January 27, 2015

Low Back Pain

 

Low Back Pain

 

 

 

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Overview of low back pain

 

Low back pain is extremely common, in most cases it can be treated without formal care. When it does need formal care, conservative treatment will usually suffice. Only rarely does low back pain require surgery.

 

How do you know if you have a low back pain problem which could be an urgency or emergency?

age:

You are a greater risk if you are less than 18 or more than 50 years old.

neurological symptoms:

If you have a loss of bladder or bowel function, inability to move, marked worsening of numbness or tingling with coughing or sneezing, this would cause me to be concerned. You should be seen in our office or go to the emergency room by ambulance if necessary if you have these problems. This is especially true if these symptoms suddenly worsen.

diseases:

Some associated conditions give you much higher risk for bad back problems, these diseases include intravenous drug use, immunosuppression, steroid use, HIV, rheumatic fever, cancer, uncontrolled diabetes, osteoporosis, and Padget’s disease.

symptoms:

certain symptoms should worry you — if you’re back pain wakes you from your sleep, or if you have night sweats you should see Dr. Kline right away. If you have numbness or weakness in your legs, this could mean that you do have a neurologic defect. If your pain is unrelenting despite treatment, if you have fevers or chills associated with your pain, if your pain is so severe that you can’t do simple tasks then you should be seen by me immediately. If you are not improving in 3 weeks, or if there is one anatomic point is much more tender than any other spot in your body, then you should return to the office within one or two business days.

Causes:

If your pain has been caused by trauma, or if your pain follows a recent gastro intestinal or genitourinary procedures, such as a surgical procedure, then you should be seen right away.

 

 

low back pain – anatomic considerations:

 

 

 

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Vertebrae: the structure of your low back–

The vertebrae are a column of bones which fit into one another through the use of joints. These joints allow the bones to move relative to one another. In the center of each bone is a hole, and when the bones are stacked one upon another, a cylindrical column is formed. The spinal cord fits into and progresses through this canal.

Discs: cushions for your low back–

These are elastic substances which fit between the vertebrae, and provide them with support and protection, they also help with movement.

Spinal cord and exiting structures: the nerve center of your low back–

The spinal cord sends neurological traffic from your body to your brain and back, it also provides local control of your body. This cord runs inside the vertebrae and discs, and these structures in turn provide protection for this vulnerable neurologic machine. The spinal cord can be thought of as being analogous to the electric trunk which your utility company sends into your house. This electric trunk goes in to the electric box in your house ( which is like your spinal cord) and then off of this trunk circuits progress to the different outlets and receptacles in your home. In a similar way, nerves come off the spinal cord and progress towards different machines in your body. Instead of providing electricity to these machines, the spinal cord “inervates” these machines. The machines can be joints, muscles, organs, and other nerves.

Muscles, tendons, and ligaments: the soft tissues of your low back–

If you have ever heard the term: “soft tissue injury” these are the soft tissues we are describing. The muscles are responsible for the motion and strength of your body. The ligaments and tendons provide the connection of your muscles to joints and bones.

 

 

 

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Etiologies of low back pain

 

General

Damage to anatomic elements are the most common cause for low back pain. Tearing of soft tissue ( strain or sprain) can cause pain, impingement ( pressure) on a nerve, or joint or disc can do the same thing. Physiologic problems such as connective tissue disease and other types of inflammation, infection, and progressive diseases( such as degenerative joint disease) can also cause pain. These etiologies are known as pain generators.

discs: bulging or herniated:

Disks can be damaged by wear and tear ( degeneration), bony growths which impinge upon them, malalignment of the vertebrae, narrowing of the spinal cord, tumors, and other problems..

nerves:

Nerves can be injured by bulging or herniated discs, growths from your bones called spurs, ligaments which are inflamed or enlarged, for spinal cord construction.

vertebrae

The vertebrae can be fractured, indicated by tumors, or malalignment.

