​Kembara Xtra - Medicine - Low Back Pain

​Kembara Xtra - Medicine - Low Back Pain 
ESSENTIAL DESCRIPTION
The lumbosacral spine and pelvic girdle are involved in low back pain (LBP), which is a very prevalent condition.
Defined by length or accompanying symptoms
Duration: Acute (6 weeks or less)
Subacute (>6 weeks but 3 months)
Chronic (more than 3 months)

 Complementary symptoms - "Mechanical" localized or non-specific LBP
- Lower extremities and back symptoms
- Visceral and systemic symptoms
Most people with LBP do not have a clear reason.
In 4 to 6 weeks, most cases are finished.
Distinguish "red" flag symptoms that demand quick attention.
Musculoskeletal and neurological systems are both affected. Synonyms include lumbago, low back syndrome, and lumbar sprain/strain.

EPIDEMIOLOGY

First episode incidence within a year: 6.3-15.3%

 Any episode's 1-year incidence is 1.5–3.6%. 
A primary care problem that is very prevalent
Lifetime prevalence: 84 percent 
9% is the global point prevalence. 
United States chronic point prevalence: 13.1%
The third decade (20 to 29 years) has the highest incidence; general prevalence rises with age until 65 years old, at which point it starts to fall.
PATHOPHYSIOLOGY AND ETIOLOGY
The most prevalent cause of LBP is muscle tension or spasm.
39% of chronic LBP is thought to be caused by disk degeneration.
About 30% are thought to have facet joint syndrome. Sacroiliac injuries/degeneration and spinal stenosis are additional potential causes. The lumbosacral spine's age-related degenerative alterations and the atrophy of the supporting musculature may also play a role.

Age, activity (lifting, sudden twisting, bending), obesity, sedentary lifestyle, physically demanding work, psychosocial variables—anxiety, depression, and stress, genetics, heavy operating equipment, poor flexibility, and smoking are risk factors.

DURATIONAL PREVENTION

 Retain a healthy weight.
Sufficient physical activity and fitness Stress management Correct lifting technique and excellent posture Smoking cessation There is inadequate evidence to suggest for or against routine preventive actions in adults.

DISEASE HISTORY
Pain's onset (sudden or gradual)

 The thigh region can experience pain from spinal structures (muscles, ligaments, facet joints, and disks), however pain below the knee is uncommon. However, the sacroiliac joint/PSIS area is where facet pain most frequently travels.
Irritation, impingement, or compression of lumbar nerve roots frequently causes more leg pain than back pain. Sacroiliac discomfort frequently refers to the thigh and might radiate below the knee.

While the L4-S1 nerve roots radiate pain below the knee, the L1-L3 nerve roots emit pain to the hip and/or thigh.
● Warning signs: Recent trauma
- Weakness, falls - Night pain, sweats, fever, weight loss - Neurologic impairments - Bowel/bladder incontinence or urinary retention - Saddle anesthesia
- Older than 70 years, traumatized or not
- Over 50 years old with a slight injury
Osteoporosis, cancer history, immunosuppression, protracted glucocorticoid use, IV medication use, and fever
Red flags (indicating a negative long-term outlook):
Lack of social support, an unfriendly workplace, depression, anxiety, drug or alcohol abuse, a history of physical or sexual abuse, excessive mobility in the spine or other joints, fear of re-injury, movement, or pain, and a cynical outlook on recovery are all factors.
Motion can cause pain, including sitting, standing, lifting, side-bending, and flexion-extension. Radicular pain may radiate to the buttocks, thighs, and lower legs, and is frequently eased by relaxation.
Child Safety Considerations
Children's back pain is abnormal and has to be thoroughly examined. The main factor necessitating additional investigation would be trauma from high impact or hyperextension sports.

