Lower Back Pain
LOWER
BACK PAIN
Jassin M. Jouria, MD
Dr. Jassin M. Jouria is a medical doctor, professor of academic medicine, and medical author. He graduated from Ross University School of Medicine and has completed his clinical clerkship training in various teaching hospitals throughout New York, including King’s County Hospital Center and Brookdale Medical Center, among others. Dr. Jouria has passed all USMLE medical board exams, and has served as a test prep tutor and instructor for Kaplan. He has developed several medical courses and curricula for a variety of educational institutions. Dr. Jouria has also served on multiple levels in the academic field including faculty member and Department Chair. Dr. Jouria continues to serves as a Subject Matter Expert for several continuing education organizations covering multiple basic medical sciences. He has also developed several continuing medical education courses covering various topics in clinical medicine. Recently, Dr. Jouria has been contracted by the University of Miami/Jackson Memorial Hospital’s Department of Surgery to develop an e-module training series for trauma patient management. Dr. Jouria is currently authoring an academic textbook on Human Anatomy & Physiology.
ABSTRACT
The lower back provides structural support, making it possible to engage in a wide range of activities. When lower back pain occurs, a patient’s mobility can be significantly impacted. What seems like a minor case of back pain may indeed develop into a chronic disorder that significantly affects the patient’s quality of life. Understanding the anatomy of the lower back, as well as the causes of lower back pain, will help healthcare professionals make diagnosis and treatment decisions that are vital to the patient’s well-being.
Continuing Nursing Education Course Director & Planners
William A. Cook, PhD,
Director
Doug Lawrence, MS, Nurse Webmaster Course Planner
Susan DePasquale, CGRN, MSN, Nurse Lead Nurse Planner
Accreditation Statement
This activity has been planned and implemented in accordance with the policies of and the continuing nursing education requirements of the American Nurses Credentialing Center's Commission on Accreditation for registered nurses.
Credit Designation
This educational activity is credited for 14 hours. Nurses may only claim credit commensurate with the credit awarded for completion of this course activity.
Course Author & Planner Disclosure Policy Statements
It is the policy of to ensure objectivity, transparency, and best practice in clinical education for all CNE educational activities. All authors and course planners participating in the planning or implementation of a CNE activity are expected to disclose to course participants any relevant conflict of interest that may arise.
Statement of Need
Nurses in all areas of health care are accountable to recognize signs and symptoms of back pain in patients as well as colleagues in the workplace. Managing low back requires specific training and continuing updates on how to effectively assess and intervene in the alleviation of pain, and to advocate for a prevention plan.
Course Purpose
This course will provide advanced learning for nurses interested in the management of low back pain for patients, and for their colleagues and themselves.
Learning Objectives
1. Describe the structure of the lumbar region.
2. Differentiate between the upper back and the lower back.
3. Identify patient groups that are at high risk for lower back pain.
4. Differentiate between a sprain and a strain.
5. Describe the role of scar tissue in lower back pain.
6. Explain the symptoms of sciatica.
7. Describe the effects of a herniated disc.
8. Identify congenital skeletal deformities that put a patient at risk of lower back pain.
9. Describe the symptoms that, in correlation with lower back pain, indicate a more serious illness.
10. Identify common causes of infection that may cause lower back pain.
11. List the most useful diagnostic tools for diagnosing lower back pain.
12. List common treatments for lower back pain.
13. Identify medicinal treatments for lower back pain.
14. Explain the risks of opioids as a treatment for lower back pain.
15. Recognize the challenges in diagnosing fibromyalgia.
16. Differentiate between discography and myelograms.
17. Describe the limitations of using x-ray as a diagnostic tool for lower back pain.
18. Explain the different types of electrodiagnostic procedures.
19. List common surgical treatments for lower back pain.
20. Identify the gender differences in osteoporosis.
Target Audience
Advanced Practice Registered Nurses, Registered Nurses, Licensed Practical Nurses, and Medical Assistants
Course Author & Director Disclosures
Jassin M. Jouria, MD has no disclosures
William S. Cook, PhD has no disclosures
Doug Lawrence, MS has no disclosures
Susan DePasquale, CGRN, MSN has no disclosures
Acknowledgement of Commercial Support
There is no commercial support for this course.
Activity Review Information
This course has been peer reviewed by Susan DePasquale, CGRN, MSN.
Review Date: October 20, 2013.
Release Date: October 25, 2013 Termination Date: October 25, 2016
INTRODUCTION
Lower back pain, lumbar pain or lumbago is one of the most common complaints that doctors encounter in their daily practice. This is not surprising since almost everyone experiences it at some point in their lives. Statistics show that Americans spend a staggering amount of $50 billion, if not more, annually for one reason or another due to low back pain. Treatment, sick leave and loss of productivity are just among the common reasons. In fact, it is the most common cause of job-related disability. It is also only behind headache as the most common neurological ailment in the United States.
This course explores the broad pathology of lower back pain, diagnostic methods, as well as its various treatment modalities. Because of the non-specific nature of lower back pain, it is hard to pinpoint its exact cause and may be attributed to several pathologic factors. Lower back pain may be acute or chronic, depending on the pathology involved, which is why the course discusses extensively its pathology and diagnostic approach.
Lower back pain refers to pain in the lumbar region of the spine. Its severity, onset and duration differ individually. The pain may be slow in onset and duration or may be constant or intermittent. It may resolve on its own or it may require medical intervention (1). The two types of lower back pain are: acute and chronic:
Acute lower back pain refers to a short-term duration of pain that usually lasts from a few days to a few weeks. Mechanical forces such as trauma to the lower back or arthritic disorders usually cause this type of back pain. Pain due to trauma may be due to sporting and vehicular accidents, sudden movements, or wrong lifting techniques. Its symptoms may range from mild to severe depending on the affected vertebra (2).
Chronic back pain refers to pain that lasts longer than a few weeks, usually more than 3 months, after its initial onset. It is usually a sign of a progressive and ongoing disease such as the degenerative process found in osteoarthritis. Other causes may be attributed to congenital defects.
Structure and function of the lumbar region
In order to understand the pathology of lower back pain, it is important to understand the complex parts and functions that make up the lumbar spine, the site of lower back pain.
The spine is divided into four major segments, namely (1):
▪ Cervical spine
▪ Thoracic spine
▪ Lumbar spine
▪ Sacral spine
[pic]
Originating from Latin, “lumbar” comes from the term ‘lumbus’ which means loin. It is a term originally coined by Claudius Galen in the 2nd century. The word was initially used to refer to both the joint as well as the bone of the spine.
The lumbar spine is a composite combination of vertebrae and multiple bony elements, which are joined together with the help of joint capsules, ligaments, tendons, muscles and nerves. It is innervated by nerves and supplied with an intricate network of blood vessels. It consists of five lumbar vertebral components numbered from L1 to L5, which are movable. The lumbar spine is composed of the anterior, middle and posterior columns (1).
The lumbar vertebrae are the largest of the true vertebrae. It forms a strong column of support at the base of the vertebral column. The most important features of lumbar spine are its (3):
▪ Large size, and
▪ Lack of transverse foramina and costal facets
Function
The lumbar spine is known to possess incredible strength. Some of its most important functions are (3):
▪ Protecting the spinal cord,
▪ Protecting the nerve roots of the spinal cord, and
▪ Lending flexibility to allow a variety of complex movements such as flexion and extension.
The lumbar spine is capable of executing a wide range of motion, more than the thoracic spine but lesser than the cervical spine. It is the lumbar facet joints that allow movements such as flexion, extension and limited amount of rotation.
Lumbar vertebrae
Structurally speaking, the lumbar vertebrae are tall but narrow. The three functional components of the lumbar vertebrae are (4, 6, 7):
1. The vertebral body,
2. The vertebral arch or neural arch, and
3. The spinous and transverse bony processes.
Lumbar vertebral bodies
The lumbar vertebral bodies are connected together with the help of intervertebral discs. The size of the lumbar vertebrae progressively increases from first to the fifth lumbar (L1 to L5) vertebrae, which are indicative of the increasing loads absorbed by each descending vertebra (4, 6, 7, 8).
Intervertebral discal surface
A ring of cortical bone present on the outer boundary of the adult vertebrae is known as the epiphyseal ring. The epiphyseal ring forms the growth zone in children and adolescents, and holds the attachments of the annular fibrils in adults. A hyaline cartilage plate is present within the epiphyseal ring (4, 6, 7).
Vertebral arch
The vertebral arch is made up of the following parts (4, 6, 7, 8):
▪ Pedicles
▪ Laminae
▪ Bony processes
* Spinous
* Articular
* Transverse
The number of facet joints and ligaments that join these structures are enumerated in the table below.
|Parts of vertebral arch |Number of facet joints and ligaments |
|Pedicles |2 |
|Laminae |2 |
|Bony process |7 |
|Spinous process |1 |
|Articular process |4 |
|Transverse process |2 |
Pedicle
The joint present on the posterior face, joining the arch to the posterolateral body is called the pedicle. It is firmly fixed to the cephaled portion of the body. The concavity present in the cephalad and caudal surface of the pedicel are known as vertebral notches (4, 6, 7).
The function of the pedicle is to act as a protective cover for the cauda equine contents.
Laminae
Laminae are strong and wide plates extending from the posterior-median side of the pedicle. It is an elongated spinous process that is directed posteriorly from the joint of the lamina.
There are two articular processes, namely; two superior and two inferior processes that extend cranially and caudally from the joint between the pedicles and the laminae. The zygophaseal joint is in the parasagittal plane. Two transverse processes also protrude laterally. These are long, slender and strong in nature, with two tubercles, namely; the inferior and superior articular tubercles located at the mammillary process and the accessory process, respectively.
Lumbar vertebral joints
The zygopophysial joints are present between the superior and inferior articular processes on the adjacent vertebrae. Also known as facet joints, they allow simple gliding movements. The region between the superior articular process and the lamina is known as pars interarticularis. Spondolysis is the condition, which results from a lack of ossification in this region (4, 6, 7, 8).
Lumbar intervertebral discs
Constituting almost one quarter of the entire length of the vertebral column, the intervertebral discs make up the main connection between vertebrae. Each disc is made up of a nucleus pulposus in which reticular and collagenous fibers are inserted and covered with the annulus fibrosus, which is a fibrocartilaginous lamina. The annulus fibrosus is further divided in three parts, namely (4, 6):
▪ Outermost: the anterior fibers with the anterior longitudinal ligament
▪ Middle: anterior and lateral fibers adding reinforcement and flexibility
▪ Innermost: posterior longitudinal ligament can bear weak midline reinforcement in the form of a narrow structure attached to the annulus, more so at the L4-5 and L5-S1 regions.
The anterior and middle fibers of the annulus are present mostly in the anterior and lateral regions but a few are also found in the posterior region. The annular fibers are attached to the vertebral bodies and are arranged in the lamellae; the reinforcing structure formed by the ligaments, which provides limited mobility to the vertebra (4, 6, 8).
Lumbar vertebral ligaments
The lumbar ligaments are (4):
▪ Anterior longitudinal ligament
▪ Posterior longitudinal ligament
▪ Supraspinous ligament
Ligamentum flavum
Intratransverse ligament
Ileolumbar ligament
▪ Intertransverse ligament
▪ Interspinous ligament
▪ Facet capsulary ligament
Anterior longitudinal ligament
The anterior longitudinal ligament is found on the ventral surface of the lumbar vertebral bodies and discs. It is present in close association with the anterior annular disc fibers. It broadens towards the bottom of the vertebral column. Its function is to maintain the stability of the joints and restrict their extension movement.
Posterior longitudinal ligament
The posterior longitudinal ligament is situated in the vertebral column, over the posterior end of the vertebral bodies and discs. Its primary function is to restrict the flexion movement of the vertebral column.
Supraspinous ligament
The function of the supraspinous ligament is to connect the tips of the spinous processes of the adjacent vertebrae from L1 to L3. This ligament interconnects the spinous processes extending from the root to the apex of the adjacent processes.
Ligamentum flavum
The ligamentum flavum connects the interlaminar interval and joins medially with the interspinous ligament, laterally with the facet capsule and itself forms the posterior side of the vertebral canal. It functions to maintain the constant disc tension.
Intratransverse ligament
The intratransverse ligament attaches to the transverse processes of the adjacent vertebrae and also inhibits the lateral bending of the trunk.
Ileolumbar ligament
The ileolumbar ligament originates from the L5 transverse process and connects posteriorly with the innermost lip of the iliac crest. Its function is to support the lateral lumbosacral ligament in stabilizing the lumbosacral joint.
Lumbar spine musculature and vasculature
There are four muscle groups, which govern the functions of the lumbar spine. These are divided into (5, 6):
▪ Extensor
▪ Flexors
▪ Lateral flexors
▪ Rotators
The lumbar vertebra is supplied with blood by the anterolateral pair of lumbar arteries originating from the aorta opposite the bodies of L1-L4. The venous drainage runs parallel to the arterial supply. The venous plexus is formed by the veins along the vertebral column inside and outside the vertebral canal (5, 6).
Risk factors for lower back pain
As mentioned in the introductory section above, lower back pain is one of the most commonly occurring musculoskeletal problems seen in medical practice. At least 100 risk factors have been identified for lower back pain, a significant number of which is attributable to a combination of individual and occupational factors (9).
The most common causes of pain in the lower back are related to physical activities and postural alignment related to a range of risk factors such as (9):
▪ Demographic variables such as age, gender and occupation
▪ Recurrent weight lifting
▪ Use of vibrating equipment
▪ Sedentary life style
▪ Weakness of muscles of the abdominal wall
▪ Obesity
▪ Smoking
▪ An increase in the lumbar lordosis
▪ Scoliosis
▪ Cardiovascular disorders
▪ Low socioeconomic standard
At risk groups
Various research studies have confirmed that a substantial percentage of the adult population who is suffering from lower back pain. This number mostly attributes their symptom to their increasing age, female gender, rural habitation, low socio-economic status and excessive smoking (9).
However, studies have also found that there is an ever-increasing prevalence of lower back pain among the adolescent and early adult population. The female gender is more prone to suffering from lower back pain due to frequent physical and hormonal changes, all of which also magnify their symptoms (10).
Lower back pain results from abnormal mechanics of the spinal column such as higher spinal loads and lower stability of the spine, which are frequently seen in various occupations that require heavy lifting and moving. The physical demands of a task dictate the biomechanics of the spine, the effects such as stiffness or damping of the trunk, and the mechanical neuromuscular response to the work related to equilibrium and stability requirements.
Age
Increasing age equates to an increase in wear and tear of various musculoskeletal structures resulting in many anomalies of the spine such as disc degeneration and spinal stenosis, all of which may result in lower back pain. Studies have found that people over the age of 30 or 40 are more susceptible to developing lower back pain compared to their younger counterparts. People between the age group of 30 to 60 years are more likely to contract disc–related disorders while those over the age of 60 mostly suffer from lower back pain due to osteoarthritis (10).
Aside from the normal degenerative processes at work in the incidence of lower back pain among the elderly, comorbidity also plays an important role.
Prevalence of lower back pain in students
Studies have supported the fact that there is a relatively high and increasing evidence of lower back pain among school-going children. The four major activities that significantly contribute to the lower back pain are (10, 11):
▪ Lifting or carrying of heavy loads such as heavy school bags
▪ Bending forward
▪ Sitting for over 30 minutes
▪ Standing for more than 10 minutes or sports activities in school or during free time
Additionally, lower back pain is more prevalent among female students, those who smoke and who perform manual lifting and moving jobs outside school.
Occupational lower back pain
There have been studies done to examine the impact of work-related psychological and mechanical stressors in the development of lower back pain in the general working population. Physically demanding jobs, prolonged standing or awkward lifting are few of the most important contributing factors to lower back pain. Those with the more severe form of lower back pain are mostly involved in jobs requiring repetitive heavy lifting, use of jackhammers or machine tools, and operating motor vehicles.
Specifically, exposure to certain repetitive biomechanical processes in the workplace increases the risk of developing lower back pain, which are listed and illustrated below:
▪ Bending or twisting
▪ Kneeling or squatting
▪ Prolonged standing
▪ Heavy physical work
▪ Nursing tasks
[pic]
Warehouse workers, movers, nurses and even primary caregivers are primarily exposed to biomechanical stressors. Prolonged standing, sometimes for hours and hours on end, is an important and consistent risk factor found among these working groups.
Another consistent risk factor has been said to be lifting heavy loads using awkward postures. One example is in nursing homes where nurses are required to lift and manually handle patients in a regular basis for changing, transporting, and feeding purposes (12). Another study has established beyond any doubt the relationship between lower back pain and nursing tasks as a leading cause for absence due to sickness among nurses. Another study has found an inverse, albeit, weak association between the height of the nurse and prevalence of lower back pain (13).
People who work in a forward bending position without adequate support such as gardening or manually lifting boxes off the ground, and those who squat or kneel are exposed to excessive rotation and higher degrees of trunk flexion which in turn are associated with lower back pain (14). Another stressor, psychological demands of highly stressful jobs, has also been linked with greater incidence of lower back pain (15). In fact, studies have suggested that stressful jobs actually cause increased muscular strain and result in greater muscle tension and other physiological reactions that put people at greater risk of developing lower back pain (16). Poor job satisfaction and lack of recognition at work are two other factors, which are attributed to contribute to the prevalence of lower back pain in the general working population.
CAUSES
Etiology
As mentioned in the previous section, lower back pain may be due to biomechanical factors at play. In this section, an overview is provided of a number of spinal conditions, which may cause pain in the lower back. The discomforting pain may be caused due to two types of causes, listed below:
▪ Mechanical disorders: spinal disorders involving mechanical forces that resulted to spinal injuries to the discs, facet joints, ligaments or muscles, causing lower back pain.
▪ Compressive disorders: spinal disorders resulting from pressure or irritation of the spinal cord or nerves. This kind of irritation causes pain, numbness and muscular weakness along the lumbar area where the nerve travels.
Mechanical spinal disorders cause irritation of lumbar nerves due to mechanical pressure exerted by bones or tissues, or disease affecting that section of the spine extending from its root at the spinal cord to the surface of the skin.
Nerve and muscle irritation
Some of the most common examples are lumbar disc disorder, bone impingement, and nerve inflammation caused by viral infection. The nerve irritation caused by damaged discs between the vertebrae is due to either wear and tear of the outer ring of the disc, or direct traumatic injury to the disc. The ensuing pain gradually radiates towards the lower extremity when it is lifted. Bone impingement usually results from movement or growth of the lumbar spine that invades the anatomical space reserved for the adjacent spinal cord and nerves. This results in compression of the spinal nerves, leading to pain, which radiates down to the lower extremities. Lower back pain may also be caused by muscular injuries, which result in nerve inflammation. Muscle strains in the paraspinal muscle are one example. Another example is pressure or irritation on the nerves leaving the spine that cause numbness and muscle weakness on the lumbar region.
Sprain, strain or spasm
The lumbar spine bears a lot of the body’s weight during physical activities like walking, and running. Lifting heavy loads can strain the lower back muscles while muscular sprain or spasms to the same area may result in pain.
An injury to the muscles or a tendon is termed as a strain while stretching or tearing of a ligament is called a sprain. As mentioned above, muscle strain to the lower back muscles can result from improper lifting techniques, overstressing the back muscles, overuse or prolonged repetitive movement of the muscles or tendons which can twist or pull a muscle.
A sudden blow to the body or a sudden twist may lead to the stretching of ligaments causing injury and pain in the lumbar region. The injury to the muscle or tendon often referred to as strain may commonly result from chronic weakness, overuse or chronic strain on the lower back. Sprain causes a joint to move abnormally, overstretching and tearing the ligaments in the process. The tear in the ligaments causes blood loss from the tissues around the joint, causing inflammation and pain in the area. The lower back sprains are more severe in nature limiting the range of motion of the lower back and causing painful spasms (18).
Spasms are sudden, forceful and continuous muscular contractions that often lead to lumbar back pain. It is mainly caused by factors related to direct injuries to the muscle, excessive physical activities such as exercise or a chronic strain. A muscle in spasm (spastic muscle) becomes hard and tight due to the uncontrolled contraction of all the fibers. Muscles that provide protection to the spine may become contracted due to chronic overuse, limiting the range of motion of its joints. Any disorder or problem in the disc, bones or the facet joint may also lead the muscle to undergo spasm as a protective measure to prevent any further damage to the spine. This protective spasm may be chronic in nature and result in chronic and persistent pain in the lower back (23).
Sciatica
The sciatic nerve is a nerve that runs from the back through to the pelvis deep, and into the buttocks. If there is pressure on one or more lumbar nerve roots, then pain may develop in certain parts of the sciatic nerve, if not all. There are many disease conditions, which may put pressure on the sciatic nerve resulting in lumbar pain such as herniated disc, spinal stenosis, degenerative disc disease, spondylolisthesis or abnormalities of the vertebrae. The lumbar pain due to sciatica may radiate from the buttocks all the way down to the other lower extremities (20).
Sciatica is best described as a symptom rather than a diagnosis. In certain cases of sciatic pain, the muscles, which are placed deep inside the buttocks, may put pressure on the sciatic nerve. This nerve is known as piriformis and the lower back pain resulting from this condition is known as piriformis syndrome. It is generally a result of an injury. The pain is due to the sciatic nerve compression or pinching of the sciatic nerve, which causes the lower back pain on one side of the body that eventually radiates to the buttocks, legs and feet (20).
Herniated disc
One of the most common causes of lower back pain is herniated disc, which is sometimes referred to as slipped disc. A rupturing or thinning out of a vertebral disc in the lumbar area, which protrudes out, ultimately leading to degeneration, marks this condition. The degeneration is often very extensive that the gel inside the disc, which is known as nucleus pulposus may escape outside.
[pic]
The damaged disc manifest in many forms, namely (17)
▪ A bulge:
the nucleus pulposus pushes out from the disc, and uniformly distributes itself symmetrically around the circumference.
▪ A protrusion:
the nucleus pulposus pushes out slightly and asymmetrically in any of the surrounding areas.
▪ An extrusion:
the nucleus pulposus becomes inflated extending into the area outside the vertebrae or completely escaping out of the disc.
The lower back pain is basically the result of the extrusion in which the gel or the nucleus pulposus escapes out of the disc to compress the nerve root, especially the sciatic nerve.
Sometimes there are abnormalities in the annular ring surrounding the disc. There are tears in the ring causing disruption of the fibrous band containing a dense network of nerves and high amount of peptides. People with degenerative disk disease are frequently affected with heightened perception of pain due to the tear in the annular ring (17). Another syndrome associated with disc disorders is cauda equine syndrome in which the four nerve strands traveling to the lowest part of the lumbar region, i.e. cauda equine, are impinged upon by a massive extrusion of the contents inside the disc. This condition is an emergency situation, which may lead to severe complications of the urinary or digestive system. The cauda equine syndrome causes a dull pain in the lumbar area, causing symptoms such as urinary incontinence and inability to control defecation (17).
Osteoarthritis
Osteoarthritis is defined as arthritis of the weight bearing joints such as hips and knees, hands, feet, and spine. Osteoarthritic conditions of the bones and joints lead to lower back pain which may be congenital, degenerative, or even due to the inflammatory processes. Osteoarthritis of the spine is a degenerative inflammation of the facet joint, which causes localized lumbar pain. The facet joint syndrome, commonly known as osteoarthritis, is a major cause of lumbar pain. The overload and increased pressure on the facet may be attributed to the degeneration of the disc and exposure of the articular surface to damage, and wear and tear of the cartilage (16).
In spinal arthritis, the cartilage between the aligning facet joints in the posterior region of the spine undergoes mechanical breakdown, resulting in the inflammation of the facet or the zygopophyseal joints. These joints undergo progressive degeneration, creating an increasing frictional lumbar pain resulting in a decreased range of motion, overall mobility and flexibility of the back in proportion to the progression of the back pain. The pain is usually triggered by routine physical activities like standing, sitting and walking. The lumbar spine osteoarthritis is also called lumbosacral arthritis. As its name suggests, it produces pain and stiffness in the lumbar spine and the sacroiliac joint, which is present between the spine and the pelvis (19).
