lower back pain - nursece4less.com · web viewlower back pain results from abnormal mechanics of...

LOWERBACK PAINJassin M. Jouria, MD

Dr. Jassin M. Jouria is a medical

doctor, professor of academic

medicine, and medical author. He

graduated from Ross University School of Medicine and has completed his clinical

clerkship training in various teaching hospitals throughout New York, including King’s

County Hospital Center and Brookdale Medical Center, among others. Dr. Jouria has

passed all USMLE medical board exams, and has served as a test prep tutor and

instructor for Kaplan. He has developed several medical courses and curricula for a

variety of educational institutions. Dr. Jouria has also served on multiple levels in the

academic field including faculty member and Department Chair. Dr. Jouria continues to

serves as a Subject Matter Expert for several continuing education organizations covering

multiple basic medical sciences. He has also developed several continuing medical

education courses covering various topics in clinical medicine. Recently, Dr. Jouria has

been contracted by the University of Miami/Jackson Memorial Hospital’s Department of

Surgery to develop an e-module training series for trauma patient management. Dr. Jouria

is currently authoring an academic textbook on Human Anatomy & Physiology.

ABSTRACT

The lower back provides structural support, making it possible to engage in a wide

range of activities. When lower back pain occurs, a patient’s mobility can be

significantly impacted. What seems like a minor case of back pain may indeed develop

into a chronic disorder that significantly affects the patient’s quality of life.

Understanding the anatomy of the lower back, as well as the causes of lower back pain,

will help healthcare professionals make diagnosis and treatment decisions that are vital

to the patient’s well-being.

nursece4less.com nursece4less.com nursece4less.com nursece4less.com nursece4less.com 1

Continuing Nursing Education Course Director & Planners

William A. Cook, PhD,NurseCe4Less.com Director

Doug Lawrence, MS, Nurse Ce4Less.com Webmaster Course Planner

Susan DePasquale, CGRN, MSN, Nurse Ce4Less.com Lead Nurse Planner

Accreditation Statement

This activity has been planned and implemented in accordance with the policies of

NurseCe4Less.com and the continuing nursing education requirements of the American

Nurses Credentialing Center's Commission on Accreditation for registered nurses.

Credit Designation

This educational activity is credited for 14 hours. Nurses may only claim credit

commensurate with the credit awarded for completion of this course activity.

Course Author & Planner Disclosure Policy Statements

It is the policy of NurseCe4Less.com to ensure objectivity, transparency, and best

practice in clinical education for all CNE educational activities. All authors and course

planners participating in the planning or implementation of a CNE activity are expected

to disclose to course participants any relevant conflict of interest that may arise.

Statement of Need

Nurses in all areas of health care are accountable to recognize signs and symptoms of

back pain in patients as well as colleagues in the workplace. Managing low back

requires specific training and continuing updates on how to effectively assess and

intervene in the alleviation of pain, and to advocate for a prevention plan.


Course Purpose

This course will provide advanced learning for nurses interested in the management of

low back pain for patients, and for their colleagues and themselves.

Learning Objectives

1. Describe the structure of the lumbar region.

2. Differentiate between the upper back and the lower back.

3. Identify patient groups that are at high risk for lower back pain.

4. Differentiate between a sprain and a strain.

5. Describe the role of scar tissue in lower back pain.

6. Explain the symptoms of sciatica.

7. Describe the effects of a herniated disc.

8. Identify congenital skeletal deformities that put a patient at risk of lower back

pain.

9. Describe the symptoms that, in correlation with lower back pain, indicate a more

serious illness.

10. Identify common causes of infection that may cause lower back pain.

11.List the most useful diagnostic tools for diagnosing lower back pain.

12.List common treatments for lower back pain.

13. Identify medicinal treatments for lower back pain.

14.Explain the risks of opioids as a treatment for lower back pain.

15.Recognize the challenges in diagnosing fibromyalgia.

16.Differentiate between discography and myelograms.

17.Describe the limitations of using x-ray as a diagnostic tool for lower back pain.

18.Explain the different types of electrodiagnostic procedures.

19.List common surgical treatments for lower back pain.

20. Identify the gender differences in osteoporosis.


Target Audience

Advanced Practice Registered Nurses, Registered Nurses, Licensed Practical Nurses,

and Medical Assistants

Course Author & Director Disclosures

Jassin M. Jouria, MD has no disclosures

William S. Cook, PhD has no disclosures

Doug Lawrence, MS has no disclosures

Susan DePasquale, CGRN, MSN has no disclosures

Acknowledgement of Commercial Support

There is no commercial support for this course.

Activity Review Information

This course has been peer reviewed by Susan DePasquale, CGRN, MSN.

Review Date: October 20, 2013.

Release Date: October 25, 2013 Termination Date: October 25, 2016


INTRODUCTION

Lower back pain, lumbar pain or lumbago is one of the most common complaints that

doctors encounter in their daily practice. This is not surprising since almost everyone

experiences it at some point in their lives. Statistics show that Americans spend a

staggering amount of $50 billion, if not more, annually for one reason or another due to

low back pain. Treatment, sick leave and loss of productivity are just among the

common reasons. In fact, it is the most common cause of job-related disability. It is also

only behind headache as the most common neurological ailment in the United States.

This course explores the broad pathology of lower back pain, diagnostic methods, as

well as its various treatment modalities. Because of the non-specific nature of lower

back pain, it is hard to pinpoint its exact cause and may be attributed to several

pathologic factors. Lower back pain may be acute or chronic, depending on the

pathology involved, which is why the course discusses extensively its pathology and

diagnostic approach.

Lower back pain refers to pain in the lumbar region of the spine. Its severity, onset and

duration differ individually. The pain may be slow in onset and duration or may be

constant or intermittent. It may resolve on its own or it may require medical intervention

(1). The two types of lower back pain are: acute and chronic:

Acute lower back pain refers to a short-term duration of pain that usually lasts from a

few days to a few weeks. Mechanical forces such as trauma to the lower back or

arthritic disorders usually cause this type of back pain. Pain due to trauma may be due

to sporting and vehicular accidents, sudden movements, or wrong lifting techniques. Its

symptoms may range from mild to severe depending on the affected vertebra (2).

Chronic back pain refers to pain that lasts longer than a few weeks, usually more than 3

months, after its initial onset. It is usually a sign of a progressive and ongoing disease

such as the degenerative process found in osteoarthritis. Other causes may be

attributed to congenital defects.


Structure and function of the lumbar regionIn order to understand the pathology of lower back pain, it is important to understand

the complex parts and functions that make up the lumbar spine, the site of lower back

pain.

The spine is divided into four major segments, namely (1):

Cervical spine

Thoracic spine

Lumbar spine

Sacral spine

Originating from Latin, “lumbar” comes from the term ‘lumbus’ which means loin. It is a

term originally coined by Claudius Galen in the 2nd century. The word was initially used

to refer to both the joint as well as the bone of the spine.

The lumbar spine is a composite combination of vertebrae and multiple bony elements,

which are joined together with the help of joint capsules, ligaments, tendons, muscles

and nerves. It is innervated by nerves and supplied with an intricate network of blood

vessels. It consists of five lumbar vertebral components numbered from L1 to L5, which

are movable. The lumbar spine is composed of the anterior, middle and posterior

columns (1).


The lumbar vertebrae are the largest of the true vertebrae. It forms a strong column of

support at the base of the vertebral column. The most important features of lumbar

spine are its (3):

Large size, and

Lack of transverse foramina and costal facets

Function

The lumbar spine is known to possess incredible strength. Some of its most important

functions are (3):

Protecting the spinal cord,

Protecting the nerve roots of the spinal cord, and

Lending flexibility to allow a variety of complex movements such as flexion and

extension.

The lumbar spine is capable of executing a wide range of motion, more than the

thoracic spine but lesser than the cervical spine. It is the lumbar facet joints that allow

movements such as flexion, extension and limited amount of rotation.

Lumbar vertebrae

Structurally speaking, the lumbar vertebrae are

tall but narrow. The three functional

components of the lumbar vertebrae are (4, 6, 7):

1. The vertebral body,

2. The vertebral arch or neural arch, and

3. The spinous and transverse bony

processes.

Lumbar vertebral bodies

The lumbar vertebral bodies are connected together with the help of intervertebral discs.

The size of the lumbar vertebrae progressively increases from first to the fifth lumbar

(L1 to L5) vertebrae, which are indicative of the increasing loads absorbed by each

descending vertebra (4, 6, 7, 8).


Intervertebral discal surface

A ring of cortical bone present on the outer boundary of the adult vertebrae is known as

the epiphyseal ring. The epiphyseal ring forms the growth zone in children and

adolescents, and holds the attachments of the annular fibrils in adults. A hyaline

cartilage plate is present within the epiphyseal ring (4, 6, 7).

Vertebral arch

The vertebral arch is made up of the following parts (4, 6, 7, 8):

Pedicles

Laminae

Bony processes

* Spinous

* Articular

* Transverse

The number of facet joints and ligaments that join these structures are enumerated in

the table below.

Parts of vertebral arch Number of facet joints and ligaments

Pedicles 2

Laminae 2

Bony process 7

Spinous process 1

Articular process 4

Transverse process 2

Pedicle

The joint present on the posterior face, joining the arch to the posterolateral body is

called the pedicle. It is firmly fixed to the cephaled portion of the body. The concavity

present in the cephalad and caudal surface of the pedicel are known as vertebral

notches (4, 6, 7).

The function of the pedicle is to act as a protective cover for the cauda equine contents.


Laminae

Laminae are strong and wide plates extending from the posterior-median side of the

pedicle. It is an elongated spinous process that is directed posteriorly from the joint of

the lamina.

There are two articular processes, namely; two superior and two inferior processes that

extend cranially and caudally from the joint between the pedicles and the laminae. The

zygophaseal joint is in the parasagittal plane. Two transverse processes also protrude

laterally. These are long, slender and strong in nature, with two tubercles, namely; the

inferior and superior articular tubercles located at the mammillary process and the

accessory process, respectively.

Lumbar vertebral joints

The zygopophysial joints are present between the

superior and inferior articular processes on the

adjacent vertebrae. Also known as facet joints,

they allow simple gliding movements. The region

between the superior articular process and the

lamina is known as pars interarticularis.

Spondolysis is the condition, which results from a

lack of ossification in this region (4, 6, 7, 8).

Lumbar intervertebral discs

Constituting almost one quarter of the entire length

of the vertebral column, the intervertebral discs

make up the main connection between vertebrae.

Each disc is made up of a nucleus pulposus in

which reticular and collagenous fibers are inserted

and covered with the annulus fibrosus, which is a

fibrocartilaginous lamina. The annulus fibrosus is

further divided in three parts, namely (4, 6):


Outermost: the anterior fibers with the anterior longitudinal ligament

Middle: anterior and lateral fibers adding reinforcement and flexibility

Innermost: posterior longitudinal ligament can bear weak midline reinforcement in

the form of a narrow structure attached to the annulus, more so at the L4-5 and

L5-S1 regions.

The anterior and middle fibers of the annulus are present mostly in the anterior and

lateral regions but a few are also found in the posterior region. The annular fibers are

attached to the vertebral bodies and are arranged in the lamellae; the reinforcing

structure formed by the ligaments, which provides limited mobility to the vertebra (4, 6, 8).

Lumbar vertebral ligaments

The lumbar ligaments are (4):

Anterior longitudinal ligament

Posterior longitudinal ligament

Supraspinous ligament

Ligamentum flavum

Intratransverse ligament

Ileolumbar ligament

Intertransverse ligament

Interspinous ligament

Facet capsulary ligament

Anterior longitudinal ligament

The anterior longitudinal ligament is found on the ventral surface of the lumbar vertebral

bodies and discs. It is present in close association with the anterior annular disc fibers.

It broadens towards the bottom of the vertebral column. Its function is to maintain the

stability of the joints and restrict their extension movement.


Posterior longitudinal ligament

The posterior longitudinal ligament is situated in the vertebral column, over the posterior

end of the vertebral bodies and discs. Its primary function is to restrict the flexion

movement of the vertebral column.

Supraspinous ligament

The function of the supraspinous ligament is to connect the tips of the spinous

processes of the adjacent vertebrae from L1 to L3. This ligament interconnects the

spinous processes extending from the root to the apex of the adjacent processes.

Ligamentum flavum

The ligamentum flavum connects the interlaminar interval and joins medially with the

interspinous ligament, laterally with the facet capsule and itself forms the posterior side

of the vertebral canal. It functions to maintain the constant disc tension.

Intratransverse ligament

The intratransverse ligament attaches to the transverse processes of the adjacent

vertebrae and also inhibits the lateral bending of the trunk.

Ileolumbar ligament

The ileolumbar ligament originates from the L5 transverse process and connects

posteriorly with the innermost lip of the iliac crest. Its function is to support the lateral

lumbosacral ligament in stabilizing the lumbosacral joint.

Lumbar spine musculature and vasculature

There are four muscle groups, which govern the functions of the lumbar spine. These

are divided into (5, 6):

Extensor

Flexors

Lateral flexors

Rotators


The lumbar vertebra is supplied with blood by the anterolateral pair of lumbar arteries

originating from the aorta opposite the bodies of L1-L4. The venous drainage runs

parallel to the arterial supply. The venous plexus is formed by the veins along the

vertebral column inside and outside the vertebral canal (5, 6).

Risk factors for lower back painAs mentioned in the introductory section above, lower back pain is one of the most

commonly occurring musculoskeletal problems seen in medical practice. At least 100

risk factors have been identified for lower back pain, a significant number of which is

attributable to a combination of individual and occupational factors (9).

The most common causes of pain in the lower back are related to physical activities and

postural alignment related to a range of risk factors such as (9):

Demographic variables such as age, gender and occupation

Recurrent weight lifting

Use of vibrating equipment

Sedentary life style

Weakness of muscles of the abdominal wall

Obesity

Smoking

An increase in the lumbar lordosis

Scoliosis

Cardiovascular disorders

Low socioeconomic standard

At risk groups

Various research studies have confirmed that a substantial percentage of the adult

population who is suffering from lower back pain. This number mostly attributes their

symptom to their increasing age, female gender, rural habitation, low socio-economic

status and excessive smoking (9).


However, studies have also found that there is an ever-increasing prevalence of lower

back pain among the adolescent and early adult population. The female gender is more

prone to suffering from lower back pain due to frequent physical and hormonal changes,

all of which also magnify their symptoms (10).

Lower back pain results from abnormal mechanics of the spinal column such as higher

spinal loads and lower stability of the spine, which are frequently seen in various

occupations that require heavy lifting and moving. The physical demands of a task

dictate the biomechanics of the spine, the effects such as stiffness or damping of the

trunk, and the mechanical neuromuscular response to the work related to equilibrium

and stability requirements.

Age

Increasing age equates to an increase in wear

and tear of various musculoskeletal structures

resulting in many anomalies of the spine such

as disc degeneration and spinal stenosis, all of

which may result in lower back pain. Studies

have found that people over the age of 30 or

40 are more susceptible to developing lower

back pain compared to their younger

counterparts. People between the age group of

30 to 60 years are more likely to contract disc–related disorders while those over the

age of 60 mostly suffer from lower back pain due to osteoarthritis (10).

Aside from the normal degenerative processes at work in the incidence of lower back

pain among the elderly, comorbidity also plays an important role.

Prevalence of lower back pain in students

Studies have supported the fact that there is a relatively high and increasing evidence of

lower back pain among school-going children. The four major activities that significantly

contribute to the lower back pain are (10, 11):


Lifting or carrying of heavy loads such as heavy school bags

Bending forward

Sitting for over 30 minutes

Standing for more than 10 minutes or sports activities in school or during free

time

Additionally, lower back pain is more prevalent among female students, those who

smoke and who perform manual lifting and moving jobs outside school.

Occupational lower back pain There have been studies done to examine the impact of work-related psychological and

mechanical stressors in the development of lower back pain in the general working

population. Physically demanding jobs, prolonged standing or awkward lifting are few of

the most important contributing factors to lower back pain. Those with the more severe

form of lower back pain are mostly involved in jobs requiring repetitive heavy lifting, use

of jackhammers or machine tools, and operating motor vehicles.

Specifically, exposure to certain repetitive biomechanical processes in the workplace

increases the risk of developing lower back pain, which are listed and illustrated below:

Bending or twisting

Kneeling or squatting

Prolonged standing

Heavy physical work

Nursing tasks


Warehouse workers, movers, nurses and even primary caregivers are primarily

exposed to biomechanical stressors. Prolonged standing, sometimes for hours and

hours on end, is an important and consistent risk factor found among these working

groups.

Another consistent risk factor has been said to be lifting heavy loads using awkward

postures. One example is in nursing homes where nurses are required to lift and

manually handle patients in a regular basis for changing, transporting, and feeding

purposes (12). Another study has established beyond any doubt the relationship between

lower back pain and nursing tasks as a leading cause for absence due to sickness

among nurses. Another study has found an inverse, albeit, weak association between

the height of the nurse and prevalence of lower back pain (13).

People who work in a forward bending position without adequate support such as

gardening or manually lifting boxes off the ground, and those who squat or kneel are

exposed to excessive rotation and higher degrees of trunk flexion which in turn are

associated with lower back pain (14). Another stressor, psychological demands of highly

stressful jobs, has also been linked with greater incidence of lower back pain (15). In fact,

studies have suggested that stressful jobs actually cause increased muscular strain and

result in greater muscle tension and other physiological reactions that put people at

greater risk of developing lower back pain (16). Poor job satisfaction and lack of


recognition at work are two other factors, which are attributed to contribute to the

prevalence of lower back pain in the general working population.

CAUSES

EtiologyAs mentioned in the previous section, lower back pain may be due to biomechanical

factors at play. In this section, an overview is provided of a number of spinal conditions,

which may cause pain in the lower back. The discomforting pain may be caused due to

two types of causes, listed below:

Mechanical disorders: spinal disorders involving mechanical forces that resulted

to spinal injuries to the discs, facet joints, ligaments or muscles, causing lower

back pain.

Compressive disorders: spinal disorders resulting from pressure or irritation of

the spinal cord or nerves. This kind of irritation causes pain, numbness and

muscular weakness along the lumbar area where the nerve travels.

Mechanical spinal disorders cause irritation

of lumbar nerves due to mechanical

pressure exerted by bones or tissues, or

disease affecting that section of the spine

extending from its root at the spinal cord to

the surface of the skin.

Nerve and muscle irritation

Some of the most common examples are

lumbar disc disorder, bone impingement,

and nerve inflammation caused by viral

infection. The nerve irritation caused by

damaged discs between the vertebrae is due to either wear and tear of the outer ring of

the disc, or direct traumatic injury to the disc. The ensuing pain gradually radiates

towards the lower extremity when it is lifted. Bone impingement usually results from


movement or growth of the lumbar spine that invades the anatomical space reserved for

the adjacent spinal cord and nerves. This results in compression of the spinal nerves,

leading to pain, which radiates down to the lower extremities. Lower back pain may also

be caused by muscular injuries, which result in nerve inflammation. Muscle strains in

the paraspinal muscle are one example. Another example is pressure or irritation on the

nerves leaving the spine that cause numbness and muscle weakness on the lumbar

region.

Sprain, strain or spasm

The lumbar spine bears a lot of the body’s weight during physical activities like walking,

and running. Lifting heavy loads can strain the lower back muscles while muscular

sprain or spasms to the same area may result in pain.

An injury to the muscles or a tendon is termed as a strain while stretching or tearing of a

ligament is called a sprain. As mentioned above, muscle strain to the lower back

muscles can result from improper lifting techniques, overstressing the back muscles,

overuse or prolonged repetitive movement of the muscles or tendons which can twist or

pull a muscle.

A sudden blow to the body or a sudden twist may lead to the stretching of ligaments

causing injury and pain in the lumbar region. The injury to the muscle or tendon often

referred to as strain may commonly result from chronic weakness, overuse or chronic

strain on the lower back. Sprain causes a joint to move abnormally, overstretching and

tearing the ligaments in the process. The tear in the ligaments causes blood loss from

the tissues around the joint, causing inflammation and pain in the area. The lower back

sprains are more severe in nature limiting the range of motion of the lower back and

causing painful spasms (18).