 

Differential diagnosis – the problems which can cause or imitate low back pain:

 

problems in the back

sprain and strain
degenerative arthritis
herniated disc
facet degeneration
spinal stenosis and spinal cord compression
spondylitis (the low back structures are not aligned properly because they are not held in place adequately)
Fracture- from trauma or osteoporosis or cancer

problems in joints around the back

Sacroilitis- pain at the junction of the hip to the low back joint
hip – pain from the hip- for example: from arthritis or fracture

Renal

kidney infections
kidney stones

infections:

Shingles
urinary tract infections such as kidney or kidney stone infections
low back, or pelvic infections.

Gynecologic

endometriosis, ovarian pathology or pelvic infections

testicular

Inflammation of the testicles or the structures entering the testicles can sometimes cause back pain.

Processes:

Cancer metastasis (spreading of cancer) into the bones can cause this pain
inflammation from arthritis
infection

gastrointestinal:

Problems in the
intestine
pancreas
belly
gall bladder (although this usually causes pain above the low back)

vascular:

Abdominal aortic aneurysm (bulging of the large blood vessel in the belly) is the most dangerous. This can result in rupture and very rapid death.
Occlusive vascular disease -thinning off of the blood vessels so they don’t adequately supply blood to the structures of the back ( ischemia).

Hernias

Hernias means that one structure, which is contained within a second, breaks through the containing structure. Pain from hernias in your groin and other areas can sometimes produce back pain.

 

How is low back pain diagnosed:

 

The mainstay of diagnosis of low back pain is the “history and physical” examination performed by Dr. Kline. There are some tests which can be useful in the diagnosis of low back pain.

 

 

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x-ray:

X-rays can demonstrate many of the problems which can cause low back pain. These include degenerative joint disease, inflammatory arthritis, spinal stenosis, spurring, infection, osteoporosis and others. Because of other diagnostic modalities, some people feel that “plain film” x-rays are no longer of any value. This is not true, since the x-ray can demonstrate the problems detailed above. In addition, frequently Magnetic Resonance Imaging studies do not demonstrate these problems as well has simple x-rays, and x-rays are much more cost effective than other diagnostic techniques. Even if an x-ray does not demonstrate any pathology, this knowledge becomes very important to me when I am trying to diagnose the etiology of low back pain. Of course, anyone who is pregnant should not have an x-ray of the low back.

Magnetic Resonance Imaging for low back pain.

Most people with low back pain will never need an Magnetic Resonance Imaging. An imaging test only has value if it is heuristic. This means that the use of this modality has a reasonable probability of causing you and I to be able to make a decision which we would’ve otherwise have been unable or unlikely to make. In the case of low back pain, in most cases, no matter what the Magnetic Resonance Imaging demonstrates, the decision as to how we will treat your low back pain will be the same. Therefore the Magnetic Resonance Imaging will not have any heuristic value, since it will not change our decision as to how to treat you. A Magnetic Resonance Imaging should be obtained if your symptoms are not improving (usually in about five weeks of aggressive conservative care), are significantly atypical, were caused by one of the processes listed above which are considered urgent or emergent, or if you have symptoms which could be considered urgent or emergent. This test might be difficult for some people, especially if they are large or claustrophobic. This tests cannot be obtained for some individuals, especially those who might have metallic implants or pacemakers.

electromylogram and nerve conduction study

This test can tell you if one of the nerves in your back is not functioning correctly, and it can give information as to where the nerve may be injured. Again, the consideration to obtain this test is similar to that set of considerations given to obtaining an Magnetic Resonance Imaging of the low back. This test is often not pleasant, as it involves placing needles ( electrodes) into the skin and conducting electricity through the body.

 

 

Treatment of low back pain.

 

 

 

 

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Activity

In the past we used to think that rest was the best treatment for low back pain. When I was a resident, we used to place people in traction when they suffered from this problem. For quite some time we have realized that this is an incorrect way of approaching low back pain. Studies have been performed which demonstrate that people who are more active recovered faster than people who are sedentary. Also, people who resume their normal activities, including work, as soon as possible, are much more likely to avoid disability than those who do not swiftly return to their normal activities. Often, a return to work initially involves limitations.