In severe cases of spinal osteoarthritis, the cartilage and fluid lubricating the facet joint are completely destroyed, resulting in friction between the bones and leading to the development of bone spurs, which occupy space in the foramen and press into the adjacent nerve roots. A growing bone spur may also progress extensively so that it projects into the spinal canal itself resulting in the narrowing of the canal, a condition called spinal stenosis. The degenerative process resulting in the formation of bone spurs is a normal part of ageing and does not directly cause pain, although its enlargement may cause irritation or entrapment of nerves passing through the spinal structures, which cause pain (19).
Spondylolisthesis
When the lumbar vertebrae slip over one another, the resulting condition is termed as spondylolisthesis. It causes mild to severe low back pain among children and adults. In children, it is the fifth bone in the lumbar region and the first bone in the sacrum area that are usually affected while in adults, the slip occurs between the fourth and the fifth lumbar vertebrae. It may be caused by a congenital defect in the spinal area, a degenerative disease like arthritis, stress or traumatic fractures, or even bone diseases (24).
Studies have found that spondylolisthesis is the most common cause of back pain in the lumbar region among the adult population aged below 50. On the other hand, degenerative spondylolisthesis occurs more commonly at age 50.
Spondylolisthesis is categorized into different types according to their etiologic origins; these are namely:
▪ Congenital spondylolisthesis:
An abnormal bone function present at birth, which may result in an abnormal arrangement of the vertebrae, predisposing it to higher risk of slipping.
▪ Isthmic spondylolisthesis:
Small stress fractures in the vertebrae which may lead to a weakening of the bone, causing it to slip out of place.
▪ Degenerative spondylolisthesis:
This is the most common type of spondylolisthesis and occurs as a result of drying up of the discs due to the ageing process, which makes them less spongy and less resistant to movement by the vertebrae.
Spondylolisthesis is marked by increased lordosis, which can develop into kyphosis during the later stages of the disease as the upper spine falls off the lower spine. It may also result in neurological damage, manifesting as leg weakness or altered sensations in the lower extremities due to the pressure on the nerve roots. It is important to note that the lumbar pain caused by spondylolisthesis often radiates down to the lower extremities. The pain may manifest in the form of stiffness, muscle tightness, and tenderness in the lumbar area where the disc has slipped (17).
Additionally, it may cause muscle spasms in the hamstring muscles of the posterior thighs. The slipped vertebrae pressing a spinal nerve may also lead to pain radiating down the leg all the way to the foot. Generally, spondylolisthesis occurs only in one level of the spine, though it can occur rarely at level two or three of the spine simultaneously (17).
Fibromyalgia
Lumbar pain may also be attributed to fibromyalgia and other myofacial pain syndromes. Fibromyalgia is a muscular pain, which results in back pain, fatigue and tenderness at areas such as the neck, shoulder, hips, back, arms and legs. Some factors which may lead to tender points in the lower back or shooting pain in the lower back may be attributed to physical or emotional trauma, abnormal pain response, sleep disorders or viral infections (21).
Fibromyalgia is a common pain syndrome. Though it is not related to a specific cause, it still results in chronic pain encompassing a wide region of the body and nonspecific tenderness in the joints, muscles, tendons and other soft tissues. Fibromyalgia is not related to any specific anatomic disorder, and some scientists have attributed its symptomatic manifestations to underlying and non-specific biochemical factors (22).
Bone pathologies
The ageing process gradually decreases the strength of the bones, and tone and elasticity of the muscles. The discs start losing its fluid and flexibility, reducing their function as a protective cushion for the vertebrae.
Lower back pain is also known to reflect bone lesions such as multiple myeloma. Osteoporosis and other bone diseases are other common factors that cause lower back pain (29).
Bone lesions
Bone lesions are the oncologic causes of lower back pain, which may either be benign or malignant spinal tumor. The spinal tumors are in close proximity to neural and meningeal tissues, bone, and cartilage, all of which are capable of undergoing neoplastic changes and metastasis. All spinal tumors cause back pain regardless of its growth status i.e. whether they are malignant or benign. Osteosarcomas are commonly present in the lumbosacral segment of the spine and result in lesions. Spinal osteosarcomas are also seen in patients with Paget’s disease (31).
Bone metastases are cancerous cells, which spread from its site of origin to another location in the body; in this case, the lumbar spine. It may cause pain and makes the bone more vulnerable to fractures, even with the slightest of mechanical pressures. It is usually characterized by the presence of increasing amount of calcium circulating in the blood.
Metastases of the bone ultimately lead to lesions or injuries to the vertebral tissues of the spine, causing pain. These lesions can be classified into two categories, namely;
▪ Lytic lesions which completely destroy the bone material, and
▪ Blastic lesions which fill the bones with more cells.
The cancerous cells attacking the vertebra disrupt the balance between the osteoclasts (cells breaking down the bone) and the osteoblasts (cells developing and growing the bone).
Bone metastases are most commonly diagnosed in the back, pelvis, upper leg, ribs, upper arm and skull. The damage or load on the periosteum causes the lower back pain. Bone metastases also cause bone loss and hypercalcemia, the combination of which is a life threatening condition (32). The Maffucci’s syndrome sometimes exhibits bone axial lesions, which may also result in lower back pain (30).
Fractures
Vertebral fractures due to compression forces acting on the bones usually result in lower back pain; this is especially true in those suffering from osteoporosis.
The lower back pain is sometimes an indication that the bones forming the spine, vertebrae, have been fractured. In most cases, the weak and brittle bones that resulted from osteoporosis are the main causative factor of the fracture, and not the compressional forces themselves. It has been found that the majority of men and women over the age of 50 have a lower back pain that is attributable to vertebral fractures (26).
Vertebral fracture is defined as “a vertebral bone in the spine that has decreased at least 15 to 20% in height due to fracture.” The fractures may be located anywhere in the spine but are most commonly found in the thoracic spine, especially in the lower vertebrae of that region of the spine. These fractures are generally classified as a wedge fracture, crush fracture or burst fracture (25).
Wedge fracture
In a spinal fracture, the compression force is generally exerted in front of the vertebra, making the anterior part of the spinal bone to collapse while the posterior remains largely unchanged, leading to its unique wedge-shaped structure. The so-called “Dowager’s hump” is a good example of this type of fracture. It characterized by a stooped posture and a mechanically stable fracture (26).
Crush fracture
A crush fracture differs from a wedge fracture in that in this case, the entire bone breaks, instead of just the anterior part.
Burst fracture
Both the anterior and the posterior portions of the spinal bone being fractured characterize a burst fracture, which results in an unstable fracture that may eventually lead to a permanent deformity or a neurological disability. People with osteoporosis have weak, thin and brittle bones that are vulnerable to fractures from light physical activities. Such activities can subject these fragile bones to compression forces that can very well result in spinal compression fractures. Generally, the compression fractures do not cause pain but some are highly disabling in nature and cause extreme pain in the lumbar region. In severe cases of osteoporosis, the vertebral fractures can even result from innocent activities such as coughing, sneezing which lead to severe pain, deformity of lumbar spine, immobility and disability, ultimately interfering with daily activities (28).
Small and hairline spinal fractures may also eventually result in complete collapse of the vertebra. This means that when the spinal vertebra incurs multiple small fractures, the cumulative effects of these fractures are nonetheless painful and disabling. Moreover, the compression fractures in the spinal vertebrae can have long term repercussions such as permanently damaging the vertebrae by reducing its strength, shape and functioning (26).
Osteoporosis
Osteoporosis is a prevalent musculoskeletal disorder, which also results in lower back pain. It is characterized by reduction in bone mass and disruption of the microarchitecture of the bone tissue. This condition leads to an increased incidence of bone weakness, which may eventually cause fractures or increase the risk of vertebral fractures. Osteoporosis results in an increased risk of medical complications inclusive of hip fracture, vertebral deformities, and wrist fracture (35).
Lower back pain may be cited as the most common symptom of osteoporosis, arising from vertebral fractures. Lower back pain, as mentioned previously, has severe impact on the quality of life. Studies have reported that osteoporosis leading to lower back pain is mostly prevalent among middle-aged women. The high bone mineral density and associated degenerative diseases are known to cause lower back pain in both the elderly and middle aged women (35).
It should be emphasized that even with decreased bone mass and abnormal structure of the spinal vertebrae; there are no symptoms which are immediately visible. If the bone is fractured, only then will symptoms such as lower back pain manifest. The fracture, caused by osteoporosis, is also referred to as fragility fracture.
The external forces which destroy the already weakened bone structure range widely from light forces such as those caused by daily activities to strong and violent forces such as those incurred during trauma and fall accidents. The lower back pain following such fractures many manifest either as acute or chronic pain. The acute lower back pain is usually seen in fractures accompanied by rapid or gradual deformation of the bone involved. Other fractures due to osteoporosis also result in chronic lower back pain, which may gradually progress into dorsal kyphosis along with vertebral deformation.
Some studies have also reported that in certain cases, the deformation due to pressure on the vertebral body develops and grows without any symptomatic lower back pain (28).
Spondylosis
Spondylosis refers to anatomical changes of vertebral bodies and intervertebral disc spaces associated with lower back pain syndrome. Osteoarthritis of the lumbar spine or spondylosis is a non-specific degenerative condition, which affects the disk, vertebral bodies, and related joints of the lumbar spine.
The degenerative anatomical changes may eventually lead to complications such as spinal stenosis, in-growth of osteophytes, hypertrophy of inferior articular process, disk herniation, bulging of the ligamentum flavum, and spondylolisthesis. Such complications result in neurogenic claudication, which includes lower back pain, leg pain and also the numbness and motor weakness in the lower extremities (27).
Spondylosis has been used to describe many degenerative conditions of the spine and progression of the lower back pain. Some of these are listed below:
▪ Facet joint osteoarthritis, which may cause lower back pain due to excessive physical or prolonged physical activities.
▪ Spinal stenosis, which is characterized by the narrowing of the spinal canal due to various causative factors which cause lower back pain.
▪ Degenerative disc disease which results in dehydration and loss of function, eventually resulting in lower back pain along with neck pain, and possibly leg pain (33).
The most significant factors causing spondylosis are the wear and tear of the spine due to overuse. Spondylosis is associated with a cascade of events, which start with wearing down of the cartilage of the facet joints, causing a friction between the bones. The friction produces osteophytes or bone spurs, which are initially aimed at restoring equilibrium in the joint but ultimately, hamper mobility and range of motion of the joints. These osteophytes may even pinch the spinal nerves, which aggravates lower back pain (34).
Skeletal irregularities
Skeletal irregularities such as abnormal curving of the spine may result in back pain. If the curves of the spine are amplified, it will make the upper back look rounded abnormally or create an abnormal arch in the lower back. A spinal condition that has been known to result in back pain is scoliosis (37).
Structural failure of the lumbar discs in conjunction with advanced signs of ageing is referred to as degenerated disc. Structural defects like endplate fracture, radial fissures and herniation are reflective of impaired disc function. It is also important to note that the structural failure is irreversible and progressive. These skeletal irregularities are also known to advance through to the physical as well as biological processes, marking the degenerative process. Spinal disc degeneration is easily detectible through imaging studies, and is usually found in close association with lower back pain and sciatica (36).
Degradation of the spinal system may also result from injury and/or disease of any of the associated systems and structure of the lumbar area. In response to these changes, the neural systems of the spine bring about compensatory changes to initiate appropriate changes in the lumbar spine, which may maintain the stability of the spine but may also prove deleterious to the different components of the spinal system. The primary instability of the lumbar spine has also been cited as one of the most common causes of lower back pain. The secondary lumbar vertebral instability due to a disease or an injury of the lumbar spine involving the disc for example osteoarthritis, spondylolisthesis, nuclear ruptures into the neural canal is also a cause of lower back pain.
Spinal degeneration
Degenerative disease of the lumbar spine or lower back negatively affects the spine and involves a compromised disc, which is responsible for the lower back pain. The degeneration is a multifactorial problem ranging from a simple wear and tear to traumatic injuries that initiate a cascade of events causing a spinal degeneration. This degenerative cascade is even triggered by minor injuries, which ultimately wear out the disc completely. In fact, it has been noted that with increasing age, varying degrees of disc degeneration is normally seen. Spinal degeneration causes inflammation of the lumbar spine, with abnormal micro-motion instability as the reason for the lower back pain (42).
Structural failure alters the local mechanical environment of disc cells from the general loading of the disc that result in their aberrant cell responses. Excessive mechanical loading brings about a distortion of the structure of the disc and initiates a succession of cell-mediated responses (inflammatory responses), which worsens the pain symptoms.
The severity and onset of disc degeneration is influenced by various factors such as:
▪ genetic inheritance
▪ age
▪ inadequate metabolite transport, and
▪ load on the disc
All factors further weaken the disc, ultimately bringing about structural failure while performing routine physical activities (36).
The structural failures of the disc, which causes low back pain are (36):
1. annulus tears
2. disc prolapse
3. endplate damage and schmorl nodes
4. internal disc disruption, and
5. disc narrowing, radial bulging and vertebral osteophytes
Annulus tears
The lumbar spine is particularly vulnerable to injuries, especially tears such as:
▪ circumferential tears,
▪ peripheral rim tears, and
▪ radial fissures
Compressive stress, bony outgrowths, trauma-related mechanical forces, and cyclic loading of the disc during bending and compression are some of the causative factors of these tears. The incidence of annular tears is not affected by age and may develop in the presence of any of the factors causing it (36).
Disc prolapse
This type of condition affects the periphery of the disc. It is also termed as disc herniation. Radial fissures lead to migration of the nucleus pulposus in proportion to annulus bringing about disc prolapse. Disc prolapse or herniation proceeds sequentially in the following manner:
▪ Disc degeneration
▪ Protrusion of the nuclear material
▪ Extrusion of the nuclear content
▪ Sequestration of the nuclear content
[pic]
The disc prolapse may result from mechanical loading, which commonly affects individuals between 30 to 40 years of age. The presence of fluid nucleus and weakening of the annulus characterize it. The nucleus pulposus is forced downwards through the radial fissure (36).
Endplate damage and schmorl nodes
The weakest point of the spine when compressed is the vertebral endplates, which accumulate trabecular micro damage. With the ageing process, the nucleus starts protruding inside the vertebral bodies in later life. The endplate damage brings about instant decompression of the nucleus, with the annulus bearing the load bulges into the nucleus cavity. The nucleus pulposus ruptures through the damaged endplate, consequently resulting in calcium accumulation which creates what is known as “Schmorl’s node” (36).
Internal disc disruption
In this type of structural damage, the anterior portion of the annulus is affected more than the posterior portion. The inner annulus collapses into the nucleus. This type of structural damage frequently occurs in ageing discs. Internal disc disruption is often due to decompression of the nucleus succeeding an endplate fracture. The ageing cartilage and the endplate are seen as detached from the underlying bone due to the loss of high internal pressure compressing them (36).
Disc narrowing, radial bulging and vertebral osteophytes
Disc narrowing, radial bulging, and vertebral osteophytes are related to spondylosis. Due to the ageing process, the nucleus pulposus extrudes into the vertebral bodies causing a reduction in the nucleus pressure and rise in the vertical load on the annulus, which ultimately bulges outward radially and even inward in certain situations. These changes are accompanied by loss of the nucleus pressure, which manifests as collapse of annular height. This loss in height prevents the separation of adjacent neural arches, with the annulus collapsing on old discs, and contributing to more than 50% of the compression force on the lumbar spine. This is why narrowed discs are also seen in relation with osteoarthritis in the apophyseal joints and with osteophytes circulating on the edge of vertebral bodies (36).
Spinal stenosis
Spinal stenosis, as defined previously, is the narrowing of the spinal canal resulting in impingement on the neural structures by the bone and soft tissues surrounding it. The most common reason for lumbar spine surgery in adults over the age of 65 years can be attributed to spinal stenosis (44). Additionally, it often results in neurogenic claudication. It is another important cause of lower back pain aside from disc protrusion and root entrapment due to degenerative changes (40).
Stenosis can result from many degenerative conditions such as osteoarthritis or degenerative spondylolisthesis. These conditions lead to clogging of spinal nerves in the lumbar area, narrowing the canal and ultimately leading to claudication and pain in the leg (41).
Lumbar spinal stenosis refers to the narrowing of the lower spinal canal in the lumbar region due to either bone or tissue growths or both blocking the size of the openings in the spinal bone. The narrowed passage compresses and irritates the nerves coming out of the spinal cord. In extreme cases, even the spinal cord is affected; either compressed or irritated which leads pain, numbness or weakness in the legs, feet and buttocks (43).
Additionally, there is also enlargement of the facet joints leading to compression of the spinal nerve roots in the lower back, which also contributes to lumbar pain (41).
Ageing is one of the most common causes of lumbar spine stenosis (41). The various factors, which lead to spinal stenosis are those related with alterations in the shape and size of the spinal canal. Some of the most frequent factors causing lumbar spinal stenosis are:
▪ thickening of the ligaments
▪ formation and development of bony spurs compressing the spinal cord, especially in those suffering from osteoarthritis, and
▪ slipping of the discs backwards into the spinal canal.
Other conditions can play a significant role in the development of spinal stenosis. Examples of such conditions are bone diseases such as Paget’s disease, ankylosing spondylitis, rheumatoid arthritis, and diffuse idiopathic skeletal hyperostosis, all of which lead to softening of the spinal bone or excessive growth of the bone (43).
Younger individuals with spinal injury or curvature of the spinal canal may also eventually develop lumbar stenosis. When patients with spinal stenosis stand, the space reserved for the blood supply of nerve roots is significantly decreased, resulting in pooled blood which irritates the nerves and cause pain. However, it should be noted that lumbar stenosis rarely causes permanent nerve damage (41).
Lumbar stenosis is classified into three different types:
▪ Lateral stenosis
▪ Central stenosis
▪ Foraminal stenosis
Lateral recess stenosis
This is the most common type of lumbar stenosis. In this case, a nerve root leaving the spinal canal faces compression from either a bulging disc or protruding bone, which extends beyond the foramen (41).
Central stenosis
This type of lumbar stenosis causes compression of the cauda equine nerve roots especially when there is a blockade of the central spinal canal (41).
Foraminal stenosis
This type of stenosis occurs when bone spurs entrap or compress a nerve root in the lumbar region. Sometimes, the opening from where the nerve root leaves the lumbar spinal canal may also be blocked.
Other conditions causing low back pain
Infections are also known to cause localized pain in the lower back. Serious and destructive diseases but uncommon in nature are also instrumental in causing back pain. These include malignancy, infection, ankylosing spondylitis and epidural abscess. The occurrence of back pain can also be owed to the presence of musculoskeletal disorders, peptic ulcers, pancreatitis, pyelonephritis, aortic aneurysms and some other serious conditions (52).
Infections
Spinal infection is generally a serious condition, which may be initially dormant then slowly progress to an active state. It may also exacerbate into sepsis immediately and exhibit rapid symptom progression. The back pain associated with spinal infection is similar to and may be mistaken for discitis or osteomyelitis, although distinguishing it from the idiopathic pain can very challenging for the clinician.
Tubercular infection due to Mycobacterium can cause lower back pain. It can very well progress, albeit rarely, into tuberculous vertebral osteomyelitis (52).
An inflammation of the spine diagnosed as spinal infection should cause alarm to any clinician (49). Researchers have suggested that chronic lower back pain may arise from bacterial infection. The discs that are infected with anaerobic bacteria can later on develop into bone edema in the adjacent vertebrae following disc herniation. The bacteria infecting the gums and skin, Propionibacterium acne, can also spread to the lower back and result in pain (45). The male condition, benign prostate hyperplasia (BPH), can trigger lower urinary tract infection, which can spread and infect the spine and also cause lower back pain.
Acute spinal infections are usually pyogenic in nature while the chronic infections can either be pyogenic, fungal, or even granulomatous. Common infections from any bacterial or fungal source can spread to the spine such as dental abscess, pneumonia, and urinary tract infection. The infection is subtle at the beginning and usually only causes localized pain in the back at the area of involvement. The resulting spinal pain has the tendency to be aggravated with increased physical activity and load on the spine (e.g. carrying heavy objects). The spinal infection generally manifests as back pain accompanied by weight loss, fatigue, fevers, and night sweats. The pain is focal in nature and may be experienced by the patient when changing positions such as from sitting to standing. Focal kyphosis can also appear in the case of vertebral collapse (52).
Infections of the deep tissues of the lumbar spine are also known to cause lower back pain and leg pain. Some of the most common infections of the lumbar spine are osteomyelitis, discitis, epidural abscess, and postoperative wound infections. Deep tissue infections that do not involve the disc space directly can also lead to lower back pain (51).
Vertebral infection
An infection of the vertebral body is known as vertebral osteomyelitis and mostly affects young healthy individuals. The infection usually spreads to the lower vertebral body through vascular pathways. Batson’s plexus (veins in the lumbar spine) drain into the pelvis and are easy routes for bacteria to travel through, enter, and infect the spine. This is why uroscopic procedures commonly result in spinal infections.
There are many risk factors for the development of osteomyelitis such as increasing age, IV drug use, and immunosuppression such as those seen in patients with diabetes mellitus, AIDS, malnutirition, cancer, and those who underwent organ transplantation. The microrganisms which most commonly infect the spine are Staphylococcus aureus and Pseudomonas spp. Infections caused by Mycobacterium tuberculosis are also known to cause infections affecting the lower back that result in debilitating symptoms. Most of the infections of the vertebral body are localized in the lumbar spine owing to the limited blood circulation in this spinal region (58).
Lyme disease
Lyme disease is a chronic infection affecting the skin, joints, and the nervous system including the spine. Spirochete bacteria, manifesting initially as a rash following a tick bite, cause it. The skin lesions develop into multiple annular secondary lesions accompanied by other symptoms such as malaise and fatigue, headache, fever and chills, general achiness and regional lymphadenopathy. Some patients also show meningeal irritation, mild encephalopathy, migratory musculoskeletal pain, hepatitis, generalized lymphadenopathy and splenomegaly, sore throat, cough, and testicular swelling (54).
Patients diagnosed with Lyme disease also develop brief episodes of joint, periarticular or musculoskeletal pain following skin lesions. Later on, they develop into chronic synovitis characterized by erosions and permanent joint disability. Lyme arthritis ranges from mild and subjective joint pain to intermittent attacks of arthritis, and sometimes even to chronic erosive manifestation of the disease (53).
Shingles
Varicella zoster virus, the causative agent of shingles, infects certain spinal levels, which eventually cause lumbar pain. The virus is known to lie dormant in the body for many years following the initial chickenpox infection. Once the virus is activated again, it infects and spreads to various parts of the body including the spine, causing nerve damage that manifests as numbness, itching, severe pain, and the characteristic blistering rashes. Shingles typically start with a highly sensitive, band-like rash appearing on the skin followed by an intense discomfort of the same area, burning and painful sensations, and itching on the back. The most commonly affected areas are the trunk, neck and back.
There are a variety of factors which trigger the infection including emotional stress, increasing age, immune deficiency, and cancer. Persons of advanced age are more likely to experience the debilitating irritating rash sensations, severe herpetic neuralgia, and vision impairment that follow the infection (46).
Epidural abscess
Spinal infection can also progress to epidural abscess, which manifests initially as a localized spinal pain that slowly develops into radicular pain, weakness, and ultimately, paralysis. Epidural abscess is generally a complication of osteomyelitis, bacteremia, and postoperative infection. The common causative organisms are Staphylococcus aureus, Streptococci and Gram-negative bacilli. The characteristic feature of spinal epidural abscess is its progression from spinal ache to radicular pain leading to weakness and eventual paralysis. The disease has serious complications and may be accompanied by fever, local tenderness, and lower back pain (47).
Other problems that can also cause back pain in the lumbar region are ankylosing spondylitis, cauda equine syndrome, and rheumatoid arthritis. Added to this list are some rare bone disorders, tumors, and other disorders which exert pressure to the spine resulting in lower back pain (50).