Spasms are sudden, forceful and continuous muscular contractions that often lead to

lumbar back pain. It is mainly caused by factors related to direct injuries to the muscle,

excessive physical activities such as exercise or a chronic strain. A muscle in spasm

(spastic muscle) becomes hard and tight due to the uncontrolled contraction of all the


fibers. Muscles that provide protection to the spine may become contracted due to

chronic overuse, limiting the range of motion of its joints. Any disorder or problem in the

disc, bones or the facet joint may also lead the muscle to undergo spasm as a

protective measure to prevent any further damage to the spine. This protective spasm

may be chronic in nature and result in chronic and persistent pain in the lower back (23).

Sciatica

The sciatic nerve is a nerve that runs from the back through to the pelvis deep, and into

the buttocks. If there is pressure on one or more lumbar nerve roots, then pain may

develop in certain parts of the sciatic nerve, if not all. There are many disease

conditions, which may put pressure on the sciatic nerve resulting in lumbar pain such as

herniated disc, spinal stenosis, degenerative disc disease, spondylolisthesis or

abnormalities of the vertebrae. The lumbar pain due to sciatica may radiate from the

buttocks all the way down to the other lower extremities

(20).

Sciatica is best described as a symptom rather than a

diagnosis. In certain cases of sciatic pain, the muscles,

which are placed deep inside the buttocks, may put

pressure on the sciatic nerve. This nerve is known as

piriformis and the lower back pain resulting from this

condition is known as piriformis syndrome. It is generally a

result of an injury. The pain is due to the sciatic nerve compression or pinching of the

sciatic nerve, which causes the lower back pain on one side of the body that eventually

radiates to the buttocks, legs and feet (20).

Herniated disc

One of the most common causes of lower back pain is herniated disc, which is

sometimes referred to as slipped disc. A rupturing or thinning out of a vertebral disc in

the lumbar area, which protrudes out, ultimately leading to degeneration, marks this

condition. The degeneration is often very extensive that the gel inside the disc, which is

known as nucleus pulposus may escape outside.


The damaged disc manifest in many forms, namely (17)

A bulge: the nucleus pulposus pushes out from the disc, and uniformly distributes itself

symmetrically around the circumference.

A protrusion: the nucleus pulposus pushes out slightly and asymmetrically in any of the

surrounding areas.

An extrusion: the nucleus pulposus becomes inflated extending into the area outside the

vertebrae or completely escaping out of the disc.

The lower back pain is basically the result of the extrusion in which the gel or the

nucleus pulposus escapes out of the disc to compress the nerve root, especially the

sciatic nerve.

Sometimes there are abnormalities in the annular ring surrounding the disc. There are

tears in the ring causing disruption of the fibrous band containing a dense network of

nerves and high amount of peptides. People with degenerative disk disease are

frequently affected with heightened perception of pain due to the tear in the annular ring

(17). Another syndrome associated with disc disorders is cauda equine syndrome in


which the four nerve strands traveling to the lowest part of the lumbar region, i.e. cauda

equine, are impinged upon by a massive extrusion of the contents inside the disc. This

condition is an emergency situation, which may lead to severe complications of the

urinary or digestive system. The cauda equine syndrome causes a dull pain in the

lumbar area, causing symptoms such as urinary incontinence and inability to control

defecation (17).

Osteoarthritis

Osteoarthritis is defined as arthritis of the weight bearing joints such as hips and knees,

hands, feet, and spine. Osteoarthritic conditions of the bones and joints lead to lower

back pain which may be congenital, degenerative, or even due to the inflammatory

processes. Osteoarthritis of the spine is a degenerative inflammation of the facet joint,

which causes localized lumbar pain. The facet joint syndrome, commonly known as

osteoarthritis, is a major cause of lumbar pain. The overload and increased pressure on

the facet may be attributed to the degeneration of the disc and exposure of the articular

surface to damage, and wear and tear of the cartilage (16).

In spinal arthritis, the cartilage between the aligning facet joints in the posterior region of

the spine undergoes mechanical breakdown, resulting in the inflammation of the facet or

the zygopophyseal joints. These joints undergo progressive degeneration, creating an

increasing frictional lumbar pain resulting in a decreased range of motion, overall

mobility and flexibility of the back in proportion to the progression of the back pain. The

pain is usually triggered by routine physical activities like standing, sitting and walking.

The lumbar spine osteoarthritis is also called lumbosacral arthritis. As its name

suggests, it produces pain and stiffness in the lumbar spine and the sacroiliac joint,

which is present between the spine and the pelvis (19).

In severe cases of spinal osteoarthritis, the cartilage and fluid lubricating the facet joint

are completely destroyed, resulting in friction between the bones and leading to the

development of bone spurs, which occupy space in the foramen and press into the

adjacent nerve roots. A growing bone spur may also progress extensively so that it

projects into the spinal canal itself resulting in the narrowing of the canal, a condition


called spinal stenosis. The degenerative process resulting in the formation of bone

spurs is a normal part of ageing and does not directly cause pain, although its

enlargement may cause irritation or entrapment of nerves passing through the spinal

structures, which cause pain (19).

Spondylolisthesis

When the lumbar vertebrae slip over one another, the resulting condition is termed as

spondylolisthesis. It causes mild to severe low

back pain among children and adults. In children,

it is the fifth bone in the lumbar region and the

first bone in the sacrum area that are usually

affected while in adults, the slip occurs between

the fourth and the fifth lumbar vertebrae. It may

be caused by a congenital defect in the spinal

area, a degenerative disease like arthritis, stress

or traumatic fractures, or even bone diseases

(24).

Studies have found that spondylolisthesis is the most common cause of back pain in the

lumbar region among the adult population aged below 50. On the other hand,

degenerative spondylolisthesis occurs more commonly at age 50.

Spondylolisthesis is categorized into different types according to their etiologic origins;

these are namely:

Congenital spondylolisthesis: An abnormal bone function present at birth, which may result in an abnormal

arrangement of the vertebrae, predisposing it to higher risk of slipping.

Isthmic spondylolisthesis: Small stress fractures in the vertebrae which may lead to a weakening of the

bone, causing it to slip out of place.

Degenerative spondylolisthesis:


This is the most common type of spondylolisthesis and occurs as a result of

drying up of the discs due to the ageing process, which makes them less spongy

and less resistant to movement by the vertebrae.

Spondylolisthesis is marked by increased lordosis, which can develop into kyphosis

during the later stages of the disease as the upper spine falls off the lower spine. It may

also result in neurological damage, manifesting as leg weakness or altered sensations

in the lower extremities due to the pressure on the nerve roots. It is important to note

that the lumbar pain caused by spondylolisthesis often radiates down to the lower

extremities. The pain may manifest in the form of stiffness, muscle tightness, and

tenderness in the lumbar area where the disc has slipped (17).

Additionally, it may cause muscle spasms in the hamstring muscles of the posterior

thighs. The slipped vertebrae pressing a spinal nerve may also lead to pain radiating

down the leg all the way to the foot. Generally, spondylolisthesis occurs only in one

level of the spine, though it can occur rarely at level two or three of the spine

simultaneously (17).

Fibromyalgia

Lumbar pain may also be attributed to fibromyalgia and other myofacial pain

syndromes. Fibromyalgia is a muscular pain, which results in back pain, fatigue and

tenderness at areas such as the neck, shoulder, hips, back, arms and legs. Some

factors which may lead to tender points in the lower back or shooting pain in the lower

back may be attributed to physical or emotional trauma, abnormal pain response, sleep

disorders or viral infections (21).

Fibromyalgia is a common pain syndrome. Though it is not related to a specific cause, it

still results in chronic pain encompassing a wide region of the body and nonspecific

tenderness in the joints, muscles, tendons and other soft tissues. Fibromyalgia is not

related to any specific anatomic disorder, and some scientists have attributed its

symptomatic manifestations to underlying and non-specific biochemical factors (22).


Bone pathologiesThe ageing process gradually decreases the strength of the bones, and tone and

elasticity of the muscles. The discs start losing its fluid and flexibility, reducing their

function as a protective cushion for the vertebrae.

Lower back pain is also known to reflect bone lesions such as multiple myeloma.

Osteoporosis and other bone diseases are other common factors that cause lower back

pain (29).

Bone lesions

Bone lesions are the oncologic causes of lower back pain, which may either be benign

or malignant spinal tumor. The spinal tumors are in close proximity to neural and

meningeal tissues, bone, and cartilage, all of which are capable of undergoing

neoplastic changes and metastasis. All spinal tumors cause back pain regardless of its

growth status i.e. whether they are malignant or benign. Osteosarcomas are commonly

present in the lumbosacral segment of the spine and result in lesions. Spinal

osteosarcomas are also seen in patients with Paget’s disease (31).

Bone metastases are cancerous cells, which spread from its site of origin to another

location in the body; in this case, the lumbar spine. It may cause pain and makes the

bone more vulnerable to fractures, even with the slightest of mechanical pressures. It is

usually characterized by the presence of increasing amount of calcium circulating in the

blood.

Metastases of the bone ultimately lead to lesions or injuries to the vertebral tissues of

the spine, causing pain. These lesions can be classified into two categories, namely;

Lytic lesions which completely destroy the bone material, and

Blastic lesions which fill the bones with more cells.

The cancerous cells attacking the vertebra disrupt the balance between the osteoclasts

(cells breaking down the bone) and the osteoblasts (cells developing and growing the

bone).


Bone metastases are most commonly diagnosed in the back, pelvis, upper leg, ribs,

upper arm and skull. The damage or load on the periosteum causes the lower back

pain. Bone metastases also cause bone loss and hypercalcemia, the combination of

which is a life threatening condition (32). The Maffucci’s syndrome sometimes exhibits

bone axial lesions, which may also result in lower back pain (30).

Fractures

Vertebral fractures due to compression forces acting on the bones usually result in

lower back pain; this is especially true in those suffering from osteoporosis.

The lower back pain is sometimes an indication

that the bones forming the spine, vertebrae,

have been fractured. In most cases, the weak

and brittle bones that resulted from osteoporosis

are the main causative factor of the fracture, and

not the compressional forces themselves. It has

been found that the majority of men and women

over the age of 50 have a lower back pain that is

attributable to vertebral fractures (26).

Vertebral fracture is defined as “a vertebral bone in the spine that has decreased at

least 15 to 20% in height due to fracture.” The fractures may be located anywhere in the

spine but are most commonly found in the thoracic spine, especially in the lower

vertebrae of that region of the spine. These

fractures are generally classified as a wedge

fracture, crush fracture or burst fracture (25).

Wedge fracture

In a spinal fracture, the compression force is

generally exerted in front of the vertebra, making the

anterior part of the spinal bone to collapse while the

posterior remains largely unchanged, leading to its


unique wedge-shaped structure. The so-called “Dowager’s hump” is a good example of

this type of fracture. It characterized by a stooped posture and a mechanically stable

fracture (26).

Crush fracture

A crush fracture differs from a wedge fracture in that in this case, the entire bone

breaks, instead of just the anterior part.

Burst fracture

Both the anterior and the posterior portions of the spinal bone being fractured

characterize a burst fracture, which results in an unstable fracture that may eventually

lead to a permanent deformity or a neurological disability. People with osteoporosis

have weak, thin and brittle bones that are vulnerable to fractures from light physical

activities. Such activities can subject these fragile bones to compression forces that can

very well result in spinal compression fractures. Generally, the compression fractures do

not cause pain but some are highly disabling in nature and cause extreme pain in the

lumbar region. In severe cases of osteoporosis, the vertebral fractures can even result

from innocent activities such as coughing, sneezing which lead to severe pain,

deformity of lumbar spine, immobility and disability, ultimately interfering with daily

activities (28).

Small and hairline spinal fractures may also eventually result in complete collapse of the

vertebra. This means that when the spinal vertebra incurs multiple small fractures, the

cumulative effects of these fractures are nonetheless painful and disabling. Moreover,

the compression fractures in the spinal vertebrae can have long term repercussions

such as permanently damaging the vertebrae by reducing its strength, shape and

functioning (26).

Osteoporosis

Osteoporosis is a prevalent musculoskeletal disorder, which also results in lower back

pain. It is characterized by reduction in bone mass and disruption of the

microarchitecture of the bone tissue. This condition leads to an increased incidence of


bone weakness, which may eventually cause

fractures or increase the risk of vertebral fractures.

Osteoporosis results in an increased risk of medical

complications inclusive of hip fracture, vertebral

deformities, and wrist fracture (35).

Lower back pain may be cited as the most common

symptom of osteoporosis, arising from vertebral

fractures. Lower back pain, as mentioned previously,

has severe impact on the quality of life. Studies have

reported that osteoporosis leading to lower back pain

is mostly prevalent among middle-aged women. The

high bone mineral density and associated degenerative diseases are known to cause

lower back pain in both the elderly and middle aged women (35).

It should be emphasized that even with decreased bone mass and abnormal structure

of the spinal vertebrae; there are no symptoms which are immediately visible. If the

bone is fractured, only then will symptoms such as lower back pain manifest. The

fracture, caused by osteoporosis, is also referred to as fragility fracture.

The external forces which destroy the already weakened bone structure range widely

from light forces such as those caused by daily activities to strong and violent forces

such as those incurred during trauma and fall accidents. The lower back pain following

such fractures many manifest either as acute or chronic pain. The acute lower back pain

is usually seen in fractures accompanied by rapid or gradual deformation of the bone

involved. Other fractures due to osteoporosis also result in chronic lower back pain,

which may gradually progress into dorsal kyphosis along with vertebral deformation.

Some studies have also reported that in certain cases, the deformation due to pressure

on the vertebral body develops and grows without any symptomatic lower back pain (28).


Spondylosis

Spondylosis refers to anatomical changes of

vertebral bodies and intervertebral disc spaces

associated with lower back pain syndrome.

Osteoarthritis of the lumbar spine or spondylosis is a

non-specific degenerative condition, which affects

the disk, vertebral bodies, and related joints of the

lumbar spine.

The degenerative anatomical changes may

eventually lead to complications such as spinal

stenosis, in-growth of osteophytes, hypertrophy of inferior articular process, disk

herniation, bulging of the ligamentum flavum, and spondylolisthesis. Such complications

result in neurogenic claudication, which includes lower back pain, leg pain and also the

numbness and motor weakness in the lower extremities (27).

Spondylosis has been used to describe many degenerative conditions of the spine and

progression of the lower back pain. Some of these are listed below:

Facet joint osteoarthritis, which may cause lower back pain due to excessive

physical or prolonged physical activities.

Spinal stenosis, which is characterized by the narrowing of the spinal canal due

to various causative factors which cause lower back pain.

Degenerative disc disease which results in dehydration and loss of function,

eventually resulting in lower back pain along with neck pain, and possibly leg

pain (33).

The most significant factors causing spondylosis are the wear and tear of the spine due

to overuse. Spondylosis is associated with a cascade of events, which start with

wearing down of the cartilage of the facet joints, causing a friction between the bones.

The friction produces osteophytes or bone spurs, which are initially aimed at restoring

equilibrium in the joint but ultimately, hamper mobility and range of motion of the joints.


These osteophytes may even pinch the spinal nerves, which aggravates lower back

pain (34).

Skeletal irregularitiesSkeletal irregularities such as abnormal curving of the spine may result in back pain. If

the curves of the spine are amplified, it will make the upper back look rounded

abnormally or create an abnormal arch in the lower back. A spinal condition that has

been known to result in back pain is scoliosis (37).

Structural failure of the lumbar discs in conjunction with advanced signs of ageing is

referred to as degenerated disc. Structural defects like endplate fracture, radial fissures

and herniation are reflective of impaired disc function. It is also important to note that

the structural failure is irreversible and progressive. These skeletal irregularities are also

known to advance through to the physical as well as biological processes, marking the

degenerative process. Spinal disc degeneration is easily detectible through imaging

studies, and is usually found in close association with lower back pain and sciatica (36).

Degradation of the spinal system may also result from injury and/or disease of any of

the associated systems and structure of the lumbar area. In response to these changes,

the neural systems of the spine bring about compensatory changes to initiate

appropriate changes in the lumbar spine, which may maintain the stability of the spine

but may also prove deleterious to the different components of the spinal system. The

primary instability of the lumbar spine has also been cited as one of the most common

causes of lower back pain. The secondary lumbar vertebral instability due to a disease

or an injury of the lumbar spine involving the disc for example osteoarthritis,

spondylolisthesis, nuclear ruptures into the neural canal is also a cause of lower back

pain.

Spinal degeneration

Degenerative disease of the lumbar spine or lower back negatively affects the spine and

involves a compromised disc, which is responsible for the lower back pain. The

degeneration is a multifactorial problem ranging from a simple wear and tear to


traumatic injuries that initiate a cascade of events causing a spinal degeneration. This

degenerative cascade is even triggered by minor injuries, which ultimately wear out the

disc completely. In fact, it has been noted that with increasing age, varying degrees of

disc degeneration is normally seen. Spinal degeneration causes inflammation of the

lumbar spine, with abnormal micro-motion instability as the reason for the lower back

pain (42).

Structural failure alters the local mechanical environment of disc cells from the general

loading of the disc that result in their aberrant cell responses. Excessive mechanical

loading brings about a distortion of the structure of the disc and initiates a succession of

cell-mediated responses (inflammatory responses), which worsens the pain symptoms.

The severity and onset of disc degeneration is influenced by various factors such as:

genetic inheritance

age

inadequate metabolite transport, and

load on the disc

All factors further weaken the disc, ultimately bringing about structural failure while

performing routine physical activities (36).

The structural failures of the disc, which causes low back pain are (36):

1. annulus tears

2. disc prolapse

3. endplate damage and schmorl nodes

4. internal disc disruption, and

5. disc narrowing, radial bulging and vertebral osteophytes

Annulus tears

The lumbar spine is particularly vulnerable to injuries, especially tears such as:

circumferential tears,

peripheral rim tears, and


radial fissures

Compressive stress, bony outgrowths, trauma-related mechanical forces, and cyclic

loading of the disc during bending and compression are some of the causative factors of

these tears. The incidence of annular tears is not affected by age and may develop in

the presence of any of the factors causing it (36).

Disc prolapse

This type of condition affects the periphery of the

disc. It is also termed as disc herniation. Radial

fissures lead to migration of the nucleus pulposus in

proportion to annulus bringing about disc prolapse.

Disc prolapse or herniation proceeds sequentially in

the following manner:

Disc degeneration

Protrusion of the nuclear material

Extrusion of the nuclear content

Sequestration of the nuclear content

The disc prolapse may result from mechanical loading, which commonly affects

individuals between 30 to 40 years of age. The presence of fluid nucleus and

weakening of the annulus characterize it. The nucleus pulposus is forced downwards

through the radial fissure (36).


Endplate damage and schmorl nodes

The weakest point of the spine when compressed is

the vertebral endplates, which accumulate

trabecular micro damage. With the ageing process,

the nucleus starts protruding inside the vertebral

bodies in later life. The endplate damage brings

about instant decompression of the nucleus, with

the annulus bearing the load bulges into the nucleus

cavity. The nucleus pulposus ruptures through the

damaged endplate, consequently resulting in calcium accumulation which creates what

is known as “Schmorl’s node” (36).

Internal disc disruption

In this type of structural damage, the anterior portion of the annulus is affected more

than the posterior portion. The inner annulus collapses into the nucleus. This type of

structural damage frequently occurs in ageing discs. Internal disc disruption is often due

to decompression of the nucleus succeeding an endplate fracture. The ageing cartilage

and the endplate are seen as detached from the underlying bone due to the loss of high

internal pressure compressing them (36).

Disc narrowing, radial bulging and vertebral osteophytes

Disc narrowing, radial bulging, and vertebral osteophytes are related to spondylosis.

Due to the ageing process, the nucleus pulposus extrudes into the vertebral bodies

causing a reduction in the nucleus pressure and rise in the vertical load on the annulus,

which ultimately bulges outward radially and even inward in certain situations. These

changes are accompanied by loss of the nucleus pressure, which manifests as collapse

of annular height. This loss in height prevents the separation of adjacent neural arches,

with the annulus collapsing on old discs, and contributing to more than 50% of the

compression force on the lumbar spine. This is why narrowed discs are also seen in

relation with osteoarthritis in the apophyseal joints and with osteophytes circulating on

the edge of vertebral bodies (36).


