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Key Clinical Updates in Spine Problems

A multidisciplinary approach to back pain care is beneficial to address its physical, psychological and social aspects, especially when pain is chronic, avoiding medication if possible.

For primary and recurrent treatment of disk disease, minimally invasive percutaneous endoscopic spine surgery, which uses an endoscope to remove fragments of disk (interlaminar or transforaminal approaches) under local anesthesia, has promise.

1. LOW BACK PAIN

ESSENTIALS OF DIAGNOSIS

  • Nerve root impingement is suspected when pain is leg-dominant rather than back-dominant.

  • Alarming symptoms include unexplained weight loss, failure to improve with treatment, severe pain for more than 6 weeks, and night or rest pain.

  • Cauda equina syndrome is an emergency; often presents with bowel or bladder symptoms (or both).

General Considerations

Low back pain remains the number one cause of disability globally and is the second most common cause for primary care visits. The annual prevalence of low back pain is 15–45%. Annual health care spending for low back and neck pain is estimated to be $87.6 billion. Low back pain is the condition associated with the highest years lived with disability. Approximately 80% of episodes of low back pain resolve within 2 weeks and 90% resolve within 6 weeks. The exact cause of the low back pain is often difficult to diagnose; its cause is often multifactorial. There are usually degenerative changes in the lumbar spine involving the disks, facet joints, and vertebral endplates (Modic changes).

Clinical Findings

A. Symptoms and Signs

Aggravating factors of flexion and prolonged sitting commonly suggest anterior spine disk problems, while extension pain suggests facet joint, stenosis, or sacroiliac joint problems. Alarming symptoms for back pain caused by cancer include unexplained weight loss, failure to improve with treatment, pain for more than 6 weeks, and pain at night or rest. History of cancer and age older than 50 years are other risk factors for malignancy. Alarming symptoms for infection include fever, rest pain, recent infection (urinary tract infection, cellulitis, pneumonia), or history of immunocompromise or injection drug use. The cauda equina syndrome is suggested by urinary retention or incontinence, saddle anesthesia, decreased anal sphincter tone or fecal incontinence, bilateral lower extremity weakness, and progressive neurologic deficits. Risk factors for back pain due to vertebral fracture include use of corticosteroids, age over 70 years, history of osteoporosis, severe trauma, and presence of a contusion or abrasion. Back pain may also be the presenting symptom in other serious medical problems, including abdominal aortic aneurysm, peptic ulcer disease, kidney stones, or pancreatitis. The patient’s previous response to treatments and the results of risk prediction tools can help guide management.

The physical examination can be conducted with the patient in the standing, sitting, supine, and finally prone positions to avoid frequent repositioning of the patient. In the standing position, the patient’s posture can be observed. ...

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