Cauda equine syndrome
Cauda equine syndrome is a relatively rare but very serious medical emergency involving the spinal cord. Its name was derived from the nerves at the end of the spine that visually resemble a horse’s tail as they extend from the spinal cord down to the back of each leg. The nerves at the end of the spinal cord are subjected to excessive pressure and inflammation. If left untreated, it will ultimately progress to permanent paralysis, impaired bladder and bowel control, mobility difficulties, and various other related neurological and physiological problems (59).
Lower back pain which is localized in a particular area is one of the symptoms of cauda equine syndrome; along with progressive weakness in the lower extremities, loss of sensation in the saddle area, urinary or bowel incontinence, and sharp stabbing pain on the legs (59). There are various factors responsible for the compression of nerves in the lumbar spine including lumbar herniated disc, lumbar spinal stenosis, vertebral collapse due to metastatic infiltration, spinal subarachnoid hemorrhage, acute extradural hematoma, ankylosing spondylitis, infections in the spinal canal, tumors or trauma, and injury affecting the lower back.
Spinal dural arteriovenous fistulas
This condition is a distinct malformation of the spinal vasculature generally located in the lower lumbar or thoracic spine. It usually affects middle aged and older men. Its symptoms include lower back pain and symptoms similar to spinal stenosis (48).
Spinal arachnoiditis
Spinal arachnoiditis most commonly affects the lumbosacral region, although it can occur anywhere in the meninges. It is characterized by thickening of the arachnoid and adherence to the pia mater and dura mater. It can affect a single nerve root or multiple nerve roots in the cauda equina. As the condition progresses, it can even restrict the spinal cord itself.
There are several causative factors that result in the development of spinal arachnoiditis, including the following:
▪ intrathecal drugs or chemical agents such as radiation, spinal and epidural anesthesia,
▪ infections such as tuberculosis, cryptococcus, syphilis, viral infections,
▪ trauma such as spinal surgery, vertebral injuries or lumbar disk herniation, and
▪ spinal subarachnoid hemorrhage.
The symptoms of spinal arachnoiditis are persistent lower back pain, which can later radiate to both legs and result in motor and sensory disorders. The symptoms may appear within days of the damage or take years to appear. More than one lumbar or sacral nerve root is usually involved in this disorder (48).
Ankylosing spondylitis
Ankylosing spondylitis is a type of arthritis, which usually progresses into chronic inflammation of the spine and sacroiliac joints. It also affects other joints and organs in the body such as eyes, lungs, kidneys, shoulders, knees, hips, heart, and ankles; however, the primary affected region is the axial skeleton and its ligaments and joints. It typically results in stiffness, joint soreness, and pain around the spine and pelvis. It ultimately brings about a complete fusion of the spine.
The patient usually experiences pain symptoms once the spinal vertebrae start to fuse together as a result of calcium accumulation in the ligaments and discs between each vertebrae. In this type of condition, there is a complete loss of mobility and greater susceptibility to fractures and injuries.
Ankylosing spondylitis occurs more frequently among males, especially younger adult males. It starts at the sacroiliac joints, before moving to the spine. The long-term spinal joint inflammation results in calcification of the ligaments around the intervertebral discs and ligaments, which eventually restricts their movement.
The final stage is the complete fusion of the vertebrae, which is known as ankylosis. The severe pain symptoms of ankylosing spondylitis manifest on the lower back, buttocks, hips, and thighs (57).
Rheumatoid arthritis
Rheumatoid arthritis is an autoimmune disease that can occur at any age. It refers to the destruction of the joints in the body at the neck and lumbar region of the spine, although it most commonly affects the former than the latter. It can lead to neck pain, back pain or pain that radiates into the legs and arms. The destruction of the spine can also result in compression of the spinal cord and spinal nerve roots, which contributes to the development of lower back pain (56). The most significant causative factors of rheumatoid arthritis are infections, heredity, and hormonal changes (55).
The symptoms of rheumatoid arthritis are similar to those of osteoarthritis. The pain and inflammation are usually focused on the base of the skull or lower back. It also affects the ability to walk (56). The disease is known to progress gradually; generally starting with minor joint pain, stiffness, and fatigue (55).
Other conditions that contribute to the development of lower back pain are abnormal aortic aneurysm, psoriatic arthritis, kidney infection, kidney stones, problems related to pregnancy, endometriosis, ovarian cysts, ovarian cancer, and uterine fibroids (60).
SYMPTOMS OF A MORE SERIOUS DISEASE
Sometimes, lower back pain is accompanied by rare symptoms associated with more serious conditions, some of which pose a life-threatening risk to the patient and require immediate medical attention.
Some of these symptoms are outlined below:
▪ Progressive weakness of the leg
▪ Loss of bowel or bladder control
▪ Weight loss along with pain
▪ Neurological impairment
▪ Severe and acute stomach pain accompanied with a lower back pain, and
▪ Fever with increasing pain intensity, which cannot be alleviated with the use of oral NSAIDs (61).
These symptoms are associated with spinal tumor, infection, fracture, and cauda equina syndrome. Thus, an unexplained weight loss and fever accompanying lower back pain may be a result of malignant disease such as multiple myeloma or a metastatic disease. Fever with lower back pain may indicate connective tissue disease such as systemic lupus erythematosus, urinary retention, and bladder or bowel incontinence. Severe and progressive weakness of the lower extremities may suggest cauda equina syndrome or spinal stenosis (62).
Infection
A fever (>100°F or 38°C) present in patients with lower back pain is indicative of an infection. There are many pathways for an infectious microorganism to enter the spine. It is not uncommon for individuals with a compromised immune system or post-operative status to develop infections more quickly. Generally, a compromised immune system is a result of insulin dependent diabetes mellitus, organ transplantation, acquired immune deficiency syndrome (AIDS), malnutrition, and even cancer (61).
Sometimes, spinal infections lead to epidural abscess which can put pressure on the nerves in the cervical, thoracic and lumbar spine, all of which may eventually lead to gross dysfunction of the nerve roots causing paraplegia or quadriplegia. The most common organisms affecting the spine are Staphylococcus aureus, Pseudomonas spp., and Mycobacterium tuberculosis (58).
Post-surgical and other wound infections are frequently seen in patients with diabetes or those with weak physical health. The onset of infection is usually slow, taking usually about 1 to 2 weeks to completely develop. The symptoms usually include fever, redness, and inflammation around the incision and wound areas. Also, a change in wound drainage and fluid consistency is indicative of an active infection. The fluid from the wound can become thick and yellow with delayed healing. Post-surgical spinal infections respond well to antibiotic treatment when caught early; in rare cases, the pus needs to be surgically extracted out to prevent further spread of infection (61).
Vertebral osteomyelitis or vertebral bone infection can also result in fever. This type of infection spreads to the spine through the blood circulation. The veins present in the lumbar spine, known as Batson’s plexus, drain the pelvis and allow the bacteria to directly enter the spine (58).
Several procedures like colonoscopy, cystoscopy, and other diagnostic tests using a thin telescope to inspect the bladder can facilitate the spread of infection. Intravenous drug use, long-term use of steroids, and dental surgery can also play an instrumental role in introducing infectious microorganisms into the bone and subsequently, the spinal structures.
The sensitivity of fever has been found to be disappointing in patients with spinal infections; Whereas, spine tenderness in response to percussion is sensitive for bacterial infection (65).
Cauda equina syndrome
Cauda equina syndrome is characterized by varying degrees of urinary and bowel incontinence, sensory loss in the perineal area, and motor weakness in the legs. The cauda equina syndrome is caused by direct or indirect trauma, ischemia, infection, and neurotoxic reactions (68).
The symptoms of cauda equina syndrome are classified as:
1. Motor
2. Sensory, and
3. Sphincter manifestations
The abnormal neurological perceptions associated with cauda equina syndrome include lower back pain, sciatica, saddle, and perineal hypoaesthesia or anaesthesia, decreased anal tone, and absence of ankle, knee and bulbocavernous reflexes, along with a bladder and bowel dysfunction. An early diagnosis and decompression of the cauda equina is of utmost importance to minimize the residual neurological deficit (66).
Specifically, the motor manifestations seen are weakness of lower limbs, decreased range of motion, evidence of hypotonia in the limb and other muscle groups, and reduced or lack of reflexes. The sensory symptoms manifest as paresthesias and objective sensory loss of dermatomal and myotomal distribution. The symptoms associated with sphincter involvement are difficult micturition, retention of urine, failure of filling of the viscous or loss of urethral sensation, and sometimes stress incontinence. The most commonly observed bowel symptoms are constipation, rectal distention, and loss of anal sensation (69).
The terminal vertebrae of the adult spinal cord is at the L1-L2 with the terminal lumbar and sacral nerve roots in the spinal canal forming the cauda equina at the distal end. Cauda equina syndrome caused by a herniated lumbar disc has the following features:
▪ Perineal anesthesia
▪ Lumbosacral root sensory deficits
Patients who suffer from back pain and urinary incontinence are measured for their urinary post void residual volume. A value more than 100-200 mL is suggestive of urinary retention. Cauda equina syndrome is the perfect indication for an immediate surgical decompression, laminectomy with mild traction of the cauda equine, and discectomy. The success of the treatment largely depends on how soon the patient received immediate surgical intervention (67).
Some of the problems associated with this large, space occupying lesion in the canal of the lumbosacral spine is its unclear pathophysiology, subtle initial signs and symptoms which makes early diagnosis challenging, and often late findings of decreased rectal tone. Hence, postoperative spine patients with residual back or leg pain that is not alleviated by analgesics, especially when urinary retention is present, should be highly suspected of having cauda equine syndrome (70).
Multiple myeloma and malignancies
Bone metastases are related to significant morbidity including pain, impaired mobility, increased calcium levels, pathological fracture, compression of spinal cord and nerve roots, and bone marrow infiltration. The major complications of metastatic bone destruction causes bone pain radiating from the back to the lower limbs. Hypercalcemia also occurs in pathologic fractures and spinal cord compression (64).
There are many symptoms associated with bone cancer such as bone pain, localized swelling and inflammation in the lumbar spine, unexplained weight loss, fatigue, fever, and even anemia. The malignancy may start from the bone and spread to other parts (primary) of the body or spread from the other parts of the body to the bone (secondary). The two cancerous malignancies that cause these symptoms are osteosarcoma (cancer of the bone tissue) and chondrosarcoma (cancer of cartilage).
Metastasis usually develops due to the interactions between tumor cells and bone cells that lead to disruption of normal bone metabolism and increased osteoclastic activity. The clinical course of metastatic bone disease in multiple myeloma results in skeletal complications, bone pain, fractures, hypercalcemia, fever, and weight loss; all of which adversely affect the quality of life (63).
Malignant neoplasm (primary or metastatic) is the most common malignant disease affecting the spine. Unexplained weight loss, pain symptoms lasting greater than one month, and failure to improve with traditional NSAIDs therapy are some of the most common signs and symptoms. Patients with lower back pain due to cancer usually complain of persistent pain unrelieved by bed rest. The physical examination does not contribute much to the early detection of underlying bone cancers except in their later stages (65).
Sciatica
Pain due to nerve root irritation is indicative of sciatica. The pain is characterized by sharp and burning sensations radiating down to the posterior and lateral aspect of the leg, foot, and ankle. Coughing and sneezing enhance the pain. When disc herniation occurs, the leg pain is more prominent than the back pain (65).
Spinal stenosis
The characteristic clinical feature of spinal stenosis is neurogenic claudication. It is characterized by pain on the legs and neurological deficits occurring while walking. Neurogenic claudication occurs while standing, with a tendency to worsen with coughing and sneezing. Increased pain on extension of spine is characteristic of spinal stenosis (65).
DIAGNOSIS
Before suggesting any diagnostic test to patients, clinicians need to look into the various signs and symptoms manifested and narrated by them. Both the subjective and objective lower back symptoms of the patient are helpful in making the right clinical decision, i.e. whether to go ahead with other various diagnostic tests or start treatment right away.
The exact site of pain in the lower back, pain intensity, the type of pain (e.g. burning, stinging, crawling), origins of the pain sensations, and the aggravating and ameliorating factors are standard questions usually asked by the clinician. In case of nonspecific pain, the patient is usually put on 3 weeks of conservative treatment, usually with pain medications.
If symptoms do not disappear spontaneously or by rest even after 3 weeks of treatment, the clinician should proceed with various diagnostic tests in order to pinpoint the exact cause of pain. Some of the most commonly used diagnostic tests are:
1. Spinal x-ray
2. Myelography
3. Computed tomography scan (CT scan)
4. Magnetic resonance imaging (MRI)
5. Electro-diagnostic tests such as:
▪ Electromyography(EMG)
▪ Nerve conduction velocity (NCV)
▪ Evoked potential studies (EP studies)
6. Bone scan
7. Thermography
8. Ultrasound imaging (USG)
Spinal x-ray
Spinal x-ray is also known as lumbosacral x-ray and lumbar spine film. It is a non-invasive diagnostic test widely used to take pictures of the lumbosacral region to visualize suspected fractures, inspections, deformities (e.g. scoliosis), and other skeletal disorders of the bones, discs and joints.
Spinal x-ray is usually suggested after a thorough examination of the back, gluteus region, spine, and recto-pelvic regions of the patient by the physician, physiotherapist and chiropractor (103, 104,105).
Spinal x-ray is ordered when the patient has the following symptoms (103,104,105);
▪ Constant, extreme and sharp pain on the lower back that is not relieved spontaneously within a couple of days or by rest;
▪ Pain is relieved only with the use of NSAIDs then persists after two weeks;
▪ Hyperaesthetic and sensitive lower back;
▪ Stubborn and stiff lower back;
▪ Crawling, tingling sensations in the lower back and lower extremities like hip, thighs, leg, foot, and big toe;
▪ Loose, weak, and tired lower back and extremities;
▪ When the patient is not relieved by massage, heat therapy (fomentation), hot baths and even physiotherapy exercises; and
▪ When all of the above complaints are seen in elderly people with fragile bones.
The image obtained by spinal x-ray of the lumbosacral region will show the five lumbar vertebrae and five fused sacral vertebrae. Beam of ionizing radiations are passed through the lower back followed by capture of 4-5 images. X-ray plates taken are visualised in good light. Bony radio opaque vertebra will appear white; soft tissues, muscles (e.g. erector spinae) and the spinal cord grey, and the air black.
Condition and diseases diagnosed using spinal x-ray are:
▪ Fractured, cracked torn bones:
Stress and compression fractures of the lower vertebrae are commonly seen in athletes such as weight lifters, gymnastics, and footballers who frequently over stretch their lower back;
▪ Spondylolisthesis:
It is also known as subluxation wherein the normal anatomical position of the spine is altered. On X-ray image, the vertebra will appear to have slid down from their actual position;
▪ Disc degeneration:
Degenerated intervertebral discs can be seen on the X-ray plate. They are the senile progressive changes on the vertebra and cartilage due to ageing and repeated micro-injuries;
▪ Hereditary and congenital structural abnormalities:
These involve the spine vertebra such as those seen during extension and back flexion;
▪ Misalignment of the spine:
Vertebral malformations such as kyphosis, scoliosis, lordosis, and kyphoscoliosis are seen on the X-ray image. The table below summarizes the findings of each vertebral malformation:
|Vertebral malformation |X-ray finding |
|Kyphosis |increased convexity or outward curvature of upper and lower back |
|Scoliosis |lateral or side to side curvature of spine |
|Lordosis |outward arch or curving of lower back |
|Kyphoscoliosis |both sideward and outward curvature of lower back |
▪ Narrowing of intervertebral joints, osteoporotic, and corrosive changes of vertebrae; and
▪ Tumors and masses in the spinal canal and surrounding tissues.
All of the above conditions and diseases produce lower back pain. Spinal x-ray is most helpful in their differential diagnosis (103,104,105).
It is also helpful to know which conditions and diseases cannot be ruled out by spinal x-ray. This is especially true when the lower back pain is due to injury to the soft tissues, muscles of the lower back, and spinal nerves since these structures are not clearly visible on X- ray films. Examples include (103,104,105):
▪ Sciatic neuritis:
this is characterized by burning and electrifying pain that radiates from the lower back-gluteal region-hamstring muscles-leg-foot;
▪ Disc prolapse:
this is due to the degeneration of intervertebral discs that slip into the intervertebral foramen, which put pressure on the spine and cause pain; and
▪ Spinal stenosis:
the narrowed spinal cavity compresses the spinal nerves and causes lower back pain.
There are several reasons why x-rays are the most frequently ordered imaging study. They are advantageous to use in clinical settings because they are (103,104,105):
▪ Rapid
▪ Cheap
▪ Non invasive, non surgical
▪ No much preparation required before x-ray is performed
▪ Easily available
▪ Universal
Spinal x-rays also have several limitations and disadvantages, namely (103,104,105);
▪ Exposure to hazardous ionizing radiation
▪ Risk of radiation exposure such as congenital malformation, cancer, tumour, growth retardation, and infertility;
▪ Minimal diagnostic value in lower back pain when the pain is due to soft tissue or nerve involvement since these structures are not clearly visible and identifiable on x-ray films.
Prior to the procedure, the radiographer and clinician need to inform the patient of the following information about the procedure, as follows:
▪ Patient may be asked to lie down on the x-ray table or stand during the procedure.
▪ Patient must remain still in proper position during the procedure to avoid blurry images.
▪ Ornaments, metals objects, and all other radio-opaque substances must be removed.
▪ Pregnant patients with lower back pain should not undergo x-ray procedures.
▪ Very young children should not be exposed to x-rays since the radiation may retard their growth.
▪ Efforts are made to ensure that the patient is only exposed to the minimum amount of radiation
▪ If only the lower back requires radiation exposure, then other body parts are covered by special clothes and materials to avoid unnecessary exposure.
Myelography
Myelography is an invasive procedure which enhances the diagnostic value of x-rays and CT scan of the spinal cavity using contrast dyes. They are generally referred to as special x-ray studies of the spinal cord and canal.
Prior to the procedure, the radiographer and clinician need to inform the patient of the following information about the procedure:
▪ Ornaments, metallic pins, mouth dentures and other metallic objects are removed prior to the start of myelography.
The steps of the procedure are enumerated below (103,104,106):
1. The patient lies on the stomach on the x-ray table while the site of injection is selected and cleaned.
2. Local anaesthetic agent is administered to the selected site of injection.
3. A barium or iodine contrast dye is injected into the lower spinal canal with the help of a spinal needle. Specifically, it is injected into the subarachnoid space.
4. Needle is withdrawn. The x-ray table is tilted downwards to allow the dye to flow freely through the spinal canal.
5. An x-ray or CT scan of the lower spinal canal is taken.
6. Lastly, the patient is released and advised to keep the head elevated. The dyes are flushed out through micturation and defecation within the next couple of days.
Flouroscopy is used to project these radiographic images into video format onto the computer screen. These images taken are known as myelograms. The barium or iodine dye highlights the injured areas of the spinal cord, nerve roots, blood vessels, and subarachnoid space on the
x-ray images. CT myelography can also be immediately performed while the dye is present in the spinal canal.
Conditions and diseases diagnosed using myelography are those associated with abnormalities of the spinal cord, nerve roots, surrounding meninges, and intervertebral discs, namely (1, 2, 4):
▪ Herniation and protrusion of intervertebral discs which put pressure on spinal nerves and nerve roots, causing pain;
▪ Spinal stenosis;
▪ Excessive osteophytes , bony spurs, and thickened ligaments;
▪ Malignant and benign tumors in the spinal canal;
▪ Inflammation of the sacroiliac joints;
▪ Inflammation of the arachnoid membrane; and
▪ Infected vertebra, intervertebral discs, meninges, and other soft tissues.
There are several reasons why myelography is advantageous to use in clinical settings, namely (103,104,105);
▪ It enhances the diagnostic value of X- ray and CT scan by highlighting the less-visible structures;
▪ It is useful in patients in whom MRI is contraindicated such as patients having pacemakers and hearing aids; and
▪ It is useful in people who are candidates for lower back surgery and have inconclusive diagnostic test results.
Myelography also has several disadvantages, namely (103,104,105):
▪ Exposure to ionizing radiations;
▪ Contrast dyes such as barium and iodine can cause allergic reactions in patients who are allergic or idiosyncratic to these dyes. Signs and symptoms such as fever, headache, itching and redness on skin, gastritis, nausea, vomiting, sneezing asthmatic wheezing, difficult micturation and defecation are indicative of allergic reaction. Serious side effects such as convulsions occur but rarely following myelography;
▪ Inflammation, bleeding, and infection may occur at the site of injection;
▪ The administration of dye (injection) can sometimes cause pain leading to patient anxiety; and
▪ Soreness at the site of injection.
The limitations of myelography are listed below as:
▪ It cannot be performed on patients with known allergy to contrast dyes;
▪ It cannot be performed on patients on antidepressant and antipsychotic drugs since these react with iodine and barium dyes, causing serious side effects;
▪ It cannot be performed on patients with congenital or acquired structural abnormalities of the spine because of the lack of available safe injection site;
▪ It must be cautiously performed on patients with bleeding tendencies such as those who are on anticoagulant medications (e.g. warfarin and aspirin);
▪ It is hazardous to pregnant patients as both dye and radiation can harm them; and,
▪ Its diagnostic value in pinpointing the exact cause of lower back pain is only limited to associated conditions and diseases within the spinal canal.
Computed tomography scan (CT scan)
CT scan is a medical imaging procedure that makes use of computerized x-rays to obtain tomographic images of specific areas of the body. The images produced are three-dimensional (3D).
CT produces a volume of data that can be manipulated in order to demonstrate various bodily structures based on their ability to block the x-ray beam.
Prior to the procedure, the radiographer and clinician need to inform the patient of the following information about the procedure:
▪ Metallic pins, ornaments, mouth dentures, and other metallic objects must be removed;
▪ Patient is required to wear loose and comfortable clothes; and
▪ Patient is laid on the examination table which slides into the CT scanner. Once inside, the patient must remain still while images are being captured.
The scanner is equipped with x-ray throwing tubes and a detector which detects the amount of radiation absorbed by the organs and body parts. Modern computers process the data and produce cross-sectional and two-dimensional detailed images of the spinal vertebra, intervertebral discs, soft tissues, and blood vessels. If a radiocontrast is to be used, clinicians need to ascertain the absence of patient allergies to the specific dye and drugs used.
The specific diseases and conditions associated with lower back pain which can be diagnosed using CT scan are (103,104),107):
▪ Structural damage to the spine, vertebra, intervertebral discs, soft tissues, and muscles;
▪ Degeneration of spinal structures including the spinal canal;
▪ Benign and malignant tumors in and around the vertebral column;
▪ Metastatic overgrowth in the vertebral column from pelvic organs such as the prostate;
▪ Protrusion of intervertebral discs;
▪ Osteoporotic and senile degeneration of the spinal canal in the elderly.
▪ Fragility of lumbosacral and iliac bones and joints;
▪ Congenital structural abnormalities of the spine;
▪ Spinal stenosis;
▪ Arthritic conditions affecting the spinal bones and joints; and
▪ Abscess in the lower back
CT scan has the following advantages (103,104,107):
▪ Very reliable
▪ Relatively simple
▪ Quick
▪ Non-invasive
▪ Pain-free
▪ Safe for patients with implant such as pacemakers, stents, and hearing aids
▪ Convenient follow up on the post-surgical status of the spine
▪ A biopsy specimen from any part of the lower spine can be taken with the help of CT scan. This is especially useful in cases where the presence of malignant cells in the spinal canal is strongly suspected.
The limitations of CT scan are listed below as (103,104,107):
▪ It is not safe for pregnant patients due to the possibility of fetal exposure to ionizing radiation;
▪ It is not recommended in growing children since it can retard growth;
▪ The use of contrast dyes is not recommended in nursing mothers since these can be transmitted to newborns via breast milk; and
▪ Barium and bismuth metals interfere with generation of clinically useful images.
Magnetic resonance imaging (MRI)
An MRI scan is a non-invasive imaging test that uses powerful magnets and radio waves to create images of the body. Unlike the previous diagnostic imaging studies discussed previously (spinal x-rays, myelography and CT scan), it does not use radiation (x-rays). It is considered to be a very accurate test for diagnosing specific causes of lower back pain.