Spinal stenosis

Spinal stenosis, as defined previously, is the narrowing of the spinal canal resulting in

impingement on the neural structures by the bone and soft tissues surrounding it. The

most common reason for lumbar spine surgery in

adults over the age of 65 years can be attributed

to spinal stenosis (44). Additionally, it often results

in neurogenic claudication. It is another important

cause of lower back pain aside from disc

protrusion and root entrapment due to

degenerative changes (40).

Stenosis can result from many degenerative

conditions such as osteoarthritis or degenerative

spondylolisthesis. These conditions lead to clogging of spinal nerves in the lumbar area,

narrowing the canal and ultimately leading to claudication and pain in the leg (41).

Lumbar spinal stenosis refers to the narrowing of the lower spinal canal in the lumbar

region due to either bone or tissue growths or both blocking the size of the openings in

the spinal bone. The narrowed passage compresses and irritates the nerves coming out

of the spinal cord. In extreme cases, even the spinal cord is affected; either compressed

or irritated which leads pain, numbness or weakness in the legs, feet and buttocks (43).

Additionally, there is also enlargement of the facet joints leading to compression of the

spinal nerve roots in the lower back, which also contributes to lumbar pain (41).

Ageing is one of the most common causes of lumbar spine stenosis (41). The various

factors, which lead to spinal stenosis are those related with alterations in the shape and

size of the spinal canal. Some of the most frequent factors causing lumbar spinal

stenosis are:

thickening of the ligaments

formation and development of bony spurs compressing the spinal cord,

especially in those suffering from osteoarthritis, and

slipping of the discs backwards into the spinal canal.


Other conditions can play a significant role in the development of spinal stenosis.

Examples of such conditions are bone diseases such as Paget’s disease, ankylosing

spondylitis, rheumatoid arthritis, and diffuse idiopathic skeletal hyperostosis, all of which

lead to softening of the spinal bone or excessive growth of the bone (43).

Younger individuals with spinal injury or curvature of the spinal canal may also

eventually develop lumbar stenosis. When patients with spinal stenosis stand, the

space reserved for the blood supply of nerve roots is significantly decreased, resulting

in pooled blood which irritates the nerves and cause pain. However, it should be noted

that lumbar stenosis rarely causes permanent nerve damage (41).

Lumbar stenosis is classified into three different types:

Lateral stenosis

Central stenosis

Foraminal stenosis

Lateral recess stenosis

This is the most common type of lumbar

stenosis. In this case, a nerve root leaving the

spinal canal faces compression from either a

bulging disc or protruding bone, which extends

beyond the foramen (41).

Central stenosis

This type of lumbar stenosis causes

compression of the cauda equine nerve roots

especially when there is a blockade of the

central spinal canal (41).


Foraminal stenosis

This type of stenosis occurs when bone spurs entrap or compress a nerve root in the

lumbar region. Sometimes, the opening from where the nerve root leaves the lumbar

spinal canal may also be blocked.

Other conditions causing low back pain

Infections are also known to cause localized pain in the lower back. Serious and

destructive diseases but uncommon in nature are also instrumental in causing back

pain. These include malignancy, infection, ankylosing spondylitis and epidural abscess.

The occurrence of back pain can also be owed to the presence of musculoskeletal

disorders, peptic ulcers, pancreatitis, pyelonephritis, aortic aneurysms and some other

serious conditions (52).

Infections Spinal infection is generally a serious condition, which may be initially dormant then

slowly progress to an active state. It may also exacerbate into sepsis immediately and

exhibit rapid symptom progression. The back pain associated with spinal infection is

similar to and may be mistaken for discitis or osteomyelitis, although distinguishing it

from the idiopathic pain can very challenging for the clinician.

Tubercular infection due to Mycobacterium can cause lower back pain. It can very well

progress, albeit rarely, into tuberculous vertebral osteomyelitis (52).

An inflammation of the spine diagnosed as spinal infection should cause alarm to any

clinician (49). Researchers have suggested that chronic lower back pain may arise from

bacterial infection. The discs that are infected with anaerobic bacteria can later on

develop into bone edema in the adjacent vertebrae following disc herniation. The

bacteria infecting the gums and skin, Propionibacterium acne, can also spread to the

lower back and result in pain (45). The male condition, benign prostate hyperplasia

(BPH), can trigger lower urinary tract infection, which can spread and infect the spine

and also cause lower back pain.


Acute spinal infections are usually pyogenic in nature while the chronic infections can

either be pyogenic, fungal, or even granulomatous. Common infections from any

bacterial or fungal source can spread to the spine such as dental abscess, pneumonia,

and urinary tract infection. The infection is subtle at the beginning and usually only

causes localized pain in the back at the area of involvement. The resulting spinal pain

has the tendency to be aggravated with increased physical activity and load on the

spine (e.g. carrying heavy objects). The spinal infection generally manifests as back

pain accompanied by weight loss, fatigue, fevers, and night sweats. The pain is focal in

nature and may be experienced by the patient when changing positions such as from

sitting to standing. Focal kyphosis can also appear in the case of vertebral collapse (52).

Infections of the deep tissues of the lumbar spine are also known to cause lower back

pain and leg pain. Some of the most common infections of the lumbar spine are

osteomyelitis, discitis, epidural abscess, and postoperative wound infections. Deep

tissue infections that do not involve the disc space directly can also lead to lower back

pain (51).

Vertebral infection

An infection of the vertebral body is known as vertebral osteomyelitis and mostly affects

young healthy individuals. The infection usually spreads to the lower vertebral body

through vascular pathways. Batson’s plexus (veins in the lumbar spine) drain into the

pelvis and are easy routes for bacteria to travel through, enter, and infect the spine. This

is why uroscopic procedures commonly result in spinal infections.

There are many risk factors for the development of osteomyelitis such as increasing

age, IV drug use, and immunosuppression such as those seen in patients with diabetes

mellitus, AIDS, malnutirition, cancer, and those who underwent organ transplantation.

The microrganisms which most commonly infect the spine are Staphylococcus aureus

and Pseudomonas spp. Infections caused by Mycobacterium tuberculosis are also

known to cause infections affecting the lower back that result in debilitating symptoms.

Most of the infections of the vertebral body are localized in the lumbar spine owing to

the limited blood circulation in this spinal region (58).


Lyme disease

Lyme disease is a chronic infection affecting the skin, joints, and the nervous system

including the spine. Spirochete bacteria, manifesting initially as a rash following a tick

bite, cause it. The skin lesions develop into multiple annular secondary lesions

accompanied by other symptoms such as malaise and fatigue, headache, fever and

chills, general achiness and regional lymphadenopathy. Some patients also show

meningeal irritation, mild encephalopathy, migratory musculoskeletal pain, hepatitis,

generalized lymphadenopathy and splenomegaly, sore throat, cough, and testicular

swelling (54).

Patients diagnosed with Lyme disease also develop brief episodes of joint, periarticular

or musculoskeletal pain following skin lesions. Later on, they develop into chronic

synovitis characterized by erosions and permanent joint disability. Lyme arthritis ranges

from mild and subjective joint pain to intermittent attacks of arthritis, and sometimes

even to chronic erosive manifestation of the disease (53).

Shingles

Varicella zoster virus, the causative agent of shingles, infects certain spinal levels,

which eventually cause lumbar pain. The virus is known to lie dormant in the body for

many years following the initial chickenpox infection. Once the virus is activated again, it

infects and spreads to various parts of the body including the spine, causing nerve

damage that manifests as numbness, itching, severe pain, and the characteristic

blistering rashes. Shingles typically start with a highly sensitive, band-like rash

appearing on the skin followed by an intense discomfort of the same area, burning and

painful sensations, and itching on the back. The most commonly affected areas are the

trunk, neck and back.

There are a variety of factors which trigger the infection including emotional stress,

increasing age, immune deficiency, and cancer. Persons of advanced age are more

likely to experience the debilitating irritating rash sensations, severe herpetic neuralgia,

and vision impairment that follow the infection (46).


Epidural abscess

Spinal infection can also progress to epidural abscess, which manifests initially as a

localized spinal pain that slowly develops into radicular pain, weakness, and ultimately,

paralysis. Epidural abscess is generally a complication of osteomyelitis, bacteremia,

and postoperative infection. The common causative organisms are Staphylococcus

aureus, Streptococci and Gram-negative bacilli. The characteristic feature of spinal

epidural abscess is its progression from spinal ache to radicular pain leading to

weakness and eventual paralysis. The disease has serious complications and may be

accompanied by fever, local tenderness, and lower back pain (47).

Other problems that can also cause back pain in the lumbar region are ankylosing

spondylitis, cauda equine syndrome, and rheumatoid arthritis. Added to this list are

some rare bone disorders, tumors, and other disorders which exert pressure to the

spine resulting in lower back pain (50).

Cauda equine syndrome

Cauda equine syndrome is a relatively rare but very serious medical emergency

involving the spinal cord. Its name was

derived from the nerves at the end of the

spine that visually resemble a horse’s tail

as they extend from the spinal cord down to

the back of each leg. The nerves at the end

of the spinal cord are subjected to

excessive pressure and inflammation. If left

untreated, it will ultimately progress to

permanent paralysis, impaired bladder and

bowel control, mobility difficulties, and

various other related neurological and physiological problems (59).

Lower back pain which is localized in a particular area is one of the symptoms of cauda

equine syndrome; along with progressive weakness in the lower extremities, loss of

sensation in the saddle area, urinary or bowel incontinence, and sharp stabbing pain on


the legs (59). There are various factors responsible for the compression of nerves in the

lumbar spine including lumbar herniated disc, lumbar spinal stenosis, vertebral collapse

due to metastatic infiltration, spinal subarachnoid hemorrhage, acute extradural

hematoma, ankylosing spondylitis, infections in the spinal canal, tumors or trauma, and

injury affecting the lower back.

Spinal dural arteriovenous fistulas

This condition is a distinct malformation of the spinal vasculature generally located in

the lower lumbar or thoracic spine. It usually affects middle aged and older men. Its

symptoms include lower back pain and symptoms similar to spinal stenosis (48).

Spinal arachnoiditis

Spinal arachnoiditis most commonly affects the lumbosacral region, although it can

occur anywhere in the meninges. It is characterized by thickening of the arachnoid and

adherence to the pia mater and dura mater. It can affect a single nerve root or multiple

nerve roots in the cauda equina. As the condition progresses, it can even restrict the

spinal cord itself.

There are several causative factors that result in the development of spinal

arachnoiditis, including the following:

intrathecal drugs or chemical agents such as radiation, spinal and epidural

anesthesia,

infections such as tuberculosis, cryptococcus, syphilis, viral infections,

trauma such as spinal surgery, vertebral injuries or lumbar disk herniation, and

spinal subarachnoid hemorrhage.

The symptoms of spinal arachnoiditis are persistent lower back pain, which can later

radiate to both legs and result in motor and sensory disorders. The symptoms may

appear within days of the damage or take years to appear. More than one lumbar or

sacral nerve root is usually involved in this disorder (48).


Ankylosing spondylitis

Ankylosing spondylitis is a type of arthritis, which usually progresses into chronic

inflammation of the spine and sacroiliac joints. It also affects other joints and organs in

the body such as eyes, lungs, kidneys,

shoulders, knees, hips, heart, and ankles;

however, the primary affected region is the axial

skeleton and its ligaments and joints. It typically

results in stiffness, joint soreness, and pain

around the spine and pelvis. It ultimately brings

about a complete fusion of the spine.

The patient usually experiences pain symptoms

once the spinal vertebrae start to fuse together

as a result of calcium accumulation in the

ligaments and discs between each vertebrae. In

this type of condition, there is a complete loss of

mobility and greater susceptibility to fractures and injuries.

Ankylosing spondylitis occurs more frequently among males, especially younger adult

males. It starts at the sacroiliac joints, before moving to the spine. The long-term spinal

joint inflammation results in calcification of the ligaments around the intervertebral discs

and ligaments, which eventually restricts their movement.

The final stage is the complete fusion of the vertebrae, which is known as ankylosis.

The severe pain symptoms of ankylosing spondylitis manifest on the lower back,

buttocks, hips, and thighs (57).

Rheumatoid arthritis

Rheumatoid arthritis is an autoimmune disease that can occur at any age. It refers to

the destruction of the joints in the body at the neck and lumbar region of the spine,

although it most commonly affects the former than the latter. It can lead to neck pain,

back pain or pain that radiates into the legs and arms. The destruction of the spine can


also result in compression of the spinal cord and spinal nerve roots, which contributes to

the development of lower back pain (56). The most significant causative factors of

rheumatoid arthritis are infections, heredity, and hormonal changes (55).

The symptoms of rheumatoid arthritis are similar to those of osteoarthritis. The pain and

inflammation are usually focused on the base of the skull or lower back. It also affects

the ability to walk (56). The disease is known to progress gradually; generally starting

with minor joint pain, stiffness, and fatigue (55).

Other conditions that contribute to the development of lower back pain are abnormal

aortic aneurysm, psoriatic arthritis, kidney infection, kidney stones, problems related to

pregnancy, endometriosis, ovarian cysts, ovarian cancer, and uterine fibroids (60).

SYMPTOMS OF A MORE SERIOUS DISEASE

Sometimes, lower back pain is accompanied by rare symptoms associated with more

serious conditions, some of which pose a life-threatening risk to the patient and require

immediate medical attention.

Some of these symptoms are outlined below:

Progressive weakness of the leg

Loss of bowel or bladder control

Weight loss along with pain

Neurological impairment

Severe and acute stomach pain accompanied with a lower back pain, and

Fever with increasing pain intensity, which cannot be alleviated with the use of

oral NSAIDs (61).

These symptoms are associated with spinal tumor, infection, fracture, and cauda equina

syndrome. Thus, an unexplained weight loss and fever accompanying lower back pain

may be a result of malignant disease such as multiple myeloma or a metastatic disease.

Fever with lower back pain may indicate connective tissue disease such as systemic


lupus erythematosus, urinary retention, and bladder or bowel incontinence. Severe and

progressive weakness of the lower extremities may suggest cauda equina syndrome or

spinal stenosis (62).

Infection

A fever (>100°F or 38°C) present in patients with lower back pain is indicative of an

infection. There are many pathways for an infectious microorganism to enter the spine.

It is not uncommon for individuals with a compromised immune system or post-

operative status to develop infections more quickly. Generally, a compromised immune

system is a result of insulin dependent diabetes mellitus, organ transplantation,

acquired immune deficiency syndrome (AIDS), malnutrition, and even cancer (61).

Sometimes, spinal infections lead to epidural abscess which can put pressure on the

nerves in the cervical, thoracic and lumbar spine, all of which may eventually lead to

gross dysfunction of the nerve roots causing paraplegia or quadriplegia. The most

common organisms affecting the spine are Staphylococcus aureus, Pseudomonas spp.,

and Mycobacterium tuberculosis (58).

Post-surgical and other wound infections are frequently seen in patients with diabetes or

those with weak physical health. The onset of infection is usually slow, taking usually

about 1 to 2 weeks to completely develop. The symptoms usually include fever,

redness, and inflammation around the incision and wound areas. Also, a change in

wound drainage and fluid consistency is indicative of an active infection. The fluid from

the wound can become thick and yellow with delayed healing. Post-surgical spinal

infections respond well to antibiotic treatment when caught early; in rare cases, the pus

needs to be surgically extracted out to prevent further spread of infection (61).

Vertebral osteomyelitis or vertebral bone infection can also result in fever. This type of

infection spreads to the spine through the blood circulation. The veins present in the

lumbar spine, known as Batson’s plexus, drain the pelvis and allow the bacteria to

directly enter the spine (58).


Several procedures like colonoscopy, cystoscopy, and other diagnostic tests using a

thin telescope to inspect the bladder can facilitate the spread of infection. Intravenous

drug use, long-term use of steroids, and dental surgery can also play an instrumental

role in introducing infectious microorganisms into the bone and subsequently, the spinal

structures.

The sensitivity of fever has been found to be disappointing in patients with spinal

infections; Whereas, spine tenderness in response to percussion is sensitive for

bacterial infection (65).

Cauda equina syndrome

Cauda equina syndrome is characterized by varying degrees of urinary and bowel

incontinence, sensory loss in the perineal area, and motor weakness in the legs. The

cauda equina syndrome is caused by direct or indirect trauma, ischemia, infection, and

neurotoxic reactions (68).

The symptoms of cauda equina syndrome are classified as:

1. Motor

2. Sensory, and

3. Sphincter manifestations

The abnormal neurological perceptions associated with cauda equina syndrome include

lower back pain, sciatica, saddle, and perineal hypoaesthesia or anaesthesia,

decreased anal tone, and absence of ankle, knee and bulbocavernous reflexes, along

with a bladder and bowel dysfunction. An early diagnosis and decompression of the

cauda equina is of utmost importance to minimize the residual neurological deficit (66).

Specifically, the motor manifestations seen are weakness of lower limbs, decreased

range of motion, evidence of hypotonia in the limb and other muscle groups, and

reduced or lack of reflexes. The sensory symptoms manifest as paresthesias and

objective sensory loss of dermatomal and myotomal distribution. The symptoms

associated with sphincter involvement are difficult micturition, retention of urine, failure

of filling of the viscous or loss of urethral sensation, and sometimes stress incontinence.


The most commonly observed bowel symptoms are constipation, rectal distention, and

loss of anal sensation (69).

The terminal vertebrae of the adult spinal cord is at the L1-L2 with the terminal lumbar

and sacral nerve roots in the spinal canal forming the cauda equina at the distal end.

Cauda equina syndrome caused by a herniated lumbar disc has the following features:

Perineal anesthesia

Lumbosacral root sensory deficits

Patients who suffer from back pain and urinary incontinence are measured for their

urinary post void residual volume. A value more than 100-200 mL is suggestive of

urinary retention. Cauda equina syndrome is the perfect indication for an immediate

surgical decompression, laminectomy with mild traction of the cauda equine, and

discectomy. The success of the treatment largely depends on how soon the patient

received immediate surgical intervention (67).

Some of the problems associated with this large, space occupying lesion in the canal of

the lumbosacral spine is its unclear pathophysiology, subtle initial signs and symptoms

which makes early diagnosis challenging, and often late findings of decreased rectal

tone. Hence, postoperative spine patients with residual back or leg pain that is not

alleviated by analgesics, especially when urinary retention is present, should be highly

suspected of having cauda equine syndrome (70).

Multiple myeloma and malignancies

Bone metastases are related to significant morbidity including pain, impaired mobility,

increased calcium levels, pathological fracture, compression of spinal cord and nerve

roots, and bone marrow infiltration. The major complications of metastatic bone

destruction causes bone pain radiating from the back to the lower limbs. Hypercalcemia

also occurs in pathologic fractures and spinal cord compression (64).

There are many symptoms associated with bone cancer such as bone pain, localized

swelling and inflammation in the lumbar spine, unexplained weight loss, fatigue, fever,

and even anemia. The malignancy may start from the bone and spread to other parts


(primary) of the body or spread from the other parts of the body to the bone

(secondary). The two cancerous malignancies that cause these symptoms are

osteosarcoma (cancer of the bone tissue) and chondrosarcoma (cancer of cartilage).

Metastasis usually develops due to the interactions between tumor cells and bone cells

that lead to disruption of normal bone metabolism and increased osteoclastic activity.

The clinical course of metastatic bone disease in multiple myeloma results in skeletal

complications, bone pain, fractures, hypercalcemia, fever, and weight loss; all of which

adversely affect the quality of life (63).

Malignant neoplasm (primary or metastatic) is the most common malignant disease

affecting the spine. Unexplained weight loss, pain symptoms lasting greater than one

month, and failure to improve with traditional NSAIDs therapy are some of the most

common signs and symptoms. Patients with lower back pain due to cancer usually

complain of persistent pain unrelieved by bed rest. The physical examination does not

contribute much to the early detection of underlying bone cancers except in their later

stages (65).

Sciatica

Pain due to nerve root irritation is indicative of sciatica. The pain is characterized by

sharp and burning sensations radiating down to the

posterior and lateral aspect of the leg, foot, and

ankle. Coughing and sneezing enhance the pain.

When disc herniation occurs, the leg pain is more

prominent than the back pain (65).

