Back pain can be classified as axial (focused on the low back), referred (pain experienced in the buttock or posterior thigh), or radicular (pain radiating down the leg). Aside from the common muscle strain that can cause LBP, there are several common back pain syndromes, such as HNP, facet disease, degenerative disc disease (DDD), spinal stenosis, and compression fractures (Figure 11.3). Some conditions are the result of degenerative changes, but others can be caused by trauma, poor lifting or stretching techniques, or simply a sudden sneeze.
HNP as described previously is a rupture of the disc through the fibrous annulus, causing pressure on adjacent nerves. The biggest number of disc herniations is in the lumbar region (90%), with 8% in the cervical spine and 1% to 2% in the thoracic spine.
Signs and Presenting Symptoms of HPN
■ Localized sudden onset of severe intensity LBP
■ Radicular pain down one or both legs
■ Weakened or loss of motor function, numbness in the affected extremity, or absent deep tendon reflexes
■ In the cervical region, the pain may be increased with bending of the neck, turning from side to side, laughing, coughing, or straining
■ Muscle spasms may occur
For an HNP located in the lumbar region, diagnostic criteria includes the use of a straight leg raise, during which the back pain is reproduced when the leg is straight raised to a 90° angle. If pain is severe and there is a neurologic impairment, magnetic resonance imaging (MRI) is recommended to assist with diagnosis (Chou et al., 2007).
■ Medications such as acetaminophen, muscle relaxants, and opioids if the pain is severe (Chou et al., 2007)
■ Lifestyle changes, such as weight loss and exercise (Chou & Huffman, 2007b)
■ Perform electromyography if there is a need to identify which nerves are affected.
■ Worsening of neurologic symptoms, such as a decrease in deep tendon reflexes, warrants an immediate referral for a neurosurgical or orthopedic evaluation
Because of the aging of the American population, a large number of patients will develop DDD related to the changes of aging. By age 20, the water and vascular supply to the disc decreases. By age 30, there is no vascular access to the disc, and the desiccation of the disc causes cracks; fissures begin developing in the vertebral body endplates, which is one of the causes of DDD. By age 70, 60% of the spinal discs have degenerated (Raj, 2008).
Signs and Symptoms of DDD
■ Motor weakness
■ Deep midline LBP that can radiate to buttocks or thighs
■ Sensory changes
■ Absent or diminished reflexes
■ In more severe cases, bowel or bladder dysfunction
Patients with DDD may develop vertebral osteophytes (bone spurs), a condition called spondylosis, which can be visualized on radiographic studies and is the stiffening of the vertebrae. It can also affect the facets of the spine, and this condition is called facet disease. Diagnostic tests used for DDD include:
■ Provocative discography with computed tomography (CT) discography
■ Gadolinium enhanced MRI
Conservative treatment with physical therapy, pain medications, gentle traction, and lifestyle changes for obese or inactive patients can be attempted. About 90% of patients can get satisfactory pain relief if the patient is willing to put in the time (Raj, 2008). Medication, surgical, and interventional treatment options include:
■ Intradiscal electrothermal therapy (IDET); see Chapter 7 on inter-ventional pain management for more information
■ Laser discectomy
■ Radiofrequency ablation
■ Manual percutaneous lumbar discectomy
■ Endoscopic percutaneous discectomy
■ Artificial disc implantation
■ Glucosamine and chondroitin; similar result as IDET
■ Cell-based therapies to repair degenerated cartilage (Raj, 2008)
Facet disease affects approximately 15% of patients with chronic LBP. Facet disease is a common term that is applied to pain that originates in the lumbar zygapophysial joints. It is estimated that 80% of patient who report LBP and sciatica are really experiencing referred pain from facet joints (Cohen & Raja, 2007). The pain commonly called facet syndrome is said to be caused by a sudden rotary strain, repetitive strain, or low-grade trauma over time (Cohen & Raja, 2007).
Signs and Symptoms of Facet Disease
■ LBP or buttock radiating down one or both legs, "sciatica"
■ Pain along the lateral aspect of the calf
■ Diagnostic blocks
■ Conservative medication treatments include the use of acetaminophen or nonsteroidal anti-inflammatory drugs (NSAIDs); see medication information provided in Chapter 3 and in a later section in this chapter
■ Conservative treatments for facet pain include exercise programs
■ Osteopathic manipulation
■ Intra-articular steroid injections
■ Radiofrequency denervation (Cohen & Raja, 2007)
Vertebral compression fractures can occur spontaneously, especially in older patients with osteoporosis, or as the result of a lifting or bending motion. The fractures can be difficult to visualize on x-ray in the early stages but become more apparent over time. The patient will report extreme pain in the area of the fracture. One of the main causes of vertebral compression fractures is osteoporosis, which makes bones brittle and porous. It is estimated that over 100 million people worldwide and 44 million in the United States are at risk for vertebral fractures related to osteoporosis (Phillips, 2003). The consequences of these fractures results in 700,000 spinal fractures annually, with 800,000 emergency room visits, 2,600,000 outpatient visits, and the placement of 180,000 older adults in long-term care (D'Arcy, 2008).
Signs and symptoms of compression fractures include acute, localized, and constant severe pain at the site of the fracture.
A standard spinal MRI will reveal the extent of the spinal compression. If medications to enhance calcium absorption are being considered, a bone density scan is required.
Options for treating pain with acute compression fractures include:
■ Pain medications, such as opioids or NSAIDs if the patient can tolerate NSAIDs
■ Topical medications, such as 5% lidocaine patch
■ Minimally invasive techniques, such as vertebroplasty and kyphoplasty.
Vertebroplasty and kyphoplasty are techniques that use a balloon inserted through a spinal needle into the vertebra to create a space. Once the space is created a liquid cement, polymethylmethacry-late, is inserted into the space. This can reduce the amount of compression on the spinal nerve by increasing the height of the vertebra. In a systematic review of vertebroplasty and kyphoplasty, 85% of the patients with vertebroplasty and 92% of the patients with kyphoplasty reported good pain relief with the procedure (Hulme, Krebs, Fergusson, & Berlemann, 2006). Pain ratings with the use of vertebroplasty were reduced from 8.2 on a 0 to 10 pain intensity scale to 3.0, and with kyphoplasty, the pain ratings were decreased from 7.4 to 3.4 (Hulme, Krebs, Fergusson, & Berlemann, 2006).
Two other mechanical spinal conditions can cause LBP:
■ Spondololysis is a physical defect in the vertebral arch because of mechanical stress, such as hyperextension of the spinal body. Physical complaints include constant LBP and at times motor or sensory loss.
■ Spondolisthesis is a slipping of the vertebra, where one overrides the lower vertebra. Severe pain, radicular symptoms, and bowel and bladder dysfunction can occur, and the patient can experience weakness in the lower extremities.
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Tired Having Back Pains All The Time, But You Choose To Ignore It? Every year millions of people see their lives and favorite activities limited by back pain. They forego activities they once loved because of it and in some cases may not even be able to perform their job as well as they once could due to back pain.