A single MRI image is called a slice, which may either be stored on a computer or printed on film. A single MRI exam can produce dozens of images. The MRI chamber is the cylindrical tube structure that creates magnetic, radio waves that surrounds the patient’s body.
Prior to the procedure, the radiographer and clinician need to inform the patient of the following information about the procedure:
▪ Metallic pins, glasses, ornaments, and piercings must be removed from the body;
▪ Patient is required to wear loose and comfortable clothes;
▪ Patient must remain still during scanning. Very young children may be sedated, if necessary.
▪ The patient is laid on the examination table which is passed through the MRI chamber. The magnetic waves generated bring the water molecules in the spinal and muscle tissues into correct alignment.
The radio waves are then passed through spinal tissues, vertebrae, and muscles. They identify the relaxation and random movement of molecules within the spinal tissues from the inline alignment created by magnetic field. The resonance and signals created are processed by the computer scanner which then produces three dimensional (3D) images of the spinal vertebrae, intervertebral discs, intervertebral space, cerebrospinal fluid, spinal muscles, and other tissues. The images of spinal canal are visible on sagittal, axial, and coronal planes.
In cases where a radiocontrast is needed to enhance the images of an MRI scan, the dye used is gadolinium which is injected into the spinal canal via an intravenous administration.
The specific diseases and conditions associated with lower back pain which can be diagnosed using an MRI scan are (103,104,108):
▪ Protrusion and herniation of degenerated intervertebral discs;
▪ Abnormal structural deformity of the spinal canal;
▪ Abnormal alignment and position of the spine such as kyphosis, scoliosis, lordosis, and kyphoscoliosis;
▪ Compression fractures;
▪ Nerve root compression;
▪ Benign and malignant overgrowth, tumors, soft tissue masses;
▪ Metastatic malignant cells in the spinal canal from pelvic, rectal, respiratory or abdominal organs
▪ Severe prominent inflammatory changes to the spinal cord; and
▪ Abnormalities of the spinal nerves affecting the muscular movement.
An MRI scan of the spine has the following advantages (103,104,108):
▪ Safe;
▪ Accurate and reliable;
▪ High diagnostic value;
▪ Clear view of the spinal canal regardless of the type and severity of disease and injury;
▪ Spinal surgeries immediately following an MRI scan can be performed;
▪ Post surgical improvement and deterioration of spinal conditions can be assessed quickly;
▪ Bleeding, infections, and scarring post surgery can be easily seen;
▪ Helpful in pinpointing exact locations of injection sites of steroid medications in patients with chronic back pain; and,
▪ No allergic reactions to the contrast dye are seen. Gadolinium does not trigger allergic reactions unlike other contrast dyes (e.g. iodine, barium) used in other imaging studies.
An MRI scan is also associated with a few adverse effects, namely (103,104,108);
a) Drowsiness and dizziness following administration of gadolinium;
b) Abnormal functioning of the implanted metallic equipments such as pacemakers, artificial joints, and stents due to exposure to magnetic waves; and
c) Claustrophobia in vulnerable patients when delivered inside the MRI chamber.
The limitations of an MRI scan are (103,104,108):
a) It is not recommended for pregnant patients due to possible fetal magnetic wave exposure;
b) Contrast dyes are not recommended for use in nursing mothers since they may be ingested by the feeding infant through breast milk.
c) Heightened sensitivity to movement which requires the patient to be still throughout the entire scan to avoid production of blurry images;
d) Lesser diagnostic value than CT scan and spinal x-rays in vertebral fractures and injuries;
e) Longer procedure duration;
f) Greater patient expense.
Electrodiagnostic test
Electrodiagnostic tests make use of the electrical signals that are produced by nerves and muscles and delivered to the brain. Injuries and diseases interfere with the conduction of these signals and are measured using three specific testing techniques, namely:
a) Electromyography (EMG)
b) Nerve conduction velocity (NCV)
c) Evoked potential studies
These tests determine the following (103,104,109):
▪ Presence or absence of trauma to the spinal nerves;
▪ Onset and duration of injury;
▪ Extent of nerve damage i.e. whether it is reversible or not;
▪ Exact location of the nerve injury;
▪ Extent of muscle damage i.e. whether the muscles are weakened, flaccid or paralysed;
▪ Integrity of motor and sensory pathways i.e. absence or presence of neurological deficits.
Electromyography (EMG)
Electromyography is one type of electrodiagnostic test. Also known simply as myography, it is a minimally invasive procedure that makes use of fine needles placed in a specific muscle to record its electrical activity. The test determines the ability of spinal muscles such as latissimus dorsi, sacrospinalis, and gluteal muscles to respond to nerve stimulation. The muscular responses are represented in a graph or numeric form on the computer monitor.
[pic]
Prior to the procedure, the radiographer and clinician need to inform the patient of the following information about the procedure:
▪ The patient must be asked about any medical history of coagulation disorders or bleeding tendencies such as haemophilia. If present, this procedure must be avoided.
▪ Implant devices such as pacemakers, stents, and shunts can interfere with the results of the procedure.
EMG must be carried out in a warm room since chilly and cold temperatures can alter the muscular response to the test. Fine pointed needles (electrodes) are pricked into the spinal muscles, after which the patient is told to move, flex, extend or contract the muscles of lower back. These actions stimulate the nerve cell, eliciting a spinal muscular response. Normally, when the spinal muscles are at rest or healthy, no electrical response is seen. But when the spinal muscles flex, contract or diseased, varying degrees of electrical response are seen. These responses can help determine whether the spinal muscles are bending forward and backward properly or not, and healthy or injured.
EMG to the lower back is suggested to the patient when he/she has following symptoms are (103,104,109):
a) Cramping, burning, sharp pain in lower back and lower extremities;
b) Weakness, flaccidity in lower back muscles; and
c) Tingling, numbness in lower back and lower leg, feet.
Conditions and diseases causing lower back pain that can be diagnosed with the help of EMG are listed below as (103,104,109):
▪ Sciatic Nerve dysfunction;
▪ Femoral nerve dysfunction;
▪ Peripheral neuropathies;
▪ Neurological dysfunction and muscular dystrophy due to associated disease complications such as AIDS;
▪ Muscular dystrophy and degeneration in auto immune disease such as myasthenia gravis;
▪ Nerve root impingement; and
▪ Polio.
The advantages of EMG in diagnosing causes of lower back pain are as follows (1,2,7):
a) It requires minimal piercing, and,
b) It elicits minimal pain
EMG is also associated with a few adverse effects, namely (103,104,109):
▪ Pain and discomfort in highly sensitive patients and young children;
▪ Prolonged pain and tenderness lasting a few days following the procedure;
▪ Bleeding tendencies in hemophilic patients; and
▪ Infections at the needle piercing site accompanied by altered blood count.
The limitations of a EMG are (103,104,109):
▪ It should be very carefully performed or avoided in patients on anticoagulant drugs such as warfarin and aspirin; and,
▪ Muscular responses vary from person to person
▪ NSAIDs such as like ibuprofen and naproxen can alter the results of the test.
Nerve conduction velocity (NCV) test
The nerve conduction velocity (NCV) test determines the speed and power of electrical impulses travelling through nerves. Unlike EMG, it is a non-invasive procedure.
Prior to the procedure, the radiographer and clinician need to inform the patient of the following information about the procedure:
▪ Patients must avoid stimulants such as coffee, drugs, alcohol, and tobacco because they alter nervous and muscular functions. Abstinence of at least 3 hours is needed.
▪ The test is safe for hemophilics and those on anticoagulant therapy.
The test must be conducted in a room that is warm and comfortable since chilly temperatures can alter the nervous response.
The NCV test is carried out using two rods which are placed on the skin and muscles of the spine. The first rod is used to send out impulses to stimulate the nerves being tested. The result is a mild electric shock. The second rod transfers the response produced by the nerves to the first rod. The transferred stimulus is recorded on a computer monitor. The speed and time at which the signals used to reach one electrode from the other is also recorded.
The results of the test depend on several factors, namely (103,104,109):
▪ Anatomy and health of the nerves
▪ Diameter of nerve, and
▪ Layer of fat surrounding the nerve
NCV is indicated in persons with the following signs and symptoms (103,104,109):
▪ Tingling, burning, and electric shock-like pain in the lower back and extremities,
▪ Hyperaesthetic lower back, and
▪ Chronic pain in the lower back and legs.
The conditions causing lower back pain that can be diagnosed with the help of NCV are spinal nerve damage and dysfunction such as (103,104,109):
▪ Pinched nerves
▪ Femoral nerve dysfunction
▪ Myopathies in diseases such as myasthenia
▪ Lambert Eaton Syndrome
▪ Spinal code damage
▪ Spinal nerve root damage
▪ Disc prolapse
▪ Conduction block
▪ Axonopathy
▪ Demyelination
The benefits of NCV are as follows:
▪ It is non-invasive
▪ It can be easily done in both adults and children
The major limitation of NCV is that healthy nerve cells are best detected, possibly masking damaged spinal nerves through normal NCV test results.
Evoked potential (EP) studies
EP studies are done when there is a confirmed involvement of the central motor-sensory nervous system in the pathology of lower back pain.
EP studies are done when the patient presents with the following manifestations (103,104,109):
▪ Neurological symptoms such as burning, stinging, and electrifying pain in the lower back
▪ Unable to stand or bend too long
▪ Unable to bend forward or backward easily due to pain, weakness and tenderness in spine
There are two types of evoked potential studies, namely:
1) Somatosensory EP studies,
2) Laser evoked EP studies, and
3) Dermatomal EP studies
There are two rods used in EP studies. One rod is used to stimulate the nerves and transmit sensations from the periphery to the centre. The other rod is placed on the top of skull to measure the velocity at which these sensations reach the brain. Essentially, it is the sensory pathway of the spinal nerves that is stimulated in somatosensory evoked potential studies. In dermatomal evoked potential studies, rods are placed anywhere on the skin, along the sensory pathway of spinal nerves.
EP studies are helpful in determining the location of nerve damage, i.e. whether it is in the motor system (conduction from centre to periphery) or in the sensory system (conduction from periphery to centre) (103,104,109):
The conditions and diseases diagnosed with the help of EP studies are (103,104,109):
▪ Radiculopathy of spinal cord
▪ Spinal compression
In somatosensory evoked potential studies, a delayed response found from the proximal nerve roots indicates damage of the S1 (sacral) spinal nerve root. The delayed response is seen in the form of H reflex on the screen. H reflex provides reliable information on the involvement of S1 nerve root in lower back pain. Damage to S1 spinal nerve roots can sometimes be seen in the form of F waves.
Laser evoked potential (LEP) studies
LEP studies, as the name suggests, makes use of infrared laser stimuli that is passed on to the spinal canal to create clear images (112).
The major limitation of evoked potential studies is its lack of usefulness in diagnosing causes of acute back pain. Its clinical value is most apparent in the diagnostic evaluation of chronic pain (112).
Bone scan
A bone scan is an invasive procedure that makes of radionuclides to create images of bones. It is also known as bone scintigraphy.
Prior to the procedure, the radiographer and clinician need to inform the patient of the following information about the procedure:
▪ Patient is asked to urinate prior to the start of the procedure since the presence of urine in the bladder can interfere with the proper visualisation of pelvic bones.
▪ Metallic ornaments, pins, and piercings should be removed prior to the scan.
The procedure proceeds as follows:
1. Site of the injection is chosen and cleaned.
2. The radioactive dye, also known as radioactive “marker” or “tracer”, is injected.
3. Patient is passed through the scanner machine for the bone scan three hours after the injection of the radioactive dye.
4. Patient positions are altered to allow scanning from different angles.
5. After the procedure, the patient is asked to drink copious amount of water to flush out the radioactive dyes.
[pic]
An even distribution of the radioactive dye into the pelvic bones generally means the structures are healthy. There are certain regions of the bones that absorb very little, if at all, any of the radioactive dye. These regions do not appear on the image generated by the scanner, and are referred to as dark or cold places. On the other hand, the regions which absorb and accumulate any of the radioactive dye will appear on the image, and are referred to as bright or hot places.
The abnormal distribution pattern of radioactive dyes used in the bones is indicative of pathologies related to bone metabolism of the spinal bones (103,104,110).
The conditions and diseases diagnosed with the help of bone scans are as follows (103,104,110):
▪ Ischemic and necrotic bones such as those seen in multiple myeloma wherein plasma cells multiply in malignant manner;
▪ Inflammatory conditions which appear as bright regions. These regions indicate rapid growth and repair such as those seen in arthritis, over growth of spinal bone, tumors in bone tissues, and infection;
▪ Paget’s disease involving the spinal vertebrae;
▪ Diffuse and occult injuries to the spinal vertebra. Stress fracture or compressed fractures often seen in athletes;
▪ Osteoporosis, osteomalacia, and osteodystrophy;
▪ Altered blood metabolism and decreased blood supply to spinal bones;
▪ Structural spinal bone changes due to metabolic disorders such as hyperparathyroidism; and,
▪ Metastatic activity of adjacent malignant cells involving the prostate, mammary, renal, and pleural tissues.
The benefits of bone scans in diagnosing causes of back pain are (103,104,110):
▪ It helps determine the onset of the injury.
▪ It helps in the visualization of spinal bones which are not normally seen in x-rays.
▪ It is instrumental in the early diagnosis of spinal bone lesions.
▪ It can help the clinician find the exact cause of lower back pain that was otherwise missed by other diagnostic tests.
The disadvantages of bone scans are (103,104,110):
a) Its invasive nature may prove to be painful and uncomfortable for young children and patients highly sensitive to pain;
b) The use of radioactive dyes can trigger allergic reactions in vulnerable and idiosyncratic patients. Reactions may vary from mild to severe and manifest as skin rashes, irritation, headache, blurred vision, nausea, vomiting, fever, and convulsions.
The limitations of bone scans are (103,104,110):
a) It is not safe to use on pregnant patients because of the use of radioactive dyes which can cause serious fetal harm.
b) It is not safe to use on nursing mothers since the radioactive dye can pass through breast milk and be ingested by feeding infants.
c) It requires a gap time of about 4 days before it can be performed in patients who previously underwent diagnostic tests using bismuth and barium.
d) Its inability to distinguish structural lesions clearly. CAT scan, MRI or tissue biopsy is required following the bone scan to study these lesions further.
e) It is a time-consuming procedure, with the preparation taking about 3-4 hrs and the scan about 1 hr.
Thermography
Thermography, also known as digital infrared thermal imaging (DITI), is a non-invasive, non-contact diagnostic imaging method that uses body heat to capture images of the body structures.
Thermography uses infrared rays detectors to determine the relative heat and temperature of tissues. Altered heat is indicative of disease or pathology which causes pain. Every organ has different temperature in the body and temperature in the left and right portions of the body is also different. Since every tissue can generate its own heat, small alterations in the heat signatures of organs and tissues is a red flag, indicating infection or pathological damage.
The initial cause of pain can be identified using thermography. The pain intensity level is recorded and presented graphically on the screen. It determines whether the pain is due to abnormalities in the spinal canal or pathology involving the surrounding tissues. It also determines whether the pain is referred from other tissues or is limited to a local area (103,104,111).
The conditions and diseases diagnosed with the help of thermography are (103,104,111):
• Injury to spinal muscles, ligaments, tendons and other soft tissues of the body
• Infection such as abscess in the spinal muscles, and tendons
• Inflammation of the spinal canal and surrounding tissues
• Nerve root compression. Nerve damage due to compression will show a decreased temperature in that zone on the screen.
The benefits of thermography are:
• It is safe to use in both children and adults
• It is relatively easy and comfortable for patients
• It is painless
• It is non-invasive
• It can be safely performed on pregnant women since no harmful ionizing radiations and magnetic waves are used
• It can be safely performed on very young children who cannot narrate verbally their exact signs and symptoms
• It helps in distinguishing the pain into two types, based on their sites of origin
The two types of pain distinguishable by thermography are (103,104,111):
1. Type 1 (specific pain): severe pain due to involvement of the spinal cord
2. Type 2 (non-specific pain): less severe pain usually due to muscular overload, muscular sprain, over stretching of muscular tissues, and ligament injury.
Ultrasound
Ultrasound, also known as sonography, is a non invasive method that transmits high-frequency sound waves, through body tissues. The echoes are recorded and transformed into video or images of the internal structures of the body. They create images of soft tissue structures, such as the gall bladder, liver, heart, kidney, female reproductive organs, and blockages in the blood vessels.
In diagnosing causes of lower back pain, sound waves are thrown on the spine and surrounding tissues through a probe. The echoes produced and reflected from the spinal tissues are converted into black and white images on the monitor. The Doppler technique can be used in conjunction with ultrasound to determine the amount of blood circulation to the spinal canal and its surrounding tissues (e.g. presence of ischemic disease).
The following conditions and diseases are diagnosed using ultrasound:
• Injuries to the tendons, ligaments and other soft tissues
• Ischemic condition of the spinal canal
The benefits of ultrasound in lower back pain are (103,104):
• It is useful in determining the proper site for insertion of needle and catheter in the spine (epidural space). Catheters are inserted into the spine for the administration of anesthetics prior to various spinal surgeries such as Caesarean Section and abscess removal from the spine.
• It is instrumental in determining the correct location and depth of spinal needle insertion during surgical removal of epidural abscess and biopsy of spinal tissues.
• It is a useful diagnostic tool in obese children and adults with scoliosis, kyphosis or kyphoscoliosis prior to corrective spinal surgery.
A major drawback of ultrasound is its inability to visualize bony congenital deformities and injuries (e.g. fractures) that cause lower back pain. Bones are not visible via ultrasound (103,104).
TREATMENT AND MANAGEMENT
The treatment and management of lower back pain consists of five general approaches, namely. These are listed below and discussed in detail in this section.
1. Physical therapy
2. Surgical interventional therapy
3. Non-surgical interventional therapy
4. Pharmacotherapy
5. Alternative therapy
|Physical and alternative |Surgical interventional therapy|Non-surgical interventional therapy |Pharmacotherapy |
|therapies | | | |
|Acupuncture |Vertebroplasty |Spinal cord stimulation |NSAIDs |
|Traction |Foraminotomy |Epidural steroid injections |Weak opioids |
|Exercises |Kyphoplasty |Facet joint corticosteroid injections |Strong opioids |
|Spinal manipulation |Spinal laminectomy |Botulinum injections |Anticonvulsants |
|IDET |Spinal fusion | |Antidepressants |
|TENS |Discectomy | |Other |
| | | |off-label drugs |
|Ultrasound |Nucleoplasty | | |
|Biofeedback |Radiofrequency lesioning | | |
|Cognitive behavioral | | | |
|therapy | | | |
General guidelines for treating lower back pain
Low back pain is undoubtedly one of the most commonly encountered medical problems, and in the United States it is estimated that an annual cost of over a $100 billion in spent either directly or indirectly for diagnosing and treating back pain. For this reason, local guidelines have been developed to thoroughly investigate and treat conditions causing back pain. The overview of these guidelines includes a thorough history of current and past problems, the nature and duration of which should be ascertained, and also a detailed examination of the back at the initial visit.
The doctor should ask patients for any alarming manifestations that may indicate a serious underlying disease; these signs and symptoms are called red flags. Red flags for back pain include history of trauma, cancer, unintentional weight loss, use of immunosuppressive drugs (including steroids), AIDS, IV drug usage, osteoporosis, age more than 50 years, focal neurological deficits, and also history of pain progression.
With the above information, the clinician will then be able to make more sense of the patient’s pain symptoms. The clinician can categorize the patient to having either nonspecific lower back pain, lower back pain secondary to radiculopathy or spinal stenosis, or low back pain secondary to a specific cause (which is indicated by presence of red flag symptoms).
Once the cause has been identified, evidence-based order sets will help the physician guide the patient through the assessment, and management and follow up plans. A follow up evidence-based order sets should again be obtained after 4 weeks of therapy to help the physician assess the patient’s symptom progression or lack thereof, and make appropriate clinical decisions such as whether to pursue further therapy or consider other therapeutic interventions.
There are various management guidelines that clinicians can follow to assess patients with back pain. One example is the UK’s National Institute of Health and Care Excellence (NICE) Pathway for low back pain below (71): The evidence based order sets contain valuable information on the need for targeted therapy of specific conditions causing lower back pain. Specific causes of low back pain that are not covered in the NICE pathway are malignancy, infection, fracture, and ankylosing spondylitis and other inflammatory disorders. A clinician who suspects that there is a specific cause for their patient's low back pain should arrange the relevant investigations (71).
As mentioned in the “Diagnosis” section, MRI should only be ordered for non-specific low back pain in the context of a referral for an opinion on spinal fusion. The clinician should consider MRI if one of these diagnoses is suspected (71):
• spinal malignancy
• infection
• fracture
• cauda equina syndrome
• ankylosing spondylitis or another inflammatory disorder.
After a thorough assessment, the clinician can then provide patient counseling to promote self-management of pain. Topics to be discussed include but are not limited to the following (71):
• information on the nature of non-specific low back pain,
• activities that may help strengthen muscles and alleviate the pain.
Essentially, clinicians need to encourage patients to stay physically active and to exercise. They should include an educational component consistent with this pathway as part of other interventions. When considering recommended therapies, clinicians need to take into account the patient’s expectations and preferences, though this might not always predict a better treatment outcome (71).
Generally speaking, nonspecific low back pain that is not associated with the presence of any red flags and is experienced for less than 6 weeks can be treated with non-steroidal anti-inflammatory drugs (NSAIDs) such as ibuprofen, diclofenac, and paracetamol. If the physician deems it necessary, a second option is available with the use of weak and strong opioids. They should be offered pamphlets/leaflets that help educate them about their condition and choice of occupational or physical therapy. They should be re-assessed after 6 weeks following the initial assessment and start of therapy (71).
Similarly, patients who present with low back pain that is secondary to radiculopathy or spinal stenosis can be treated with the aforementioned medications, and in certain cases with gabapentin.
Patients who present with the above mentioned red flags should be assessed thoroughly with imaging studies and laboratory tests. Patients with suspected fractures, bone infections such as discitis and osteomyelitis, and malignancy are the group most likely to benefit from this extended diagnostic assessment. Depending on the clinical scenario, a number of different tests may prove beneficial. Typically, MRI scans with or without contrast are adequate imaging modalities that help pinpoint the underlying musculoskeletal causes. In cases where MRI scans are unavailable or contraindicated, CT scans may be used instead. For suspected specific conditions, technetium bone scan, lumbar spine radiography, and inflammatory marker tests like erythrocyte sedimentation rate (ESR) and/or C-reactive protein may also be performed.
In cases where a patient exhibits progressive symptoms or presents with focal neurological deficits, further imaging studies may need to be performed. These studies may include (in addition to MRI) myelography and postmyelography CT of the lumbar spine. A further need for lumbar spine CT with or without intravenous contrast may also arise. In certain other cases, electromyography/nerve conduction velocity studies may also need to be performed for accurate diagnosis (72).
It is expected that these guidelines would reasonably provide an appropriate assistance in developing a care plan that significantly benefits the patient by reducing the number of unnecessary imaging studies. This would reduce the inappropriate use of narcotic and opioid drugs, and also by potentially decreasing the number of unnecessary and inappropriate invasive procedures.
Ice and Heat
The treatment of back pain depends on a number of factors such as its cause, type, duration, and severity. Ice and heat packs are common and effective methods of treating acute and sometimes sub-acute back pain. Heat packs are typically not recommended when swelling accompanies back pain especially immediately after the occurrence of injuries. Heat causes vasodilation, which may increase the swelling. In the initial hours (up to 48-72) following an injury, ice or cold packs can be placed on to the affected area to reduce the pain.
Swelling or inflammation ensues following direct trauma to the blood vessels of the back. Swelling occurs when blood leaks from the damaged capillaries and accumulates in the surrounding tissue spaces; this causes the visible swelling. Ice or cold packs help constrict the blood vessels and reduce the extravasation of serum and blood, which in turn reduces the inflammation. Once the swelling dies down following application of cold packs, the pain also significantly goes down. First aid responders will do well to remember not to place ice packs in direct contact with the skin since doing so predisposes the patient to the risk of cold burns or frostbites. Placing a cloth between the two surfaces and limiting the amount of cold exposure minimizes this risk. Ice packs should be placed for 15-20 minutes up to 3-4 times a day. It is generally recommended to alternate the use of ice and heat packs in order to provide immediate optimum pain and inflammatory relief.