Spinal stenosis

The characteristic clinical feature of spinal stenosis

is neurogenic claudication. It is characterized by

pain on the legs and neurological deficits occurring

while walking. Neurogenic claudication occurs while standing, with a tendency to


worsen with coughing and sneezing. Increased pain on extension of spine is

characteristic of spinal stenosis (65).

DIAGNOSIS

Before suggesting any diagnostic test to patients, clinicians need to look into the various

signs and symptoms manifested and narrated by them. Both the subjective and

objective lower back symptoms of the patient are helpful in making the right clinical

decision, i.e. whether to go ahead with other various diagnostic tests or start treatment

right away.

The exact site of pain in the lower back, pain intensity, the type of pain (e.g. burning,

stinging, crawling), origins of the pain sensations, and the aggravating and ameliorating

factors are standard questions usually asked by the clinician. In case of nonspecific

pain, the patient is usually put on 3 weeks of conservative treatment, usually with pain

medications.

If symptoms do not disappear spontaneously or by rest even after 3 weeks of treatment,

the clinician should proceed with various diagnostic tests in order to pinpoint the exact

cause of pain. Some of the most commonly used diagnostic tests are:

1. Spinal x-ray

2. Myelography

3. Computed tomography scan (CT scan)

4. Magnetic resonance imaging (MRI)

5. Electro-diagnostic tests such as:

Electromyography(EMG)

Nerve conduction velocity (NCV)

Evoked potential studies (EP studies)

6. Bone scan

7. Thermography

8. Ultrasound imaging (USG)


Spinal x-raySpinal x-ray is also known as lumbosacral x-ray

and lumbar spine film. It is a non-invasive

diagnostic test widely used to take pictures of the

lumbosacral region to visualize suspected

fractures, inspections, deformities (e.g. scoliosis),

and other skeletal disorders of the bones, discs

and joints.

Spinal x-ray is usually suggested after a thorough

examination of the back, gluteus region, spine,

and recto-pelvic regions of the patient by the physician, physiotherapist and chiropractor

(103, 104,105).

Spinal x-ray is ordered when the patient has the following symptoms (103,104,105);

Constant, extreme and sharp pain on the lower back that is not relieved

spontaneously within a couple of days or by rest;

Pain is relieved only with the use of NSAIDs then persists after two weeks;

Hyperaesthetic and sensitive lower back;

Stubborn and stiff lower back;

Crawling, tingling sensations in the lower back and lower extremities like hip,

thighs, leg, foot, and big toe;

Loose, weak, and tired lower back and extremities;

When the patient is not relieved by massage, heat therapy (fomentation), hot

baths and even physiotherapy exercises; and

When all of the above complaints are seen in elderly people with fragile bones.

The image obtained by spinal x-ray of the lumbosacral region will show the five lumbar

vertebrae and five fused sacral vertebrae. Beam of ionizing radiations are passed

through the lower back followed by capture of 4-5 images. X-ray plates taken are

visualised in good light. Bony radio opaque vertebra will appear white; soft tissues,

muscles (e.g. erector spinae) and the spinal cord grey, and the air black.


Condition and diseases diagnosed using spinal x-ray are:

Fractured, cracked torn bones:

Stress and compression fractures of the lower vertebrae are commonly seen in

athletes such as weight lifters, gymnastics, and footballers who frequently over

stretch their lower back;

Spondylolisthesis:

It is also known as subluxation wherein the normal anatomical position of the

spine is altered. On X-ray image, the vertebra will appear to have slid down from

their actual position;

Disc degeneration:

Degenerated intervertebral discs can be seen on the X-ray plate. They are the

senile progressive changes on the vertebra and cartilage due to ageing and

repeated micro-injuries;

Hereditary and congenital structural abnormalities:

These involve the spine vertebra such as those seen during extension and back

flexion;

Misalignment of the spine:

Vertebral malformations such as kyphosis, scoliosis, lordosis, and kyphoscoliosis

are seen on the X-ray image. The table below summarizes the findings of each

vertebral malformation:

Vertebral malformation X-ray finding

Kyphosis increased convexity or outward curvature of upper and lower

back

Scoliosis lateral or side to side curvature of spine

Lordosis outward arch or curving of lower back

Kyphoscoliosis both sideward and outward curvature of lower back

Narrowing of intervertebral joints, osteoporotic, and corrosive changes of

vertebrae; and

Tumors and masses in the spinal canal and surrounding tissues.


All of the above conditions and diseases produce lower back pain. Spinal x-ray is most

helpful in their differential diagnosis (103,104,105).

It is also helpful to know which conditions and diseases cannot be ruled out by spinal x-

ray. This is especially true when the lower back pain is due to injury to the soft tissues,

muscles of the lower back, and spinal nerves since these structures are not clearly

visible on X- ray films. Examples include (103,104,105):

Sciatic neuritis:

this is characterized by burning and electrifying pain that radiates from the lower

back-gluteal region-hamstring muscles-leg-foot;

Disc prolapse:

this is due to the degeneration of intervertebral discs that slip into the

intervertebral foramen, which put pressure on the spine and cause pain; and

Spinal stenosis:

the narrowed spinal cavity compresses the spinal nerves and causes lower back

pain.

There are several reasons why x-rays are the most frequently ordered imaging study.

They are advantageous to use in clinical settings because they are (103,104,105):

Rapid

Cheap

Non invasive, non surgical

No much preparation required before x-ray is performed

Easily available

Universal

Spinal x-rays also have several limitations and disadvantages, namely (103,104,105);

Exposure to hazardous ionizing radiation

Risk of radiation exposure such as congenital malformation, cancer, tumour,

growth retardation, and infertility;


Minimal diagnostic value in lower back pain when the pain is due to soft tissue or

nerve involvement since these structures are not clearly visible and identifiable

on x-ray films.

Prior to the procedure, the radiographer and clinician need to inform the patient of the

following information about the procedure, as follows:

Patient may be asked to lie down on the x-ray table or stand during the

procedure.

Patient must remain still in proper position during the procedure to avoid blurry

images.

Ornaments, metals objects, and all other radio-opaque substances must be

removed.

Pregnant patients with lower back pain should not undergo x-ray procedures.

Very young children should not be exposed to x-rays since the radiation may

retard their growth.

Efforts are made to ensure that the patient is only exposed to the minimum

amount of radiation

If only the lower back requires radiation exposure, then other body parts are

covered by special clothes and materials to avoid unnecessary exposure.

MyelographyMyelography is an invasive procedure which enhances the diagnostic value of x-rays

and CT scan of the spinal cavity using contrast dyes. They are generally referred to as

special x-ray studies of the spinal cord and canal.


following information about the procedure:

Ornaments, metallic pins, mouth dentures and other metallic objects are

removed prior to the start of myelography.

The steps of the procedure are enumerated below (103,104,106):


1. The patient lies on the stomach on the x-ray table while the site of injection is

selected and cleaned.

2. Local anaesthetic agent is administered to the selected site of injection.

3. A barium or iodine contrast dye is injected into the lower spinal canal with the

help of a spinal needle. Specifically, it is injected into the subarachnoid space.

4. Needle is withdrawn. The x-ray table is tilted downwards to allow the dye to flow

freely through the spinal canal.

5. An x-ray or CT scan of the lower spinal canal is taken.

6. Lastly, the patient is released and advised to keep the head elevated. The dyes

are flushed out through micturation and defecation within the next couple of days.

Flouroscopy is used to project these radiographic

images into video format onto the computer

screen. These images taken are known as

myelograms. The barium or iodine dye highlights

the injured areas of the spinal cord, nerve roots,

blood vessels, and subarachnoid space on the

x-ray images. CT myelography can also be

immediately performed while the dye is present in

the spinal canal.

Conditions and diseases diagnosed using myelography are those associated with

abnormalities of the spinal cord, nerve roots, surrounding meninges, and intervertebral

discs, namely (1, 2, 4):

Herniation and protrusion of intervertebral discs which put pressure on spinal

nerves and nerve roots, causing pain;

Spinal stenosis;

Excessive osteophytes , bony spurs, and thickened ligaments;

Malignant and benign tumors in the spinal canal;

Inflammation of the sacroiliac joints;

Inflammation of the arachnoid membrane; and

Infected vertebra, intervertebral discs, meninges, and other soft tissues.


There are several reasons why myelography is advantageous to use in clinical settings,

namely (103,104,105);

It enhances the diagnostic value of X- ray and CT scan by highlighting the less-

visible structures;

It is useful in patients in whom MRI is contraindicated such as patients having

pacemakers and hearing aids; and

It is useful in people who are candidates for lower back surgery and have

inconclusive diagnostic test results.

Myelography also has several disadvantages, namely (103,104,105):

Exposure to ionizing radiations;

Contrast dyes such as barium and iodine can cause allergic reactions in patients

who are allergic or idiosyncratic to these dyes. Signs and symptoms such as

fever, headache, itching and redness on skin, gastritis, nausea, vomiting,

sneezing asthmatic wheezing, difficult micturation and defecation are indicative

of allergic reaction. Serious side effects such as convulsions occur but rarely

following myelography;

Inflammation, bleeding, and infection may occur at the site of injection;

The administration of dye (injection) can sometimes cause pain leading to patient

anxiety; and

Soreness at the site of injection.

The limitations of myelography are listed below as:

It cannot be performed on patients with known allergy to contrast dyes;

It cannot be performed on patients on antidepressant and antipsychotic drugs

since these react with iodine and barium dyes, causing serious side effects;

It cannot be performed on patients with congenital or acquired structural

abnormalities of the spine because of the lack of available safe injection site;

It must be cautiously performed on patients with bleeding tendencies such as

those who are on anticoagulant medications (e.g. warfarin and aspirin);

It is hazardous to pregnant patients as both dye and radiation can harm them;

and,


Its diagnostic value in pinpointing the exact cause of lower back pain is only

limited to associated conditions and diseases within the spinal canal.

Computed tomography scan (CT scan)

CT scan is a medical imaging procedure that makes use of computerized x-rays to

obtain tomographic images of specific areas of the body. The images produced are

three-dimensional (3D).

CT produces a volume of data that can be manipulated in order to demonstrate various

bodily structures based on their ability to block the x-ray beam.



Metallic pins, ornaments, mouth dentures, and other metallic objects must be

removed;

Patient is required to wear loose and comfortable clothes; and

Patient is laid on the examination table which slides into the CT scanner. Once

inside, the patient must remain still while images are being captured.

The scanner is equipped with x-ray throwing tubes and a detector which detects the

amount of radiation absorbed by the organs and

body parts. Modern computers process the data

and produce cross-sectional and two-dimensional

detailed images of the spinal vertebra,

intervertebral discs, soft tissues, and blood

vessels. If a radiocontrast is to be used, clinicians

need to ascertain the absence of patient allergies

to the specific dye and drugs used.

The specific diseases and conditions associated with lower back pain which can be

diagnosed using CT scan are (103,104),107):


Structural damage to the spine, vertebra, intervertebral discs, soft tissues, and

muscles;

Degeneration of spinal structures including the spinal canal;

Benign and malignant tumors in and around the vertebral column;

Metastatic overgrowth in the vertebral column from pelvic organs such as the

prostate;

Protrusion of intervertebral discs;

Osteoporotic and senile degeneration of the spinal canal in the elderly.

Fragility of lumbosacral and iliac bones and joints;

Congenital structural abnormalities of the spine;

Spinal stenosis;

Arthritic conditions affecting the spinal bones and joints; and

Abscess in the lower back

CT scan has the following advantages (103,104,107):

Very reliable

Relatively simple

Quick

Non-invasive

Pain-free

Safe for patients with implant such as pacemakers, stents, and hearing aids

Convenient follow up on the post-surgical status of the spine

A biopsy specimen from any part of the lower spine can be taken with the help of

CT scan. This is especially useful in cases where the presence of malignant cells

in the spinal canal is strongly suspected.

The limitations of CT scan are listed below as (103,104,107):

It is not safe for pregnant patients due to the possibility of fetal exposure to

ionizing radiation;

It is not recommended in growing children since it can retard growth;

The use of contrast dyes is not recommended in nursing mothers since these

can be transmitted to newborns via breast milk; and


Barium and bismuth metals interfere with generation of clinically useful images.

Magnetic resonance imaging (MRI)

An MRI scan is a non-invasive imaging test that uses powerful magnets and radio

waves to create images of the body. Unlike the previous diagnostic imaging studies

discussed previously (spinal x-rays, myelography and CT scan), it does not use

radiation (x-rays). It is considered to be a very accurate test for diagnosing specific

causes of lower back pain.

A single MRI image is called a slice, which may either be stored on a computer or

printed on film. A single MRI exam can produce dozens of images. The MRI chamber is

the cylindrical tube structure that creates magnetic, radio waves that surrounds the

patient’s body.



Metallic pins, glasses, ornaments, and piercings must be removed from the body;

Patient is required to wear loose and comfortable clothes;

Patient must remain still during scanning. Very young children may be sedated, if

necessary.

The patient is laid on the examination table which is passed through the MRI

chamber. The magnetic waves generated bring the water molecules in the spinal

and muscle tissues into correct alignment.

The radio waves are then passed through spinal

tissues, vertebrae, and muscles. They identify the

relaxation and random movement of molecules

within the spinal tissues from the inline alignment

created by magnetic field. The resonance and

signals created are processed by the computer

scanner which then produces three dimensional

(3D) images of the spinal vertebrae, intervertebral


discs, intervertebral space, cerebrospinal fluid, spinal muscles, and other tissues. The

images of spinal canal are visible on sagittal, axial, and coronal planes.

In cases where a radiocontrast is needed to enhance the images of an MRI scan, the

dye used is gadolinium which is injected into the spinal canal via an intravenous

administration.

The specific diseases and conditions associated with lower back pain which can be

diagnosed using an MRI scan are (103,104,108):

Protrusion and herniation of degenerated intervertebral discs;

Abnormal structural deformity of the spinal canal;

Abnormal alignment and position of the spine such as kyphosis, scoliosis,

lordosis, and kyphoscoliosis;

Compression fractures;

Nerve root compression;

Benign and malignant overgrowth, tumors, soft tissue masses;

Metastatic malignant cells in the spinal canal from pelvic, rectal, respiratory or

abdominal organs

Severe prominent inflammatory changes to the spinal cord; and

Abnormalities of the spinal nerves affecting the muscular movement.

An MRI scan of the spine has the following advantages (103,104,108):

Safe;

Accurate and reliable;

High diagnostic value;

Clear view of the spinal canal regardless of the type and severity of disease and

injury;

Spinal surgeries immediately following an MRI scan can be performed;

Post surgical improvement and deterioration of spinal conditions can be

assessed quickly;

Bleeding, infections, and scarring post surgery can be easily seen;


Helpful in pinpointing exact locations of injection sites of steroid medications in

patients with chronic back pain; and,

No allergic reactions to the contrast dye are seen. Gadolinium does not trigger

allergic reactions unlike other contrast dyes (e.g. iodine, barium) used in other

imaging studies.

An MRI scan is also associated with a few adverse effects, namely (103,104,108);

a) Drowsiness and dizziness following administration of gadolinium;

b) Abnormal functioning of the implanted metallic equipments such as pacemakers,

artificial joints, and stents due to exposure to magnetic waves; and

c) Claustrophobia in vulnerable patients when delivered inside the MRI chamber.

The limitations of an MRI scan are (103,104,108):

a) It is not recommended for pregnant patients due to possible fetal magnetic wave

exposure;

b) Contrast dyes are not recommended for use in nursing mothers since they may

be ingested by the feeding infant through breast milk.

c) Heightened sensitivity to movement which requires the patient to be still

throughout the entire scan to avoid production of blurry images;

d) Lesser diagnostic value than CT scan and spinal x-rays in vertebral fractures and

injuries;

e) Longer procedure duration;

f) Greater patient expense.

Electrodiagnostic testElectrodiagnostic tests make use of the electrical signals that are produced by nerves

and muscles and delivered to the brain. Injuries and diseases interfere with the

conduction of these signals and are measured using three specific testing techniques,

namely:

a) Electromyography (EMG)

b) Nerve conduction velocity (NCV)

c) Evoked potential studies


These tests determine the following (103,104,109):

Presence or absence of trauma to the spinal nerves;

Onset and duration of injury;

Extent of nerve damage i.e. whether it is reversible or not;

Exact location of the nerve injury;

Extent of muscle damage i.e. whether the muscles are weakened, flaccid or

paralysed;

Integrity of motor and sensory pathways i.e. absence or presence of neurological

deficits.

Electromyography (EMG)

Electromyography is one type of electrodiagnostic test. Also known simply as

myography, it is a minimally invasive procedure that makes use of fine needles placed

in a specific muscle to record its electrical activity. The test determines the ability of

spinal muscles such as latissimus dorsi, sacrospinalis, and gluteal muscles to respond

to nerve stimulation. The muscular responses are represented in a graph or numeric

form on the computer monitor.




The patient must be asked about any medical history of coagulation disorders or

bleeding tendencies such as haemophilia. If present, this procedure must be

avoided.

Implant devices such as pacemakers, stents, and shunts can interfere with the

results of the procedure.

EMG must be carried out in a warm room since chilly and cold temperatures can alter

the muscular response to the test. Fine pointed needles (electrodes) are pricked into the

spinal muscles, after which the patient is told to move, flex, extend or contract the

muscles of lower back. These actions stimulate the nerve cell, eliciting a spinal

muscular response. Normally, when the spinal muscles are at rest or healthy, no

electrical response is seen. But when the spinal muscles flex, contract or diseased,

varying degrees of electrical response are seen. These responses can help determine

whether the spinal muscles are bending forward and backward properly or not, and

healthy or injured.

EMG to the lower back is suggested to the patient when he/she has following symptoms

are (103,104,109):

a) Cramping, burning, sharp pain in lower back and lower extremities;

b) Weakness, flaccidity in lower back muscles; and

c) Tingling, numbness in lower back and lower leg, feet.

Conditions and diseases causing lower back pain that can be diagnosed with the help of

EMG are listed below as (103,104,109):

Sciatic Nerve dysfunction;

Femoral nerve dysfunction;

Peripheral neuropathies;

Neurological dysfunction and muscular dystrophy due to associated disease

complications such as AIDS;

Muscular dystrophy and degeneration in auto immune disease such as

myasthenia gravis;

Nerve root impingement; and


Polio.

The advantages of EMG in diagnosing causes of lower back pain are as follows (1,2,7):

a) It requires minimal piercing, and,

b) It elicits minimal pain

EMG is also associated with a few adverse effects, namely (103,104,109):

Pain and discomfort in highly sensitive patients and young children;

Prolonged pain and tenderness lasting a few days following the procedure;

Bleeding tendencies in hemophilic patients; and

Infections at the needle piercing site accompanied by altered blood count.

The limitations of a EMG are (103,104,109):

It should be very carefully performed or avoided in patients on anticoagulant

drugs such as warfarin and aspirin; and,

Muscular responses vary from person to person

NSAIDs such as like ibuprofen and naproxen can alter the results of the test.

Nerve conduction velocity (NCV) test

The nerve conduction velocity (NCV) test determines the speed and power of electrical

impulses travelling through nerves. Unlike EMG, it is a non-invasive procedure.



Patients must avoid stimulants such as coffee, drugs, alcohol, and tobacco

because they alter nervous and muscular functions. Abstinence of at least 3

hours is needed.

The test is safe for hemophilics and those on anticoagulant therapy.

The test must be conducted in a room that is warm and comfortable since chilly

temperatures can alter the nervous response.


The NCV test is carried out using two rods which

are placed on the skin and muscles of the spine.

The first rod is used to send out impulses to

stimulate the nerves being tested. The result is a

mild electric shock. The second rod transfers the

response produced by the nerves to the first rod.

The transferred stimulus is recorded on a

computer monitor. The speed and time at which

the signals used to reach one electrode from the

other is also recorded.

The results of the test depend on several factors, namely (103,104,109):

Anatomy and health of the nerves

Diameter of nerve, and

Layer of fat surrounding the nerve

NCV is indicated in persons with the following signs and symptoms (103,104,109):

Tingling, burning, and electric shock-like pain in the lower back and extremities,

Hyperaesthetic lower back, and

Chronic pain in the lower back and legs.

