Lower back pain is a common clinical condition, and the treatment of lower back pain has changed dramatically in the last 10 years, and the social cost of medical care and work incapacity due to lower back pain is enormous. Lower back pain is the leading cause of work incapacity in people younger than 55 years of age who are able to work.
Lower back pain has many different etiologies. Many lower back pains cannot be diagnosed by medical history, physical examination findings, or diagnostic tests. Psychosocial and occupational risk factors often influence the diagnosis, making it difficult to explain in terms of organic pathology. Repeated bending and turning of the lower back increases the risk of low back pain and disc herniation. Smoking, obesity, may also be associated with the incidence of lower back pain. It has been found that the incidence of lumbar disc herniation is three times higher in smokers than in nonsmokers. The incidence of both low back pain and lumbar disc herniation is higher among smokers; lower back pain may also be a manifestation of psychological disorders.
I. Clinical manifestations
The clinical manifestations of lumbar disc disease are mainly low back pain with unilateral or bilateral radiating pain in the buttocks and posterior thighs, aggravated by coughing or sneezing, positive straight leg raising test or weakened Achilles reflex. Reduced nerve root sensitivity and unilateral pain with or without significant muscle tension are suggestive of spinal origin disease.
The most common causes of non-spinal origin low back pain are renal and vascular disease; cancer can also cause back pain with nocturnal resting pain, unexplained weight loss and fatigue, among other manifestations.
II. Imaging
With the improvement of diagnostic and therapeutic tools, human beings are gradually recognizing that many lower back pains have clear organic causes that can be effectively treated. The rapid development of radiology, electromagnetic diagnosis and puncture techniques have increased the credibility of diagnosis and produced more instructive treatment options.
X-rays can be used to diagnose lower back pain, with positive and lateral views of the lumbar spine usually being the primary examination and useful in the evaluation of the condition of the bones and ligaments. The advantage of lumbar spine imaging is the dynamic observation of hyperflexion and hyperextension films to estimate nerve compression.
III. Treatment options
There are many approaches to the treatment of lower back pain, with a large number of relevant literature related reports, but few conclusive results. The therapeutic difficulty lies in the fact that there are too few links between the findings of pathological studies and the patient’s manifestations of pain and dysfunction, which requires the search for therapies that target clinical symptoms that are not currently explained. These therapies are applicable to any form of pain, regardless of whether the pain mechanism is clear.
1. Bed rest
Lower back pain is often a self-limiting condition. More than 80% of patients with lower back pain are able to improve their symptoms in the first two weeks. Bed rest is the most commonly used treatment for lower back pain, but it is controversial. The overall consensus is that if bed rest is effective, the duration of bed rest should not exceed 2 days.
2.Medication
Pain medications are often used in the treatment of lower back pain. Non-steroidal anti-inflammatory drugs are commonly used as anti-inflammatory and analgesic drugs, and the common adverse effects are gastrointestinal adverse reactions and nephrotoxicity. Selective COX-2 inhibitors are anti-inflammatory while reducing the risk of gastrointestinal side effects and others. Aminoacetophen and others are commonly used painkillers, but the side effects are significant and excessive doses can cause hepatotoxicity. Opioids are effective for symptom control, but long-term application can produce side effects such as drowsiness, vertigo, fatigue, nausea, dyspnea, and constipation. Short-acting narcotics are capable of causing insomnia. Long-acting opioids have less addictive properties and good drug resistance. All narcotic drugs should be used as sparingly as possible. Hormones have significant gastrointestinal risks, and long-term application has the potential to cause bone loss and increased infection, which can cause humeral head and femoral head necrosis and should be applied sensibly. Muscle relaxants can be used to treat acute lower back pain and are not indicated for long-term treatment. Muscle spasms around the spine are usually associated with acute lumbar sprains of various causes and are effective when this class of drugs is applied. Antidepressants have an important role, especially when accompanied by mood disorders. Their synergistic effect of antidepressant and analgesic is particularly useful in people whose lower back pain increases their depressed mood. Antiepileptic drugs (e.g., carbamazepine), are useful in the treatment of nerve pain, especially lower extremity pain. Their effectiveness in treating low back pain is still questioned.
3. Physiotherapy
Physical therapy is a broad term that can refer to stretching limbs and strength exercises, low back pain schools, and other modalities. Physical therapy is more effective than drug therapy alone; it is also more effective than massage for chronic pain. Specific lumbar hyperextension exercises have good results for patients with chronic low back pain. Suspension traction also has a role to play. They can play a role in reducing local muscle spasm and stabilizing the spine. Exactly what kind of exercise is beneficial to the patient is not fully understood.
