Lv Dan, Department of Pain, Tianjin First Central Hospital Many patients hospitalized in the Department of Pain, Tianjin First Central Hospital, have high expectations of pain relief for patients with low back and leg pain and want immediate results. These patients are of different sizes, weights and ages, and the causes of pain are complex with different lesions, so they need to be treated differently. Low back pain is only a symptom, and most are associated with herniated lumbar discs, while a few patients may not find an obvious cause and associated lesions. Since low back pain can severely limit a patient’s mobility, patients often develop a strong sense of loss when the pain cannot be reduced or takes a long time to relieve. Zheng Baoshen, Department of Pain, Tianjin First Central Hospital I. Analyzing the causes of low back and leg pain There are many causes of low back and leg pain, which may be caused by skeletal muscle tension, while the latter may be caused by strain and spinal pathology due to aging, infection or malignancy. Patients at risk of developing low back pain are as follows: – those who have a poor physical condition and are unable to participate in regular physical activity; – those who are older than 55 years of age; – workers who have been involved in heavy physical labor for a significant period of time (e.g., construction workers); and – those who are obese; – people with narrowed spinal canal and spinal stenosis; – people who smoke or use drugs; – people of low socioeconomic status. When evaluating a patient with low back pain, there are a number of warning signs that must be taken into account. Malignancy may be the cause of pain if the patient loses significant weight or complains of pain that worsens at night and is not relieved by lying down at rest. Neurologic symptoms such as sudden onset of incontinence or worsening foot drop may indicate spinal cord injury or progression of neurologic disease. Another alarming sign is severe or progressive neurologic dysfunction and weakness of vital muscles in the lower extremities. This may be cauda equina syndrome. Other causes of low back pain are kidney or urinary tract infections, and gynecological disorders such as ovarian cysts can also cause low back pain. Second, the method of assessing pain When low back pain is acute, most physicians are fairly confident in the pain diagnosis. However, when the pain becomes chronic, regardless of the patient’s pain level, the physician will feel that the patient’s performance is all the same. Patients with chronic pain have learned to cope with their pain and often appear to be pain free, making it difficult to identify pain levels. In addition, patients with chronic low back pain may have vague or multiple site complaints and may have difficulty identifying the site of pain. In performing a basic pain assessment, we must ask the patient the following questions: – the patient’s pain intensity level, as determined by a validated pain rating scale (0 to 10 numeric scale), and all changes in the patient’s pain with activity or movement; – the area of pain and all areas from which pain radiates; – the duration of the pain, as well as any events that may have caused the pain, such as lifting heavy objects; – the nature of the pain (e.g., sharp, dull, or shooting pain); – any dysfunction such as the inability to walk up and down stairs, pain that interferes with sleeping, eating, social relationships, etc. Chronic pain is difficult to manage and control. When pain persists without relief, patients often report an inability to concentrate, sleep well, participate in hobbies, help with household chores, or participate in physical activity and work. Chronic pain has a significant impact on patients and their families. Patients often feel crazy and irritable, unable to handle affairs well, feel worthless and depressed. C. Treatment Options Acute Low Back Pain – Stay active. There is no indication for bed rest in acute low back pain. Maintaining as much activity as possible can promote recovery and maintain function; – If the patient has a clear indication and has no history of cardiovascular disease or gastrointestinal bleeding, a short course of non-steroidal anti-inflammatory drugs (NSAIDs ), i.e., non-selective anti-inflammatory drugs (e.g., ibuprofen or naproxen) or COX-2 inhibitors (celecoxib), may be very Useful. When using these medications, use them for as short a time as possible, use the smallest effective dose possible, and try to use them in patients who do have a clear indication and have very low risk factors; – Give the patient a medication that is appropriate for the patient’s reported level of pain; – Heat therapy, cold packs, pain creams, or massage may be tried. Chronic low back pain is a complex condition to treat because of its persistence and daily symptoms. Many patients with chronic low back pain have a physiologic injury, but the injury does not progress. In treating these patients, we must utilize a multidisciplinary approach. – Injured patients receive physical therapy programs that focus on improving mobility; – NSAIDs have no role in chronic low back pain. These medications can be beneficial when used short-term at the smallest possible dose in patients with acute low back pain. The inflammatory response in patients with chronic low back pain is different than in patients with acute low back pain. Acute injuries produce swelling and an inflammatory response. When the pain becomes chronic, the body has adapted and the inflammatory response has disappeared and stopped. Only the soft tissue injury or spinal injury persists, causing the patient dyskinesia and persistent pain. – Add sleep-promoting and antidepressant medications such as selective 5-hydroxytryptamine norepinephrine reuptake inhibitors (SSNRI), selective reuptake inhibitors (SSRI), or tricyclic antidepressants (TCA). – Referring patients to treatment programs that help patients build coping skills and a positive image of themselves. -$ Use nonpharmacologic interventions such as heat therapy, cold packs, acupuncture, or pain creams if the patient is interested.$ – Treat with direct epidural corticosteroid injections at the site of$ disc compression on the nerve root.$ IV. Pharmacological treatment of chronic low back pain The World Health Organization (WHO) three-step therapy for pain relief was first developed for the treatment of cancer pain, but is now commonly used for the treatment of all types of pain. Pain medications should be chosen according to the patient’s pain level. Patients with chronic pain requiring pain relief for more than 24 hours can use extended-release pain medications. Mild pain – pain intensity 1 to 3 – Dextropropoxyphene: contains acetaminophen 650 mg/tablet. Monitor total daily acetaminophen intake (especially harmful for those >60 years of age). Moderate pain – Pain intensity 4 to 6 – Acetaminophen-codeine: can be considered a moderate strength pain reliever at higher doses; – Oxycodone-acetaminophen; – Oxycodone-aspirin; – Controlled release oxycodone （Oxycodone – acetaminophen; – Oxycodone – aspirin; – Controlled-release oxycodone (OxyContin) Severe pain – pain intensity 7 to 10 – High-dose controlled-release oxycodone; – Immediate-release morphine; – Controlled-release morphine; – Hydroxymorphone; – Fentanyl patches: V. Latest Treatment In recent years, many mature techniques for the treatment of lumbar disc herniation have been widely used in the clinic, such as: collagenase dissolution, percutaneous nucleus pulposus removal, plasma disc decompression, intervertebral foramenoscopy nucleus pulposus removal, etc. In the Pain Department of Tianjin First Central Hospital, it has been widely used in the treatment of patients with various kinds of lumbar intervertebral disc herniation pains, and it has shown a high degree of safety and remarkable curative effect.