Low Back Pain-When To seek treatment

Graf Hilgenhurst, M.D.

Low back pain is among the most common complaints known to man. It is a frequent cause of lost work days, second only to the common cold and other upper respiratory tract infections. Most low back pain will resolve in a couple of weeks with or without treatment. The trick is in knowing when to seek medical care. Guidelines written for emergency room and family physicians generally do not recommend x-rays or other expensive tests right off the bat. If they did, we would waste a lot of money on tests that wouldn't show much. Instead, initial recommendations following an acute back injury are usually based on symptomatic treatment. Rest, ice, non-narcotic pain medications such as anti-inflammatories (NSAIDs), and perhaps muscle relaxants are often prescribed as firstline therapies. Sometimes a short course of a narcotic pain medication (Lortab, Percocet) is recommended, but only for a few days. If this doesn't do the trick, further workup is in order.

Here are some terms that you should be familiar with:

 

• Acute pain: Pain of sudden onset, usually after an obvious injury (bending, lifting). Most acute pain does not go on to become chronic pain.

 

• Chronic pain: Pain that persists after normal healing should have occurred, generally defined as pain that lasts greater than 1-3 months. 80% of acute back pain resolves in one month, 90% resolves within three months. That leaves 10-20% that persists as chronic pain.

 

• Red flag conditions: These are things that might be a warning of more serious problems. Any change in bowel or bladder function (difficulty starting your urinary stream, losing control of bowel or bladder function, or change in erectile or sexual function) could all be signs of a more serious neurologic problem. Likewise any weakness or numbness in the legs could indicate damage to nerves.

 

• X-rays: Studies done to look at the alignment of bones. Unfortunately, they don't tell much about soft tissue such as nerves, muscles, or discs. Usually an AP (front to back) and lateral (sideways) are ordered at a minimum. Some doctors will also order an oblique (half sideways) view, or add flexion extension films to see with the spine looks like with movement.

 

• MRI: Short for Magnetic Resonance Imaging. This study shows bones, muscles, disks, and nerves. It's expensive, and therefore not something doctors order right away. It's also loud (they will give you earplugs), requires you to lie still, and takes some time (a half hour or so). It's the single best study to look for structural problems in your back.

 

• CT scan: This is like a three-dimensional x-ray. It gives a fantastic look at bones, but again doesn't really show soft tissues.

 

• Myelogram: This is an invasive study, done by injecting contrast dye into the spinal fluid. When combined with a CT scan, it gives a pretty good look at nerves and disks as well as bones.

 

• EMG/nerve conduction study: This is a study done with small needles in the muscles to detect nerve transmission. It can be helpful in figuring out which nerves are involved when there is weakness or numbness.

Causes of back pain: Up to the 85% of low back pain is never found to have an exact diagnosis. It is generally written off as a "sprain", "strain", "mechanical low back pain", "musculoskeletal pain", or lumbago, which is yet another word for low back pain. Doctors theorize that muscle insertions can be stretched or torn, or that pain can be the result of acute inflammation. The truth is that unless something shows up on a study, we just don't know. The good news is that most lumbar strains will resolve on their own. That leaves the other 15% for which there is a positive test result. Here are some structural abnormalities that can be seen on MRI or CT scan:

 

• Lumbar disc herniation: This is when part of the disc between the bones breaks off or leaks out to a space it is not supposed to be in. causing pressure on the nerves. This can result in radiating pain down the back of the leg, and is one of the more treatable sources of low back pain.

 

• Disc degeneration: This is a flattening or drying out of the disc, which decreases its effectiveness as a shock absorber. It is generally considered to be an effect of aging. It is a common source of chronic back pain in older individuals.

 

• Fracture or slippage: A fracture of the bones can be seen on X- ray. It can cause pressure on the nerves going into the legs.

The correlation between what a radiologist sees and what the patient feels isn't always great, and it is not unusual to have an image that looks worse on the left while the patient's pain is on the right, or vice versa. This is where the art of medicine combined with good history taking and physical examination skills can make a big difference.

Treatment of low back pain: The most important first step in treating your back pain is accurate diagnosis. While it is reasonable to give your back a couple of weeks or maybe a month to heal in the absence of any red flag symptoms, after that you need a good workup. This means going to a doctor who specializes in back treatment (orthopedic surgeon, pain management specialist, neurologist, or specialist in physical medicine and rehabilitation). After taking your history and performing a physical exam, generally an MRI is the study of choice. Once you have reviewed the result of the MRI with your physician (get him or her to show you the actual images!), the two of you can develop a treatment plan. Mostly, this will involve conservative (non- surgical) treatment. Surgery is reserved for patients who have not improved after a good try at conservative therapy. Conservative treatment generally consists of physical therapy, a trial of pain medication for up to three months, perhaps chiropractic therapy, and possibly some injections if a specific nerve or nerves can be isolated as the source of the pain. Before considering surgery it is reasonable to get a second opinion as to how much it is likely to help you. Most patients will get better over time, although it will probably take longer than either the patient or their doctor would like it to.