The conditions causing lower back pain that can be diagnosed with the help of NCV are

spinal nerve damage and dysfunction such as (103,104,109):

Pinched nerves

Femoral nerve dysfunction

Myopathies in diseases such as myasthenia

Lambert Eaton Syndrome

Spinal code damage

Spinal nerve root damage

Disc prolapse

Conduction block

Axonopathy


Demyelination

The benefits of NCV are as follows:

It is non-invasive

It can be easily done in both adults and children

The major limitation of NCV is that healthy nerve cells are best detected, possibly

masking damaged spinal nerves through normal NCV test results.

Evoked potential (EP) studies

EP studies are done when there is a confirmed involvement of the central motor-

sensory nervous system in the pathology of lower back pain.

EP studies are done when the patient presents with the following manifestations

(103,104,109):

Neurological symptoms such as burning, stinging, and electrifying pain in the

lower back

Unable to stand or bend too long

Unable to bend forward or backward easily due to pain, weakness and

tenderness in spine

There are two types of evoked potential studies, namely:

1) Somatosensory EP studies,

2) Laser evoked EP studies, and

3) Dermatomal EP studies

There are two rods used in EP studies. One rod is used to stimulate the nerves and

transmit sensations from the periphery to the centre. The other rod is placed on the top

of skull to measure the velocity at which these sensations reach the brain. Essentially, it

is the sensory pathway of the spinal nerves that is stimulated in somatosensory evoked

potential studies. In dermatomal evoked potential studies, rods are placed anywhere on

the skin, along the sensory pathway of spinal nerves.


EP studies are helpful in determining the location of nerve damage, i.e. whether it is in

the motor system (conduction from centre to periphery) or in the sensory system

(conduction from periphery to centre) (103,104,109):

The conditions and diseases diagnosed with the help of EP studies are (103,104,109):

Radiculopathy of spinal cord

Spinal compression

In somatosensory evoked potential studies, a delayed response found from the proximal

nerve roots indicates damage of the S1 (sacral) spinal nerve root. The delayed

response is seen in the form of H reflex on the screen. H reflex provides reliable

information on the involvement of S1 nerve root in lower back pain. Damage to S1

spinal nerve roots can sometimes be seen in the form of F waves.

Laser evoked potential (LEP) studies

LEP studies, as the name suggests, makes use of infrared laser stimuli that is passed

on to the spinal canal to create clear images (112).

The major limitation of evoked potential studies is its lack of usefulness in diagnosing

causes of acute back pain. Its clinical value is most apparent in the diagnostic

evaluation of chronic pain (112).

Bone scanA bone scan is an invasive procedure that makes of radionuclides to create images of

bones. It is also known as bone scintigraphy.



Patient is asked to urinate prior to the start of the procedure since the presence

of urine in the bladder can interfere with the proper visualisation of pelvic bones.

Metallic ornaments, pins, and piercings should be removed prior to the scan.


The procedure proceeds as follows:

1. Site of the injection is chosen and cleaned.

2. The radioactive dye, also known as radioactive “marker” or “tracer”, is injected.

3. Patient is passed through the scanner machine for the bone scan three hours

after the injection of the radioactive dye.

4. Patient positions are altered to allow scanning from different angles.

5. After the procedure, the patient is asked to drink copious amount of water to flush

out the radioactive dyes.

An even distribution of the radioactive dye into the pelvic bones generally means the

structures are healthy. There are certain regions of the bones that absorb very little, if at

all, any of the radioactive dye. These regions do not appear on the image generated by

the scanner, and are referred to as dark or cold places. On the other hand, the regions

which absorb and accumulate any of the radioactive dye will appear on the image, and

are referred to as bright or hot places.

The abnormal distribution pattern of radioactive dyes used in the bones is indicative of

pathologies related to bone metabolism of the spinal bones (103,104,110).

The conditions and diseases diagnosed with the help of bone scans are as follows

(103,104,110):

Ischemic and necrotic bones such as those seen in multiple myeloma wherein

plasma cells multiply in malignant manner;


Inflammatory conditions which appear as bright regions. These regions indicate

rapid growth and repair such as those seen in arthritis, over growth of spinal

bone, tumors in bone tissues, and infection;

Paget’s disease involving the spinal vertebrae;

Diffuse and occult injuries to the spinal vertebra. Stress fracture or compressed

fractures often seen in athletes;

Osteoporosis, osteomalacia, and osteodystrophy;

Altered blood metabolism and decreased blood supply to spinal bones;

Structural spinal bone changes due to metabolic disorders such as

hyperparathyroidism; and,

Metastatic activity of adjacent malignant cells involving the prostate, mammary,

renal, and pleural tissues.

The benefits of bone scans in diagnosing causes of back pain are (103,104,110):

It helps determine the onset of the injury.

It helps in the visualization of spinal bones which are not normally seen in x-rays.

It is instrumental in the early diagnosis of spinal bone lesions.

It can help the clinician find the exact cause of lower back pain that was

otherwise missed by other diagnostic tests.

The disadvantages of bone scans are (103,104,110):

a) Its invasive nature may prove to be painful and uncomfortable for young children

and patients highly sensitive to pain;

b) The use of radioactive dyes can trigger allergic reactions in vulnerable and

idiosyncratic patients. Reactions may vary from mild to severe and manifest as

skin rashes, irritation, headache, blurred vision, nausea, vomiting, fever, and

convulsions.

The limitations of bone scans are (103,104,110):

a) It is not safe to use on pregnant patients because of the use of radioactive dyes

which can cause serious fetal harm.


b) It is not safe to use on nursing mothers since the radioactive dye can pass

through breast milk and be ingested by feeding infants.

c) It requires a gap time of about 4 days before it can be performed in patients who

previously underwent diagnostic tests using bismuth and barium.

d) Its inability to distinguish structural lesions clearly. CAT scan, MRI or tissue

biopsy is required following the bone scan to study these lesions further.

e) It is a time-consuming procedure, with the preparation taking about 3-4 hrs and

the scan about 1 hr.

ThermographyThermography, also known as digital infrared thermal imaging (DITI), is a non-invasive,

non-contact diagnostic imaging method that uses body

heat to capture images of the body structures.

Thermography uses infrared rays detectors to

determine the relative heat and temperature of tissues.

Altered heat is indicative of disease or pathology which

causes pain. Every organ has different temperature in

the body and temperature in the left and right portions

of the body is also different. Since every tissue can

generate its own heat, small alterations in the heat signatures of organs and tissues is a

red flag, indicating infection or pathological damage.

The initial cause of pain can be identified using thermography. The pain intensity level is

recorded and presented graphically on the screen. It determines whether the pain is due

to abnormalities in the spinal canal or pathology involving the surrounding tissues. It

also determines whether the pain is referred from other tissues or is limited to a local

area (103,104,111).

The conditions and diseases diagnosed with the help of thermography are (103,104,111):

Injury to spinal muscles, ligaments, tendons and other soft tissues of the body

Infection such as abscess in the spinal muscles, and tendons

Inflammation of the spinal canal and surrounding tissues


Nerve root compression. Nerve damage due to compression will show a

decreased temperature in that zone on the screen.

The benefits of thermography are:

It is safe to use in both children and adults

It is relatively easy and comfortable for patients

It is painless

It is non-invasive

It can be safely performed on pregnant women since no harmful ionizing

radiations and magnetic waves are used

It can be safely performed on very young children who cannot narrate verbally

their exact signs and symptoms

It helps in distinguishing the pain into two types, based on their sites of origin

The two types of pain distinguishable by thermography are (103,104,111):

1. Type 1 (specific pain): severe pain due to involvement of the spinal cord

2. Type 2 (non-specific pain): less severe pain usually due to muscular overload,

muscular sprain, over stretching of muscular tissues, and ligament injury.

UltrasoundUltrasound, also known as sonography,

is a non invasive method that transmits

high-frequency sound waves, through

body tissues. The echoes are recorded

and transformed into video or images of

the internal structures of the body. They

create images of soft tissue structures,

such as the gall bladder, liver, heart,

kidney, female reproductive organs, and

blockages in the blood vessels.


In diagnosing causes of lower back pain, sound waves are thrown on the spine and

surrounding tissues through a probe. The echoes produced and reflected from the

spinal tissues are converted into black and white images on the monitor. The Doppler

technique can be used in conjunction with ultrasound to determine the amount of blood

circulation to the spinal canal and its surrounding tissues (e.g. presence of ischemic

disease).

The following conditions and diseases are diagnosed using ultrasound:

Injuries to the tendons, ligaments and other soft tissues

Ischemic condition of the spinal canal

The benefits of ultrasound in lower back pain are (103,104):

It is useful in determining the proper site for insertion of needle and catheter in

the spine (epidural space). Catheters are inserted into the spine for the

administration of anesthetics prior to various spinal surgeries such as Caesarean

Section and abscess removal from the spine.

It is instrumental in determining the correct location and depth of spinal needle

insertion during surgical removal of epidural abscess and biopsy of spinal

tissues.

It is a useful diagnostic tool in obese children and adults with scoliosis, kyphosis

or kyphoscoliosis prior to corrective spinal surgery.

A major drawback of ultrasound is its inability to visualize bony congenital deformities

and injuries (e.g. fractures) that cause lower back pain. Bones are not visible via

ultrasound (103,104).

TREATMENT AND MANAGEMENT

The treatment and management of lower back pain consists of five general approaches,

namely. These are listed below and discussed in detail in this section.


1. Physical therapy

2. Surgical interventional therapy

3. Non-surgical interventional therapy

4. Pharmacotherapy

5. Alternative therapy

Physical and alternative therapies

Surgical interventional

therapy

Non-surgical interventional therapy

Pharmacotherapy

Acupuncture Vertebroplasty Spinal cord stimulation NSAIDsTraction Foraminotomy Epidural steroid injections Weak opioids

Exercises Kyphoplasty Facet joint corticosteroid injections

Strong opioids

Spinal manipulation

Spinal laminectomy Botulinum injections Anticonvulsants

IDET Spinal fusion AntidepressantsTENS Discectomy Other

off-label drugsUltrasound Nucleoplasty

Biofeedback Radiofrequency lesioning

Cognitive behavioral

therapy

General guidelines for treating lower back pain

Low back pain is undoubtedly one of the most commonly encountered medical

problems, and in the United States it is estimated that an annual cost of over a $100

billion in spent either directly or indirectly for diagnosing and treating back pain. For this

reason, local guidelines have been developed to thoroughly investigate and treat

conditions causing back pain. The overview of these guidelines includes a thorough

history of current and past problems, the nature and duration of which should be

ascertained, and also a detailed examination of the back at the initial visit.

The doctor should ask patients for any alarming manifestations that may indicate a

serious underlying disease; these signs and symptoms are called red flags. Red flags

for back pain include history of trauma, cancer, unintentional weight loss, use of


immunosuppressive drugs (including steroids), AIDS, IV drug usage, osteoporosis, age

more than 50 years, focal neurological deficits, and also history of pain progression.

With the above information, the clinician will then be able to make more sense of the

patient’s pain symptoms. The clinician can categorize the patient to having either

nonspecific lower back pain, lower back pain secondary to radiculopathy or spinal

stenosis, or low back pain secondary to a specific cause (which is indicated by

presence of red flag symptoms).

Once the cause has been identified, evidence-based order sets will help the physician

guide the patient through the assessment, and management and follow up plans. A

follow up evidence-based order sets should again be obtained after 4 weeks of therapy

to help the physician assess the patient’s symptom progression or lack thereof, and

make appropriate clinical decisions such as whether to pursue further therapy or

consider other therapeutic interventions.

There are various management guidelines that clinicians can follow to assess patients

with back pain. One example is the UK’s National Institute of Health and Care

Excellence (NICE) Pathway for low back pain below (71): The evidence based order sets

contain valuable information on the need for targeted therapy of specific conditions

causing lower back pain. Specific causes of low back pain that are not covered in the

NICE pathway are malignancy, infection, fracture, and ankylosing spondylitis and other

inflammatory disorders. A clinician who suspects that there is a specific cause for their

patient's low back pain should arrange the relevant investigations (71).


As mentioned in the “Diagnosis” section, MRI should only be ordered for non-specific

low back pain in the context of a referral for an opinion on spinal fusion. The clinician

should consider MRI if one of these diagnoses is suspected (71):

spinal malignancy

infection

fracture

cauda equina syndrome

ankylosing spondylitis or another inflammatory disorder.

After a thorough assessment, the clinician can then provide patient counseling to

promote self-management of pain. Topics to be discussed include but are not limited to

the following (71):

information on the nature of non-specific low back pain,


activities that may help strengthen muscles and alleviate the pain.

Essentially, clinicians need to encourage patients to stay physically active and to

exercise. They should include an educational component consistent with this pathway

as part of other interventions. When considering recommended therapies, clinicians

need to take into account the patient’s expectations and preferences, though this might

not always predict a better treatment outcome (71).

Generally speaking, nonspecific low back pain that is not associated with the presence

of any red flags and is experienced for less than 6 weeks can be treated with non-

steroidal anti-inflammatory drugs (NSAIDs) such as ibuprofen, diclofenac, and

paracetamol. If the physician deems it necessary, a second option is available with the

use of weak and strong opioids. They should be offered pamphlets/leaflets that help

educate them about their condition and choice of occupational or physical therapy. They

should be re-assessed after 6 weeks following the initial assessment and start of

therapy (71).

Similarly, patients who present with low back pain that is secondary to radiculopathy or

spinal stenosis can be treated with the aforementioned medications, and in certain

cases with gabapentin.

Patients who present with the above mentioned red flags should be assessed

thoroughly with imaging studies and laboratory tests. Patients with suspected fractures,

bone infections such as discitis and osteomyelitis, and malignancy are the group most

likely to benefit from this extended diagnostic assessment. Depending on the clinical

scenario, a number of different tests may prove beneficial. Typically, MRI scans with or

without contrast are adequate imaging modalities that help pinpoint the underlying

musculoskeletal causes. In cases where MRI scans are unavailable or contraindicated,

CT scans may be used instead. For suspected specific conditions, technetium bone

scan, lumbar spine radiography, and inflammatory marker tests like erythrocyte

sedimentation rate (ESR) and/or C-reactive protein may also be performed.


In cases where a patient exhibits progressive symptoms or presents with focal

neurological deficits, further imaging studies may need to be performed. These studies

may include (in addition to MRI) myelography and postmyelography CT of the lumbar

spine. A further need for lumbar spine CT with or without intravenous contrast may also

arise. In certain other cases, electromyography/nerve conduction velocity studies may

also need to be performed for accurate diagnosis (72).

It is expected that these guidelines would reasonably provide an appropriate assistance

in developing a care plan that significantly benefits the patient by reducing the number

of unnecessary imaging studies. This would reduce the inappropriate use of narcotic

and opioid drugs, and also by potentially decreasing the number of unnecessary and

inappropriate invasive procedures.

Ice and HeatThe treatment of back pain depends on a number of factors such as its cause, type,

duration, and severity. Ice and heat packs are common and effective methods of

treating acute and sometimes sub-acute back pain. Heat packs are typically not

recommended when swelling accompanies back

pain especially immediately after the occurrence of

injuries. Heat causes vasodilation, which may

increase the swelling. In the initial hours (up to 48-

72) following an injury, ice or cold packs can be

placed on to the affected area to reduce the pain.

Swelling or inflammation ensues following direct

trauma to the blood vessels of the back. Swelling

occurs when blood leaks from the damaged

capillaries and accumulates in the surrounding tissue spaces; this causes the visible

swelling. Ice or cold packs help constrict the blood vessels and reduce the extravasation

of serum and blood, which in turn reduces the inflammation. Once the swelling dies

down following application of cold packs, the pain also significantly goes down. First aid

responders will do well to remember not to place ice packs in direct contact with the skin


since doing so predisposes the patient to the risk of cold burns or frostbites. Placing a

cloth between the two surfaces and limiting the amount of cold exposure minimizes this

risk. Ice packs should be placed for 15-20 minutes up to 3-4 times a day. It is generally

recommended to alternate the use of ice and heat packs in order to provide immediate

optimum pain and inflammatory relief.

As mentioned previously, heat packs are best avoided in the initial hours of injury as it

causes further vasodilation of the vessels, which encourages further tissue

inflammation. However, once the inflammation has reduced, heat packs and electric

heat pads may then be used to treat the pain. Electric heat pads should be started and

maintained on low temperatures to avoid

burns. Other effective methods of delivering

heat include hot water bottles,

microwaveable gel packs, saunas, and

treatment with steam. Some people have

also reportedly benefited from taking hot

showers.

Studies show that heat therapy can have

the most prominent effects during the first

week following an injury. Evidence also suggests that superficial heat therapy can help

with acute and sub-acute lower back pain especially if it is accompanied by proper

exercise, which improves musculoskeletal function (73). A trial conducted in 90 patients

showed significant relief of acute back pain following application of heat blankets. There

is however conflicting evidence to suggest the superiority of either treatment (ice and

heat) in opposition to one another (74).

Bed RestBed rest is commonly advised or sometimes self-prescribed by many individuals

following acute lower back pain to reduce the pain and muscle stress. However, no

significant evidence exists to suggest that bed rest benefits patients suffering from acute

lower back pain. On the contrary, some evidence actually point towards the opposite i.e.


it is actually slightly advantageous to stay active through mild exercises in these

circumstances. Studies have verified that patients suffering from lower back pain and

sciatica actually experience greater pain intensity and decreased functional recovery

following bed rest (75).

ExerciseExercise has innumerable health benefits, which include improved cardiovascular

functioning, reduced risk of chronic illnesses such blood pressure, type 2 diabetes, renal

disease, and even certain types of cancers. It has also been shown to be beneficial in

improving self-esteem, regulating mood, and improving symptoms of depression.

Similarly, patients with lower back pain can benefit from daily-targeted exercises

through improved functionality and reduced pain symptoms. However, it should be

remembered that the type of exercise plays an important role in determining the benefits

of exercise on patients. Additionally, the type of back pain also determines which

exercises must be avoided.

Targeted exercises are generally recommended and to be started within 1-2 weeks after

onset of initial pain symptoms. Patients should keep in mind to always start with mild

exercises and to avoid activities that increase their pain intensity. Specifically, patients

with lower back pain will do well to remember to stay away from high impact exercises

such as running since it can very well exacerbate the pain. Exercises with maneuvers

that target the trunk region are also best avoided in the initial couple of weeks following

the onset of symptoms.

It is also important for to patients stick with light to moderate exercises. Low impact

aerobic exercises and swimming are generally advised. Exercise techniques usually

target endurance, strength, and flexibility. The techniques used in these exercises

augment the physical capacities of patients, and strengthen their muscles.

Some of the popular exercise routines that benefit patients with back pain are described

below [76]. These exercises are generally best started only following the advice of a


clinician or physical therapist. Additionally, patients are advised to stop if they develop

pain at any time during the exercises.

Bottom to heels stretch

This type of exercise aimed at stretching and mobilizing the spine. Patients are advised

to kneel on all fours and keep their knees under the hips and hands under the

shoulders. The goal of the exercise is to slowly

retreat the back while maintaining the natural

curve of the spine. Correct positioning is

mandatory and patients are advised only to

stretch as far as they are comfortable. Patients

with knee problems are advised to avoid this

type of exercise.

Knee rolls

Knee rolls also help in stretching and mobilizing the spine. Patients are advised to lie on

their back while keeping a cushion beneath the

head for comfort. The knees are kept together

and bent. The arms are outstretched with both

shoulders placed on the ground. The knees are

then rolled onto one side followed by a similar

movement of the pelvis. This position is held in

place for one deep breath. The same

maneuver is to be performed on the other side.

The exercise is usually repeated 8-10 times

per side to achieve the beneficial results.

Patients are advised to remember to alternate the exercises between the two sides, as

well as to keep pillows between the knees for cushioning effect and comfort.

Back extension exercises

Back extension exercises also target the spine, stretching and mobilizing its muscles.

Patients are advised to lie on their stomach and prop themselves onto their elbows. The


shoulders and back are kept in an optimal position by keeping the shoulders drawn

back and the neck elongated and stretched. This position serves to lengthen the spine.

In back extension exercises, patients are advised to keep their hips on the ground and

to avoid bending the neck backwards as this may cause discomfort or worse, injure the

neck muscles.

