Pain in the Back

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Low back pain is one of the most common reasons why people seek medical care. Most low back pain is caused by minor problems with muscles, joints, or ligaments in the back. In rare cases, less than 1%, low back pain is caused by a serious spinal problem. Low back pain is categorized by how long the pain lasts. Acute low back pain lasts less than four weeks, subacute four to 12 weeks, and chronic more than 12 weeks.

Evaluation of low back pain requires a detailed medical history and physical examination. Most patients reporting pain only located in the lower back do not require imaging studies including X rays, CT scan, or MRI. Warning signs indicating that low back pain may be from a more serious source include pain radiating into the buttocks and leg, new leg weakness or paralysis, changes in bladder or bowel function, numbness around the buttocks or genitals, fever, or a history of cancer. The presence of any of these symptoms should trigger an immediate investigation.

Most people with acute or subacute low back pain improve within weeks. Chronic low back pain symptoms are more likely to persist and fluctuate over time. According to the American College of Physicians (ACP), most patients with acute or subacute low back pain should be advised that their pain will improve over time, regardless of treatment. Patients should remain as active as possible and avoid prolonged bed rest. Nondrug treatments can be initiated, including superficial heat, massage, acupuncture, and spinal manipulation (chiropractic care). If medication is needed to alleviate pain, it should be given at the lowest effective dosage and for the shortest possible time. Nonsteroidal anti-inflammatory drugs (NSAIDS, for example ibuprofen) or skeletal muscle relaxant drugs (i.e., cyclobenzaprine [Flexeril]) can decrease acute or subacute low back pain. Oral or injected steroids are not effective, and opiates should never be prescribed for simple low back pain.

Patients with severe pain that radiates down the back of the leg (sciatica) should have imaging studies performed and, if the pain is persistent, should consider more invasive treatment. If there is a compressed nerve, invasive options may include spinal injections containing a local anesthetic and a steroid, or surgery. For those with chronic low back pain, the ACP recommends a combination of nondrug treatments and exercise, including combinations of physical therapy, acupuncture, tai chi, yoga, motor control exercises, progressive relaxation, electromyographic biofeedback, low-level laser therapy, cognitive behavior therapy, and spinal manipulation. For chronic low back pain patients who do not respond to nondrug treatments, NSAIDs are initially recommended to control pain. Second-line therapy includes tramadol (a low-level opiate) or duloxetine (an antidepressant). Opioids other than tramadol should only be considered for those with chronic low back pain who fail all other treatments and for whom the potential benefit outweighs the known risks.

Patients with disabling chronic low back pain and impaired quality of life should be referred to spine specialists to discuss invasive treatment options such as radiofrequency ablation (insertion of a heated needle into the back to destroy nerve endings) or laminectomy and discectomy or fusion (back surgeries). Invasive treatments require consideration of risks, benefits, and costs plus the patient’s values and preferences.

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By Peter Galvin, MD


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