The evaluation and management of low back pain

The evaluation and management of low back pain § § Asgar Ali Kalla Professor and Head Division of Rheumatology University of Cape Town

Some helpful statistics u Backpain affects two thirds of adults u Second to URTI in frequency u Affects men and woman equally u Most common between 30 and 50 years u Expensive cause of work related disability u Uncertainty about optimal approach

90% of low back pain is mechanical u Musculoligamentous injuries u Age-related degeneration in the intervertebral discs and facet joints u Spinal stenosis u Disc herniation u Osteoporotic compression fractures u Spondylolysis and spondylolisthesis

Natural history u Spontaneous improvement is the rule u 50% better at 1 week u > 90% better at 8 weeks u 7 -10% persist beyond 6 months

Medical causes u Uncommon but important not to miss them – Spondylarthropathy – Spinal infection – Osteoporosis – Malignancy – Referred visceral pain F pelvis, renal, aortic aneurysm, pancreatitis

Clinical evaluation u Precise anatomical diagnosis often elusive – Is a systemic disease causing the pain? – Is there neurological compromise that may require surgical evaluation? – Is there social or psychological distress that may amplify or prolong pain?

serious neurology serious medical systemic symptoms BACK PAIN conservative management

Management: Watchful waiting u Patient education – Spontaneous recovery is the rule – Those who remain active despite pain have less future chronic pain – Exercise has prevention power u Rest: 2 days or less u Analgesics to permit activity u Reassess if pain worsens or neurological symptoms develop

Why not get imaging studies? u Imaging can be misleading: many abnormalities as common in pain-free individuals as in those with back pain u If under age 60 – low yield: unexpected Xray findings 1: 2500 – bulging disc in 1 of 3 – herniated disc in 1 of 5

u Over age 60 and pain-free – herniated disc in 1 of 3 – bulging disc in 80% – all have age-related disc and apophyseal joint degeneration – spinal stenosis in 1 of 5 cases

BACK PAIN conservative management PERSISTENT PAIN DEVELOPING NEUROLOGY red flags imaging lab tests