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ESSENTIALS OF DIAGNOSIS

  • Low back pain (LBP) affects as many as 80% of individuals. Degenerative changes of the lumbar spine are the most common cause.

  • More than 90% of these patients are substantially better within 8 weeks, although recurrences are common.

  • The initial evaluation should focus on identification of the few patients with neurologic involvement, fracture, or possible systemic disease (infection, malignancy, or spondyloarthritis), the management of whom may require an urgent or specific intervention.

  • Early imaging is rarely indicated in the absence of significant neurologic involvement, trauma, or suspicion of systemic disease.

  • Imaging abnormalities, often the result of age-related degenerative changes, should be carefully interpreted because they are frequently present in asymptomatic individuals and may not be the cause of the patient’s pain.

  • Persistent LBP should be treated with an individually tailored program that includes analgesia, core strengthening, stretching, aerobic conditioning, loss of excess weight, and patient education.

  • There is no evidence for the effectiveness of epidural corticosteroid injections in patients without radiculopathy secondary to disk herniation.

  • A large number of injection techniques, physical therapy modalities, and nonsurgical interventional therapies lack evidence of efficacy.

  • The major indication for back surgery is presence of a serious or progressive neurologic deficit.

  • A pathoanatomic diagnosis and precise identification of the pain generator cannot be made in up to 85% of patients. Thus, the results of back surgery (especially spinal fusion) are disappointing when the goal is relief of LBP rather than relief of radicular symptoms or treatment for the relief of neurogenic signs.

GENERAL CONSIDERATIONS

Low back pain (LBP) affects the area between the lower rib cage and gluteal folds. It is the most common musculoskeletal complaint, the number one cause of disability globally, the most prevalent chronic pain syndrome, and the leading cause of limitation of activity in patients younger than 45 years. An estimated 65–85% of the population will experience LBP during their lifetime. LBP is uncommon in the first decade of life, but prevalence increases steeply during the teenage years. Approximately 40% of children between the ages of 9 and 18 years report having LBP. The prevalence increases with age until around 70 years, then gradually declines. LBP is more common in women.

The natural history of LBP, especially the duration and chronicity, is somewhat controversial. Back pain is increasingly understood as a long-lasting condition with a variable course rather than episodes of unrelated occurrences. Acute LBP improves substantially in most patients within days to weeks, and more than 90% are better at 8 weeks. However, two-thirds of these patients still report low-grade discomfort at 3 and 12 months. Recurrences of acute LBP are common and also tend to be brief. Approximately 10% of patients develop chronic persistent, and at times disabling, LBP that is affected by a range of biophysical, psychological, and social factors. These individuals with chronic pain are largely responsible for the associated high costs, currently estimated ...

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