabling low back pain is over-represented among people with low socioeconomic status, where possibilities for job modification are limited.
  • Lifestyle factors, such as smoking, obesity, and low levels of physical activity, that relate to poorer general health, are also associated with occurrence of low back pain episodes.

Prevention and Treatment of low back pain

  • There is lack of evidence for prevention of low back pain: back belt, ergonomic furniture, work-place education, no-lift policies, mattresses, lifting device. The only known effective interventions (based on low to moderate quality evidence) are exercise combined with education, or exercise alone.
  • Do not recommend passive electrical or physical modalities, such as ultrasound, transcutaneous electrical nerve stimulation (TENS), traction, short-wave diathermy, and back support for low back pain.
  • No one exercise seems superior to another.
  • Some guidelines do not recommend passive therapies, such as spinal manipulation or mobilisation, massage, and acupuncture, some consider them optional, and others suggest a short course for patients who do not respond to other treatment.
  • Spinal imaging is inappropriate for non-specific low back pain (W. Brinjikji at el. 2015).
  • Interventional therapies (e.g. injections, surgery and medicines) have a limited role for non-specific low back pain.
  • Non-pharmacological treatments in the form of advice, reassurance, and activity should be the first line treatmen option for non-specific low back pain.
  • Paracetamol is not recommended.
  • Consider oral non-steroidal anti-inflammatory drugs (NSAIDs), taking into account potential risks, and if using them, prescribe the lowest effective dose for the shortest possible time.
  • Routine use of opioids is not recommended, since benefits are small and substantial risks exist, including overdose and addiction. If used, they should only be in carefully selected patients, for a short duration, and with appropriate monitoring.