Pharyngitis
- causes and risk factors
- signs, symptoms, and diagnosis
- pathophysiology
- treatments
- consequences and course
- the patient
- health care team
- community involvement
- resources and references
Low back pain is a extremely common, with a lifetime incidence of 90%. Peak prevalence is between 45-60.
It is the 5th most common reason for visiting a physician, the most common cause of chronic disability in people over 45, and the largest WSIB category.
Causes and Risk Factors
Back pain can be caused by local, radicular, or referred sources, or can be related to mental health concerns.
Over 95% of back pain is mechanical in cause.
- ligamentous/muscle strain
- facet joint degeneration
- disc injury
- spondylosis
- spondylolisthesis
- compression fracture
- spinal stenosis
- pregnancy
Two percent is non-mechanical.
Medical causes of back pain
Neoplastic: primary, metastatic, myltiple myeloma
infections: osteomyelitis, TB
metabolic: osteoporosis, osteomalacia, Paget's disease
rheumatologic: ankylosing spondylitis, polymyalgia rheumatica
referred pain: perforated ulcer, pancreatitis, pyelonephritis, ectopic pregnancy, herpes zoster, AAA
Signs, Symptoms, and Diagnosis
- history
- physical exam
- lab investigations
- diagnostic imaging
History
Mechanical back pain is worse with movement and improved with rest.
Pain is most concerning when worse at rest and with o change in position.
Areflexia, lower extremity weakness, fecal incontinence, urinary retention, saddle anesthesia, and decreased anal tone suggest cauda equina syndrome.
Physical Exam
Neurologic exam (strength, tone, reflexes) for L4, L5, S1 helps determine level of spinal involvement
Peripheral pulses
special tests
straight leg raise: positive if pain <70 degrees, aggrevated by ankle dorsiflexion - suggests sciatica
crossed leg raise
femoral stretch test: patient prone, knee flexed, passive extension of hip: L4 radiculopathy
Lab Investigations
CBC, ESR, urinalysis (infection, cancer)
Diagnostic Imaging
plain films not recommended on initial investigation.
Indications for lumbar X-ray:
- no improvement after 1 month
- fever >38C
- unexplained weight loss
- prolonged corticosteroid use
- significant trauma
- progresive neuromuscular deficit
- suspicion of ankylosing spondylitis
- history of cancer
- alcohol/drug abuse (osteomyelitis, trauma, fracture)
bone scan to detect infection, tumour, occult fracture
consider CT or MRI if worsening neurological deficits, infection, tumour
Pathophysiology
Treatments
Reassurance and education are important; 70% improve in 2 weeks, and 90% in 6 weeks.
Recommended comfort measures include:
- limited bed rest (avoid debilitation)
- stay active, within limits of pain, to speed recovery and avoid chronic disability
- activity modification: temporarily avoid activities that stress spine
- encourage early return to work/activities
- heat/cold therapies
The Alexander Techique, which teaches self-awareness of posture and movment, can reduce disability and time off work (Little et al, 2008)
Manipulation
Massage may be helpful
Spianl traction, TENS, biofeedback, acupuncture, injections
Medications
- acetaminophen
- NSAIDs
- muscle relexants <7 days, but be cautious with drowsiness
- NOT narcotics
Surgery
Surgery may be considered if:
- suspected cauda equina syndrome
- worsening neurological deficit
- intractable pain, not responding to conservative therapy
Warn patients of red flags (bowel/bladder symptoms, groin numbness
Consequences and Course
Acute back pain lasts < 6 weeks, while subacute is 6-12 weeks and chronic back pain lasts >12 weeks.
90% resolve in 6 weeks, while <5% becomes chronic.
The Patient
Health Care Team
Community Involvement
Resources and References
Little P, Lewith G, Webley F, et al. 2008. Randomised controlled trial of Alexander technique lessons, exercise, and massage (ATEAM) for chronic and recurrent back pain. BMJ. 337:a884.