Deep abdominal strengthening

This is done by lying flat on the back and placing a small cushion beneath the head to

slightly lift it. The knees are bent and the feet

placed hip-width apart. The upper body is

then kept maximally relaxed. The technique

involves drawing up the muscles of the

abdomen and back during exhalation. It

should be remembered that this exercise

serves to gently tighten the lower abdomen

musculature and should not be done using

more than 25% of the patient’s maximum

strength. It is also important to remember to

relax the shoulders and the neck.

Pelvic tilts

These exercises also aim to stretch and strengthen the muscles of the lower back. The

startup position is similar to the one adopted for deep abdominal strengthening in which


the patient lies flat on the back with a cushion beneath the head and the feet flat and hip

width apart. The patient then proceeds to flatten the back further towards the floor and

at the same time, contract the abdominal musculature and the back gently pushed

towards the feet in order to attain a slight arch of the back. This position contracts the

back muscles. The exercise is repeated, beginning with the starting position. It is ideally

repeated 10-15 times, moving the pelvis back and forth in a subtle rocking motion.

These exercises are believed to help patients alleviate their symptoms of lower back

pain. In fact, there is a study that further supports the beneficial effects of non-weight

bearing exercises such as those mentioned above on females suffering from chronic

non-specific back pain. This study also found that such exercises help improve

functional status, relieve pain intensity, and restore the normal range of motion and

allowing lumbar flexion and extension in females suffering from non-specific chronic

lower back pain [77].

Another study conducted in Canada focused on the use of a specific type of exercise

machine that can help train the back muscles for better endurance. The study showed

the machine to be effective in both healthy individuals and patients suffering from non-

specific back pain. Poor back muscle endurance is often associated with lower back

pain, and is seen to be the group that could benefit the most from this invention [78].


Exercises are undoubtedly effective in reducing pain symptoms of the lower back. As

mentioned earlier, there have been studies conducted in the past that show the benefit

of mild to moderate exercises in patients with back pain as compared to bed rest in

terms of improvement in functional status. Moreover, there are no evidence-based

studies that show the superiority of bed rest to exercise for alleviating pain in the same

patient group.

Spinal manipulationSpinal manipulation, also known as spinal manipulative therapy and chiropractic

adjustment, is a manual therapy technique practiced by many health care professionals

including chiropractors, osteopathic physicians, naturopathic physicians, physical

therapists, and sometimes also by medical doctors to help patients alleviate their

symptoms of lower back pain. The technique involves deliberate delivery of force to the

synovial joints of the lumbo-sacral and sacroiliac regions to treat the related conditions

of lower back pain. The technique is not

limited to these joints and is performed on

other joints in the body for other pain

symptoms (e.g. neck pain).

Spinal manipulation basically refers to the

local application of a single quick and forcible

movement of small amplitude to the targeted

joints. The movement is often termed as a

‘high velocity thrust’, with the patient carefully

positioned prior to its delivery. It is generally considered to be a quick and safe

intervention that has the potential to provide relief from back pain. It is especially

effective in alleviating the symptoms of acute back pain, more so than chronic back

pain.

Despite its popularity, evidence of its effectiveness is debatable i.e. its quantifiable

benefit in the treatment of lower back pain symptoms. There are different approaches

towards spinal manipulation and no solid guidelines have been established owing to the


varied individual responses to this type of treatment. Some people do not recommend

this treatment at all whereas others recommend it as a last resort treatment in cases

when patients do not respond to other conventional forms of therapy.

A large systematic review conducted to test the effectiveness of spinal manipulation in

treating lower back pain concluded with promising results. The review itself was thought

to be the first of its kind and was published in 2012. It included 6 studies that met the

study criteria. The most prominent results featured in this review included varying

degrees of beneficial effects seen in patients receiving spinal manipulation therapy with

minimal adverse effects being reported. Moreover, it was seen that patients undergoing

spinal manipulation for lower back pain reported less use of pain medication, decreased

visits to health care professionals, and also lower rate of yearly absence from work.

Some of the individual studies analyzed in this review concluded that significant

improvement was seen in disability scores of patient’s up to 6 months post treatment

with spinal manipulation (79).

The review showed that most studies concluded a notable improvement in patients who

underwent spinal manipulation for their lower back pain. However, the degree of

effectiveness varied between patients. Although the review mostly favored the use of

spinal manipulation for lower back pain, it also found one study, which reported the

adverse effects of spinal manipulation. The study particularly showed that non-thrust

manipulation was observed to have a worst outcome than two experimental thrust

manipulation groups [79,80]. For the purpose of clarification, the non-thrust group

comprised of individuals given posterior to anterior mobilizations to the L4-L5 spinal

processes. Patient feedback on this procedure was largely negative which may be due

to the irritating effects to the patients.

Another systematic review conducted on the adverse effects of spinal manipulation

similarly concluded that serious or severe complications of this procedure are rare [81].


Many patients also reported improvement in their pain scores for up to four weeks. One

study in particular reported improvement of temporal pain summation in patients

receiving manipulation over lower back extension and stationary cycling.

Another systematic review conducted in the US and published in 2010 showed similar

promising results of spinal manipulative therapy use in patients with acute lower back

pain. This review concluded that evidence from recently conducted trials supported the

use of spinal manipulation in patients with cute lower back pain. Patients receiving 5 to

10 sessions spread over a period of 2 to 4 weeks showed comparable and some even

superior evidence of improvement in acute lower back pain symptoms to other forms of

treatment (e.g. medication, self-management, and exercise therapies). The review even

proposed that patients, not benefitting from self-care alone, to be offered spinal

manipulative therapy as a treatment option by their health care professionals [82].

Another study conducted in Egypt in 2011 showed that patients receiving sustained

spinal manipulative therapy for lower back pain showed greater improvements in their

pain symptoms and disability scores compared to individuals receiving single or short

term sessions. The study was divided into three groups:

1. Group 1:

Patients receiving 12 sessions of spinal manipulative therapy over a month

2. Group 2:

Patients receiving 12 sessions over a month and no treatment thereafter

3. Group 3:

Patients receiving 12 sessions of spinal manipulative therapy over one month

and then maintenance manipulation therapy every 2 weeks for a period of 9

months.

The study concluded that Group 3 patients benefited the most from this technique. Their

pain and disability scores showed marked improvement compared to the non-

maintained group. It also concluded that patients who received no maintenance therapy

following the study period maintained their improved pain and disability scores and did

not revert back to pre-treatment numbers. From this study, it is safe to conclude the


valuable role of maintenance therapy in patients receiving spinal manipulation for

chronic lower back pain [83].

Non-surgical interventional therapiesPatients with chronic lower back pain who failed to respond to conservative treatment

are strong candidates for interventional therapies. There are two types of therapies that

fall under this broad category; they are namely:

Non-surgical interventional therapy

Surgical interventional therapy

Each one requires an invasive approach to delivering treatment at the target site to

provide pain relief. As mentioned previously, non-surgical interventional therapy

consists of spinal cord stimulation, epidural steroid injections, facet joint corticosteroid

injections, and botox injections.

Spinal cord stimulation (SCS)

Spinal cord stimulation is a procedure performed using a device to deliver electrical

signals to the spinal cord to achieve relief for chronic pain. The device used is called a

spinal cord stimulator.

The procedure involves implantation of stimulating electrodes into the epidural space

and placement of an electric pulse generator in either the gluteal or lower abdominal

region. These two devices, along with a generator remote control, are connected

through wires. There are different theories through which spinal cord stimulation

achieve pain relief. For instance, in neuropathic pain, it has been proposed that it

suppresses hyperexcitability of neurons; thus, changing the local neurochemistry of the

dorsal horn.

Experiments have shown that in such circumstances, there is a decreased production of

excitatory amino acids, aspartate and glutamate, and an increase in serotonin and

GABA (gamma amino butyric acid) levels. On the other hand, this mechanism is not

observed in patients with ischemic pain. When spinal cord stimulation is performed on

patients with ischemic pain, beneficial effects seem to arise from the restoration of


balance to the oxygen demand-supply of the ischemic area. This in turn may be a result

of sympathetic system inhibition and/or through vasodilation.

Spinal cord stimulation comes with a wide range of complications including:

Infections

Headaches

Paraplegia

Death

Because of the severe complications that can occur from this procedure, however low

their risk may be, it is reserved only as an alternative and last course to conservative

treatment of lower back pain. It has been suggested that patients with persistent and

disabling lower back pain despite undergoing surgery for herniated discs (with no

evidence to support a persistently compressed nerve root), may be good candidates for

spinal cord stimulation. This subset of patients needs to be made aware of the risks and

benefits of the procedure to help them make an informed decision regarding their

treatments. Long and short-term complications of the procedure should be thoroughly

discussed with these patients [157].

Epidural steroid injections

The practice of injecting steroids into the epidural space is a common practice in the

treatment of radicular lower back pain. The goal of the therapy is to provide a strong


anti-inflammatory (steroid) medication into the space to achieve adequate analgesia. It

is usually given for back pain that is secondary to nerve impingement or disc herniation.

However, it is not a first line treatment option

and should not be given before other treatment

modalities (including conservative

management) have been tried and tested.

Patients with radicular back pain that is

secondary to a herniated disc should be

offered a detailed discussion of the pros and

cons of epidural steroid injections as a possible therapeutic modality [157].

Facet joint corticosteroid injection

A facet joint injection delivers a dose of corticosteroid medication into the facet joints to

anesthetize them and block pain perception. The major indications for facet joint

injections include:

Clinical suspicion of facet syndrome

Tenderness over these joints

Chronic lower back pain without radiological evidence of any disease

Persistent pain after spinal fusion surgery

It should be remembered that this treatment modality has not been supported by

evidence-based data as a superior method of

treating lower back pain.

A study published in 2011 supported the use of

facet joint injection as a diagnostic and treatment

modality in chronic lower back pain. It found that

when these injections are delivered under

fluoroscopic guidance, they exhibit high accuracy

and effectiveness. It suggested the benefit of facet joint corticosteroid injection in short-

term pain relief. Also, the procedure was found to exhibit very limited long-term benefit

in pain relief [62].


Botulinum (Botox) injection

Botulinum toxin A (BTX-A) is a substance produced by the bacteria Clostridium

botulinum, a bacteria commonly implicated in food poisoning. It is a neuromuscular

blocking agent that blocks acetylcholine, a neurotransmitter primary responsible for

muscular contractions. The toxin, when injected in small amounts into the painful

muscles, can relieve spasms by interfering with their nerve conduction pathway.

BTX-A’s supposed positive role in pain management was originally only attributed to its

inhibition of acetylcholine release from the synapse, affecting motor endings but sparing

sensory neurons. However, preclinical studies have also

demonstrated the effects of BTX-A on nociceptive neurons,

suggesting its ability to produce analgesia as a secondary

effect that may be the result of muscle paralysis, enhanced

circulation, and release of nerve fibers under compression

by abnormally contracting muscle.

For most limb muscles, motor point stimulation is generally

used to identify muscles, especially the smaller muscles in

the forearm. For the clinician who is new to the procedure, the use of simple, audio-only

electromyography may help enhance the clinician's understanding of functional anatomy

and make informed decisions on injection localization. For muscles requiring

electromyographic guidance, a cannulated monopolar needle cathode, through which

BTX-A can be injected, is used. Surface reference (anode) and ground electrodes

should be placed near the cathode needle (159).

The patient is placed in a position that allows for the targeted muscle to be relaxed so

that the motor point can be easily located. BTX-A is then given after aspiration to

prevent intravascular injection. Alcohol, if used to clean the skin, should be allowed to

dry completely to prevent deactivating the BTX-A. The use of operating rooms or

special procedure (sterile) rooms equipped with monitoring devices for the purpose of

intramuscular injections using small caliber needles is not necessary. Most patients can

be treated safely in an office setting by trained clinicians (159).


Good quality evidence is missing in supporting the role of botulinium toxins in treating

back pain. However, small-scale studies conducted over the years have reported its

clinical benefits. A Cochrane review identified one study, consisting of 31 participants

that showed BTX-A to be superior to saline injections in the treatment of pain at 3 and

8-week intervals. Patients who received these injections showed marked improvement

in their functional status eight weeks after first receiving them [160]. Lastly, severe side

effects have also been reported with BTX-A injections, limiting its promising role in pain

management.

In cases where patients do not respond to conservative treatment and non-surgical

interventions, surgical procedures may be the only course of action left to take. Surgical

interventions include but are not limited to spinal laminectomy, spinal fusion,

vertebroplasty, kyphoplasty, discectomy, foraminotomy, and nucleoplasty.

Spinal laminectomyLower back pain can range from being mild or dull to irritating, severe, and disabling,

depending on the patient, circumstances, and underlying cause. Patients with disabling

back pain that seriously threaten or undermine their functional abilities (e.g. nerve

damage or bone pathologies that indicate surgical intervention) are generally good

candidates for surgical treatment if their pain is refractory to non-invasive therapies.

One such surgical treatment is a procedure called spinal laminectomy.

Laminectomy is typically performed to release pressure from the spinal column, treat

disc herniation and similar related issues, and to remove tumors that impinged on the

nerves of the spine. The procedure basically

comprises of removing the bony posterior part of the

vertebra overlying the spinal column, or the lamina

(85).

The procedure usually requires overnight hospital

stay and depending on the surgeon, may be

performed under general or spinal anesthesia. The nerve compression is released by


cutting out the bony growths/spurts/tumors. The surgeon may also choose to do a

spinal fusion in the same operation if deemed necessary. This involves the fusion of two

bones to provide adequate support to the spinal column. Although the procedure is

seen to benefit a number of patients with different underlying medical conditions, it does

carry the risk of complications stemming from the use of general anesthesia, surgery-

induced spinal nerve damage, bleeding, infections, and blood clots in the legs and

lungs. There may be other risks not mentioned. In order to be safe, it is always

advisable to discuss the possible risks of the operation with the surgeon in order to

obtain a focused risk assessment pertaining to the patient’s specific underlying disorder

(85).

A study conducted in the UK and published in August 2013 found laminectomy to

exhibit pain-relieving effects on patients with back pain secondary to lumbar spinal

stenosis. These patients also showed a significant decrease in lower back pain scores

as early as six weeks following the procedure, which was sustained up to a year. Lastly,

these patients also reported lower disability index scores (86).

Spinal fusionSpinal fusion is another surgical technique that involves the fusion or joining together of

two or more vertebral bodies, thereby effectively restricting any movement between

them. This can be done using supplementary bony tissue, from either the patient (auto

graft) or a donor (allograft), to enhance the osteoblastic activity of the bony tissue to

promote fusion.

Spinal fusion is indicated to reduce pain associated with frictional forces of two spinal

bones rubbing together, correct any underlying deformity, and provide greater stability

to a weakened spine. Examples of conditions requiring spinal fusion include (90):

Broken vertebrae (not all vertebral fractures require surgical intervention, in fact

only those causing spinal instability would require spinal fusion)

Deformities of the spine such as kyphosis and scoliosis

Severe arthritis of the spine or spondylolisthesis wherein one vertebra slips

forward on to the vertebra placed below it.


Weak spine due to the surgical removal of herniated discs. Spinal fusion

provides stability to the spine.

Chronic back pain that cannot be attributed to a specific disease or disorder.

However, there are controversial views about the effectiveness and

appropriateness of this procedure in patients with nonspecific but chronic lower

back pain.

When other surgical interventions are also indicated such as foraminotomy,

laminectomy or discectomy, these are

almost always done prior to the spinal

fusion. The procedure involves the patient

being put under general anesthesia, and

then the surgeon exposing the spine

through an incision on the back (or

sometimes on the side). The two

vertebrae are then fused together by

placing the graft material on the back of

the spine or between them. Finally, surgical cages, plates, rods or screws may be used

to hold the vertebrae in place and facilitate proper tissue healing. The surgery usually

lasts between 3-4 hours.

Spinal fusion, like other invasive interventions, is also associated with a number of risks,

namely (90):

Complications due to general anesthesia

Post-operative infections

Poor wound healing

Bleeding

Blood clots

Injury to the adjacent spinal nerves and blood vessels,

Pain may be felt at the site where the supplementary bony tissue was obtained.


A paradoxical back pain is also a risk associated with spinal fusion stemming from

surgical complications. This happens due to the shift of stress from the fused vertebrae

onto other adjacent parts of the spine, which in turn accelerates the degenerative

process of wear and tear, and ultimately causes back pain.

A systematic review of 25 studies that was published in 2008 found that spinal fusion is

especially clinically useful in patients with degenerative disc diseases such as

spondylolisthesis. Specifically, the study found it to substantially improve disability

scores in this particular patient group. However, the procedure is ineffective in patients

with chronic lower back pain, showing no marked improvement in their disability scores

post-surgery [91].

Although a study published in 2001 in Sweden advocated the use of spinal surgery in

patients with chronic lower back pain [93], a more recent meta-analysis published in 2013

suggests that spinal fusion is no more effective than conservative treatment in

improving disability scores in patients with chronic lower back pain. The review also

states that further studies on the subject are also likely to suggest similar outcomes [92].

Kyphoplasty Kyphoplasty, also called balloon kyphoplasty, is used to treat or stop the pain caused by

spine compression fractures or a collapse of the bones. The fractures are usually a

result of osteoporosis (a weakening of the bone), cancer or an injury that caused the

bone to break. The goal is to restore the height of the vertebral body, stabilize the

bones, align the spine and alleviate pain. The procedure may be performed either in a

hospital or an outpatient clinic. Treating one fractured vertebra with balloon kyphoplasty

may only take about an hour (94).

Patients should first consult with the interventional radiologist a few days before the

procedure. Patients may be asked to stop certain medications, such as aspirin,

ibuprofen, non-steroidal inflammatory drugs or blood thinners such as warfarin and

Coumadin. These medicines make the blood hard to clot. If patients are taking any

medication, they should ask their doctor if it is allowed. Patients should inform the


radiologist and clinical staff members if there’s a chance of pregnancy and allergic

reactions to local or general anesthesia and x-ray dye, which is a contrast media.

Smoking and drinking a lot of alcohol should also be stopped. On the day of

kyphoplasty surgery, patients may also be asked not to eat or drink several hours prior

to the test (94).

On the day of the surgery, patients should wear

comfortable clothes and shoes. They should also

bring a list of their medications and avoid bringing

jewelry and valuables.

The procedure begins with the induction of

anesthesia. First, the back area is cleaned and

sterilized. Local or general anesthesia is then

applied. A small incision is made in the back area

and a hollow needle, called a tracer, is placed

through the incision until it reaches the fractured vertebra. Interventional radiologist may

perform intraosseous venography examination to make sure that the needle is

positioned in the correct area. Most interventional radiologists, however, skip this part

and proceed directly with kyphoplasty (94).

A balloon, also called a bone tamp, is inserted through the hollow needle. The balloon is

then carefully and gently inflated in the vertebral body. A hole or cavity is created and

the bone is pushed back to its normal shape and height. The balloon tamp is then

removed.

After the balloon removal, bone cement (polymethylmethacrylate) is injected under low

pressure into the space or void created by the balloon. Polymethylmethacrylate (PMMA)

quickly hardens and the bone is stabilized. The needle or trocar is then removed. The

skin incision is covered with a bandage.


The results include the alignment of the spine and restoration of the vertebrae height.

After the procedure, back pain is generally relieved.

To perform the procedure in the correct area, real-time images are needed. Fluoroscopy

is the most commonly used imaging technique. Modern fluoroscopy consists of an x-ray

image intensifier, fluorescent screen and CCD (charge-coupled device) video camera.

After the surgery, patients will be closely observed in the recovery room. Patients can

go home after the surgery but others may choose to spend another day in the hospital.

It is recommended not to drive, unless approved by the doctor. Patients may arrange

transportation from the hospital or outpatient clinic. They should be able to walk after

the surgery but it is recommended to stay in bed for 24 hours. After a day of bed rest,

the patient can return to daily activities but should not do heavy or strenuous work for at

least 6 weeks. If there is pain in the skin incision, ice may be applied to the wound (94).

One of the advantages of kyphoplasty is that the bone cement, which is

polymethylmethacrylate, used in the procedure is viscous. It thus decreases the

possibility of cement leak into other parts of the vertebra, including the sensitive spinal

cavity (94).