Exercises:

Exercise is often initially prescribed by trained medical personnel such as physical therapists. They should be tailored to your specific capabilities, needs, and underlying low back pain etiology’s. In most cases these exercises should be started at home as soon as possible, and they should be carried on for the rest of your life in order to help prevent the recurrence of low back pain. Exercises which are done incorrectly can harm you, so it is important that you understand how to perform these exercises correctly. Exercises performed adequately are one of the best ways we know to prevent the recurrence of low back pain.

Ergonomics

Proper static ( standing, sitting, and sleeping) techniques and postures are extremely important in preventing low back pain. Dynamic ( lifting, bending, pushing, pulling) techniques, limitations, and procedures are also very important in treating and preventing low back pain.

Physical therapy

Modalities (heat, ice, electric stimulation, Tens stimulation, ultrasound, and others), massage, exercise, stabilization, and neurologic rehabilitation are some of the techniques which can be quite helpful in the treatment of low back pain.

Occupational therapy

Occupational therapy can be used with or without physical therapy. One of the main goals of this technique is to enable maximal function, given fixed limitations from low back pain. Another goal for occupational therapy is to suggest mechanisms and techniques which would decrease the likelihood of future back injury during activities of daily living.

 

 

 

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Osteopathic manipulation

Osteopathic techniques ( active, high velocity, low velocity, muscle energy, and many others) can help prevent and treat low back pain.

Oral Medications:

NSAI’s

Aspirin derivatives, usually known as non steroidal anti-inflammatory medications,
are extremely useful in treating low back pain. These molecules help to decrease pain, as well as to stop the inflammation- inflammation helps cause the pathology of low back pain. There are significant limitations to the use of these medications, they must be used with caution in anyone who has belly pathology, heart disease, blood pressure problems, or kidney disease and others. They should not be used by nursing or pregnant women.

Tylenol

can be used to help reduce the suffering caused by low back pain, these medicines can harm your liver but they generally don’t have as many risks in their use as aspirin derivatives. They are not as useful as non steroidal anti inflammatory medications since do not stop the inflammation which at least partially underlies the pathology of low back pain.

Ultram

is a newer type of pain medication, it is synergistic in its effectiveness with Tylenol, but it can cause sedation, seizures, and addiction, as well as other problems.

Narcotics

such as hydrocodone are useful in treating low back pain. In general in the acute setting, they should only be used for a short period of time, usually less than two weeks. These substances are addicting, and sedating and they can cause constipation. There is concern for their misuse, as they are subject to diversion into the criminal community. At times these medications must be used continuously and long-term for those patients who suffer from “failed back syndrome”.

 

Injections:

Trigger point injections

these are normally injections into inflamed nerves, often they involve the injection of steroids and or local anesthetics. Dr. Kline can provide these injections for you, this procedure can be preformed in the office.

Spinal injections:

these involve the injection of steroids directly into discs or joints within the back. These injections can be very effective, especially for patients who have failed to improve with conservative care. They are typically quite expensive, and they are considered surgeries; as such they carry significant risks. They are normally performed under special types of ultrasound or x-ray guidance, and they are usually performed in a surgical suite. These injections are commonly administered by “pain medicine doctors” or anesthesiologists.

Acupuncture:

Acupuncture involves placing needles into various “Meridia” in order to normalize energy flows within the body. These techniques have been shown to be more effective than placebo in many patients, and they should be performed by practitioners who have had a great deal of training and experience with this procedure. This technique was developed as part of a Chinese tradition, and it’s theoretic underpinnings do not have a foundation in traditional Western medical concepts.

 

Surgery – considerations in Low Back Pain

 

 

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The surgeon:

At times, patients suffer from urgencies or emergencies which require surgery. Other patients require surgery because they do not recover with the techniques and modalities described above. Orthopedic surgeons perform surgeries on the back, but in my practice, I usually request neurosurgical consultation when I am considering surgery. Surgery should be performed by physicians who have a sub specialty in this area, perform a large volume of back surgeries, and have been formally trained in back surgery.

per-surgery – due diligence and the decision-making mechanism:

