Evaluation And Management Of Back Pain

backpainIt is estimated that up to 84 percent of adults have back pain at some time in their lives. Patients who continue to have back pain beyond the acute period (4 weeks) have subacute pain ( between 4 and 12 weeks) and may go on to develop chronic back pain ( ≥12 weeks) .

Risk factors include smoking, obesity, female gender, physically and psychologically strenuous work, sedentary work, low educational attainment, Workers’ Compensation insurance, job dissatisfaction, and psychologic factors such as somatization disorder, anxiety, and depression.

Initial evaluation include proper history, examination and if requires diagnostic tests .Red flags such aspersistent pain, older age, prolog use of steroids ,fever, swelling ,neurological deficit and bladder & bowel involvement should not be ignored .

Although there are variable etiologies (trauma , tumor, infection ,degeneration, inflammatory arthropathy  and deformity) ,fracture of spine , T.B. spine ,metastasis secondaries ,disc prolapse, degenerative disc disease ,facet arthropathy ,ankylosing spondylitis , rheumatoid arthritis , spondylosis, spondylolisthesis and osteoporosis are the common  diagnosis .Majority of patients seen in primary care will have nonspecific  back pain( > 85%)  meaning that the patient has back pain in the absence of any specific underlying condition ,which resolve within few days to week .

Investigations: Diagnostic imaging of the spine has a high rate of abnormal findings in asymptomatic persons. Therefore, imaging should be used in carefully selected patients and interpreted with appropriate clinical correlation. Different investigations suggested  with red flag findings are X-rays (dynamic  x-rays when required ), MRI , CT scan , PET scan and if required  Biopsy. In some patients with suspected infection ( T.B. spine etc ), inflammatory (ankylosing spondylitis ) or malignancy, routine blood investigations along with the erythrocyte sedimentation rate (ESR) and/or C-reactive protein (CRP) may be helpful.

Treatment: Patient education focusing on activity, aggravating factors, the natural history of the disease, its relatively benign etiology, and expected time course for improvement may speed recovery and prevent chronic pain. Recommendations should include staying active but avoiding heavy lifting, bending, twisting, and prolonged sitting. Patients should be encouraged to return to work at light duty rather than wait for complete resolution of the pain.

Most of the patients get relief with conservative management in the form of pharmacological agents with maximal recommended doses of non steroidal anti-inflammatory drugs (NSAIDs) and acetaminophen, followed by adjunctive medications as opiods , muscle relaxants and corticosteroids and antibiotics, if required. Medication should always be associated with non pharmacological measures as:  Behavior therapy, yoga, exercise therapy, focusing on strengthening and stabilizing the core muscle groups of the abdomen and back

. Acupuncture massage and pressure point massage

. Back schools, physio as low-level laser therapy, lumbar supports, prolotherapy, short wave diathermy,  traction, transcutaneous electrical nerve stimulation, and ultrasound are also effective modalities


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