Low back pain is pain, muscle tension, or stiffness in the lower back with or without leg pain (sciatica). It is defined as chronic when it persists for 12 weeks or more.

About 8 in 10 people suffer from low back pain at some stage of their life. In most cases it is a self-limiting condition and not due to any serious cause. Sixty percent of patients with acute low back pain recover in six weeks and up to 80% to 90% recover with in 12 weeks.

USEFUL TERMINOLOGY

Sciatica — Evidence of nerve root irritation typically manifests as sciatica, a sharp or burning pain radiating down the posterior or lateral aspect of the leg, usually to the foot or ankle. Pain radiating below the knee is more likely to represent true radiculopathy than proximal leg pain. Sciatic nerve pain is often associated with numbness or tingling. Sciatica due to disc herniation usually increases with coughing, sneezing, or performance of Valsalva maneuver.

Radiculopathy — Radiculopathy is a condition in which a disease process affects the function of one or more nerve roots. The clinical presentations of lumbosacral radiculopathy vary according the level of nerve root or roots involved. The most frequent are the L5 and S1 radiculopathies. Patients present with pain, sensory loss, weakness, and reflex changes consistent with the nerve root involved

Cauda Equina — Bowel or bladder dysfunction may be a symptom of severe compression of the cauda equina, which is a medical emergency. Urinary retention with overflow incontinence is typically present, often with associated saddle anesthesia, bilateral sciatica, and leg weakness. The cauda equina syndrome can be caused by a massive midline disc herniation or tumour.

Spinal Stenosis — Nerve root entrapment in lumbar spinal stenosis is caused by narrowing of the spinal canal (congenital or acquired), nerve root canals, or intervertebral foramina. This narrowing is usually caused by bony hypertrophic changes in the facet joints and by thickening of the ligamentum flavum. Disc bulging and spondylolisthesis may contribute. Symptoms of significant lumbar spinal

stenosis include back pain, transient tingling in the legs, and ambulation-induced pain localized to the calf and distal lower extremity, resolving with rest. This pain with walking, referred to as ‘pseudoclaudication’ or ‘neurogenic claudication’, is clinically distinguished from vascular claudication by the presence of normal arterial pulses.

EVALUATION OF PATIENTS WITH LOW BACK PAIN

The initial evaluation, including a history and physical examination, of patients with chronic low back pain should attempt to place patients into one of the following categories:

The medical history and examination should focus on red flags indicating the possibility of a serious underlying condition.

RED FLAGS

PSYCHOSOCIAL ‘YELLOW FLAGS’ PREDICTING LONG-TERM DISABILITY

Psychosocial issues play an important role in guiding the treatment of patients with chronic low back pain. Patients with chronic low back pain who have a reduced sense of life control, disturbed mood, negative self-efficacy, high anxiety levels, and mental health disorders, and who engage in catastrophizing tend to respond less well to treatments. ‘Yellow flags’ are psychosocial risk factors for long-term disability. Evaluation of psychosocial problems and yellow flags are useful in identifying patients with a poor prognosis.

Yellow flags include

PAIN MANAGEMENT PROTOCOL FOR CHRONIC LOW BACK PAIN

INTERVENTIONAL TREATMENTS OFFERED FOR LOW BACK PAIN