As mentioned previously, heat packs are best avoided in the initial hours of injury as it causes further vasodilation of the vessels, which encourages further tissue inflammation. However, once the inflammation has reduced, heat packs and electric heat pads may then be used to treat the pain. Electric heat pads should be started and maintained on low temperatures to avoid burns. Other effective methods of delivering heat include hot water bottles, microwaveable gel packs, saunas, and treatment with steam. Some people have also reportedly benefited from taking hot showers.
Studies show that heat therapy can have the most prominent effects during the first week following an injury. Evidence also suggests that superficial heat therapy can help with acute and sub-acute lower back pain especially if it is accompanied by proper exercise, which improves musculoskeletal function (73). A trial conducted in 90 patients showed significant relief of acute back pain following application of heat blankets. There is however conflicting evidence to suggest the superiority of either treatment (ice and heat) in opposition to one another (74).
Bed Rest
Bed rest is commonly advised or sometimes self-prescribed by many individuals following acute lower back pain to reduce the pain and muscle stress. However, no significant evidence exists to suggest that bed rest benefits patients suffering from acute lower back pain. On the contrary, some evidence actually point towards the opposite i.e. it is actually slightly advantageous to stay active through mild exercises in these circumstances. Studies have verified that patients suffering from lower back pain and sciatica actually experience greater pain intensity and decreased functional recovery following bed rest (75).
Exercise
Exercise has innumerable health benefits, which include improved cardiovascular functioning, reduced risk of chronic illnesses such blood pressure, type 2 diabetes, renal disease, and even certain types of cancers. It has also been shown to be beneficial in improving self-esteem, regulating mood, and improving symptoms of depression. Similarly, patients with lower back pain can benefit from daily-targeted exercises through improved functionality and reduced pain symptoms. However, it should be remembered that the type of exercise plays an important role in determining the benefits of exercise on patients. Additionally, the type of back pain also determines which exercises must be avoided.
Targeted exercises are generally recommended and to be started within 1-2 weeks after onset of initial pain symptoms. Patients should keep in mind to always start with mild exercises and to avoid activities that increase their pain intensity. Specifically, patients with lower back pain will do well to remember to stay away from high impact exercises such as running since it can very well exacerbate the pain. Exercises with maneuvers that target the trunk region are also best avoided in the initial couple of weeks following the onset of symptoms.
It is also important for to patients stick with light to moderate exercises. Low impact aerobic exercises and swimming are generally advised. Exercise techniques usually target endurance, strength, and flexibility. The techniques used in these exercises augment the physical capacities of patients, and strengthen their muscles.
Some of the popular exercise routines that benefit patients with back pain are described below [76]. These exercises are generally best started only following the advice of a clinician or physical therapist. Additionally, patients are advised to stop if they develop pain at any time during the exercises.
Bottom to heels stretch
This type of exercise aimed at stretching and mobilizing the spine. Patients are advised to kneel on all fours and keep their knees under the hips and hands under the shoulders. The goal of the exercise is to slowly retreat the back while maintaining the natural curve of the spine. Correct positioning is mandatory and patients are advised only to stretch as far as they are comfortable. Patients with knee problems are advised to avoid this type of exercise.
Knee rolls
Knee rolls also help in stretching and mobilizing the spine. Patients are advised to lie on their back while keeping a cushion beneath the head for comfort. The knees are kept together and bent. The arms are outstretched with both shoulders placed on the ground. The knees are then rolled onto one side followed by a similar movement of the pelvis. This position is held in place for one deep breath. The same maneuver is to be performed on the other side. The exercise is usually repeated 8-10 times per side to achieve the beneficial results. Patients are advised to remember to alternate the exercises between the two sides, as well as to keep pillows between the knees for cushioning effect and comfort.
Back extension exercises
Back extension exercises also target the spine, stretching and mobilizing its muscles. Patients are advised to lie on their stomach and prop themselves onto their elbows. The shoulders and back are kept in an optimal position by keeping the shoulders drawn back and the neck elongated and stretched. This position serves to lengthen the spine. In back extension exercises, patients are advised to keep their hips on the ground and to avoid bending the neck backwards as this may cause discomfort or worse, injure the neck muscles.
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Deep abdominal strengthening
This is done by lying flat on the back and placing a small cushion beneath the head to slightly lift it. The knees are bent and the feet placed hip-width apart. The upper body is then kept maximally relaxed. The technique involves drawing up the muscles of the abdomen and back during exhalation. It should be remembered that this exercise serves to gently tighten the lower abdomen musculature and should not be done using more than 25% of the patient’s maximum strength. It is also important to remember to relax the shoulders and the neck.
Pelvic tilts
These exercises also aim to stretch and strengthen the muscles of the lower back. The startup position is similar to the one adopted for deep abdominal strengthening in which the patient lies flat on the back with a cushion beneath the head and the feet flat and hip width apart. The patient then proceeds to flatten the back further towards the floor and at the same time, contract the abdominal musculature and the back gently pushed towards the feet in order to attain a slight arch of the back. This position contracts the back muscles. The exercise is repeated, beginning with the starting position. It is ideally repeated 10-15 times, moving the pelvis back and forth in a subtle rocking motion.
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These exercises are believed to help patients alleviate their symptoms of lower back pain. In fact, there is a study that further supports the beneficial effects of non-weight bearing exercises such as those mentioned above on females suffering from chronic non-specific back pain. This study also found that such exercises help improve functional status, relieve pain intensity, and restore the normal range of motion and allowing lumbar flexion and extension in females suffering from non-specific chronic lower back pain [77].
Another study conducted in Canada focused on the use of a specific type of exercise machine that can help train the back muscles for better endurance. The study showed the machine to be effective in both healthy individuals and patients suffering from non-specific back pain. Poor back muscle endurance is often associated with lower back pain, and is seen to be the group that could benefit the most from this invention [78].
Exercises are undoubtedly effective in reducing pain symptoms of the lower back. As mentioned earlier, there have been studies conducted in the past that show the benefit of mild to moderate exercises in patients with back pain as compared to bed rest in terms of improvement in functional status. Moreover, there are no evidence-based studies that show the superiority of bed rest to exercise for alleviating pain in the same patient group.
Spinal manipulation
Spinal manipulation, also known as spinal manipulative therapy and chiropractic adjustment, is a manual therapy technique practiced by many health care professionals including chiropractors, osteopathic physicians, naturopathic physicians, physical therapists, and sometimes also by medical doctors to help patients alleviate their symptoms of lower back pain. The technique involves deliberate delivery of force to the synovial joints of the lumbo-sacral and sacroiliac regions to treat the related conditions of lower back pain. The technique is not limited to these joints and is performed on other joints in the body for other pain symptoms (e.g. neck pain).
Spinal manipulation basically refers to the local application of a single quick and forcible movement of small amplitude to the targeted joints. The movement is often termed as a ‘high velocity thrust’, with the patient carefully positioned prior to its delivery. It is generally considered to be a quick and safe intervention that has the potential to provide relief from back pain. It is especially effective in alleviating the symptoms of acute back pain, more so than chronic back pain.
Despite its popularity, evidence of its effectiveness is debatable i.e. its quantifiable benefit in the treatment of lower back pain symptoms. There are different approaches towards spinal manipulation and no solid guidelines have been established owing to the varied individual responses to this type of treatment. Some people do not recommend this treatment at all whereas others recommend it as a last resort treatment in cases when patients do not respond to other conventional forms of therapy.
A large systematic review conducted to test the effectiveness of spinal manipulation in treating lower back pain concluded with promising results. The review itself was thought to be the first of its kind and was published in 2012. It included 6 studies that met the study criteria. The most prominent results featured in this review included varying degrees of beneficial effects seen in patients receiving spinal manipulation therapy with minimal adverse effects being reported. Moreover, it was seen that patients undergoing spinal manipulation for lower back pain reported less use of pain medication, decreased visits to health care professionals, and also lower rate of yearly absence from work. Some of the individual studies analyzed in this review concluded that significant improvement was seen in disability scores of patient’s up to 6 months post treatment with spinal manipulation (79).
The review showed that most studies concluded a notable improvement in patients who underwent spinal manipulation for their lower back pain. However, the degree of effectiveness varied between patients. Although the review mostly favored the use of spinal manipulation for lower back pain, it also found one study, which reported the adverse effects of spinal manipulation. The study particularly showed that non-thrust manipulation was observed to have a worst outcome than two experimental thrust manipulation groups [79,80]. For the purpose of clarification, the non-thrust group comprised of individuals given posterior to anterior mobilizations to the L4-L5 spinal processes. Patient feedback on this procedure was largely negative which may be due to the irritating effects to the patients.
Another systematic review conducted on the adverse effects of spinal manipulation similarly concluded that serious or severe complications of this procedure are rare [81].
Many patients also reported improvement in their pain scores for up to four weeks. One study in particular reported improvement of temporal pain summation in patients receiving manipulation over lower back extension and stationary cycling.
Another systematic review conducted in the US and published in 2010 showed similar promising results of spinal manipulative therapy use in patients with acute lower back pain. This review concluded that evidence from recently conducted trials supported the use of spinal manipulation in patients with cute lower back pain. Patients receiving 5 to 10 sessions spread over a period of 2 to 4 weeks showed comparable and some even superior evidence of improvement in acute lower back pain symptoms to other forms of treatment (e.g. medication, self-management, and exercise therapies). The review even proposed that patients, not benefitting from self-care alone, to be offered spinal manipulative therapy as a treatment option by their health care professionals [82].
Another study conducted in Egypt in 2011 showed that patients receiving sustained spinal manipulative therapy for lower back pain showed greater improvements in their pain symptoms and disability scores compared to individuals receiving single or short term sessions. The study was divided into three groups:
1. Group 1:
Patients receiving 12 sessions of spinal manipulative therapy over a month
2. Group 2:
Patients receiving 12 sessions over a month and no treatment thereafter
3. Group 3:
Patients receiving 12 sessions of spinal manipulative therapy over one month and then maintenance manipulation therapy every 2 weeks for a period of 9 months.
The study concluded that Group 3 patients benefited the most from this technique. Their pain and disability scores showed marked improvement compared to the non-maintained group. It also concluded that patients who received no maintenance therapy following the study period maintained their improved pain and disability scores and did not revert back to pre-treatment numbers. From this study, it is safe to conclude the valuable role of maintenance therapy in patients receiving spinal manipulation for chronic lower back pain [83].
Non-surgical interventional therapies
Patients with chronic lower back pain who failed to respond to conservative treatment are strong candidates for interventional therapies. There are two types of therapies that fall under this broad category; they are namely:
• Non-surgical interventional therapy
• Surgical interventional therapy
Each one requires an invasive approach to delivering treatment at the target site to provide pain relief. As mentioned previously, non-surgical interventional therapy consists of spinal cord stimulation, epidural steroid injections, facet joint corticosteroid injections, and botox injections.
Spinal cord stimulation (SCS)
Spinal cord stimulation is a procedure performed using a device to deliver electrical signals to the spinal cord to achieve relief for chronic pain. The device used is called a spinal cord stimulator.
The procedure involves implantation of stimulating electrodes into the epidural space and placement of an electric pulse generator in either the gluteal or lower abdominal region. These two devices, along with a generator remote control, are connected through wires. There are different theories through which spinal cord stimulation achieve pain relief. For instance, in neuropathic pain, it has been proposed that it suppresses hyperexcitability of neurons; thus, changing the local neurochemistry of the dorsal horn.
Experiments have shown that in such circumstances, there is a decreased production of excitatory amino acids, aspartate and glutamate, and an increase in serotonin and GABA (gamma amino butyric acid) levels. On the other hand, this mechanism is not observed in patients with ischemic pain. When spinal cord stimulation is performed on patients with ischemic pain, beneficial effects seem to arise from the restoration of balance to the oxygen demand-supply of the ischemic area. This in turn may be a result of sympathetic system inhibition and/or through vasodilation.
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Spinal cord stimulation comes with a wide range of complications including:
• Infections
• Headaches
• Paraplegia
• Death
Because of the severe complications that can occur from this procedure, however low their risk may be, it is reserved only as an alternative and last course to conservative treatment of lower back pain. It has been suggested that patients with persistent and disabling lower back pain despite undergoing surgery for herniated discs (with no evidence to support a persistently compressed nerve root), may be good candidates for spinal cord stimulation. This subset of patients needs to be made aware of the risks and benefits of the procedure to help them make an informed decision regarding their treatments. Long and short-term complications of the procedure should be thoroughly discussed with these patients [157].
Epidural steroid injections
The practice of injecting steroids into the epidural space is a common practice in the treatment of radicular lower back pain. The goal of the therapy is to provide a strong anti-inflammatory (steroid) medication into the space to achieve adequate analgesia. It is usually given for back pain that is secondary to nerve impingement or disc herniation.
However, it is not a first line treatment option and should not be given before other treatment modalities (including conservative management) have been tried and tested. Patients with radicular back pain that is secondary to a herniated disc should be offered a detailed discussion of the pros and cons of epidural steroid injections as a possible therapeutic modality [157].
Facet joint corticosteroid injection
A facet joint injection delivers a dose of corticosteroid medication into the facet joints to anesthetize them and block pain perception. The major indications for facet joint injections include:
• Clinical suspicion of facet syndrome
• Tenderness over these joints
• Chronic lower back pain without radiological evidence of any disease
• Persistent pain after spinal fusion surgery
It should be remembered that this treatment modality has not been supported by evidence-based data as a superior method of treating lower back pain.
A study published in 2011 supported the use of facet joint injection as a diagnostic and treatment modality in chronic lower back pain. It found that when these injections are delivered under fluoroscopic guidance, they exhibit high accuracy and effectiveness. It suggested the benefit of facet joint corticosteroid injection in short-term pain relief. Also, the procedure was found to exhibit very limited long-term benefit in pain relief [62].
Botulinum (Botox) injection
Botulinum toxin A (BTX-A) is a substance produced by the bacteria Clostridium botulinum, a bacteria commonly implicated in food poisoning. It is a neuromuscular blocking agent that blocks acetylcholine, a neurotransmitter primary responsible for muscular contractions. The toxin, when injected in small amounts into the painful muscles, can relieve spasms by interfering with their nerve conduction pathway.
BTX-A’s supposed positive role in pain management was originally only attributed to its inhibition of acetylcholine release from the synapse, affecting motor endings but sparing sensory neurons. However, preclinical studies have also demonstrated the effects of BTX-A on nociceptive neurons, suggesting its ability to produce analgesia as a secondary effect that may be the result of muscle paralysis, enhanced circulation, and release of nerve fibers under compression by abnormally contracting muscle.
For most limb muscles, motor point stimulation is generally used to identify muscles, especially the smaller muscles in the forearm. For the clinician who is new to the procedure, the use of simple, audio-only electromyography may help enhance the clinician's understanding of functional anatomy and make informed decisions on injection localization. For muscles requiring electromyographic guidance, a cannulated monopolar needle cathode, through which BTX-A can be injected, is used. Surface reference (anode) and ground electrodes should be placed near the cathode needle (159).
The patient is placed in a position that allows for the targeted muscle to be relaxed so that the motor point can be easily located. BTX-A is then given after aspiration to prevent intravascular injection. Alcohol, if used to clean the skin, should be allowed to dry completely to prevent deactivating the BTX-A. The use of operating rooms or special procedure (sterile) rooms equipped with monitoring devices for the purpose of intramuscular injections using small caliber needles is not necessary. Most patients can be treated safely in an office setting by trained clinicians (159).
Good quality evidence is missing in supporting the role of botulinium toxins in treating back pain. However, small-scale studies conducted over the years have reported its clinical benefits. A Cochrane review identified one study, consisting of 31 participants that showed BTX-A to be superior to saline injections in the treatment of pain at 3 and 8-week intervals. Patients who received these injections showed marked improvement in their functional status eight weeks after first receiving them [160]. Lastly, severe side effects have also been reported with BTX-A injections, limiting its promising role in pain management.
In cases where patients do not respond to conservative treatment and non-surgical interventions, surgical procedures may be the only course of action left to take. Surgical interventions include but are not limited to spinal laminectomy, spinal fusion, vertebroplasty, kyphoplasty, discectomy, foraminotomy, and nucleoplasty.
Spinal laminectomy
Lower back pain can range from being mild or dull to irritating, severe, and disabling, depending on the patient, circumstances, and underlying cause. Patients with disabling back pain that seriously threaten or undermine their functional abilities (e.g. nerve damage or bone pathologies that indicate surgical intervention) are generally good candidates for surgical treatment if their pain is refractory to non-invasive therapies. One such surgical treatment is a procedure called spinal laminectomy.
Laminectomy is typically performed to release pressure from the spinal column, treat disc herniation and similar related issues, and to remove tumors that impinged on the nerves of the spine. The procedure basically comprises of removing the bony posterior part of the vertebra overlying the spinal column, or the lamina (85).
The procedure usually requires overnight hospital stay and depending on the surgeon, may be performed under general or spinal anesthesia. The nerve compression is released by cutting out the bony growths/spurts/tumors. The surgeon may also choose to do a spinal fusion in the same operation if deemed necessary. This involves the fusion of two bones to provide adequate support to the spinal column. Although the procedure is seen to benefit a number of patients with different underlying medical conditions, it does carry the risk of complications stemming from the use of general anesthesia, surgery-induced spinal nerve damage, bleeding, infections, and blood clots in the legs and lungs. There may be other risks not mentioned. In order to be safe, it is always advisable to discuss the possible risks of the operation with the surgeon in order to obtain a focused risk assessment pertaining to the patient’s specific underlying disorder (85).
A study conducted in the UK and published in August 2013 found laminectomy to exhibit pain-relieving effects on patients with back pain secondary to lumbar spinal stenosis. These patients also showed a significant decrease in lower back pain scores as early as six weeks following the procedure, which was sustained up to a year. Lastly, these patients also reported lower disability index scores (86).
Spinal fusion
Spinal fusion is another surgical technique that involves the fusion or joining together of two or more vertebral bodies, thereby effectively restricting any movement between them. This can be done using supplementary bony tissue, from either the patient (auto graft) or a donor (allograft), to enhance the osteoblastic activity of the bony tissue to promote fusion.
Spinal fusion is indicated to reduce pain associated with frictional forces of two spinal bones rubbing together, correct any underlying deformity, and provide greater stability to a weakened spine. Examples of conditions requiring spinal fusion include (90):
▪ Broken vertebrae (not all vertebral fractures require surgical intervention, in fact only those causing spinal instability would require spinal fusion)
▪ Deformities of the spine such as kyphosis and scoliosis
▪ Severe arthritis of the spine or spondylolisthesis wherein one vertebra slips forward on to the vertebra placed below it.
▪ Weak spine due to the surgical removal of herniated discs. Spinal fusion provides stability to the spine.
▪ Chronic back pain that cannot be attributed to a specific disease or disorder. However, there are controversial views about the effectiveness and appropriateness of this procedure in patients with nonspecific but chronic lower back pain.
When other surgical interventions are also indicated such as foraminotomy, laminectomy or discectomy, these are almost always done prior to the spinal fusion. The procedure involves the patient being put under general anesthesia, and then the surgeon exposing the spine through an incision on the back (or sometimes on the side). The two vertebrae are then fused together by placing the graft material on the back of the spine or between them. Finally, surgical cages, plates, rods or screws may be used to hold the vertebrae in place and facilitate proper tissue healing. The surgery usually lasts between 3-4 hours.
Spinal fusion, like other invasive interventions, is also associated with a number of risks, namely (90):
▪ Complications due to general anesthesia
▪ Post-operative infections
▪ Poor wound healing
▪ Bleeding
▪ Blood clots
▪ Injury to the adjacent spinal nerves and blood vessels,
▪ Pain may be felt at the site where the supplementary bony tissue was obtained.
A paradoxical back pain is also a risk associated with spinal fusion stemming from surgical complications. This happens due to the shift of stress from the fused vertebrae onto other adjacent parts of the spine, which in turn accelerates the degenerative process of wear and tear, and ultimately causes back pain.
A systematic review of 25 studies that was published in 2008 found that spinal fusion is especially clinically useful in patients with degenerative disc diseases such as spondylolisthesis. Specifically, the study found it to substantially improve disability scores in this particular patient group. However, the procedure is ineffective in patients with chronic lower back pain, showing no marked improvement in their disability scores post-surgery [91].
Although a study published in 2001 in Sweden advocated the use of spinal surgery in patients with chronic lower back pain [93], a more recent meta-analysis published in 2013 suggests that spinal fusion is no more effective than conservative treatment in improving disability scores in patients with chronic lower back pain. The review also states that further studies on the subject are also likely to suggest similar outcomes [92].
Kyphoplasty
Kyphoplasty, also called balloon kyphoplasty, is used to treat or stop the pain caused by spine compression fractures or a collapse of the bones. The fractures are usually a result of osteoporosis (a weakening of the bone), cancer or an injury that caused the bone to break. The goal is to restore the height of the vertebral body, stabilize the bones, align the spine and alleviate pain. The procedure may be performed either in a hospital or an outpatient clinic. Treating one fractured vertebra with balloon kyphoplasty may only take about an hour (94).
Patients should first consult with the interventional radiologist a few days before the procedure. Patients may be asked to stop certain medications, such as aspirin, ibuprofen, non-steroidal inflammatory drugs or blood thinners such as warfarin and Coumadin. These medicines make the blood hard to clot. If patients are taking any medication, they should ask their doctor if it is allowed. Patients should inform the radiologist and clinical staff members if there’s a chance of pregnancy and allergic reactions to local or general anesthesia and x-ray dye, which is a contrast media. Smoking and drinking a lot of alcohol should also be stopped. On the day of kyphoplasty surgery, patients may also be asked not to eat or drink several hours prior to the test (94).
On the day of the surgery, patients should wear comfortable clothes and shoes. They should also bring a list of their medications and avoid bringing jewelry and valuables.
The procedure begins with the induction of anesthesia. First, the back area is cleaned and sterilized. Local or general anesthesia is then applied. A small incision is made in the back area and a hollow needle, called a tracer, is placed through the incision until it reaches the fractured vertebra. Interventional radiologist may perform intraosseous venography examination to make sure that the needle is positioned in the correct area. Most interventional radiologists, however, skip this part and proceed directly with kyphoplasty (94).
A balloon, also called a bone tamp, is inserted through the hollow needle. The balloon is then carefully and gently inflated in the vertebral body. A hole or cavity is created and the bone is pushed back to its normal shape and height. The balloon tamp is then removed.
After the balloon removal, bone cement (polymethylmethacrylate) is injected under low pressure into the space or void created by the balloon. Polymethylmethacrylate (PMMA) quickly hardens and the bone is stabilized. The needle or trocar is then removed. The skin incision is covered with a bandage.
The results include the alignment of the spine and restoration of the vertebrae height. After the procedure, back pain is generally relieved.
To perform the procedure in the correct area, real-time images are needed. Fluoroscopy is the most commonly used imaging technique. Modern fluoroscopy consists of an x-ray image intensifier, fluorescent screen and CCD (charge-coupled device) video camera.
After the surgery, patients will be closely observed in the recovery room. Patients can go home after the surgery but others may choose to spend another day in the hospital. It is recommended not to drive, unless approved by the doctor. Patients may arrange transportation from the hospital or outpatient clinic. They should be able to walk after the surgery but it is recommended to stay in bed for 24 hours. After a day of bed rest, the patient can return to daily activities but should not do heavy or strenuous work for at least 6 weeks. If there is pain in the skin incision, ice may be applied to the wound (94).
One of the advantages of kyphoplasty is that the bone cement, which is polymethylmethacrylate, used in the procedure is viscous. It thus decreases the possibility of cement leak into other parts of the vertebra, including the sensitive spinal cavity (94).
The balloon inflation within the bone reduces deformity, which may lead to hunchback appearance, for the balloon restores the height of the vertebra. The procedure is also viewed as minimally invasive which results in less operative trauma and shorter hospital stays. Patients can usually go home after the operation on the same day. Less tissue damage and blood loss will result due to smaller incisions.