MEDICAL ANALYSIS
Pay attention to posture, stride, and facial expressions.
Check the range of mobility in your lumbar spine.
Check for muscle spasm or point soreness.
Scan for indications of muscular atrophy.
Perform a comprehensive physical examination to check for a broad differential (the whole differential is stated in the section below).
– Evaluate your reflexes, strength, pulse, and sensation in full.
- Slump test: Have the patient lean forward while sitting on a table. After that, try to get the patient to extend one leg at a time while having them touch chin to chest. Do this while routinely reevaluating for symptom recurrence, which may be a sign of a disk herniation.
- Straight leg test: While the patient is lying down, raise the patient's leg straight. Maintain a straight knee. Dorsiflex ankle while elevating leg to be more precise. This can test for a herniated disk as well.
- Check for anal wink reflex and saddle anesthesia.
- Bilateral FABER and FADIR hip test
- Look for any psychological problems that might be a factor.
- Stork test: Place the opposite hip in flexion while standing on one leg. Lean back. Consider spondylolisthesis over facet OA if you experience pain in the lumbosacral region.
- The Waddell sign, which includes broad tenderness and reactivity to physical examinations, may be a symptom of a psychological component or depression.

Localized/nonspecific "mechanical" LBP (87%) is the differential diagnosis. - Lumbar sprains or strains (70%)
- Facet and disk degeneration (10%)
- Compression fracture due to osteoporosis (4%).
- 2 percent spondylolisthesis
- Severe kyphosis and scoliosis
- Transitional vertebrae with asymmetries (1%)
- Fracture due to trauma (1%).
Back discomfort with symptoms in the lower extremities (7%%) (1)[A]
- A herniated disk (4%)
- 3 % spinal stenosis
Visceral and systemic symptoms
Neoplasia (0.7%
 Metastatic carcinoma and multiple myeloma
• Leukemia/lymphoma
Retroperitoneal tumors and spinal cord tumors: infection (0.01%)
Osteomyelitis, Septic Discitis, Epidural Abscess, Paraspinous Abscess
The inflammatory illness shingles (0.03%)
Reactive arthritis, psoriatic spondylitis, ankylosing spondylitis, and visceral inflammation of the colon (0.05%)
Endometriosis, chronic pelvic inflammatory disease, and prostatitis
Nephrolithiasis and pyelonephritis, aortic aneurysm, pancreatitis and cholecystitis, other penetrating ulcers, osteochondrosis, and Paget disease
Cava equina syndrome

DETECTION & INTERPRETATION OF DIAGNOSIS

Initial examinations (lab, imaging)
Routine imaging has no clinical benefit; it is only advised in cases of progressive, severe neurologic deficits or "red flags"; it has a high rate of false positives; evidence of a possible herniated disk can be seen on computed tomography (CT), magnetic resonance imaging (MRI), myelography, and lumbar spine X-ray in 20–76% of asymptomatic patients. It is also not advised for initial presentation in the absence of red flags. If there is a history of acute trauma (fell, etc.) or a high risk of disease, postpone films for six weeks. MRI of the lumbar spine is helpful to assess bone etiology (such as fracture) in patients who report with neurologic impairments, fail to recover after 6 weeks of conservative treatment, or if there is a high suspicion of malignancy or cauda equina syndrome.
- Helpful for suspected metastatic illness, nerve root compression, or ruptured disks
If a patient has a pacemaker, metallic hardware, or another condition that precludes an MRI, a CT scan of the lumbar spine is an appropriate alternative. Lab tests are not necessary at the time of the initial presentation if there are no related red flags, signs, or symptoms. However, if an infection or bone marrow neoplasm is suspected, complete blood count (CBC) with differential should be considered.
3-phase bone scan - Erythrocyte sedimentation rate (ESR) - C-reactive protein (CRP) level
Diagnostic procedures/other neurosurgical consultation for suspected cauda equina syndrome or acute neurologic impairments


TREATMENT

The provision of supportive care and enabling restoration to functional activities are the main objectives. Patients should be aware of alarm symptoms that call for a follow-up appointment.

First Line: MEDICATION
Physical treatment: Early referral to physical therapy for sciatica patients improves both short- and long-term outcomes.
– Patients who feel better with low back extension (standing up straight) can consider the McKenzie method.
- Manual therapy, including osteopathic manipulative treatments (OMTs) such as myofascial release, counterstrain, bilateral ligamentous methods, and muscular energy techniques as tolerated

