Back Pain- A Brief Overview

Introduction:
Back pain is one of the most common reasons that adults see their physician. Most cases of acute back pain are a result of mechanical causes. Only a few cases have an underlying serious pathology Acute back pain is usually treated with reassurance, returning to activities, and acetaminophen
with or without an NSAID. Psychological factors increase the risk of development of chronic pain. Chronic back pain is difficult to treat and the best outcomes are typically achieved by a multidisciplinary approach.

1. Acute: Back pain that comes on suddenly and lasts less than 6 weeks is classified as Acute Back pain.
2. Chronic: Back pain that lasts for more than 3 months is classified as chronic and is relatively less common as compared to acute back pain.

Causes And Risk factors: The back pain may originate from the muscles, nerves, bones, joints or other structures in the spine. Sometimes it may also be referred from internal structures like pancreas and gallbladder. A few causes and risk factors are listed below:

• Old age.
• Manual labor or excessive back strain.
• Osteoarthritis of the spine.
• Lack of physical exercise.
• Obesity.
• Psychological conditions like depression and anxiety.
• Bulging or rupture vertebral disc.
• Osteoporosis.
• Skeletal irregularities
• Ankylosing spondylitis.
• Underlying malignancy.
• Pregnancy
• Kidney stones or infection
• Cauda equina syndrome

Clinical features: The episodes of back pain may be acute, sub acute on chronic depending upon the underlying cause. The pain be characterized as a dull ache, shooting or piercing pain or a burning sensation. The pain may radiate into the legs and feet. 

The most common area of pain is the lower back or the lumbar region. 

There may be associated limited flexibility or range of motion of the spine. 

Red flags Indicating Serious Pathology of Back Pain include; 

•  age younger than 20 or older than 55 years;
• significant trauma; 
• fever; 
• unexplained weight loss; 
• neurologic signs of
• cauda equina; 
• progressive neurologic deficit.

Diagnosis: 

The diagnosis can be classified into three categories:

1. Nonspecific back pain—Pain for less than 6 weeks (acute), 6 to12 weeks (subacute), or more than 12 weeks (chronic); negative straight-leg raise test; absence of red flags.

2. Radicular syndrome—LBP with radiation down leg; positive straight-leg raise test; absence of red flags.

3. Serious pathology—Further work-up required for presence of red flags, 

Following Laboratory testing may be helpful in the presence of red flags: 

• Complete blood count (CBC) to evaluate for anemia (malignancy) or leukocytosis (infection).

• Consider human leukocyte antigen (HLA)-B27 in younger patients with inflammatory symptoms.

Imaging Studies: 

• In acute back pain without red flags, imaging can be delayed for 6 weeks.

• Radiographs may show degenerative joint disease changes in osteoarthritis; vertebral fractures; malignancies; and findings of ankylosing spondylitis including erosions, sclerosis, syndesmophytes

• MRI is the best imaging test for disc herniation and imaging of the spinal cord. Emergent MRI is indicated in patients with suspected spinal cord compromise or cauda equina syndrome.

• CT myelogram is a useful alternative to evaluate disc herniation in patients who cannot undergo MRI.

Management: 

The treatment usually depends on the underlying cause of the back pain.

It is important to look for red flags and rule out serious causes. 

Most national guidelines agree on the following management for acute back pain: 

• Nonpharmacologic:

~ Reassure patients without red flags that they do not have a serious condition, advise them to remain active, discourage bed rest, and encourage an early return to work while back pain is still present.

~ Exercise is considered no more effective than return to normal activities for LBP within the first 4 to 6 weeks.

• Medications:

~ Acetaminophen

~ Add NSAID if needed (ask about GI problems and protect against ulcers as needed).

~ Consider a short course of opiates or muscle relaxers if pain is severe and inadequately treated with acetaminophen and NSAIDs.

~ Consider antidepressants (such as amitriptyline) or anticonvulsants (such as gabapentin) for radicular pain.

• Complementary and alternative therapy:

~ National guidelines differ; some recommend and some do not recommend spinal manipulative therapy for acute back pain.

~ Spinal manipulative therapy has a similar effect on pain relief and functional status as other interventions.

• Referral or hospitalization:

~ Patients with cauda equina syndrome should have expedient imaging and urgent referral to a spinal surgeon.