4, acupressure therapy
Acupressure (such as massage) is the most common method of treating lower back pain. About 15% of people in the United States undergo acupressure treatment each year. Acupressure and physical therapy have equivalent efficacy in the treatment of acute low back pain and are both more effective than medication alone. There is evidence to support that long-term acupressure can treat chronic low back pain, but the mechanism of acupressure is not clear.
5.Lumbosacral support
The purpose of using a lumbosacral support (such as a lumbar brace) is to provide stabilization. Vertebral fractures, vertebral slippage and postoperative support are all indications for brace therapy. There is no literature to support the long-term application of lumbar supports for the treatment of lower back pain. Possible reasons for not using a brace are: poor patient compliance and the tendency to develop psychological dependence, leading to ineffective immobilization. There are controversial reports in the literature regarding the role of braces in restricting activity.
6. Selective closure
Selective spinal closure helps to clearly diagnose the site of pain and also increases the anti-inflammatory effect of glucocorticoids locally, producing local anesthesia and therapeutic effects. Epidural closure is the most commonly used method of selective closure. Pain in the sacroiliac joint can be difficult to treat because of its diffuse innervation. Sacroiliac joint closure can provide some diagnostic and therapeutic benefit.
The intervertebral joints can be a source of low back pain, and local closure techniques have shown that the intervertebral joints can cause low back pain. Patient history, physical examination, and imaging studies cannot be used alone to diagnose intervertebral joint-derived low back pain, and CT of the lumbar spine in asymptomatic individuals over the age of 50 often shows degenerative changes in the intervertebral joints. Extension pain, as opposed to flexion-aggravated pain, accompanied by radiographic evidence of arthropathy, suggests pain of arthralgiogenic origin. Branches of the medial branches of the nerve roots innervate the two inferior intervertebral joints. If selective blockade of these nerves relieves the lower back pain, it helps to diagnose the intervertebral joint causing the pain. Correlating radiographic evidence with the relief of pain produced by local anesthesia in the intervertebral space can be considered a diagnostic basis for intervertebral joint pathology. Sometimes medial branch nerve blocks are effective but brief, and pain relief can be more permanent with electrofrequency removal of the nerve root. This technique is performed by inserting a guide needle to locate the nerve that innervates the intervertebral joint and destroying the innervated nerve fibers with a frequency shot. Single-segment nerve root dissection is not very successful, and multi-segment nerve root dissection may have better results.
7.Intervertebral disc electrothermal therapy
In recent years, the treatment of discogenic lower back pain with disc electrothermal therapy has become popular. The method involves placing a guide pin around the posterior aspect of the annulus fibrosus and heating the pin. Discography and MR examinations, often show high signal or internal tears in the posterior part of the fibrous annulus, and pain is produced by stimulation of chemical and mechanical injury receptors. The exact mechanism of pain relief is unclear. Cadaveric studies have shown that spinal stability is not altered after electrothermal treatment of the intervertebral disc.
IV. REVIEW
The treatment of lower back pain is a challenge for the therapist. Treatment should be highly individualized based on symptoms and imaging findings, etc., with the patient being an active participant throughout the process in order to facilitate recovery and return to activity. The best option for non-surgical treatment is active treatment and intervention, coupled with patient education and rehabilitation guidance. Treatment is often a combination of various therapies. The treatment plan should be tailored to the patient’s specific situation.
Early acute low back pain is often self-limiting in nature, with or without treatment, with significant symptom reduction within one to a few weeks of onset and possible improvement in the short term. Treatment includes medication: non-steroidal drugs, aminoacetophen, muscle relaxants, analgesics (even anesthetics), etc.; short-term bed rest; physical therapy, such as: functional exercise, traction, acupuncture, etc.; chiropractic therapy: acupressure, massage, etc. For the treatment of severe lower back pain, a combination of NSAIDs and muscle relaxants is recommended, with no more than 2 days of bed rest. NSAIDs should be continued until the pain subsides; physical therapy should be started within a week. Treatment should include flexion and extension, strength exercises, and lower back stability exercises. Symptom relief should be applied only in the early stages to enable the patient to start exercises as early as possible.
Long-term chronic lower back pain is more difficult to treat and the etiology is not easily defined. Treatment includes: medication: antidepressants; lumbar orthopedic braces such as lumbar braces; participation in low back pain schools; physical therapy; selective closure: epidural closure, nerve root medial branch closure, etc.; dorsal radiculotomy; and intradiscal electrothermal therapy. Education of the patient is part of the complete treatment process. Teaching patients how to protect themselves is one of the most effective ways to treat lower back pain.