The balloon inflation within the bone reduces deformity, which may lead to hunchback

appearance, for the balloon restores the height of the vertebra. The procedure is also

viewed as minimally invasive which results in less operative trauma and shorter hospital

stays. Patients can usually go home after the operation on the same day. Less tissue

damage and blood loss will result due to smaller incisions.

After the surgery, patients experience less pain; and, in fact, most of them feel pain-

free. There is also faster recovery and reduced complications after the surgery.

The benefits also include mobility improvement and better quality of life. The patient

does not need physical therapy and can return to normal physical activities.

Consequences of future vertebral fracture are also reduced. The risk of pneumonia is

reduced because the patients can get out of bed after the procedure (94).


Although balloon kyphoplasty procedure is minimally invasive, there are also associated

risks. Because there is a skin incision, infections may occur. Risks also include allergic

reactions to anesthesia or medication. Bleeding, infection, breathing and heart problems

due to anesthesia may also result.

Malpositioned instruments during the procedure may cause nerve damage and spinal

cord injury. The bone cement (polymethylmethacrylate) used can leak to surrounding

areas. This is not serious unless it moves to dangerous locations such as the spinal

cord and lungs resulting to infections. But these cases are very rare (94).

VertebroplastyVertebroplasty, like kyphoplasty, is a medical procedure used to treat painful vertebral

compression fractures (VCF) due to osteoporosis, cancer, metastatic tumor or an injury

causing the bone to crack or collapse. The only difference is that in vertebroplasty, no

balloon or bone tamp is used (113).

Osteoporosis, which is mostly the cause of VCF, is the thinning and weakening of the

bones due to the loss of normal density, mass and strength of a bone. This causes

bones to become porous and easy to break. This disease can cause one or more

vertebrae to collapse leading to compression fractures.

Vertebroplasty is also a minimally invasive procedure, which means that it is not as

invasive as an open surgery, for only a small nick on the skin is made. Stitches are not

needed after the surgery, as a band-aid will work.

This procedure may be recommended if a person is

experiencing severe pain for 2 months or more that

is not alleviated by pain medicines, physical therapy

and bed rest. The procedure may be performed in a

hospital or an outpatient clinic (113).

An evaluation of the patient will be performed

including blood test, diagnostic imaging, physical


exam, spine x-rays, bone scan or MRI. Patients may be given bone-strengthening

medication.

A few days before the surgery, patients should inform their doctor about the medications

they are taking, including herbal supplements, and if they are drinking a lot of alcohol.

Women must also make it known if there is a chance of pregnancy to prevent over

exposure to radiations such as x-ray, which can affect the baby (113). Patients may also

be asked to stop smoking and taking medications, such as aspirin, coumadin, ibuprofen,

warfarin and other blood thinning medicines. They should ask their doctor what

medicines are allowed to take.

Several hours before the surgery, patients will be asked not to eat or drink anything.

Medicines given by the doctor may be taken with only a small amount of water. Patients

should wear comfortable clothes and shoes and avoid bringing valuables. Blood tests

will be done to ensure normal blood clot.

Patients will lie down on the table facing down. A monitor will be connected to track

heart rate, pulse and blood pressure. An intravenous (IV) line will be inserted into a vein

in the arm to give moderate sedative medication. Medicines for nausea, pain and

infection (antibiotics) may be given (114).

The back area will be cleaned or sterilized and then shaved. Local anesthesia will be

injected into the skin and tissues near the fracture. A small incision in the skin is made

and a hollow needle called a trocar will be inserted until the tip reaches within the

affected vertebra. To ensure correct positioning of the needle, real-time x-ray images

are used.

Orthopedic cement is then injected. The most commonly used bone cement is the

polymethylmetacrylate (PMMA), which is viscous, toothpaste like material. This bone

cement hardens quickly, usually within 20 minutes. After the cement injection, the trocar

is removed. To check the distribution of bone cement, x-rays may be performed. After

this, pressure will be applied and the skin incision covered with a bandage. The IV line

will then be removed (114).


Patients may go home after the surgery or may choose to spend another day in the

hospital. It is recommended not to drive after the surgery, so patients should arrange

transportation from the hospital or outpatient clinic prior to the surgery (114). They should

be able to walk after the surgery however a 24-hour bed rest is advised. After a day of

bed rest, patients should be able to go back to their normal activities; and, strenuous or

heavy work should be avoided for at least 6 weeks.

To alleviate pain caused by the skin incision, an ice pack may be applied on the skin

covered with cloth. This may be done for 15 minutes per hour. The bandage should not

be removed for 48 hours. Patients should also consult their doctor first before retaking

medications such as blood thinners.

Follow-up visits may be recommended by the interventional radiologist to discuss side

effects experienced by the patient and conduct physical check-up, blood test and

imaging procedure.

Vertebroplasty is a minimally invasive procedure so there is less operative trauma,

faster recovery and shorter hospital stays. In most cases, patients stay only a day in the

hospital or outpatient clinic. Only a small nick in the skin is made, so there is less tissue

damage, blood loss and scarring (114).

Most patients experience immediate pain relief. For others it may take a few days to feel

pain-free. About 75 % of patients who have undergone vertebroplasty have improved

mobility and became more active. Thus, the consequences of osteoporosis are

reduced. The risk of pneumonia is also lessened because patients are able to get out of

bed after the surgery.

Patients can perform normal daily activities without any physical therapy or

rehabilitation. They also need fewer pain medications. In general, vertebroplasty is safe

and effective and results to a better quality of life (114). Like any other procedures or

surgeries, vertebroplasty, although minimally invasive, has risks too. During the

procedure, the skin is penetrated, so infections may occur. The risk of infection,


however, is less than 0.1 %. Allergic reactions to anesthesia, x-ray dye (contrast media)

and other medications may arise (114).

A small amount of bone cement can leak to surrounding areas, which is not really

serious, unless it goes to dangerous locations such as the spinal cavity or the blood

vessels of the lungs. The problem of cement leakage is more common in vertebroplasty

than kyphoplasty (114).

After vertebroplasty, about 10 % of patients may develop additional vertebral fractures.

They may experience relief from pain for a few days after the procedure but the pain

comes back again soon. Bleeding, infection, neurological symptoms and increased back

pain may also occur. Paralysis is a very rare case (114).

DiscectomyA discectomy, also called discotomy or open discectomy, is the partial or complete

removal of herniated, degenerated or ruptured disc that presses on the spinal cord or a

nerve root. The stressing and pressing on the spinal cord can cause much pain.

The spinal column is composed of inter-locking vertebral bones and between those

vertebrae is a flexible, cartilaginous plate called intervertebral disc. Intervertebral disc

acts as a cushion that prevents interlocking vertebrae from rubbing each other and

producing friction, which may cause bone degeneration (95).

As discussed previously, a herniated disc is the bulging out of the jelly-like, central

portion of the spinal disc called nucleus pulposus as a result of the tear in the outer ring

of an intervertebral disc. In discectomy, the nucleus pulposus is surgically removed.

Age, diseases, lifting injuries, repetitive straining, spine trauma and deformities may

contribute to the tearing and wearing of intervertebral discs. Persons with herniated disc

may experience symptoms such as weakening of the lower extremity muscles, severe

back and leg pain that lingers for 6 weeks or more.


Abnormal sensations may occur, such as electric shock pains, due to nerve pressure. If

it occurs in the cervical region, the electrical shocks go from the neck down the arms. If

it is in the lumbar region, shocks go from the lower back down the legs. Numbness,

tingling and needles may also be experienced in the same regions. Abnormalities in

bowel movement, urinating and numbness around the genitals may also be experienced

as a result of nerve compression in the lowest region of the lumbar spine (95).

Physical examinations are performed including testing of muscle strength, reflexes and

sensations. The most commonly used aid in diagnosing herniated disc is the magnetic

resonance imaging (MRI).

Prior to the procedure, patients should inform their doctor regarding any medications

they are taking and whether they have allergic reactions to certain drugs. The doctors

should also be informed of the patient’s medical history. Pre-operative testing is done.

This includes chest x-ray, blood test, electrocardiography (ECG) and other tests (95).

Patients who are overweight should talk to their doctor about losing weight. Smoking

should be stopped several days before the surgery. A few hours prior to the operation,

eating or drinking is prohibited.

The determination of the type of surgery to be performed depends on the patient’s age,

diagnosis, medical history and personal

preference. Patients should be well informed

about the different types of discectomy (95).

The procedure begins with the induction of

anesthesia. An intravenous line (IV) will be

connected to the patient. They may be given

general or regional anesthesia. When general

anesthesia is used, the patient will be unaware

of the procedure and unable to feel pain.

Regional anesthesia, also known as nerve block,


however, keeps the patient awake but unable to feel pain. Vital signs of the patient need

to be closely monitored throughout the surgery and upon recovery.

There are various types of discectomy, and these are listed below as (95):

Cervical discectomy which is the removal of a disc in the cervical spine (neck

area),

Lumbar discectomy which is the removal of a disc in the lumbar spine,

Sacral discectomy which is the removal of a disc in the sacral spine, between

the pelvic or hip bones), and

Thoracic discectomy, which is the removal of a disc in the thoracic spine.

A discectomy may be performed by a neurosurgeon, (specializing in the treatment of

nerves), or an orthopedic surgeon (specializing in the treatment of bones and muscles);

and, there are three general approaches to discectomy. These are listed below as:

1. Open surgery

2. Microdiscectomy

3. Anterior discectomy

In open surgery, a 2-4 inch incision is made down the middle of the affected spine that

allows the doctor to view the surgical area. This type of surgery is mostly performed for

the treatment of lumbar spine herniated disc, and if additional procedures are needed

such as spinal fusion, foraminotomy or laminectomy.

Microdiscectomy is relatively less invasive than the open surgery. It is considered a

minimally invasive procedure. A small incision (less than 1 inch) is made along the side

of the affected spine and special instruments are inserted through the incision. This

procedure is performed when no other treatment is needed. Unlike open surgery,

microdiscectomy entails lesser pain, infections and faster recovery (95).

In anterior discectomy, an incision is made in the front part of the body. In cervical

discectomy, the incision is made through the neck. In lumbar and sacral discectomy, it

is through the belly or abdomen. In thoracic discectomy, the incision is made in the

chest (95).


Patients may stay in the hospital for a period for further observations. In most cases,

however, one or two days in the hospital are enough. The recovery stage is gradual. It

depends on the patient’s age, health, anesthesia used and the type of procedure

performed. The doctor may encourage walking and avoid sitting for a long period of

time. It takes about 2 to 6 weeks for full recovery.

After the surgery, patients may experience the disappearance of electrical shock pain,

tingling numbness and weakness. For others, it may take a few weeks. Every surgery

has certain risks and complications. They can develop during or after surgery. The risks

include allergic reactions, breathing and heart problems due to anesthesia. Infections

and bleeding that leads to shock. Blood clot can occur in the leg or pelvis, which can

travel to the brain, heart and lungs and can cause stroke, pulmonary embolism and

heart attack (95).

Complications include nerve damage, which can lead to permanent weakness. Disc

fragments that are not removed may require additional surgery. This case may occur in

microdiscectomy. Recurring pain may also be experienced.

Patients should make sure to inform the medical team members about any allergies.

Restrictions regarding diet, activities and lifestyle should be followed. For pregnant

women, it is necessary to inform the doctor before proceeding with the surgery. The

doctor should be notified immediately in case there is bleeding, swelling, increased pain

and fever. The medicines given by the doctor should be taken exactly as directed (95).

ForaminotomyForaminotomy is a surgery that widens the back opening where nerve roots leave the

canal. It comes from two words, foramen and otomy. Foramen is a hollow passage or a

natural opening through bone. On the other hand, otomy means to incise or cut.

There are 31 pairs of spinal nerve roots that pass through the foramen. These spinal

nerves provide sensations. The nerve opening may narrow, which is called foraminal

stenosis. A nerve root may leave the spinal cord through the openings (neural

foramena) in the spinal column. When the nerve root openings become narrow,


pressure on the nerve can result. A bone, disc, excessive ligament, scar tissue and

pinched nerves may compress the foramen.

This procedure takes the pressure from the

nerves in the spinal column allowing easy

movement of the spine. Foraminotomy can

often be performed as a minimally invasive

procedure. It may be endoscopically or

microscopically. In minimally invasive

procedures, only a small cut or incision is

made. The result is less pain, blood loss

and faster recovery time (96).

Symptoms of foraminal stenosis include deep and steady pain in the hands, arms, calf,

shoulder, lower back and thighs. It also includes pain due to a certain movement or

activity. Muscle weakness, numbness and tingling may also be experienced. The

symptoms of foraminal stenosis may become worse gradually. A magnetic resonance

imaging (MRI) is needed to make sure that the symptoms are caused by foraminal

stenosis.

Patients should inform the doctors about any medication they are taking. Smoking

should be stopped because it can result to slower recovery. Taking medicines that

make the blood hard to clot such as aspirin, ibuprofen, naproxen, etc. should be

stopped two weeks before foraminotomy procedure. Patients should at the same time

ask what medications are allowed for them to take (96).

Patients who have heart disease, diabetes and other medical problems may be asked

by the surgeon to see their regular doctor. They should inform if they have been

drinking a lot of alcohol. The doctors should also be notified if the patient gets a cold,

fever, flu or other illnesses.

Patients may also visit a physical therapist to learn about exercises that can be done

before the surgery.


Six to twelve hours before the surgery, patients will be asked not to eat or drink

anything. Medicines given by the doctor should be taken with only a small sip of water.

A patient may bring a cane or wheelchair if it is available (96).

Using an x-ray localizes the area of interest. The patient will be given general

anesthesia, so he/she will be asleep and unable to feel pain during the procedure. The

patient will lie down on the operating table facing down. A cut or incision will be made in

the middle of the back of the spine. The incision length varies depending on the part of

the spinal column to be operated. For cervical foraminotomy, the cut or incision is made

in front or back (anterior or posterior) of the neck. For lumbar foraminotomy, it is in the

lower back (96).

Skin, ligaments and muscles will be moved or pushed to the side and the surgeon may

use a surgical microscope, endoscope or arthroscope to view the inside of the back.

The surgeon can now visualize the foramen and remove offending materials. Some of

the bones may be shaved or cut to enable opening of the foramen (nerve opening). Disk

fragments will then be removed. To make more room, other bone at the back of the

vertebrae may also be removed. Aside from that, the surgeon may correct identified

disc issues. To cauterize the disc, a laser is usually used. Spinal fusion may also be

performed to ensure stability of the spinal column (96).

The muscles and ligaments that were moved will be placed back in their position. The

tissue and muscles are closed using absorbable sutures. The skin will also be closed

using the same kind of sutures and sterilized strips. These may be removed if the

wound is already healed.

If the surgery was done on the neck, it is recommended that the patient wear a soft

neck collar. After the surgery, patients can usually get out of bed and sit up for almost 2

hours. Patients can usually go home after the surgery; however, it takes about a week

or two to be able to drive. After 4 weeks, they can perform light activities (96).


After foraminotomy, patients may have partial or full relief of the symptoms. However,

there is always a possibility of future spine problems. If a patient had a spinal fusion in

addition to foraminotomy, problems may arise in the spinal column above and below the

fusion in the future. There is a greater chance of future problems if additional

procedures such as laminotomy or laminectomy are needed (96).

The success rate of foraminotomy is between 45% - 90%. There is a large middle

ground for success rates because many factors are to be considered. One of the factors

is the ability, experience, expertise and training of the surgeon. Accurate diagnosis is

also one major factor. Although the surgeon may have the right expertise, it would make

no difference if the diagnosis were not accurate. Accurate diagnosis is the key to finding

out the correct location of the damage. It also helps the surgeon to make the right

approach, whether bilateral, anterior or posterior (96).

Risks associated with anesthesia include allergic reactions and breathing problems.

Bleeding and infections of the wound and vertebral bones may also occur. Spinal nerve

damage may result and cause pain, weakness or loss of sensory perception. After

surgery, partial or lack of pain relief may also be experienced. There are also the risk of

refractory back pain in the future and thrombophlebitis due to blood clot (96).

NucleoplastyNucleoplasty, also known as percutaneous disc decompression, is a minimally invasive,

image-guided procedure that is useful in relieving back pain caused by herniated discs.

As discussed in the previous section, vertebral discs function as shock absorbers

between vertebrae. When discs herniate, they put pressure on the nerve roots, trigger

pain receptors, and cause back pain. Patients with back and leg pain secondary to

herniated discs, especially those demonstrating disc herniation less than 6mm on MRI,

can benefit from nucleoplasty. The procedure removes the offending disc tissues,

relieve the chronic pain and restore functional mobility (117).

Nucleoplasty is generally indicated in patients with chronic (longer than 6 weeks) lower

back pain, usually secondary to herniated discs, who have not benefited from


conservative treatment approaches. Patients who are severely debilitated and impaired

functionally by the pain are the ones who stand to benefit the most from this procedure.

The ideal candidate for nucleoplasty will have radicular and axial symptoms associated

with a contained herniated disc (117). Examples of radicular signs and symptoms include

(117):

Radicular symptoms greater than Axial symptoms

Radiologic evidence of contained disc protrusion

Discography concordant, if indicated

Failed conservative treatment

Disc height greater than 50%

Examples of axial Symptoms (due to a contained disc herniation) include (117):

Discography positive for concordant pain

Disc height greater than 75%

Failed conservative treatment

Since the procedure involves minimal invasive techniques, it is performed on an

outpatient basis instead of the overnight stay required from many invasive procedures.

To begin with, a fine needle is inserted into the herniated disc with the aid of x-ray

guided imaging. It is followed by the insertion of the ‘spine wand’ into the nucleus of the

disc using the needle. This device uses coblation to ablate and remove tissues in the

nucleus pulposus of the disc. Because tissue removal is achieved at temperatures of

approximately 40-70ºC, thermal damage to surrounding tissue is minimized.

After coblation, the annulus ring shrinks in size, which substantially relieves the

pressure on the adjacent nerves. Although the time scales vary from physician to

physician, the whole procedure usually lasts less than an hour and patients are

discharged from the hospital within a couple of hours following surgery. Disc infection is

a rare complication (117).

Nucleoplasty is usually not recommended in individuals over 60 years of age and those

with spondylolisthesis and segmental instability. Moreover, it is not usually performed on


patients with disc herniation measuring more than 6 mm on MRI. Additionally,

nucleoplasty is contraindicated in patients with severe disc degeneration, who appear to

have complete annular disruption, and whose painful disc measures half or less than

half the size of the adjacent disc.

Although generally safe and well tolerated, nucleoplasty can result in a few

complications, namely (117):

Soreness at the site of the injection within 24 hours following the procedure;

Numbness and tingling sensations which can last for a long time; and

Greater pain intensity that may persist for a long time.

Nucleoplasty is a fairly recent development in diagnostic medicine. Although it is a

popular alternative treatment for discogenic back pain, some critics have called its long-

term clinical benefits into question.

A study conducted in Romania in 2013 compared the clinical usefulness of nucleoplasty

against open discectomy as a treatment for back pain. Long-term post-operative pain

scores in both groups were found to be similar. Additionally, no major complications

were reported with nucleoplasty, with patients exhibiting rapid recovery and returning to

their daily routine 3 days following the procedure (115).

A systematic review published in Pain Physician in 2011 recommends nucleoplasty to

be a category 1C procedure which means that strong evidence exists supporting its

therapeutic effectiveness in treating lower back pain [116]. However, prospective

randomized controlled trials with higher quality of evidence are necessary to confirm

these findings, and to determine ideal patient selection for this procedure.

Intradiscal electrothermal therapy (IDET) Intradiscal electrothermal therapy (IDET), also known as intradiscal electrothermal

annulopasty, is a relatively new procedure that was introduced in 1997 as an alternative

treatment for discogenic low back pain. It is a minimally invasive procedure and

successful treatment with IDET helps patients achieve pain relief without having to go


through major back surgery. This is the kind of treatment that can very well help patients

avoid surgical disc removal, disc replacement, and even spinal fusion (118).

Discogenic low back pain is thought to arise from nerve fibers that have outgrown their

limitations and reached into the interior of the disc. This process is related to the

destruction of the tough annulus layer of the disc. Another mechanism by which

discogenic pain is triggered is injury to the disc. An injury may cause tissue materials

from the nucleus pulposus to dislocate to the outer layer of the disc where pain

receptors are present (118).