Patients should be reassured that discomfort is typically self-limited and that treatment should reduce pain and enhance function.
- No longer than 48 hours in bed.
- Promoting activity as tolerated speeds up healing; try to get some walking in.
- Early intervention with formal physical therapy - Maintain lumbar lordosis by sitting in a straight-backed chair rather than a sofa or a chair with soft cushions.
- Proven effectiveness of intense patient education for long-term pain management and return to work
Acetaminophen 325 to 650 mg PO q4-6h PRN pain (max 4 g/day) is a common medication.
NSAIDs, or nonsteroidal anti-inflammatory medications
 Ibuprofen, 400–600 mg PO, three–four times per day (maximum 3,200 mg/day)
Naproxen 250 to 500 mg PO every 12 hours, with a daily maximum of 1,500 mg
- When B vitamins were combined with NSAIDs (at least 50 mg of vitamin B1 [thiamine], 50 mg of vitamin B6 [pyridoxine], and 2,000 g of B12 [cyanocobalamin]), medication requirements and pain levels were lower than when NSAIDs were used alone.

Obstetric considerations: Pregnant women should use drugs with caution; the benefit must clearly outweigh the risk.
OMT and chiropractic treatment can be applied in a multidisciplinary manner; both the general public and pregnant patients can benefit.

Cyclobenzaprine 5–10 mg PO up to TID PRN (maximum 30 mg/day) is the second-line treatment for moderate to severe pain.
-2 mg of tizanidine PO up to TID PRN
- Prevent opioid use (if necessary, use for no more than 4 days) for LBP; opioids in the treatment of LBP do not significantly outperform NSAIDs plus placebo or placebo alone and may even lead to chronic opioid dependence and/or LBP.
– Topiramate has been shown to be more effective than a placebo at reducing pain and enhancing function in a single, short trial.
Topical lidocaine is probably no better than a placebo. Combining naproxen with the benzodiazepine diazepam (Valium) does not reduce pain or disability scores.
Antidepressants are among other treatments. Randomized trials have demonstrated that the tricyclic antidepressants (amitriptyline, nortriptyline, and desipramine) help patients experience a slight pain decrease. There is insufficient proof that selective serotonin reuptake inhibitors are superior to placebo in treating chronic low back pain. The management of concomitant depression may benefit LBP.
Compared to other antidepressants, Cymbalta has demonstrated efficacy in reducing persistent LBP pain.
often increase dosage to 60 mg every day.
Injections - Aspect Both lumbar intra-articular injections and therapeutic facet joint nerve blocks in the lumbar spine have demonstrated efficacy.
- Epidural: provides temporary relief from chronic pain linked to documented radicular symptoms brought on by a ruptured disk. 
- Lumbar radiofrequency: A recent RCT found no clinically significant difference between radiofrequency and exercise program compared to exercise program alone in terms of LBP reduction.

Aspects of Geriatrics
Older patients on nonselective NSAIDs should take misoprostol or a proton pump inhibitor for gastrointestinal safety.
Patients should take a proton pump inhibitor or misoprostol for gastrointestinal protection if they are also taking a COX-2 selective inhibitor and aspirin.
The risk of adverse drug responses is increased by the age-related reduction in cytochrome P450 function and polypharmacy (common in older patients).

ALTERNATIVE & COMPLEMENTARY MEDICINE
Recent changes to the guidelines advise against acupuncture.
Chronic LBP can benefit from yoga. According to recent research, yoga can improve long-term function and lower pain in general while treating chronic low back pain as effectively as physical therapy.
NSAIDs and exercise are equally effective at reducing pain and improving functional status as spinal manipulative therapy (including osteopathic treatment).

CONTINUING CARE AFTERCARE RECOMMENDATIONS
Regular exercise to control symptoms and manage weight
Encourage patients to continue being active.
Inform patients about red flags, recurrence, and chronicity.
patient observation
Reassurance is crucial. To check on progress, follow up within 2 to 4 weeks of the initial presentation. Typically, people get better on their own.
- Evaluate the level of pain, range of motion, and any historical characteristics (red flags).
Reassess for organic factors if there is insufficient improvement.

COMPLICATIONS

Acetaminophen has the potential for hepatotoxicity at high doses, and regular use of NSAIDs can raise the risk of gastrointestinal toxicity and nephrotoxicity. According to recommendations, the maximum daily dosage should be 4 g.
Opioid agonists and centrally acting skeletal muscle relaxants have the potential to cause drowsiness, disorientation, dependency, and abuse. If patients need pain drugs for a prolonged period of time, proceed with utmost caution.

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