After the surgery, patients experience less pain; and, in fact, most of them feel pain-free. There is also faster recovery and reduced complications after the surgery.
The benefits also include mobility improvement and better quality of life. The patient does not need physical therapy and can return to normal physical activities. Consequences of future vertebral fracture are also reduced. The risk of pneumonia is reduced because the patients can get out of bed after the procedure (94).
Although balloon kyphoplasty procedure is minimally invasive, there are also associated risks. Because there is a skin incision, infections may occur. Risks also include allergic reactions to anesthesia or medication. Bleeding, infection, breathing and heart problems due to anesthesia may also result.
Malpositioned instruments during the procedure may cause nerve damage and spinal cord injury. The bone cement (polymethylmethacrylate) used can leak to surrounding areas. This is not serious unless it moves to dangerous locations such as the spinal cord and lungs resulting to infections. But these cases are very rare (94).
Vertebroplasty
Vertebroplasty, like kyphoplasty, is a medical procedure used to treat painful vertebral compression fractures (VCF) due to osteoporosis, cancer, metastatic tumor or an injury causing the bone to crack or collapse. The only difference is that in vertebroplasty, no balloon or bone tamp is used (113).
Osteoporosis, which is mostly the cause of VCF, is the thinning and weakening of the bones due to the loss of normal density, mass and strength of a bone. This causes bones to become porous and easy to break. This disease can cause one or more vertebrae to collapse leading to compression fractures.
Vertebroplasty is also a minimally invasive procedure, which means that it is not as invasive as an open surgery, for only a small nick on the skin is made. Stitches are not needed after the surgery, as a band-aid will work. This procedure may be recommended if a person is experiencing severe pain for 2 months or more that is not alleviated by pain medicines, physical therapy and bed rest. The procedure may be performed in a hospital or an outpatient clinic (113).
An evaluation of the patient will be performed including blood test, diagnostic imaging, physical exam, spine x-rays, bone scan or MRI. Patients may be given bone-strengthening medication.
A few days before the surgery, patients should inform their doctor about the medications they are taking, including herbal supplements, and if they are drinking a lot of alcohol. Women must also make it known if there is a chance of pregnancy to prevent over exposure to radiations such as x-ray, which can affect the baby (113). Patients may also be asked to stop smoking and taking medications, such as aspirin, coumadin, ibuprofen, warfarin and other blood thinning medicines. They should ask their doctor what medicines are allowed to take.
Several hours before the surgery, patients will be asked not to eat or drink anything. Medicines given by the doctor may be taken with only a small amount of water. Patients should wear comfortable clothes and shoes and avoid bringing valuables. Blood tests will be done to ensure normal blood clot.
Patients will lie down on the table facing down. A monitor will be connected to track heart rate, pulse and blood pressure. An intravenous (IV) line will be inserted into a vein in the arm to give moderate sedative medication. Medicines for nausea, pain and infection (antibiotics) may be given (114).
The back area will be cleaned or sterilized and then shaved. Local anesthesia will be injected into the skin and tissues near the fracture. A small incision in the skin is made and a hollow needle called a trocar will be inserted until the tip reaches within the affected vertebra. To ensure correct positioning of the needle, real-time x-ray images are used.
Orthopedic cement is then injected. The most commonly used bone cement is the polymethylmetacrylate (PMMA), which is viscous, toothpaste like material. This bone cement hardens quickly, usually within 20 minutes. After the cement injection, the trocar is removed. To check the distribution of bone cement, x-rays may be performed. After this, pressure will be applied and the skin incision covered with a bandage. The IV line will then be removed (114).
Patients may go home after the surgery or may choose to spend another day in the hospital. It is recommended not to drive after the surgery, so patients should arrange transportation from the hospital or outpatient clinic prior to the surgery (114). They should be able to walk after the surgery however a 24-hour bed rest is advised. After a day of bed rest, patients should be able to go back to their normal activities; and, strenuous or heavy work should be avoided for at least 6 weeks.
To alleviate pain caused by the skin incision, an ice pack may be applied on the skin covered with cloth. This may be done for 15 minutes per hour. The bandage should not be removed for 48 hours. Patients should also consult their doctor first before retaking medications such as blood thinners.
Follow-up visits may be recommended by the interventional radiologist to discuss side effects experienced by the patient and conduct physical check-up, blood test and imaging procedure.
Vertebroplasty is a minimally invasive procedure so there is less operative trauma, faster recovery and shorter hospital stays. In most cases, patients stay only a day in the hospital or outpatient clinic. Only a small nick in the skin is made, so there is less tissue damage, blood loss and scarring (114).
Most patients experience immediate pain relief. For others it may take a few days to feel pain-free. About 75 % of patients who have undergone vertebroplasty have improved mobility and became more active. Thus, the consequences of osteoporosis are reduced. The risk of pneumonia is also lessened because patients are able to get out of bed after the surgery.
Patients can perform normal daily activities without any physical therapy or rehabilitation. They also need fewer pain medications. In general, vertebroplasty is safe and effective and results to a better quality of life (114). Like any other procedures or surgeries, vertebroplasty, although minimally invasive, has risks too. During the procedure, the skin is penetrated, so infections may occur. The risk of infection, however, is less than 0.1 %. Allergic reactions to anesthesia, x-ray dye (contrast media) and other medications may arise (114).
A small amount of bone cement can leak to surrounding areas, which is not really serious, unless it goes to dangerous locations such as the spinal cavity or the blood vessels of the lungs. The problem of cement leakage is more common in vertebroplasty than kyphoplasty (114).
After vertebroplasty, about 10 % of patients may develop additional vertebral fractures. They may experience relief from pain for a few days after the procedure but the pain comes back again soon. Bleeding, infection, neurological symptoms and increased back pain may also occur. Paralysis is a very rare case (114).
Discectomy
A discectomy, also called discotomy or open discectomy, is the partial or complete removal of herniated, degenerated or ruptured disc that presses on the spinal cord or a nerve root. The stressing and pressing on the spinal cord can cause much pain.
The spinal column is composed of inter-locking vertebral bones and between those vertebrae is a flexible, cartilaginous plate called intervertebral disc. Intervertebral disc acts as a cushion that prevents interlocking vertebrae from rubbing each other and producing friction, which may cause bone degeneration (95).
As discussed previously, a herniated disc is the bulging out of the jelly-like, central portion of the spinal disc called nucleus pulposus as a result of the tear in the outer ring of an intervertebral disc. In discectomy, the nucleus pulposus is surgically removed.
Age, diseases, lifting injuries, repetitive straining, spine trauma and deformities may contribute to the tearing and wearing of intervertebral discs. Persons with herniated disc may experience symptoms such as weakening of the lower extremity muscles, severe back and leg pain that lingers for 6 weeks or more.
Abnormal sensations may occur, such as electric shock pains, due to nerve pressure. If it occurs in the cervical region, the electrical shocks go from the neck down the arms. If it is in the lumbar region, shocks go from the lower back down the legs. Numbness, tingling and needles may also be experienced in the same regions. Abnormalities in bowel movement, urinating and numbness around the genitals may also be experienced as a result of nerve compression in the lowest region of the lumbar spine (95).
Physical examinations are performed including testing of muscle strength, reflexes and sensations. The most commonly used aid in diagnosing herniated disc is the magnetic resonance imaging (MRI).
Prior to the procedure, patients should inform their doctor regarding any medications they are taking and whether they have allergic reactions to certain drugs. The doctors should also be informed of the patient’s medical history. Pre-operative testing is done. This includes chest x-ray, blood test, electrocardiography (ECG) and other tests (95).
Patients who are overweight should talk to their doctor about losing weight. Smoking should be stopped several days before the surgery. A few hours prior to the operation, eating or drinking is prohibited.
The determination of the type of surgery to be performed depends on the patient’s age, diagnosis, medical history and personal preference. Patients should be well informed about the different types of discectomy (95).
The procedure begins with the induction of anesthesia. An intravenous line (IV) will be connected to the patient. They may be given general or regional anesthesia. When general anesthesia is used, the patient will be unaware of the procedure and unable to feel pain. Regional anesthesia, also known as nerve block, however, keeps the patient awake but unable to feel pain. Vital signs of the patient need to be closely monitored throughout the surgery and upon recovery.
There are various types of discectomy, and these are listed below as (95):
▪ Cervical discectomy which is the removal of a disc in the cervical spine (neck area),
▪ Lumbar discectomy which is the removal of a disc in the lumbar spine,
▪ Sacral discectomy which is the removal of a disc in the sacral spine, between the pelvic or hip bones), and
▪ Thoracic discectomy, which is the removal of a disc in the thoracic spine.
A discectomy may be performed by a neurosurgeon, (specializing in the treatment of nerves), or an orthopedic surgeon (specializing in the treatment of bones and muscles); and, there are three general approaches to discectomy. These are listed below as:
1. Open surgery
2. Microdiscectomy
3. Anterior discectomy
In open surgery, a 2-4 inch incision is made down the middle of the affected spine that allows the doctor to view the surgical area. This type of surgery is mostly performed for the treatment of lumbar spine herniated disc, and if additional procedures are needed such as spinal fusion, foraminotomy or laminectomy.
Microdiscectomy is relatively less invasive than the open surgery. It is considered a minimally invasive procedure. A small incision (less than 1 inch) is made along the side of the affected spine and special instruments are inserted through the incision. This procedure is performed when no other treatment is needed. Unlike open surgery, microdiscectomy entails lesser pain, infections and faster recovery (95).
In anterior discectomy, an incision is made in the front part of the body. In cervical discectomy, the incision is made through the neck. In lumbar and sacral discectomy, it is through the belly or abdomen. In thoracic discectomy, the incision is made in the chest (95).
Patients may stay in the hospital for a period for further observations. In most cases, however, one or two days in the hospital are enough. The recovery stage is gradual. It depends on the patient’s age, health, anesthesia used and the type of procedure performed. The doctor may encourage walking and avoid sitting for a long period of time. It takes about 2 to 6 weeks for full recovery.
After the surgery, patients may experience the disappearance of electrical shock pain, tingling numbness and weakness. For others, it may take a few weeks. Every surgery has certain risks and complications. They can develop during or after surgery. The risks include allergic reactions, breathing and heart problems due to anesthesia. Infections and bleeding that leads to shock. Blood clot can occur in the leg or pelvis, which can travel to the brain, heart and lungs and can cause stroke, pulmonary embolism and heart attack (95).
Complications include nerve damage, which can lead to permanent weakness. Disc fragments that are not removed may require additional surgery. This case may occur in microdiscectomy. Recurring pain may also be experienced.
Patients should make sure to inform the medical team members about any allergies. Restrictions regarding diet, activities and lifestyle should be followed. For pregnant women, it is necessary to inform the doctor before proceeding with the surgery. The doctor should be notified immediately in case there is bleeding, swelling, increased pain and fever. The medicines given by the doctor should be taken exactly as directed (95).
Foraminotomy
Foraminotomy is a surgery that widens the back opening where nerve roots leave the canal. It comes from two words, foramen and otomy. Foramen is a hollow passage or a natural opening through bone. On the other hand, otomy means to incise or cut.
There are 31 pairs of spinal nerve roots that pass through the foramen. These spinal nerves provide sensations. The nerve opening may narrow, which is called foraminal stenosis. A nerve root may leave the spinal cord through the openings (neural foramena) in the spinal column. When the nerve root openings become narrow, pressure on the nerve can result. A bone, disc, excessive ligament, scar tissue and pinched nerves may compress the foramen. This procedure takes the pressure from the nerves in the spinal column allowing easy movement of the spine. Foraminotomy can often be performed as a minimally invasive procedure. It may be endoscopically or microscopically. In minimally invasive procedures, only a small cut or incision is made. The result is less pain, blood loss and faster recovery time (96).
Symptoms of foraminal stenosis include deep and steady pain in the hands, arms, calf, shoulder, lower back and thighs. It also includes pain due to a certain movement or activity. Muscle weakness, numbness and tingling may also be experienced. The symptoms of foraminal stenosis may become worse gradually. A magnetic resonance imaging (MRI) is needed to make sure that the symptoms are caused by foraminal stenosis.
Patients should inform the doctors about any medication they are taking. Smoking should be stopped because it can result to slower recovery. Taking medicines that make the blood hard to clot such as aspirin, ibuprofen, naproxen, etc. should be stopped two weeks before foraminotomy procedure. Patients should at the same time ask what medications are allowed for them to take (96).
Patients who have heart disease, diabetes and other medical problems may be asked by the surgeon to see their regular doctor. They should inform if they have been drinking a lot of alcohol. The doctors should also be notified if the patient gets a cold, fever, flu or other illnesses.
Patients may also visit a physical therapist to learn about exercises that can be done before the surgery.
Six to twelve hours before the surgery, patients will be asked not to eat or drink anything. Medicines given by the doctor should be taken with only a small sip of water. A patient may bring a cane or wheelchair if it is available (96).
Using an x-ray localizes the area of interest. The patient will be given general anesthesia, so he/she will be asleep and unable to feel pain during the procedure. The patient will lie down on the operating table facing down. A cut or incision will be made in the middle of the back of the spine. The incision length varies depending on the part of the spinal column to be operated. For cervical foraminotomy, the cut or incision is made in front or back (anterior or posterior) of the neck. For lumbar foraminotomy, it is in the lower back (96).
Skin, ligaments and muscles will be moved or pushed to the side and the surgeon may use a surgical microscope, endoscope or arthroscope to view the inside of the back. The surgeon can now visualize the foramen and remove offending materials. Some of the bones may be shaved or cut to enable opening of the foramen (nerve opening). Disk fragments will then be removed. To make more room, other bone at the back of the vertebrae may also be removed. Aside from that, the surgeon may correct identified disc issues. To cauterize the disc, a laser is usually used. Spinal fusion may also be performed to ensure stability of the spinal column (96).
The muscles and ligaments that were moved will be placed back in their position. The tissue and muscles are closed using absorbable sutures. The skin will also be closed using the same kind of sutures and sterilized strips. These may be removed if the wound is already healed.
If the surgery was done on the neck, it is recommended that the patient wear a soft neck collar. After the surgery, patients can usually get out of bed and sit up for almost 2 hours. Patients can usually go home after the surgery; however, it takes about a week or two to be able to drive. After 4 weeks, they can perform light activities (96).
After foraminotomy, patients may have partial or full relief of the symptoms. However, there is always a possibility of future spine problems. If a patient had a spinal fusion in addition to foraminotomy, problems may arise in the spinal column above and below the fusion in the future. There is a greater chance of future problems if additional procedures such as laminotomy or laminectomy are needed (96).
The success rate of foraminotomy is between 45% - 90%. There is a large middle ground for success rates because many factors are to be considered. One of the factors is the ability, experience, expertise and training of the surgeon. Accurate diagnosis is also one major factor. Although the surgeon may have the right expertise, it would make no difference if the diagnosis were not accurate. Accurate diagnosis is the key to finding out the correct location of the damage. It also helps the surgeon to make the right approach, whether bilateral, anterior or posterior (96).
Risks associated with anesthesia include allergic reactions and breathing problems. Bleeding and infections of the wound and vertebral bones may also occur. Spinal nerve damage may result and cause pain, weakness or loss of sensory perception. After surgery, partial or lack of pain relief may also be experienced. There are also the risk of refractory back pain in the future and thrombophlebitis due to blood clot (96).
Nucleoplasty
Nucleoplasty, also known as percutaneous disc decompression, is a minimally invasive, image-guided procedure that is useful in relieving back pain caused by herniated discs. As discussed in the previous section, vertebral discs function as shock absorbers between vertebrae. When discs herniate, they put pressure on the nerve roots, trigger pain receptors, and cause back pain. Patients with back and leg pain secondary to herniated discs, especially those demonstrating disc herniation less than 6mm on MRI, can benefit from nucleoplasty. The procedure removes the offending disc tissues, relieve the chronic pain and restore functional mobility (117).
Nucleoplasty is generally indicated in patients with chronic (longer than 6 weeks) lower back pain, usually secondary to herniated discs, who have not benefited from conservative treatment approaches. Patients who are severely debilitated and impaired functionally by the pain are the ones who stand to benefit the most from this procedure. The ideal candidate for nucleoplasty will have radicular and axial symptoms associated with a contained herniated disc (117). Examples of radicular signs and symptoms include (117):
• Radicular symptoms greater than Axial symptoms
• Radiologic evidence of contained disc protrusion
• Discography concordant, if indicated
• Failed conservative treatment
• Disc height greater than 50%
Examples of axial Symptoms (due to a contained disc herniation) include (117):
• Discography positive for concordant pain
• Disc height greater than 75%
• Failed conservative treatment
Since the procedure involves minimal invasive techniques, it is performed on an outpatient basis instead of the overnight stay required from many invasive procedures.
To begin with, a fine needle is inserted into the herniated disc with the aid of x-ray guided imaging. It is followed by the insertion of the ‘spine wand’ into the nucleus of the disc using the needle. This device uses coblation to ablate and remove tissues in the nucleus pulposus of the disc. Because tissue removal is achieved at temperatures of approximately 40-70ºC, thermal damage to surrounding tissue is minimized.
After coblation, the annulus ring shrinks in size, which substantially relieves the pressure on the adjacent nerves. Although the time scales vary from physician to physician, the whole procedure usually lasts less than an hour and patients are discharged from the hospital within a couple of hours following surgery. Disc infection is a rare complication (117).
Nucleoplasty is usually not recommended in individuals over 60 years of age and those with spondylolisthesis and segmental instability. Moreover, it is not usually performed on patients with disc herniation measuring more than 6 mm on MRI. Additionally, nucleoplasty is contraindicated in patients with severe disc degeneration, who appear to have complete annular disruption, and whose painful disc measures half or less than half the size of the adjacent disc.
Although generally safe and well tolerated, nucleoplasty can result in a few complications, namely (117):
• Soreness at the site of the injection within 24 hours following the procedure;
• Numbness and tingling sensations which can last for a long time; and
• Greater pain intensity that may persist for a long time.
Nucleoplasty is a fairly recent development in diagnostic medicine. Although it is a popular alternative treatment for discogenic back pain, some critics have called its long-term clinical benefits into question.
A study conducted in Romania in 2013 compared the clinical usefulness of nucleoplasty against open discectomy as a treatment for back pain. Long-term post-operative pain scores in both groups were found to be similar. Additionally, no major complications were reported with nucleoplasty, with patients exhibiting rapid recovery and returning to their daily routine 3 days following the procedure (115).
A systematic review published in Pain Physician in 2011 recommends nucleoplasty to be a category 1C procedure which means that strong evidence exists supporting its therapeutic effectiveness in treating lower back pain [116]. However, prospective randomized controlled trials with higher quality of evidence are necessary to confirm these findings, and to determine ideal patient selection for this procedure.
Intradiscal electrothermal therapy (IDET)
Intradiscal electrothermal therapy (IDET), also known as intradiscal electrothermal annulopasty, is a relatively new procedure that was introduced in 1997 as an alternative treatment for discogenic low back pain. It is a minimally invasive procedure and successful treatment with IDET helps patients achieve pain relief without having to go through major back surgery. This is the kind of treatment that can very well help patients avoid surgical disc removal, disc replacement, and even spinal fusion (118).
Discogenic low back pain is thought to arise from nerve fibers that have outgrown their limitations and reached into the interior of the disc. This process is related to the destruction of the tough annulus layer of the disc. Another mechanism by which discogenic pain is triggered is injury to the disc. An injury may cause tissue materials from the nucleus pulposus to dislocate to the outer layer of the disc where pain receptors are present (118).
Prior to the procedure, clinicians use discography techniques to visualize the nature and extent of the disc herniation. Once identified, patients are advised to prepare for surgery (118). At the start of the procedure, patients are given sedatives and local anesthetics to minimize the pain. Under fluoroscopic guidance, a catheter and a heating element are inserted into the annulus of the disc. The catheter, upon reaching its optimum position, is heated to 90°C for 15 to 20 minutes. The heat delivered destroys the nerve fibers, toughens the disc tissues and also heals any small disc tears. Antibiotics may be administered locally or intravenously to prevent the onset of infection on the disc (118).
IDET does not provide immediate relief from lower back pain. In fact, the pain symptoms may initially seem to increase for a short time immediately following the procedure. During this time, clinicians usually advise patients to incorporate mild exercises such as walking and short stretches into their daily routine. However, strenuous exercises are best avoided until 5-6 months after the procedure. During the initial months following procedure, clinicians also advise patients to avoid prolonged periods of sitting, lifting, and bending (118).
IDET therapy is an effective method of treating lower back pain associated with a select group of spinal disc diseases. It is not recommended in patients with severe disc degeneration and conditions that undermine spinal instability such as spondylolisthesis and spinal stenosis. It is also not recommended in patients who have three or more symptomatic discs, large disc herniation, significant narrowing of discs, and diffused disc degeneration. Moreover, patients are obese or strongly dependent on pain medications may not show an optimum response to the procedure (118).
Like other invasive spinal procedures, IDET also carries a few risks of complication such as:
• Disc infection
• Nerve root injury
• Disc herniation
• Post-treatment disc degeneration
• Paradoxical increase in pain intensity
A single arm prospective clinical trial conducted in the US and published in 2008 studied the effects of IDET in patients with lower back pain. The results of the study showed improvement in pain scales as well as mean tolerance scores for sitting, standing and walking. Seventy-five percent of the patients who underwent the procedure were classified as successfully treated; having exhibited improved pain scales and/or overall physical functioning. The study concluded that IDET therapy in select subset of patients with mild disc degeneration, confirmatory imaging evidence of annular disruption, and concordant pain provocation by low pressure discography are those who stand to benefit the most from this novel procedure [119].
In 2008, the Connecticut Pain Care in the US published a set of guidelines for IDET therapy. They identified five compulsory indications, all of which are enumerated below [120]:
1) persistent axial low back pain +/- leg pain and non-responsive to > or = 6 weeks of conservative care;
2) history consistent with discogenic low back pain without marked lower extremity neurological deficit;
3) one to 3 desiccated discs with or without small, contained herniated nucleus pulposus by T2-weighted magnetic resonance imaging, with at least 50% remaining disc height;
4) concordant pain provocation by low pressure (< 50 psi above opening pressure) discography; and
5) posterior annular disruption by post-discography computed tomography.
IDET is an effective and safe method of treatment in lower back pain that is refractory to conservative treatment. However, it is only beneficial in select subset of populations and should only normally be offered to those whose outcomes are favorable and outweigh the risks outlined above.
Radiofrequency nerve lesioning
Radiofrequency nerve lesioning, also known as facet rhizotomy, is a treatment modality that involves the use of a special machine to help interrupt nerve conduction temporarily. The interruption of nerve conduction is responsible for the cessation of pain signal transmission. Its mechanism of action is primarily based on the heat generated by radio waves or electrical impulses to damage specific nerves to halt their transmission of pain temporarily. Nerve conduction can be blocked typically for up to of 6-9 months using this procedure. It is especially beneficial in the treatment of chronic spinal pain conditions such as spinal arthritis (spondylosis), pain due to whip lash injury, chronic regional pain syndrome, and sometimes even pain secondary to nerve entrapments (128).
Radiofrequency lesioning is performed under the guidance of fluoroscopy. Since nerves cannot be visualized, bony landmarks are identified to gauge nerve pathways. It proceeds in the following steps (128):
1. The area of needle insertion is numbed by local anesthetics.
2. The radiofrequency needle is inserted.
3. Once the needle tip is in place, another special needle is inserted. The correct positioning of the needle is achieved by visualizing its placement on the x-ray.
4. Electrical stimulation follows which results in tingling sensations or sometimes, numbness. The electric current is passed for about 90-120s using the radio frequency machine, which heats the surrounding tissue. This local heat action renders the nerve numb temporarily.
Radiofrequency lesioning is not done under general anesthesia since patients may be required to be awake to give appropriate feedback during the procedure. Again, depending on the expertise of the surgeon, the procedure can last anywhere from 30 minutes to an hour. Patients may experience soreness after the procedure, which resolves in the next couple of days, even without medication. Because of the minimal tissue invasion, tissue and wound healing is fast, allowing patients to return to work within 1-2 days following the procedure (128).