When a patient considers having surgery I strongly suggest that they engage in due diligence. If you are considering surgery, you should ask your surgeon what his/her outcomes are for people in your situation (age, occupation, coexisting illnesses) and with your type of back problem. If the surgeon does not keep statistics, that should make you somewhat leery of utilizing that individual. You should compare surgeons based on their outcomes. You should obtain at least two high quality surgical consultations. Very frequently surgeons will disagree on techniques and even the advisability of surgery. You should also be sure that your surgeon sends their consultation to Dr. Kline, and preferably call Dr. Kline to speak with him concerning their impressions. You should then return to the office to speak to Dr. Kline about the input of the surgeons. I advise all patients considering surgery to bring a family member or friend with them to these pre-surgical consultations, as the concepts involved with surgical decision-making can be confusing, complex and even overwhelming. Patient involvement, patient input in the per-surgical process, and thoughtful decision-making are essential components to help produce acceptable surgical outcomes. In my experience, surgical results are the best, and patient satisfaction with surgical products are greatest, when patients work with me in the decision-making and pre surgical processes.

pre-surgical medical clearance

Between two and four weeks prior to your surgery, you should return to my office for a per-surgical evaluation. The purpose of this evaluation is to try to be sure that your medical conditions are optimized prior to surgery, and that the surgical team is aware of your medical conditions and medications in order for them to take appropriate action to minimize your risk during and after your procedure. I will frequently perform evaluations during our presurgical clearance examination in order to attempt to make your surgery as safe as possible. These may include EKGs, pulmonary function tests, laboratory evaluations, oxygen measurements, and others. I may also change your medications prior to, during, and immediately after surgery in order to optimize your safety. I will work with you and provide you with an intensive and prolonged per-surgical history and physical examination – this procedure will normally takes me between 30 and 60 minutes. I will then generate a typed report and may attach to it salient study reports. I will normally try to fax this information to your surgical team, I will also give you a copy of this report and any appropriate studies to take to your surgeon, so that your team will have access to this information prior to surgery. Again, our purpose in the per-surgical clearance is to make your surgery is safe for you as we can.

 

 

charlatans and other money making machines

 

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Introduction to the dark side

This is the nasty side of the treatment of low back pain. There are many people out there who are unscrupulous. A lot of money can be made off of your low back, and although I hate to say it, there are physicians and other medical practitioners who will try to victimize you and take advantage of you because you have low back pain. Here are some of the warning signs which I have noticed over my 30 years of practice: I present them to  you in order that you may avoid the injuries which some of my patients have experienced:

Magical techniques

If your practitioner promises magical techniques which “mainstream medicine refuses to acknowledge” please look at this person with a jaundiced eye. We are all working very hard to provide the best medical care of  low back pain as quickly as we can, and in general we don’t overlook techniques which would be helpful to you.
repetitive procedures without benefit
If your doctor or practitioner “does the same thing over and over “, yet you are not improving, you should seriously consider a second opinion.

organized sin

If your physician seems to have a strong relationship with a referring attorney, chiropractor, neurologist, Orthopedic Surgeon,  and pain medicine doctor – and if your physician seems to refer you to all of them, that could be a very strong warning sign.   Again, I would recommend a second opinion if you notice any of these practices.

internal referrals – organized revenue generation machines

Many times physicians practice in large groups, or are paid by large organizations for outcomes. Some of these organizations are just wonderful, but some of these outcomes are strictly economic. If your physician insists on referring you only to specialists, therapists and other “revenue producers” with whom your doctor may have a business relationship, then, in my opinion, you should consider steering clear of all of these people.

 

 

Summary of low back pain:

 

Back pain is extremely common. In most cases low back pain can be effectively treated with conservative care. A careful consideration of the etiologies and differential diagnoses for your back pain should be undertaken, and appropriate medical and mechanical care should be instituted. You should do all you can to decrease the risk of future back problems by utilizing appropriate ergonomic techniques and exercises. In the rare case in which surgery is required, due diligence and active participation in decision-making with Dr. Kline can yield a result which you are most likely to be satisfied with.

 

By accepting this information you understand and agree that my entire responsibility in this matter is to give you medical information and or opinion. Any information in this post (blog) and its attachments is provided with the understanding, that unless indicated otherwise, it is for informational purposes only and is not intended as legal, medical, or other professional advice.

Merk Manual

National Library of Medicine

 

 

 

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