Chronic LBP with no clear cause; psychiatric disorders, substance abuse may be associated.
Treatment: Low Back Pain Acute Low Back Pain (ALBP) - Pain of <3 months duration.
- Spine infections, fractures, tumors, or rapidly progressive neurologic deficits require urgent diagnostic evaluation.
- If “risk factors” (Table 48-2) are absent, initial treatment is symptomatic and no diagnostic tests necessary.
- When leg pain absent, prognosis is excellent; full recovery in 85%.
- Clinical trials do not show benefit from bed rest >2 days. Possible benefits of early activity—cardiovascular conditioning, disk and cartilage nutrition, bone and muscle strength, increased endorphin levels.
- Spinal manipulation appears to be equivalent to conventional medical therapies and may be a useful alternative for some patients.
- Proof lacking to support physical therapy, massage, acupuncture, ultrasound, laser therapy, corsets, or traction.
- Self-application of ice or heat or use of shoe insoles is optional given low cost and risk.
- Drug treatment of ALBP includes NSAIDs and acetaminophen (Chap. 5. Pain and Its Management).
- Muscle relaxants (cyclobenzaprine) may be useful but sedation is a common side effect.
- Opioids are not clearly superior to NSAIDs or acetaminophen for ALBP.
- No evidence to support oral or injected epidural glucocorticoids.
Chronic Low Back Pain (CLBP) - Pain lasting >12 weeks; differential diagnosis includes most conditions described above.
- Cause can be clarified by neuroimaging and EMG/nerve conduction studies; diagnosis of radiculopathy secure when results concordant with findings on neurologic examination. Treatment should not be based on neuroimaging alone: up to one-third of asymptomatic young adults have a herniated lumbar disk by CT or MRI.
- Management based on identification of underlying cause; when specific cause not found, conservative management necessary.
- Treatment measures include acetaminophen, NSAIDs, and tricyclic antidepressants.
- Evidence supports the use of exercise therapy; effective in returning some pts to work, diminishing pain, and improving walking distances.
- Cognitive-behavioral therapy may have some use; long-term results unclear.
- Alternative therapies including spinal manipulation, acupuncture, and massage are frequently tried; trials are mixed as to their effectiveness.
- Epidural glucocorticoids and facet joint injections are not effective in the absence of radiculopathy.
- Surgical intervention for chronic LBP without radiculopathy is controversial, and clinical trials do not support its use.
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