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17.3 Low Back Pain

Table of Contents

Low back pain is a common presenting complaint especially among the elderly. It may be a mild, transient symptom or chronic and disabling complaint. There are many causes of low back pain but a cause can usually be found from a good clinical history and physical examination. In some patients however, no cause will be found and these people are described as having nonspecific back pain. Acute ligamentous (sprain) lesions and muscular strain are usually self-limiting.

Diagnostic Criteria

Proper history and careful physical examination

  • Acute ligamentous (sprain) lesions
  • Muscular strain
  • Chronic osteoarthritis

Other causes include:

  • Back strain due to poor posture worsened by mechanical factors like overuse, obesity and pregnancy
  • A protruding or ruptured intervertebral disk
  • Traumatic ligament rupture or muscle tear
  • Fracture
  • Infection (e.g. tuberculosis or septic discitis)
  • Malignancy e.g. metastases, multiple myeloma or spinal tumour, prostatic carcinoma
  • Congenital abnormalities e.g. abnormal intervertebral facets, sacralization of L−5 transverse process
  • Spondylolisthesis − i.e. Slipping forward of a vertebra upon the one below
  • Narrowed spinal canal from spinal stenosis
  • Psychogenic pain: The back is a common site of psychogenic pain. Inconsistent historical and physical findings on sequential examination may make one suspicious of this diagnosis
  • Fibromyalgia rheumatica, connective tissue diseases (give dexamethasone 0.1mg/kg od)

Table 17.2: Points of Distinction between Inflammatory and Mechanical Back Pain

Inflammatory Mechanical
ONSET Gradual Sudden
WORST PAIN In the morning In the evening
MORNING STIFFNESS Present Absent
EFFECT OF EXERCISE Relieves pain Aggravates pain

Features that suggest that back pain may be serious

  • Recent onset
  • Weight loss
  • Symptoms elsewhere e.g. chronic cough, weakness of the lower limbs, incontinence etc
  • Localized pain in the dorsal spine
  • Fever
  • Raised ESR

Investigations

  • X-ray is common
  • CT scan and/or MRI in case of spinal stenosis
  • FBC, ESR

Non-Pharmacological Treatment

Treat by relieving muscle spasm with bed rest in a comfortable position with hip and knees semi flexed; Physiotherapy

Pharmacological Treatment

A: Ibuprofen 400mg (PO) 8 hourly for 5 days

For severe pain

C: Diclofenac 75 mg IM 12 hourly by deep IM injection

OR

C: Diclofenac 50 mg rectal 8 hourly for 3 days C: Diclofenac gel 12 hourly

OR

C: Tramadol, 50 mg (PO) 8 hourly for 3 days.

For chronic low back pain

  • Weight reduction in the obese,
  • Improving muscle tone,
  • Physiotherapy,
  • Improving posture.
  • Surgical procedures may be necessary, e.g. in disc disease or spinal stenosis.

Give NSAID, (refer dose as for pain as above). AVOID narcotic analgesics. If symptoms persist, refer the patient.

Refer the patient to the next facility with adequate expertise and facilities

Several investigations including X-ray, CT SCAN, MRI, FBC, serum uric acid etc should be performed according to specialist protocol. Treatment may still be non surgical as above or otherwise.

For radicular pain in chronic low back pain:

D: Gabapentin PO 300mg nocte for 4 weeks

C: Vit B1+B6+B12 1tablets once daily for 4 weeks

D: Pregabalin 75mg nocte for 4 weeks

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