When done correctly, the procedure can provide prolonged pain relief that may last years after the procedure. The long lasting pain-relief it provides makes it a good palliative treatment option in patients with chronic lower back pain.
Although radiofrequency is a minimally invasive procedure, it does carry the risk of infection to the spinal structures. Patients taking anticoagulants may experience excessive bleeding, despite the minimal wound created by the procedure. It should not be performed on patients as an alternative to corrective surgery. Lastly, patients who experience widespread and non-localized pain are not likely to benefit from radiofrequency of a single nerve because of the multifocal nature of the pain.
A retrospective study published in 2013 and conducted in Australia investigated the effects of radiofrequency lateral branch neurotomy in patients with from sacro-iliac joint mediated low back pain. Some of the parameters assessed were visual analog scale (VAS) pain scores, quality of life, medication usage, and also patient satisfaction. The study found a significant reduction in pain scales during follow up assessments. Patients also reported an improved quality of life along with decreased need for opioid medications. Additionally, some patients reported long-term pain relief lasting as much as up to 20 months after treatment [129].
A study conducted in 2008 in the US provided retrospective data regarding pain relief and changes in functionality in patients who underwent radiofrequency lesioning treatment. Data from 27 individuals was analyzed and found to suggest that a significant number of the participants with chronic sacroiliac joint pain benefited the most from the procedure. Specifically, this group experienced marked improvement in their pain scores and also in their functional status [130].
Another American study published in 2001 was the first of its kind to review the use of radiofrequency lesioning in patients with sacroiliac syndrome. Thirty-three patients who underwent a series of 51 consecutive radiofrequency lesioning were identified and assessed pre- and post- operatively in terms of pain scores, opioid use, and physical examination. The study concluded that radiofrequency lesioning might prove to be of substantial benefit in certain subset of patients. Additionally, the study suggested the delivery of effective analgesia using this treatment in patients with sacroiliac syndrome [131].
Acupuncture
Acupuncture is a form of ancient Chinese medicine that is based on the belief that an energy or life force flows through the body channels called meridians. This energy or force is referred to as Qi (pronounced as ‘chee’). The practitioners of acupuncture believe that when Qi is not able to flow freely throughout the body, an illness ensues. Acupuncture practitioners believe there to be approximately 2000 points in the human body, all of which when stimulated corrects the life force imbalance in the body.
Scientists and some modern acupuncture practitioners believe that acupuncture helps stimulate certain nerves and muscles, and attribute its beneficial effects to this very reason. The traditional form of the treatment, trigger point acupuncture, involves the use of fine needles inserted into the skin at specific points. Its use has become very popular in recent years, with majority of the results of studies done on it pointing to positive outcomes in terms of pain reduction, cementing its effectiveness in the management and treatment of pain.
Currently, acupuncture for treating lower back pain is recommended by the National institute of Health and Clinical Excellence (NICE). The NICE guideline published in 2009 suggest that acupuncture may be offered for 10 sessions lasting up to 12 weeks for nonspecific lower back pain [88]. Another guideline published by the American Pain Society (APS) and American College of Physicians (ACP) also recommend acupuncture as an alternative form of pain treatment to patients with lower back pain who have not benefited from conventional forms of therapy [89].
Acupuncture provides pain relief by stimulating various nerves and muscles, which help reduce the intensity and frequency of pain symptoms. Moreover, it is also associated with the release of endorphins and other kinds of neuro-hormonal factors, which are the body’s natural substances that generate feelings of well-being. It is also effective in reducing inflammation through the release of immunomodulatory and vascular factors that play a role in the body’s inflammatory responses. Since acupuncture also stimulates muscles, it is also believed to improve muscle stiffness and joint mobility by stimulating the microcirculation locally, which ultimately helps in reducing the swelling associated with tissue injury [97].
Numerous research findings have proven acupuncture to be significantly better than no treatment at all in cases of chronic back pain. Some studies have even suggested it to be equally effective if not more, than other forms of conventional treatment. It is certainly useful in patients who wish to avoid the use of analgesic medications or wish to augment their existing conventional therapy with another form of treatment that is relatively safe and noninvasive to alleviate severe symptom episodes (97).
A study was conducted in 2005 by the University of Sheffield, UK to determine the cost effectiveness, safety of acupuncture, and clinical benefits, i.e. long-term pain relief of acupuncture. Patients aged between 18-65 years with nonspecific back pain for 4-52 weeks were enrolled into the study. The results showed that individuals receiving acupuncture did not report any serious or life threatening adverse effects. They also reported lesser worry and anxiety symptoms associated with back pain at 12 and 24 months compared to the conventional care group. Another significant finding was that at 24 month, the patients treated with acupuncture reported significant decrease in the use of pain medications. The same group was also found to be more likely to report a pain free interval of 12 months. However, no additional benefits regarding function and disability were reported. The study also suggested that acupuncture therapy referred by GPs could prove to be cost effective in the long run (98).
A systematic review undertaken by the University of Ulster in Northern Ireland on 2008 also advocated the use of acupuncture versus no treatment for nonspecific lower back pain. The study concluded that moderate evidence existed to support the use of acupuncture therapy when compared to no treatment at all; however, no difference in short term pain relief was identified between acupuncture versus sham acupuncture treatment. Another significant finding of the report was that acupuncture was shown to provide significant clinical benefits when used as a supplement to conventional therapy. However, the effectiveness of the treatment alone when compared to conventional therapy requires more thorough research. Conclusively, the review advocated the use of acupuncture than no treatment at all and its use as an adjunct to conventional therapy in individuals with nonspecific back pain [99].
A specific acupuncture technique that has become popular in the recent years is motion style acupuncture. This technique is new and differs from the conventional trigger point acupuncture in that it involves mobilizing the patient (e.g. doing exercises) while the needles are being placed into specific meridian points. In the treatment of lower back pain, the needles are usually positioned onto back of the neck, elbows, and extremities, i.e. hands and feet. The patient is then mobilized with the help of the practitioners.
Motion style acupuncture may prove to be an effective alternative and adjunctive treatment in patients with lower back pain. A study conducted in Korea and published in 2013 recruited 58 patients and compared the effectiveness of motion style acupuncture versus non-steroidal anti-inflammatory drug (NSAID) injection. The results showed that the pain intensity in patients receiving acupuncture was reduced significantly. The disability levels of these patients also declined significantly. The clinical effects lasted up to a month following the treatments [97,100].
Other studies have also advocated the use of trigger point acupuncture for back pain. A study conducted in Japan in 2009 suggested it to be a fairly effective method in treating back pain in elderly patients compared to sham acupuncture [101]. Trigger point acupuncture essentially differs from conventional acupuncture in that specific trigger points are targeted. Trigger points, also known as trigger sites or muscle knots, are actually hyperirritable parts of skeletal muscles which may also be associated with palpable nodules found on the taut bands of muscle fibers. Acupuncture practitioners believe these to be the source of many unexplained pain symptoms, even in cases of referred pain. Compression of any trigger point elicits three kinds of responses, namely:
1. Local pain
2. Referred pain, and
3. Local twitch response
Trigger points are usually classified into various types depending on their specific characteristics, namely:
1. Active trigger points which refer to either local or distal pain,
2. Latent trigger points, which refer to points that exist but only actively elicit pain when compressed.
3. Key trigger points which refer to a pain referral pattern along a nerve pathway.
4. Satellite trigger points, which refer to those that elicit pain only upon activation by key trigger points.
The above trigger points can arise from of a number of diseases or dysfunctions including inflammation, muscle overload, trauma, homeostatic imbalances, infection, and smoking. A study conducted in Japan in 2006 found that deep needling these trigger points via acupuncture is a superior method of treating lower back pain than superficial needling of the same trigger points [102].
Like other alternative forms of treatment for lower back pain, acupuncture has shown effectiveness and safety in both acute and chronic lower back pain. It is undoubtedly useful in treating back pain that is irresponsive to conventional therapy and those who need an additional treatment to augment the benefits of their existing primary pain treatment.
Traction
Traction refers to a treatment modality that primarily involves the use of pulleys, ropes and/or weights to apply mechanical forces on tissues that usually surround broken bones. The purpose of traction is to apply a force that is strong to draw apart two adjoining bones, increasing their shared joint space, and providing pain relief (121).
The mechanical forces may be applied manually or with the aid of devices such as ropes and pulley. Although traction has been largely replaced by modern orthopedic techniques, some of its techniques are used in a variety of clinical scenarios today. It is especially useful in aligning different bony structures following a fracture as well as to promote its healing, decrease the pain, and provide stability before being operated on. It is also used to treat bony deformities such as scoliosis of the spine and correct musculoskeletal problems such as muscle contractures (121). Generally speaking, there are two different types of traction, namely (121):
1. Skin traction, and
2. Skeletal traction
Skin traction
Skin involves the application of a mild pulling force on the soft tissues of the body such as the skin, tendons, and muscles. Skin traction does not necessarily facilitate fracture healing but it helps in aligning the fractured part of the bones and prevents bone shortening during the healing process. It is usually carried out during the hospital stay of the patient (121).
It is performed while the patient lies in a supine position on the bed. A pulley system attached to the bed and equipment such as adhesive tapes, special gloves, boots, and splints are attached to the weights are used to apply the necessary mechanical force.
Skeletal traction
Skeletal traction is usually indicated when greater mechanical force is required to facilitate fracture healing. This method differs from skin traction in that the force applied directly to the skeleton. Skeletal traction involves the surgical implantation of pins, wires, and screws into the bones. This is usually done under general anesthesia. The weights are then applied after implantation. The duration of weight application largely depends on the patient’s clinical needs (extent of injury, presence of positive healing factors, etc.) (121).
Spinal decompression traction therapy
Spinal decompression traction therapy is another treatment modality for back pain. Its aim is to create greater space between the injured spinal structures by pulling apart the vertebrae. This action allows decompression of structures in the spinal cord and improves circulation.
One unproven theory suggests pulling apart the discs to improve their water absorbing ability, thus affording them greater shock absorption abilities. Spinal traction is performed either mechanically or manually. Sometimes, the force is applied intermittently through manual and mechanical traction. A sustained traction, lasting no more than 30 minutes, is usually done using mechanical devices.
Although in theory traction appears to provide a good rationale for the treatment of back pain, there is little evidence to suggest its actual clinical benefit in the treatment of lower back pain. A recent systematic review published in 2013 analyzed 32 randomized control trials that involved a total of 2762 patients with lower back pain. These control trials were conducted to establish the role of traction in patients with acute, subacute and chronic non- specific lower back pain (with or without sciatica). The results of the review found low to moderate quality evidence of traction being more beneficial than placebo in reducing pain intensity, and improving functional status of the patient and recovery speed. In the same review, traction exhibited very little substantial benefit compared to physiotherapy [122].
TENS [transcutaneous electrical nerve stimulation] therapy
Transcutaneous electrical nerve stimulation or TENS therapy involves the use of a small low- voltage electric current to provide relief in patients with lower back pain. A small battery-operated device containing two electrodes connected to the skin generates the electric current. The device can be attached to a belt and carried close to the body.
Like traction therapy, transcutaneous electrical nerve stimulation has greater theoretical value than practical application. In theory, the electrical nerve stimulation closes the ‘voltage-gate mechanism’ of the spinal cord, which eliminates the sensory signal conduction of pain. However, this is still just a theory and has not been proven yet to be the case [123].
Some patients report a reduction in pain perception when electrical impulses are being delivered. However, this may be due to the fact that simulation of the nerves temporarily blocks the pain sensory pathways, providing a false sense of relief. Proponents of TENS therapy believe that the induction of electrical signals in the body produces endorphins, the body’s natural opioid substances, which trigger pain relief [123].
TENS treatment is generally started after a thorough evaluation of the patient’s medical history and need for treatment. The following are important points to remember when using a TENS device [123]:
• It is best avoided during the initial stages of pregnancy and patients who have pacemaker implants.
• As with every other device, it is recommended that individuals who wish to use this treatment modality to read and follow the instructions carefully.
• Patients should clean the skin before putting on the electrodes.
• Patients need to check the integrity of their skin prior to application of electrodes, as these should not be placed on broken or burnt skin.
• It should not be used while sleeping or showering.
• It should not be used in conjunction with other heating or electrical pads.
• It should not be used while driving.
• Patients should contact their doctor in case any adverse reaction occurs.
• It should only be used for the purpose it was prescribed for by the healthcare professional to avoid unnecessary harm.
Although a study conducted in Turkey and published in 2012 favors the use of TENS therapy during the third trimester of pregnancy, this is generally not the consensus regarding this treatment modality. This particular study showed that pregnant patients who underwent TENS treatment at 32 weeks gestation experienced a significant pain reduction compared to treatments with acetaminophen and exercise [123].
A small-scale recent study conducted in Italy and published in 2013 emphasized the importance of appropriate selection of electrode placement location in TENS therapy in obtaining the strongest pain relief. It reported frequent peripheral nerve trunk stimulation to provide the greatest pain relief. The study consisted of 10 volunteers who underwent three different sessions of TENS therapy. The study also suggested the negative implications of continuous stimulation such as the development of tolerance [124].
Another type of transcutaneous electrical nerve stimulation is high frequency electrical stimulation via the peripheral nerve. A study conducted in January 2007 in Italy enrolled 18 volunteers and studied the effects of high frequency transcutaneous peripheral nerve stimulation (HF-TPNS) on improving heat pain threshold during and after delivery. The heat pain threshold was initially measured under basal conditions, then during and after the application of HF-TPNS. The results showed that this type of treatment has the potential to induce hypoalgesia or decreased sensitivity to pain stimuli [125].
Ultrasound
As discussed in the previous section, ultrasound or sonography is a common diagnostic imaging tool. However, ultrasound is also used as a treatment modality in lower back pain. Ultrasound therapy has been used for several decades now and found effective in treating spinal conditions such as osteoarthritis, herniated discs, and pinched nerves [126]. It may be used as an adjunct to other treatments to provide optimum pain relief.
The basic mechanism of action of ultrasound treatments is based on the action of sonic waves that pass from the ultrasound wand over the skin to the tissue beneath it. Specifically, they cause vibrations and increase heat generation by the tissues. Warmer temperatures promote improved circulation to the area, thereby reducing inflammation and pain, and also relaxing the muscles in the area. There are two main types of ultrasound therapies, namely:
• Mechanical, and
• Thermal
Both therapies involve the delivery of sound waves into the affected area with the help of a transducer. Each type differs in their sound wave delivery rates. Thermal ultrasound therapy involves the delivery/transmission of sound waves at a continuous rate. The sound waves reach the deep tissue molecules, causing microscopic vibrations that produce friction and heat in the area they are delivered to. Tissue metabolism increases, with the warming effect promoting tissue healing. Mechanical ultrasound therapy, on the other hand, delivers sound waves in a pulsatile manner. It produces a much lower heat than the thermal therapy. It promotes continuous contraction and expansion of the molecules of soft tissues, which helps in reducing inflammation and pain perceptions. The therapy recommended to patients depends on the underlying condition and their causes. Patients with muscle sprains, strains, or myofascial pain stand to benefit the most from thermal ultrasound therapy. On the other hand, patients with pain associated with swelling and carpal tunnel syndrome will benefit the most from mechanical ultrasound therapy.
Although ultrasound therapy is generally considered safe, it is contraindicated in cases after immediate injury. Some of its other limitations and drawbacks are:
• It may possibly speed up the spread of diseases via the blood, and is therefore not safe in patients diagnosed with or are suspected of cancer.
• It is contraindicated in patients with active infection, bone fractures, and also during pregnancy.
• It is contraindicated on sensitive body parts such as eyes and sex organs
• It should not be used in children since the sound waves can adversely affect the growth plates.
• It should be avoided in patients with pacemakers.
• It should not be used over broken skin, lesions, and healing fractures.
A study conducted in Iran in 2012 recruited 50 patients suffering from non-specific chronic lower back pain. The patients were randomized into two groups and underwent combination therapies consisting of ultrasound with exercise, and placebo ultrasound with exercise. The treatments were given alternatively, switching treatments between days, three times a week for four weeks for a total of ten sessions. Although beneficial effects were seen in both groups, it was found that patients receiving ultrasound therapy in addition to exercise showed a significant improvement in terms of functionality, lumbar flexion, extension ROM, and endurance time [127].
PHARMACOLOGY TREATMENTS
Over the counter (OTC) drugs for low back pain
Over the counter (OTC) pain medications are used to provide symptomatic pain relief. Examples include NSAIDs such as ibuprofen, acetaminophen, mefenamic acid, diclofenac, and aspirin.
Non-Steroidal Anti-inflammatory Drugs (NSAIDs)
Clinical trials have found that non-selective NSAIDs show superior efficacy in the treatment of acute lower back pain treatment without the need for additional analgesics (137). Ibuprofen was found to be especially effective in the treatment of chronic lower back pain (132). Other studies claim effectiveness of NSAIDs in the treatment of back pain with sciatica (137).
Mechanism of action:
NSAIDs relieve nociceptive pain due to tissue damage and inflammatory mechanisms. These drugs inhibit the enzyme, cyclooxygenase (COX) resulting in decreased synthesis of pro-inflammatory prostaglandins from arachidonic acid in the central nervous system and the peripheral sites in the body. Non-selective NSAIDs inhibit both the COX-1 or COX-2 enzymes. COX-1 is involved in pain mechanisms as well as the normal functioning of the gastrointestinal tract, platelets, and kidneys while COX-2 does not. Cox-2 is particularly active in reducing inflammatory responses (134).
Side effects of NSAIDs:
NSAIDs are associated with various risk factors. The toxicity associated with the use of both selective COX-2 inhibitors and non-selective inhibitors are similar. Their most common adverse effects known are listed below (134):
▪ Cardiovascular system:
Rise in blood pressure, fluid retention, myocardial infarction
▪ Neurological system:
Headaches, confusion, hallucinations, depression, tremor, meningitis, tinnitus, vertigo, neuropathy
▪ Gastrointestinal system:
Nausea, vomiting, dyspepsia, diarrhea, constipation, gastric mucosal irritation, peptic ulcers, esophagitis, gastrointestinal hemorrhage
▪ Hematological system:
anemia, bone marrow depression, reduced platelet aggregation
▪ Hepatic system:
hepatotoxicity
▪ Renal system:
nephritis, changes in renal blood flow, edema, inhibition of renin release
▪ Others:
precipitation of asthma, skin rashes
Selection of NSAIDs:
The selection of the most appropriate NSAID is an important step in successfully treating pain symptoms. Clinicians agree that some patients respond to some drugs better than others. Whichever is the NSAID of choice the drug must only be used for the shortest time possible. With chronic conditions, the drug can be used for up to 2 to 4 weeks since their maximum effect may be delayed. Before prescribing any NSAID, clinicians need to consider non-drug treatment as well as the risk-benefit profile (134).
Topical NSAID formulations:
NSAIDs in topical and transdermal formulations are widely used in the treatment of local musculoskeletal disorders. Examples include diclofenac, ibuprofen, ketoprofen, and piroxicam. NSAID gels are frequently used for muscular aches and pains. They are considered to be great alternative to oral NSAIDs, especially when rapid and local pain relief is required. They are also advantageous because they do not cause gastric irritation, unlike many of its oral NSAID counterparts (134).
Examples of NSAIDs:
Aspirin
Aspirin acts by irreversibly blocking the enzyme cyclooxygenase-1, thereby reducing the production of inflammatory substances, prostanoids (134).
Patients with history of hypersensitivity to any NSAID should not take aspirin. Likewise, those suffering from peptic ulcer should avoid it because of its adverse effects on the gastric mucosa. It should not be used in children under the age of 12 because of its propensity to cause Reye’s syndrome. Patients who are taking Ginkgo biloba along with aspirin may sometimes exhibit spontaneous bleeding.
Aspirin is used as an anti-platelet, analgesic, antipyretic, and anti-inflammatory drug at various doses. It can cause gastrointestinal and cerebral hemorrhage. Its dosage for anti-platelet therapy, though minimal, can also cause minimal adverse reactions.
Diclofenac
Diclofenac sodium is an analgesic-antipyretic and anti-inflammatory drug. Like other NSAIDs, it inhibits prostaglandin synthesis. It reduces neutrophil chemotaxis and superoxide production at the site of inflammation. It is well absorbed after oral administration and eliminated from the body via urine and bile. It has high tissue perfusion and thus, able to achieve high concentration in the synovial fluid (136).
Diclofenac is indicated in the pain management of rheumatoid arthritis, osteoarthritis, bursitis, ankylosing spondylitis, dysmenorrhea, post traumatic and post inflammatory conditions. It exhibits immediate pain relief after oral administration.
Diclofenac sodium is generally associated with mild epigastric pain, nausea, headache, dizziness, and rashes. It is also associated with gastric ulceration and bleeding. It can rarely cause kidney damage and reversible increase in serum aminotransferase.
Ibuprofen
One of the safest drugs, ibuprofen, also blocks the synthesis of prostaglandin, inhibit platelet aggregation, and prolong bleeding time. It is well-absorbed following oral absorption and is highly bound to plasma proteins. It is used as an OTC analgesic in rheumatoid arthritis, osteoarthritis, and other musculoskeletal disorders where pain is more pronounced than inflammation. It is also useful in soft tissue injuries, fractures, and vasectomy in alleviating pain, swelling, and inflammation (136).
Ibuprofen is associated with mild side effects such as gastric discomfort, nausea, vomiting, headache, dizziness, blurred vision, tinnitus, and depression.
Piroxicam
Piroxicam is a long-acting NSAID, and a reversible inhibitor of COX. It lowers prostaglandin concentration in the synovial fluid, and also inhibits platelet aggregation. It is very well absorbed after oral administration and almost 99% of it is bound to plasma proteins. Its metabolites are eliminated from the body via urine and bile (136).
It is associated with common side effects such as heartburn, nausea, and anorexia. Rashes and pruritus are also seen in rare cases.
It is indicated in both short and long term pain relief in rheumatoid arthritis, osteoarthritis, ankylosing spondylitis, acute gout, musculoskeletal injuries, dentistry, episiotomy, and dysmenorrhea.
Acetaminophen/paracetamol
Research evidence is strong on the efficacy of acetaminophen in short-term pain relief of a variety of pain conditions such as joint pain (133). Unlike other NSAIDs, it lacks anti-inflammatory effects. Popularly known as paracetamol, it has both analgesic and antipyretic actions in the central nervous system (135).
Mechanism of action:
Acetaminophen inhibits the enzyme prostaglandin synthetase in the hypothalamus as well as the synthesis of spinal prostaglandin. Additionally, it also inhibits the synthesis of nitric oxide in macrophages.
As mentioned previously, it shows negligible anti-inflammatory action in normal therapeutic doses because of its insignificant inhibition of prostaglandin (135).
Alternatively in conditions where arachidonic acid concentration is low, acetaminophen weakly inhibits the isozymes COX-1 and COX-2 as well as prostaglandin synthesis, accounting for its very low and negligible anti-inflammatory effects (135).
Properties:
Acetaminophen is rapidly absorbed, reaching its peak plasma concentration within 10 to 60 minutes following oral absorption. Its analgesic effect is exhibited within 30 minutes of oral administration and 15 minutes of Intra venous administration. It does not bind to the plasma proteins, highly lipid soluble, and thus, easily enters the brain by crossing the blood brain barrier. The analgesic effect is primarily exhibited in the brain. It undergoes extensive first pass metabolism in the liver and is converted to its metabolites. Its elimination occurs via the kidneys (135).
Acetaminophen should be used with caution in individuals with hepatic and renal disorders to avoid toxicity (133).
Indication:
It is comparably less effective than the nonsteroidal anti-inflammatory drugs in providing relief from moderate to severe pain. It is the first line of analgesic in the treatment of mild to moderate pain especially if it is of soft tissue and musculoskeletal origin. It is also helpful in reducing the daily doses of NSAIDs or opioids, allowing a significant reduction in their doses and subsequent adverse effects (135).
