Low back pain

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**Low back pain**
*Classification & external resources*
ICD-10	M 54.5
ICD-9	724.2

It has been suggested that this article or section be merged with Back pain. (Discuss)

Low back pain can be either an acute or chronic disabling condition. For many, it may be an ongoing condition that flares up occasionally for a few days or weeks, then becomes more manageable again. It will affect most adults at some stage in their life and accounts for more sick leave taken than any other single condition.

An acute lower back injury may be caused by a traumatic event, like a car accident or a fall. It occurs suddenly and its victims will usually be able to pinpoint exactly when it happened. In acute cases, the structures damaged will more than likely be soft tissue like muscles, ligaments and tendons. With a serious accident, vertebral fractures in the lumbar spine may also occur. At the lowest end of the spine, some patients may have tailbone pain (also called coccyx pain or coccydynia).

Chronic lower back pain usually has a more insidious onset, occurring over a long period of time. Physical causes may include osteoarthritis, rheumatoid arthritis, degeneration of the discs between the vertebrae, or a spinal disc herniation, a vertebral fracture (such as from osteoporosis), or rarely, a tumor (including cancer) or infection. The cause may also be psychological or emotional, and can be diagnosed as TMS or tension myositis syndrome.

1 Causes
2 Diagnosis
3 Treatments
4 See also
5 External links

[edit] Causes

Possible causes of low back pain:

Mechanical:
- Apophyseal osteoarthritis
- Diffuse Idiopathic Skeletal Hyperostosis
- Degenerative Discs
- Scheuermann's kyphosis
- Spinal disc herniation (slipped disc)
- Spinal stenosis
- Spondylolisthesis and other congenital abnormalities
- Fractures
- Non-specific muscular or ligamentous strains or sprains
- Leg Length Difference
- Restricted hip motion
- Misaligned pelvis

Inflammatory:
- Seronegative spondylarthritides (e.g. ankylosing spondylitis)
- Rheumatoid arthritis
- Infection

Neoplastic:
- Bone tumors (primary or metastatic)
- Intradural Spinal tumors

Metabolic:
- Osteoporotic fractures
- Osteomalacia
- Ochronosis
- Chondrocalcinosis

Paget's disease

Referred pain:
- Pelvic/abdominal disease
- Posture

Tension myositis syndrome

Depression

[edit] Diagnosis

Diagnosing the underlying cause of low back pain is usually done by a medical doctor, physiotherapist (physical therapist) or by a chiropractor. Often, getting a diagnosis of the underlying cause of low back pain and/or related symptoms, such as sciatica, is quite complex. A complete diagnosis is usually made through a combination of a patient's medical history, physical examination, and, when necessary, diagnostic testing, such as an MRI scan or x-ray. There are a number of health care professionals who may specialize in diagnosing and treating low back pain, including chiropractors, osteopathic physicians, physical therapists (physiotherapists), physiatrists, anesthesiologists/pain medicine physicians, and orthopedic or neurosurgeons.

Research shows that the presence of a leg length difference does not mean you will have back pain. Diagnosis of leg length difference is quite easy. Just stand in front of a mirror in your underwear on a flat, level floor in front of a mirror (a bathroom is usually good). Look at your hips to see if they are level. If one seems higher, put a magazine under the short leg. Keep adding magazines until your hips look level. Measure the height of the magazines. This is the difference in the length of your two legs. 90% of the population has a leg length difference; the same percentage that experiences lower back pain during their lifetime. A difference of only 1% would be 1/3rd inch or more.

Diagnosis of restricted internal hip rotation is also easy. Lie on your stomach with your legs together. Bend your knees 90 degrees so that the soles of your feet point up toward the ceiling. Keeping your knees together, move your feet apart. Your lower legs will form a V. Have someone measure the angle of each lower leg in relation to a vertical line. The angle should be the same for both legs. Each leg should be a minimum of 45 degrees; 60 degrees if you play golf or tennis. Vad, et al, found restricted internal hip rotation on the lead hip associated with lower back pain in professional golfers.

[edit] Treatments

The course of treatment for low back pain will usually be dictated by the diagnosis of the underlying cause of the pain. For the vast majority of patients, low back pain can be treated with non-surgical care. ClinicalEvidence.com has systematically reviewed randomized controlled trials published through April, 2004 and concluded:

Treatments
	For acute low back pain	For chronic low back pain
"Beneficial"	Advice to stay active Pain medications, such as NSAIDs or acetaminophen	Exercise Intensive multidisciplinary treatment programs (evidence of benefit for intensive programs but none for less intensive programs)
"Likely to be beneficial"	Multidisciplinary treatment programs (for subacute low back pain) Spinal manipulation (in the short term)	Analgesics Antidepressants Non-steroidal anti-inflammatory drugs Acupuncture Back schools Behavioral therapy Spinal Manipulation
"Unlikely to be beneficial"
"Trade off between benefits and harms"	Muscle relaxants medications	Muscle relaxants medications
"Likely to be ineffective or harmful"	Bed rest	Facet joint injections
"Unknown effectiveness"	Acupuncture treatment Epidural steroid injections Back schools Behavioral therapy Electromyographic biofeedback Lumbar supports Massage (but see below) Multidisciplinary treatment programs (for acute low back pain) Temperature treatments (short wave diathermy, ultrasound, ice, heat) Traction Transcutaneous electrical nerve stimulation	Epidural steroid injections Local injections Electromyographic biofeedback Lumbar supports Massage (but see below) Traction Transcutaneous electrical nerve stimulation

Surgery for lower back pain In a certain subset of patients who have failed more conservative treatment, surgery is an option. In some patients, low back pain is due to degenerative disc disease. Essential diagnostic evaluation includes an MRI scan. Surgical strategies include:

Laminectomy - to relieve spinal stenosis or nerve compression
Fusion (Instrumentation) - to eliminate abnormal motion in the spine
artificial disc replacement - to replace degenerative disks

Additional treatments have been more recently reviewed by the Cochrane Collaboration:

Massage therapy may benefit some patients (PMID 12076429)
Ice and/or heat application (or moist heat) has uncertain benefit (PMID 16437495).

Individual randomized controlled trials, thus interpretation may be subject to publication bias, also confounded by absence of double blinding have shown benefit for:

Viniyoga (PMID 16365466), Iyengar (PMID 15836974), and Hatha yoga (PMID 15055095 - small trial).
Correcting leg length difference may help (PMID 16271551). To correct leg length difference, insert a hard rubber or cork heel pad into the shoe of the short leg if the difference between the two legs is 3/8ths inch or less. If more, have a shoe repairman build up the sole and heel. Taper the toe to avoid tripping. If more than 3/4 inch, start with 1/2 of what you need so that your body can adjust.
Muscle Energy Technique (MET) may help (PMID 14524509 - small study)

Other treatments that were not reviewed are

Education and attitude adjustment (TMS)
Increasing internal hip rotation
Increase internal hip rotation with stretching or connective tissue massage

For any one condition, it may be necessary to try a variety of treatments in order to find the best one (or combination) to best manage the pain. In almost all cases, physical therapy and/or a regular exercise program that includes stretching, strengthening and low impact cardio conditioning will be part of the treatment and rehabilitation program.