Low Back Pain: A Common Sense Approach

Saturday, January 29, 2005 | 0

The following article on general low back pain is the first installment in a series on the important aspects of one of the most ubiquitous problems in medicine today.

DEFINITION:

Low back pain is defined as any pain affecting the lower part of the back. It can be referred from elsewhere (such as kidney) or originating from the back directly. It is classically considered acute if it is less than 6-12 weeks in duration and chronic if longer than 12 weeks. The period in between 6-12 weeks is considered sub-acute. We will consider back pain to be a pain or ache between the lower ribs and the upper legs. It may be associated with movement, coughing or sneezing or may occur at rest. It may or may not be associated with spasm. It may be felt in one location and/or associated with pain in distant locations such as the foot, knee, or buttocks further complicating its proper evaluation.

EPIDEMIOLOGY:

Most back pain is not serious and resolves with or without treatment within a few days or weeks. It accounts for over 14 million office visits to clinicians annually and billions of dollars in lost productivity, as well as medical and disability claims. The incidence rate is highest in the industries involved with eating and drinking, followed by hospitals, grocery stores and services which involve delivery and driving. It is estimated that driving for more than twenty minutes consecutively increases risk of low back pain three fold over controls. Other risk factors include poor fitness, obesity, poor posture and ergonomics, depression and repetitive stress on the area, including activities that involve pounding such as seen in jack hammer operators.

DIFFERENTIAL DIAGNOSIS:

The understanding of the proper evaluation of back pain is critical to the safe and rapid resolution of the cause(s) and the preservation of productivity. This will translate into savings from lost days, bad will, over utilization of medical services and disability ratings.

While most back pain is of non serious causes there are some life threatening conditions that will present as "back pain" as the chief complaint and must not be missed.

There are several serious concerns to remember when initially screening a patient complaining of "back pain". These require immediate and professional care and include: possible tumors of the spine; cancers elsewhere in the body; abnormal vital signs that might suggest a ruptured aortic aneurysm (a tear in the main artery taking blood away from the heart); pain following major trauma (especially a fall from a height greater than 20 feet); pain in a person over 50 or younger than 20 years of age; the presence of constitutional symptoms (including fever, chills or weight loss); recent infection; immune suppression; pain that worsens when the patient is supine or is severe especially at night; pain associated with anesthesia (loss of feeling) in the "saddle" distribution; bladder or rectal dysfunction; or pain that is progressing and/or associated with neurological deficits.

Once the above important differential considerations can be excluded we are left with the usual type of patient seen in the occupational medicine setting. This patient suffers pain either from a sprain/strain syndrome or from varying levels of pain emanating from a more neurogenic cause such as the pinching of a nerve in or about the spine. One common form of this is referred to as "sciatica" which specifically refers to an inflammation of the nerve fibers originating from the lower lumbar and upper sacral spinal cord.

The next installment(s) will deal with the cost effective methods to evaluate, treat, and establish prognosis (or rate) patients with back pain.

Marco N. Vitiello, M.D., is Chairman and CEO of MED-TEK in Miami, FL. He can be reached at (305) 595-7177, or by e-mail at mvitiello@med-tek.com>.

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