Other indications of acetaminophen are (135):
▪ Alternative to aspirin
▪ Treatment of mild procedural pain
▪ Management of fever
Paracetamol is safe for use in children. The recommended dose of acetaminophen in adults is 0.5 to 1 g given every 4 to 6 hours (135).
Adverse effects / toxicity of acetaminophen:
Acetaminophen is very safe to use in therapeutic doses. There is very low risk of side effects, which includes an increased risk of upper gastrointestinal complications in increased doses.
Acetaminophen is known to increase the risk of hypertension in women. In very rare instances, patients may also experience urticarial or erythematous rashes, fever, and blood dyscrasias as adverse effects (135).
Overdose of paracetamol is associated with potentially life threatening toxicity. The toxicity can manifest as either hepatotoxicity, hypoglycemia, or acute renal tubular necrosis.
Formulations:
Acetaminophen is available as immediate release tablets and capsules, oral solutions and suspensions, chewable tablets, soluble/effervescent tablets and, modified release tablets. It is available in rectal and injectable formulations (135).
Acetaminophen is also available in several oral preparations in combination with other medications such as other analgesics, decongestants, antihistamines, and antiemetics.
Anticonvulsant and antidepressant medications for lower back pain
The development of newer classes of antidepressants and anticonvulsant drugs in the recent years expanded their clinical indications, including their off-label use in the management and treatment of chronic pain. This is achieved by their actions on specific neurotransmitters and ion channels. These classes of drugs exhibit varying efficacy in the treatment of different types of pain. They are widely prescribed off label in the management of neuropathic and non-neuropathic pain (138).
The antidepressants that are used in pain management are the classic tricyclic antidepressants like amitriptyline, nortriptyline, and desipramine; and novel antidepressants like bupropion, venlafaxine, and duloxetine. These drugs have been found to be especially effective in the treatment of neuropathic pain (138).
First generation antiepileptic drugs like carbamazepine, phenytoin, and second-generation antiepileptic drugs like gabapentin and pregabalin have been effectively used in the treatment of neuropathic pain (138).
Antidepressant drugs
Antidepressant medications are used in the treatment of pain for the following common reasons (139):
▪ Psychiatric disorders are common among those suffering from chronic pain
▪ Sleep disturbances are also consistently found among those in chronic pain
▪ Certain antidepressant classes provide pain relief as an independent feature from relief of depression and other psychiatric symptoms.
Mechanism of action:
Tricyclic antidepressants inhibit the transmission of pain in the spinal cord by blocking the reuptake of neurotransmitters, serotonin and norepinephrine. These neurotransmitters are instrumental in several pain pathways. Additionally, tricyclic antidepressants have high affinity for histamine H1 receptor that may be helpful in producing pain relief. As such, tricyclic antidepressants are also used in the management of acute pain (138).
The newer antidepressant drugs like venlafaxine and duloxetine block the reuptake of serotonin and norepinephrine but do not block other neuroreceptors, which may result in side effects related with tricyclic antidepressants. Bupropion is thought to exert its mechanism of action by blocking the uptake of dopamine (138).
Use:
Tricyclic antidepressants are particularly useful in treating symptoms of chronic back pain. Serotonin norepinephrine reuptake inhibitors (e.g. duloxetine and milnacipran) are used to treat pain of both neuropathic and non-neuropathic origins. Of the two, duloxetine is the only one that is FDA-approved for use in musculoskeletal pain (145). Antidepressants with mixed–receptor and noradrenergic activity exhibits greater efficacy in the treatment of patients with neuropathic pain (138).
Adverse reactions:
The most common side effects associated with tricyclic antidepressant are dry mouth, constipation, urinary retention, sedation, and weight gain. The novel antidepressants bupropion, venlafaxine and duloxetine exhibit side effects such as anxiety, insomnia, sedation, loss of weight, seizures, head ache, nausea, sweating, hypertension, dry mouth, constipation, and dizziness (138).
Drug interaction:
There are many clinically significant interactions involving antidepressants. These include the interaction between fluvoxamine and benzodiazepines, clozapine, theophylline, and warfarin, wherein it increases their respective plasma concentrations. Sertraline and fluoxetine can also increase the concentration of benzodiazepines, clozapine and warfarin (142).
Some antidepressants are substrates of the CYP enzymes and also inhibit the metabolic clearance of other drugs resulting in significant drug–drug interaction (142).
Examples of antidepressants:
Amitriptyline and trimipramine
Amitriptyline and trimipramine are tricyclic antidepressants and nonselective uptake inhibitor of noradrenaline and serotonin. Following oral administration, they show a high level of absorption. They are metabolized in the liver into active metabolites. Generally, amitriptyline or trimipramine are given once daily with definite changes in steady state plasma concentration. They are known to cause many adverse effects including dry mouth, blurred vision, constipation, urinary retention, sedation, postural hypotension, sexual dysfunction, and weight gain. Amitriptyline is one of the most sedating compounds of the tricyclic antidepressant class. Alcohol has been studied to exacerbate the effects of amitriptyline. They should be used with caution in children as they can impair cardiac conduction and even result in fatal arrhythmias. They show interactions with serotonergic medications leading to serotonin syndrome (140).
Venlafaxine
Venlafaxine is a serotonin reuptake inhibitor. At higher doses it also acts as a noradrenaline reuptake inhibitor. It is a weak dopamine reuptake inhibitor. Venlafaxine and its metabolite have both short half-lives, which makes the recommended dose to be given twice daily. It shows several side effects including nausea, vomiting, anorexia, headache, increased sweating, rashes, agitation, periodic limb movements of sleep, sexual dysfunction, hypotension, and hyponatremia. Withdrawal symptoms may also appear if the drug is stopped suddenly without tapering the dose gradually. It should not be used in children or adolescents since it has been reported to instigate hostility and thoughts of suicide (140).
Antiepileptic/anticonvulsant drugs
Anticonvulsant drugs are also used in the treatment of neuropathic pain. They exert analgesic effects through multiple neuronal mechanisms such as blockade of voltage gated sodium channels, enhancement of GABAergic neurotransmission, and inhibition of glutamatergic neurotransmission. These mechanisms of inhibition of neuronal hyper excitability are also present in neuropathic pain. Modulation of this mechanism is the target of neuropathic pain therapy with anticonvulsants (139).
Mechanism of action:
Antiepileptic drugs act at several sites, which may be relevant to the perception of pain. They trigger the inhibition of neuronal excitation, thereby providing pain relief. The major sites of action of antiepileptic agents in pain relief are voltage gated ion channels (sodium and calcium), ligand gated ion channels, excitatory receptors for glutamate and N-methyl-D-aspartate, and inhibitory receptors of GABA and glycine (138).
Use:
Both first generation and second-generation antiepileptic medications are used in the treatment of pain. However, it is the second-generation medications that exhibit greater tolerance since they cause lesser sedation and have lower central nervous system activity.
Antiepileptic drugs are used in the management of neuropathic pain. Carbamazepine is extensively used in the treatment of trigeminal neuralgia. Occasionally these agents are also used in the treatment of other types of pain such as lower back pain (145). Phenytoin is frequently used in the treatment of chronic pain (138).
Second generation antiepileptic drugs have documented efficacy in patients with painful diabetic nephropathy, and post-herpetic neuralgia (Maizels & McCarberg, 2005). There is not much evidence to prove their efficacy in the management of lower back pain which makes them better suited as adjunctive therapy in cases when the first lines of drugs are ineffective (145).
Adverse reactions:
First generation antiepileptic drugs like carbamazepine and phenytoin are associated with side effects like dizziness, diplopia, nausea, ataxia, slurred speech, confusion and rashes (138).
Second generation antiepileptic agents are known to be more tolerated but exhibit certain side effects such as drowsiness, dizziness, fatigue, nausea, sedation, and weight gain (138).
Drug interaction:
The plasma concentration of hydantoins is increased in the presence of any drug metabolized by CYP2C9 or CYP2C10. Carbamazepine is known to enhance the metabolism of phenytoin and hence their concomitant use results in reduced concentration of phenytoin. The reverse is also true, i.e. phenytoin may reduce the concentration of carbamazepine (151).
Examples of anticonvulsants:
Carbamazepine
Carbamazepine is an anticonvulsant, which works by blocking the sodium channels. It is used in epileptiform conditions of neurological origins. Studies have found strong evidence of its clinical efficacy in the management of trigeminal neuralgia, and other neuropathic pain conditions (141).
It is remarkable in its ability to induce its own metabolism, which is started within 3 to 5 days of initiation of therapy and completed in 3 to 4 weeks. It also interacts with other drugs like corticosteroids, cyclosporine, oral contraceptives, other antiepileptic drugs, and warfarin.
It shows many dose-related side effects, namely:
▪ Sedation
▪ Headache
▪ Ataxia
▪ Dizziness
▪ Nausea
▪ Visual symptoms like diplopia
▪ Skin rash
▪ Diarrhea and,
▪ Hepatitis
Gabapentin
Gabapentin is structurally similar to GABA. Its mechanism of action is rooted in its ability to inhibit glutamate synthesis and increase GABA concentration in the brain. It acts upon the calcium-gated ion channels to bring about its effects (141).
It is widely prescribed to treat neuropathic pain. It acts on the spinal cord to interact with neuronal calcium channels to decrease neurotransmitter release and increase the synthesis of GABA. It has been documented to reduce neuropathic pain by almost 50%.
It is absorbed via the amino acid uptake system in the gastrointestinal tract, with its bioavailability decreasing with a corresponding increase in dose. It interacts with antacids. It remains unchanged in the urine when eliminated. Among its most common adverse effects are somnolence, dizziness, and ataxia.
Phenytoin
Phenytoin inhibits the voltage-gated sodium channels. It is highly bound to albumin, with its unbound portion exhibting pharmacological activity. Phenytoin is associated with a plethora of adverse effects, which may be dose-related or idiosyncratic in nature. Examples include neurotoxic symptoms such as drowsiness, dysarthria, tremor, ataxia, diplopia, and cognitive difficulties. It may also result in gum hypertrophy, acne, hirsutism, and facial coarsening. Phenytoin shows a wide range of interactions with major drug classes. It has very poor water solubility. Its intra muscular injection should be completely avoided (141).
Pregabalin
Pregabalin is an analogue of gamma–aminobutyric acid, with both anticonvulsant and analgesic properties. It blocks calcium channels and reduces the release of neurotransmitters such as glutamate, noradrenaline and substance P (141).
It is well absorbed orally and eliminated from the body via urine. It has not shown any clinically significant drug interactions. The side effects related to its use are somnolence, dizziness, blurred vision, weight gain, peripheral edemas, and increased creatine kinase levels (141).
Comparative account of anticonvulsant and antidepressant drugs
The antidepressant and anticonvulsant drugs have shown comparable efficacy in the management of pain of neuropathic origin, but there are profound differences in the safety profiles, drug tolerance, and side effect associated with specific drug classes. According to certain clinical trials, SSRI’s are found to be most effective in treating neuropathic pain when compared to tricyclic antidepressants, sodium channel blocking antiepileptic drugs, and gabapentin. In the treatment of non-neuropathic pain, tricyclic antidepressants are the only class of drugs that has well documented efficacy in the treatment of pain.
A research meta-analysis in patients with chronic back pain has shown that antidepressants exhibit significant, albeit small, decrease in pain. But the improvement in pain has not been associated with an improvement in day-to-day quality of life. Antidepressants that showed serotonergic activity showed even lesser efficacy in reducing pain (152).
Opioid Analgesics
Opioid analgesics are still the mainstay in pain management and treatment since the first discovery of their parent compound, opium, hundreds of years ago. The opioid analgesics are drugs used especially in the treatment of moderate to severe pain in post-operative and cancer patients. Their analgesic effects are attributed to their ability to reduce the pain sensation. The most significant feature of this class of drugs is its sensory role in inhibiting responses to painful stimuli, regulating the gastrointestinal, endocrine and anatomic functions. These drugs are also addictive and play an important role in cognition and memory (155,154).
Endogenous opioid peptides
Peptides can be classified in three different families:
▪ Enkephalins
▪ Endorphins
▪ Dynorphins
All three families of opioids are derived from natural precursors; prepro-opiomelanocortin (POMC), preproenkephalin, and dynorphins, respectively. The main opioid peptide, which has been derived from POMC is β-endorphins (155).
Opioid receptors
There are three classical opioid receptors classified as μ, δ and κ. The opioids, which are used for clinical purpose are selective for and activate μ receptors. Some drugs also change their receptor selectivity at high doses while others act on more than one receptor; being an agonist for one receptor while being an antagonist for another. Morphine and most of the clinical opioid drugs exert their action by acting on the μ receptors (155).
Effects of clinically used opioids
The opioid analgesics have been known to exert their effects on a wide range of physiological systems. Their actions include production of analgesia, affect mood and change the respiratory, cardiovascular, gastrointestinal and neuroendocrine function. Delta (Δ) opioids have also been useful in some cases to alleviate pain. Studies on animals have also shown that κ-opioid receptors are most effective in the spinal region (155).
Morphine like drugs produces analgesia, drowsiness, mood changes and mental clouding. Another significant feature is that pain is relieved without causing unconsciousness (155).
Mechanism of action:
Opioid analgesics interact with one or more opioid receptors (including μ, δ, κ) at the supraspinal, spinal and peripheral regions to result in analgesia. The opioid analgesics, which are currently in use, are μ agonists but some δ and κ agonists also produce analgesia. The opioid receptors exist as heterodimers and respond in more a complex and elaborate manner to different combination of drugs (155).
Opioids inhibit the presynaptic release of neurotransmitters from the C-fiber terminals, promote postsynaptic activity in the nociceptive pathways, and trigger the disintegration of other pathways involved in nociceptive regulation. Opioid analgesics classified as pure agonists of opioid receptors or mixed agonist-antagonist drugs act at specific receptors (154).
Use of opioids for treatment of acute pain:
Morphine and fentanyl are clinically used to relieve severe acute pain. Since opioid overdose is associated with increasing risk of toxic effects such as respiratory depression, rapid dosage increments are not advisable. Essentially, rapid dosage increments disrupt the balance between analgesia and safety. Its administration usually starts with a low dose with repeat doses given at approximately 5-minute intervals to achieve the required analgesic effects (155).
Adverse effects of opioids:
Opioids are associated with many adverse or side effects on various body systems including cardiovascular, neurological, dermatological, gastrointestinal, musculoskeletal, neuroendocrine, respiratory, and urinary systems. The withdrawal symptoms of opioids are manifested as body aches, diarrhea, loss of appetite, ‘goose flesh’, loss of appetite, restlessness or nervousness, runny nose, squeezing, tremors, stomach cramps, nausea, and loss of sleep, diaphoresis, asthenia, tachycardia or fever (154).
The adverse effects of opioids are listed below (154):
▪ Cardiovascular system:
Bradycardia, release of histamine resulting in vasodilation and hypotension;
▪ Neurological system:
Mental clouding dependent on dose, delirium, sedation, nausea and vomiting, apnoea, spinal and epidural morphine may also reactivate herpes simplex, but the central adverse effects are much delayed following an intraspinal administration of morphine;
▪ Dermatological system:
sweating, flushing, urticarial and pruritus;
▪ Gastrointestinal system:
Vomiting, anorexia, reduction in gastric motility, delayed gastric emptying, biliary colic, slowed digestion, increased time for intestinal transit, increased anal sphincter tone, constipation;
▪ Musculoskeletal system:
myoclonus, chest wall rigidity;
▪ Neuroendocrine system:
hypothalamia resulting in reduced gonadotrophins, adrenocorticotrophic hormones, beta endorphin, testosterone and cortisol and increased prolactin;
▪ Respiratory system:
respiratory depression which is directly related to the dose, bronchospasm;
▪ Urinary system:
Urinary retention, difficulty with micturition, increased tone of external sphincter, decreased muscle tone of detrusor muscle, antidiuretic effect.
It should be noted here that most of the adverse effects could be reversed with the use of naloxone, which is an opioid antagonist. Its use will also reduce the analgesic effects.
Interactions and precautions with opioids:
Opioids may interact with other medicines, which is why they should be used with caution and only under medical advice and supervision. The health care practitioner should always confirm with the patient if he is using any other prescription medications, OTC medications, complementary and alternative medicines, and illicit compounds (154).
Opioids should not be used within 14 days of the use of monoamine oxidase inhibitors (MAO) such as pethidine or tramadol since serious adverse reactions may occur.
▪ Opioids should be used with caution when given with other central nervous system depressant drugs such as sedatives, hypnotics, antipsychotics, antidepressants, anesthetics or alcohol as the sedative and antidepressant effects of opioids may be exacerbated.
▪ When given with anticholinergic drugs, the patient should be made aware of an increased chance of developing constipation or urinary retention.
▪ Partial opioid agonist such as buprenorphine may decrease the analgesic effects produced by morphine and may even initiate the withdrawal symptoms.
▪ Drugs affecting the hepatic cytochrome system may also alter the blood level of opioids, which may either result in toxicity or decreased effectiveness.
▪ There is a risk of arrhythmia when opioid are given with drugs like methadone.
Opioid use in the elderly:
Older adults are more sensitive to the analgesic and other effects of opioids, which is why lower doses are generally more appropriate for this particular subset of population group. Lower doses produce an equivalent analgesia in the elderly when compared to higher doses in adults. Additionally, due to the elderly’s greater likelihood of reduced renal function, the risk of accumulation of active opioid metabolites is also greater along with increased brain sensitivity leading to respiratory depression or nausea (156).
Opioid drugs:
Morphine
The prototype of this group, morphine, is an agonist for all opioid receptors, specially the μ receptor. Morphine is well absorbed following oral use but almost 30% of it is metabolized during first pass hepatic metabolism. The metabolites of morphine are morphine-3-glucuronide and morphine-6-glucuronide. Morphine is eliminated via renal excretion in the form of its metabolites (156).
The duration of morphine action is 3 to 6 hours. It is administered via oral, subcutaneous, intramuscular, intravenous, epidural, intrathecal and intracerebroventricular routes with the preferred mode of administration being oral. Morphine is used in the treatment of chronic pain, cancer pain, and also non-cancer pain. It is also used for pain management in palliative care such as terminally ill patients. Tolerance to morphine develops rapidly.
Oxycodone
Oxycodone has greater bioavailability compared to its other opioid counterpart, morphine, which makes it twice more potent. It undergoes metabolism to form the metabolite, oxymorphone, through the action of the hepatic enzyme, CYP2D6. The efficacy profile of oxycodone is similar to morphine. It is also available in an oral modified release formulation, which brings about early onset of analgesia lasting almost 12 hours.
Buprenorphine
Buprenorphine is a partial opioid agonist at μ receptors and an antagonist at κ receptors. It has a prolonged duration of action. It is available as sublingual, parenteral, and transdermal preparations of which the sublingual preparation is indicated for use in acute and chronic pain, cancer pain, and opioid detoxification (153).
It is metabolized by the cytochrome P450 3A4. It is worth mentioning that buprenorphine can lead to respiratory depression, which is unresponsive to the reversal effects of naloxone. It is not recommended for use in palliative care. The transdermal patches are not effective for acute pain or in cases where the need for analgesic effects varies constantly.
It is used in the treatment of opioid overdose.
Fentanyl
Fentanyl is a very potent opioid, which is synthesized in the lab. It has a short duration of action. It has been indicated for use in both management of acute and chronic pain. It is administered orally, parenterally as intramuscular, intra venous, sub cutaneous, intrathecal or epidural, and transdermal patch (154).
It is metabolized in the liver to form inactive metabolites. It is suitable for patients with compromised renal system and those who are hemodynamically compromised. Its adverse effects are similar to that of morphine but with lesser frequency of constipation and confusion.
COGNITIVE BEHAVIORAL THERAPY
Cognitive Behavior therapy or CBT is a type of psychological therapy that involves engaging the patient in dialogue to change existing thoughts and behavior. It helps patient tackle a number of problems in a more positive way.
Cognitive behavior therapy is routinely done by psychiatrists, psychologists and other professionals trained in the treatment of mental illnesses such as anxiety, depression, post-traumatic stress disorder, and personality disorders, to name a few. Evidence-based studies suggest its role in the management of chronic painful conditions such as lower back pain, irritable bowel syndrome (IBS) and arthritis.
Cognitive behavior therapy tends to focus on changing the patient’s way of dealing with problems. It focuses on changing the way a patient thinks and behaves, allowing and welcoming a completely different response to difficult situations than previously exhibited. It helps improve the patient’s state of mind. It does not provide a solution to the problems; however, it equips the patient with new behavior and thoughts to overcome negative thinking and manage existing problems.
A recent systematic review conducted in Belgium assessed the use of cognitive behavior therapy in patients with acute and sub-acute chronic back pain. The review suggested the incorporation of operant conditioning, a CBT-based strategy, into ambulatory physiotherapy practice to manage chronic back pain symptoms [161].
Biofeedback
Biofeedback is a technique that enables patients to control their sympathetic responses to various injuries and trauma. It can help patients control various body functions and responses such as heart rate and pain perception. As such, it is often advocated as an important relaxation technique.
During the treatment process, patients are connected to an external sensor device, which provides the feedback used to control sympathetic responses. It brings about subtle changes such as relaxation of specifically targeted muscles and subsequent pain relief.
Biofeedback is a noninvasive treatment modality and carries very minimal and insignificant risks, if any. It may be used in a number of conditions especially in cases where pain relief is an immediate need. It is also a treatment option in patients who are not keen to take medications (possibly due to side effects and allergies) and exhibited refractory pain following conventional treatments.
The use of biofeedback in the treatment of chronic back pain is intensely being studied worldwide. There are multiple trials that advocate the use of Biofeedback in patients with no specific chronic lower back pain. For example, a study conducted at the University of Limerick, Ireland in 2013 involving 24 participants concluded that postural biofeedback that is appropriately matched to specific clinical presentations of patients could significantly help in reducing lower back discomfort even with a single session [162].
Another fairly recent scientific paper published in June 2013 reviewed the available existing literature regarding biofeedback techniques and their clinical effectiveness in physical rehabilitation. The review suggested that EMG (electromyogram) biofeedback could be beneficial in relieving pain associated with musculoskeletal conditions and cardiovascular accident. Additionally, the review also highlighted the fact that real time ultra sonography (RTUS) biofeedback could potentially prove to be effective in treating patients with chronic low back pain [163].
Aside from alleviating chronic back pain, biofeedback is also most useful in conditions such as constipation, incontinence, and irritable bowel disease.
SUMMARY
The spine is a complex region of the body whose major function is to provide skeletal support and structure. It is made up of bones, tough cartilages and ligaments, joints, and highly sensitive nerve roots that supply sensations to all parts of the body. Trauma, deformities, degeneration, metastases, and infections can all undermine the spine’s major function. A case of lower back pain is usually an indication of a disease process in any of the spinal structures that warrants an immediate medical assessment.
Lower back pain is a general symptom that is associated with various medical conditions; some of which are benign and easy to treat (e.g. overexertion, minor sports injuries) and some, which have high morbidity and life-threatening implications (e.g. spinal stenosis, cauda equine syndrome).
The diagnosis of lower back pain, both acute and chronic, require careful review of medical history, physical examination, and results of diagnostic imaging and specialized techniques. The most commonly ordered imaging modality in spinal disorders involving lower back pain is spinal x-ray of the lumbar and sacro-iliac regions. It is cheap, universally available and delivers quick images. On the other hand, it is limited to the visualization of bones since it does not capture clinically useful images of soft tissues such as muscles and nerves, making it useless in identifying conditions such as nerve impingement, muscle sprains, and strains. Other imaging modalities provide superior visibility of soft tissue structures such as the CT and MRI scans. As such, they are more expensive and not as universally available and accessible as x-ray machines. Other diagnostic tools such as ultrasound and bone scan are also useful in diagnosing causes of back pain.
The treatment approaches to back pain, both acute and chronic, depends largely on the symptoms, patient history, physical health, and suspected underlying causes. Because the causes of back pain are generally difficult to pinpoint, the clinician usually starts with common OTC pain-relievers until further tests and evaluation have provided sufficient evidence to suggest interventional therapies such as surgery and steroid injections.
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