Prior to the procedure, clinicians use discography techniques to visualize the nature and

extent of the disc herniation. Once identified, patients are advised to prepare for surgery

(118). At the start of the procedure, patients are given

sedatives and local anesthetics to minimize the pain.

Under fluoroscopic guidance, a catheter and a heating

element are inserted into the annulus of the disc. The

catheter, upon reaching its optimum position, is heated to

90°C for 15 to 20 minutes. The heat delivered destroys

the nerve fibers, toughens the disc tissues and also heals

any small disc tears. Antibiotics may be administered

locally or intravenously to prevent the onset of infection on the disc (118).

IDET does not provide immediate relief from lower back pain. In fact, the pain

symptoms may initially seem to increase for a short time immediately following the

procedure. During this time, clinicians usually advise patients to incorporate mild

exercises such as walking and short stretches into their daily routine. However,

strenuous exercises are best avoided until 5-6 months after the procedure. During the

initial months following procedure, clinicians also advise patients to avoid prolonged

periods of sitting, lifting, and bending (118).

IDET therapy is an effective method of treating lower back pain associated with a select

group of spinal disc diseases. It is not recommended in patients with severe disc


degeneration and conditions that undermine spinal instability such as spondylolisthesis

and spinal stenosis. It is also not recommended in patients who have three or more

symptomatic discs, large disc herniation, significant narrowing of discs, and diffused

disc degeneration. Moreover, patients are obese or strongly dependent on pain

medications may not show an optimum response to the procedure (118).

Like other invasive spinal procedures, IDET also carries a few risks of complication

such as:

Disc infection

Nerve root injury

Disc herniation

Post-treatment disc degeneration

Paradoxical increase in pain intensity

A single arm prospective clinical trial conducted in the US and published in 2008 studied

the effects of IDET in patients with lower back pain. The results of the study showed

improvement in pain scales as well as mean tolerance scores for sitting, standing and

walking. Seventy-five percent of the patients who underwent the procedure were

classified as successfully treated; having exhibited improved pain scales and/or overall

physical functioning. The study concluded that IDET therapy in select subset of patients

with mild disc degeneration, confirmatory imaging evidence of annular disruption, and

concordant pain provocation by low pressure discography are those who stand to

benefit the most from this novel procedure [119].

In 2008, the Connecticut Pain Care in the US published a set of guidelines for IDET

therapy. They identified five compulsory indications, all of which are enumerated below

[120]:

1) persistent axial low back pain +/- leg pain and non-responsive to > or = 6

weeks of conservative care;

2) history consistent with discogenic low back pain without marked lower

extremity neurological deficit;


3) one to 3 desiccated discs with or without small, contained herniated nucleus

pulposus by T2-weighted magnetic resonance imaging, with at least 50%

remaining disc height;

4) concordant pain provocation by low pressure (< 50 psi above opening

pressure) discography; and

5) posterior annular disruption by post-discography computed tomography.

IDET is an effective and safe method of treatment in lower back pain that is refractory to

conservative treatment. However, it is only beneficial in select subset of populations and

should only normally be offered to those whose outcomes are favorable and outweigh

the risks outlined above.

Radiofrequency nerve lesioningRadiofrequency nerve lesioning, also known as facet rhizotomy, is a treatment modality

that involves the use of a special machine to help interrupt nerve conduction

temporarily. The interruption of nerve conduction is responsible for the cessation of pain

signal transmission. Its mechanism of action is primarily based on the heat generated

by radio waves or electrical impulses to damage specific nerves to halt their

transmission of pain temporarily. Nerve conduction can be blocked typically for up to of

6-9 months using this procedure. It is especially beneficial in the treatment of chronic

spinal pain conditions such as spinal arthritis (spondylosis), pain due to whip lash injury,

chronic regional pain syndrome, and sometimes even pain secondary to nerve

entrapments (128).

Radiofrequency lesioning is performed under the guidance of fluoroscopy. Since nerves

cannot be visualized, bony landmarks are identified to gauge nerve pathways. It

proceeds in the following steps (128):

1. The area of needle insertion is numbed by local anesthetics.

2. The radiofrequency needle is inserted.

3. Once the needle tip is in place, another special needle is inserted. The correct

positioning of the needle is achieved by visualizing its placement on the x-ray.


4. Electrical stimulation follows which results in tingling sensations or sometimes,

numbness. The electric current is passed for about 90-120s using the radio

frequency machine, which heats the surrounding tissue. This local heat action

renders the nerve numb temporarily.

Radiofrequency lesioning is not done under general anesthesia since patients may be

required to be awake to give appropriate

feedback during the procedure. Again,

depending on the expertise of the surgeon, the

procedure can last anywhere from 30 minutes to

an hour. Patients may experience soreness after

the procedure, which resolves in the next couple

of days, even without medication. Because of the

minimal tissue invasion, tissue and wound

healing is fast, allowing patients to return to work

within 1-2 days following the procedure (128).

When done correctly, the procedure can provide prolonged pain relief that may last

years after the procedure. The long lasting pain-relief it provides makes it a good

palliative treatment option in patients with chronic lower back pain.

Although radiofrequency is a minimally invasive procedure, it does carry the risk of

infection to the spinal structures. Patients taking anticoagulants may experience

excessive bleeding, despite the minimal wound created by the procedure. It should not

be performed on patients as an alternative to corrective surgery. Lastly, patients who

experience widespread and non-localized pain are not likely to benefit from

radiofrequency of a single nerve because of the multifocal nature of the pain.

A retrospective study published in 2013 and conducted in Australia investigated the

effects of radiofrequency lateral branch neurotomy in patients with from sacro-iliac joint

mediated low back pain. Some of the parameters assessed were visual analog scale

(VAS) pain scores, quality of life, medication usage, and also patient satisfaction. The


study found a significant reduction in pain scales during follow up assessments.

Patients also reported an improved quality of life along with decreased need for opioid

medications. Additionally, some patients reported long-term pain relief lasting as much

as up to 20 months after treatment [129].

A study conducted in 2008 in the US provided retrospective data regarding pain relief

and changes in functionality in patients who underwent radiofrequency lesioning

treatment. Data from 27 individuals was analyzed and found to suggest that a significant

number of the participants with chronic sacroiliac joint pain benefited the most from the

procedure. Specifically, this group experienced marked improvement in their pain

scores and also in their functional status [130].

Another American study published in 2001 was the first of its kind to review the use of

radiofrequency lesioning in patients with sacroiliac syndrome. Thirty-three patients who

underwent a series of 51 consecutive radiofrequency lesioning were identified and

assessed pre- and post- operatively in terms of pain scores, opioid use, and physical

examination. The study concluded that radiofrequency lesioning might prove to be of

substantial benefit in certain subset of patients. Additionally, the study suggested the

delivery of effective analgesia using this treatment in patients with sacroiliac syndrome

[131].

AcupunctureAcupuncture is a form of ancient Chinese medicine that is based on the belief that an

energy or life force flows through the body channels called meridians. This energy or

force is referred to as Qi (pronounced as ‘chee’). The practitioners of acupuncture

believe that when Qi is not able to flow freely throughout the body, an illness ensues.

Acupuncture practitioners believe there to be approximately 2000 points in the human

body, all of which when stimulated corrects the life force imbalance in the body.

Scientists and some modern acupuncture practitioners believe that acupuncture helps

stimulate certain nerves and muscles, and attribute its beneficial effects to this very

reason. The traditional form of the treatment, trigger point acupuncture, involves the use


of fine needles inserted into the skin at specific points. Its use has become very popular

in recent years, with majority of the results of studies done on it pointing to positive

outcomes in terms of pain reduction, cementing its effectiveness in the management

and treatment of pain.

Currently, acupuncture for treating lower back pain is recommended by the National

institute of Health and Clinical Excellence (NICE). The NICE guideline published in 2009

suggest that acupuncture may be offered for 10 sessions lasting up to 12 weeks for

nonspecific lower back pain [88]. Another guideline published by the American Pain

Society (APS) and American College of Physicians (ACP) also recommend acupuncture

as an alternative form of pain treatment to patients with lower back pain who have not

benefited from conventional forms of therapy [89].

Acupuncture provides pain relief by stimulating various nerves and muscles, which help

reduce the intensity and frequency of pain

symptoms. Moreover, it is also associated

with the release of endorphins and other

kinds of neuro-hormonal factors, which are

the body’s natural substances that generate

feelings of well-being. It is also effective in

reducing inflammation through the release

of immunomodulatory and vascular factors

that play a role in the body’s inflammatory responses. Since acupuncture also

stimulates muscles, it is also believed to improve muscle stiffness and joint mobility by

stimulating the microcirculation locally, which ultimately helps in reducing the swelling

associated with tissue injury [97].

Numerous research findings have proven acupuncture to be significantly better than no

treatment at all in cases of chronic back pain. Some studies have even suggested it to

be equally effective if not more, than other forms of conventional treatment. It is

certainly useful in patients who wish to avoid the use of analgesic medications or wish


to augment their existing conventional therapy with another form of treatment that is

relatively safe and noninvasive to alleviate severe symptom episodes (97).

A study was conducted in 2005 by the University of Sheffield, UK to determine the cost

effectiveness, safety of acupuncture, and clinical benefits, i.e. long-term pain relief of

acupuncture. Patients aged between 18-65 years with nonspecific back pain for 4-52

weeks were enrolled into the study. The results showed that individuals receiving

acupuncture did not report any serious or life threatening adverse effects. They also

reported lesser worry and anxiety symptoms associated with back pain at 12 and 24

months compared to the conventional care group. Another significant finding was that at

24 month, the patients treated with acupuncture reported significant decrease in the use

of pain medications. The same group was also found to be more likely to report a pain

free interval of 12 months. However, no additional benefits regarding function and

disability were reported. The study also suggested that acupuncture therapy referred by

GPs could prove to be cost effective in the long run (98).

A systematic review undertaken by the University of Ulster in Northern Ireland on 2008

also advocated the use of acupuncture versus no treatment for nonspecific lower back

pain. The study concluded that moderate evidence existed to support the use of

acupuncture therapy when compared to no treatment at all; however, no difference in

short term pain relief was identified between acupuncture versus sham acupuncture

treatment. Another significant finding of the report was that acupuncture was shown to

provide significant clinical benefits when used as a supplement to conventional therapy.

However, the effectiveness of the treatment alone when compared to conventional

therapy requires more thorough research. Conclusively, the review advocated the use

of acupuncture than no treatment at all and its use as an adjunct to conventional

therapy in individuals with nonspecific back pain [99].

A specific acupuncture technique that has become popular in the recent years is motion

style acupuncture. This technique is new and differs from the conventional trigger point

acupuncture in that it involves mobilizing the patient (e.g. doing exercises) while the

needles are being placed into specific meridian points. In the treatment of lower back


pain, the needles are usually positioned onto back of the neck, elbows, and extremities,

i.e. hands and feet. The patient is then mobilized with the help of the practitioners.

Motion style acupuncture may prove to be an effective alternative and adjunctive

treatment in patients with lower back pain. A study conducted in Korea and published in

2013 recruited 58 patients and compared the effectiveness of motion style acupuncture

versus non-steroidal anti-inflammatory drug (NSAID) injection. The results showed that

the pain intensity in patients receiving acupuncture was reduced significantly. The

disability levels of these patients also declined significantly. The clinical effects lasted up

to a month following the treatments [97,100].

Other studies have also advocated the use of trigger point acupuncture for back pain. A

study conducted in Japan in 2009 suggested it to be a fairly effective method in treating

back pain in elderly patients compared to sham acupuncture [101]. Trigger point

acupuncture essentially differs from conventional acupuncture in that specific trigger

points are targeted. Trigger points, also known as trigger sites or muscle knots, are

actually hyperirritable parts of skeletal muscles which may also be associated with

palpable nodules found on the taut bands of muscle fibers. Acupuncture practitioners

believe these to be the source of many unexplained pain symptoms, even in cases of

referred pain. Compression of any trigger point elicits three kinds of responses, namely:

1. Local pain

2. Referred pain, and

3. Local twitch response

Trigger points are usually classified into various types depending on their specific

characteristics, namely:

1. Active trigger points which refer to either local or distal pain,

2. Latent trigger points, which refer to points that exist but only actively elicit pain

when compressed.

3. Key trigger points which refer to a pain referral pattern along a nerve pathway.

4. Satellite trigger points, which refer to those that elicit pain only upon activation

by key trigger points.


The above trigger points can arise from of a number of diseases or dysfunctions

including inflammation, muscle overload, trauma, homeostatic imbalances, infection,

and smoking. A study conducted in Japan in 2006 found that deep needling these

trigger points via acupuncture is a superior method of treating lower back pain than

superficial needling of the same trigger points [102].

Like other alternative forms of treatment for lower back pain, acupuncture has shown

effectiveness and safety in both acute and chronic lower back pain. It is undoubtedly

useful in treating back pain that is irresponsive to conventional therapy and those who

need an additional treatment to augment the benefits of their existing primary pain

treatment.

TractionTraction refers to a treatment modality that primarily involves the use of pulleys, ropes

and/or weights to apply mechanical forces on tissues that usually surround broken

bones. The purpose of traction is to apply a force that is strong to draw apart two

adjoining bones, increasing their shared joint space, and providing pain relief (121).

The mechanical forces may be applied manually or with the aid of devices such as

ropes and pulley. Although traction has been largely replaced by modern orthopedic

techniques, some of its techniques are used in a variety of clinical scenarios today. It is

especially useful in aligning different bony structures following a fracture as well as to

promote its healing, decrease the pain, and provide stability before being operated on. It

is also used to treat bony deformities such as scoliosis of the spine and correct

musculoskeletal problems such as muscle contractures (121). Generally speaking, there

are two different types of traction, namely (121):

1. Skin traction, and

2. Skeletal traction

Skin traction

Skin involves the application of a mild pulling force on the soft tissues of the body such

as the skin, tendons, and muscles. Skin traction does not necessarily facilitate fracture


healing but it helps in aligning the fractured part of the bones and prevents bone

shortening during the healing process. It is usually carried out during the hospital stay of

the patient (121).

It is performed while the patient lies in a supine position on the bed. A pulley system

attached to the bed and equipment such as adhesive tapes, special gloves, boots, and

splints are attached to the weights are used to apply the necessary mechanical force.

Skeletal traction

Skeletal traction is usually indicated

when greater mechanical force is

required to facilitate fracture healing.

This method differs from skin traction

in that the force applied directly to the

skeleton. Skeletal traction involves the

surgical implantation of pins, wires,

and screws into the bones. This is

usually done under general

anesthesia. The weights are then applied after implantation. The duration of weight

application largely depends on the patient’s clinical needs (extent of injury, presence of

positive healing factors, etc.) (121).

Spinal decompression traction therapy

Spinal decompression traction therapy is another treatment modality for back pain. Its

aim is to create greater space between the injured spinal structures by pulling apart the

vertebrae. This action allows decompression of structures in the spinal cord and

improves circulation.

One unproven theory suggests pulling apart the discs to improve their water absorbing

ability, thus affording them greater shock absorption abilities. Spinal traction is

performed either mechanically or manually. Sometimes, the force is applied


intermittently through manual and mechanical traction. A sustained traction, lasting no

more than 30 minutes, is usually done using mechanical devices.

Although in theory traction appears to provide a good rationale for the treatment of back

pain, there is little evidence to suggest its actual clinical benefit in the treatment of lower

back pain. A recent systematic review published in 2013 analyzed 32 randomized

control trials that involved a total of 2762 patients with lower back pain. These control

trials were conducted to establish the role of traction in patients with acute, subacute

and chronic non- specific lower back pain (with or without sciatica). The results of the

review found low to moderate quality evidence of traction being more beneficial than

placebo in reducing pain intensity, and improving functional status of the patient and

recovery speed. In the same review, traction exhibited very little substantial benefit

compared to physiotherapy [122].

TENS [transcutaneous electrical nerve stimulation] therapyTranscutaneous electrical nerve stimulation or TENS therapy involves the use of a small

low- voltage electric current to provide relief in patients with lower back pain. A small

battery-operated device containing two electrodes connected to the skin generates the

electric current. The device can be attached to a belt and carried close to the body.

Like traction therapy, transcutaneous electrical nerve stimulation has greater theoretical

value than practical application. In theory, the electrical nerve stimulation closes the

‘voltage-gate mechanism’ of the spinal cord, which eliminates the sensory signal

conduction of pain. However, this is still just a theory and has not been proven yet to be

the case [123].

Some patients report a reduction in pain perception when electrical impulses are being

delivered. However, this may be due to the fact that simulation of the nerves temporarily

blocks the pain sensory pathways, providing a false sense of relief. Proponents of

TENS therapy believe that the induction of electrical signals in the body produces

endorphins, the body’s natural opioid substances, which trigger pain relief [123].


TENS treatment is generally started after a thorough evaluation of the patient’s medical

history and need for treatment. The following are important points to remember when

using a TENS device [123]:

It is best avoided during the initial stages of pregnancy and patients who have

pacemaker implants.

As with every other device, it is recommended that individuals who wish to use

this treatment modality to read and follow the instructions carefully.

Patients should clean the skin before putting on the electrodes.

Patients need to check the integrity of their skin prior to application of electrodes,

as these should not be placed on broken or burnt skin.

It should not be used while sleeping or showering.

It should not be used in conjunction with other heating or electrical pads.

It should not be used while driving.

Patients should contact their doctor in case any adverse reaction occurs.

It should only be used for the purpose it was prescribed for by the healthcare

professional to avoid unnecessary harm.

Although a study conducted in Turkey and published in 2012 favors the use of TENS

therapy during the third trimester of pregnancy, this is generally not the consensus

regarding this treatment modality. This particular

study showed that pregnant patients who underwent

TENS treatment at 32 weeks gestation experienced

a significant pain reduction compared to treatments

with acetaminophen and exercise [123].

A small-scale recent study conducted in Italy and

published in 2013 emphasized the importance of

appropriate selection of electrode placement

location in TENS therapy in obtaining the strongest pain relief. It reported frequent

peripheral nerve trunk stimulation to provide the greatest pain relief. The study

consisted of 10 volunteers who underwent three different sessions of TENS therapy.


The study also suggested the negative implications of continuous stimulation such as

the development of tolerance [124].

Another type of transcutaneous electrical nerve stimulation is high frequency electrical

stimulation via the peripheral nerve. A study conducted in January 2007 in Italy enrolled

18 volunteers and studied the effects of high frequency transcutaneous peripheral nerve

stimulation (HF-TPNS) on improving heat pain threshold during and after delivery. The

heat pain threshold was initially measured under basal conditions, then during and after

the application of HF-TPNS. The results showed that this type of treatment has the

potential to induce hypoalgesia or decreased sensitivity to pain stimuli [125].

UltrasoundAs discussed in the previous section, ultrasound or sonography is a common diagnostic

imaging tool. However, ultrasound is also used as a treatment modality in lower back

pain. Ultrasound therapy has been used for several decades now and found effective in

treating spinal conditions such as osteoarthritis, herniated discs, and pinched nerves

[126]. It may be used as an adjunct to other treatments to provide optimum pain relief.

The basic mechanism of action of ultrasound treatments is based on the action of sonic

waves that pass from the ultrasound wand over the skin to the tissue beneath it.

Specifically, they cause vibrations and increase heat generation by the tissues. Warmer

temperatures promote improved circulation to the area, thereby reducing inflammation

and pain, and also relaxing the muscles in the area. There are two main types of

ultrasound therapies, namely:

Mechanical, and

Thermal

Both therapies involve the delivery of sound waves into the affected area with the help

of a transducer. Each type differs in their sound wave delivery rates. Thermal ultrasound

therapy involves the delivery/transmission of sound waves at a continuous rate. The

sound waves reach the deep tissue molecules, causing microscopic vibrations that

produce friction and heat in the area they are delivered to. Tissue metabolism


increases, with the warming effect promoting tissue healing. Mechanical ultrasound

therapy, on the other hand, delivers sound

waves in a pulsatile manner. It produces a

much lower heat than the thermal therapy.

It promotes continuous contraction and

expansion of the molecules of soft tissues,

which helps in reducing inflammation and

pain perceptions. The therapy

recommended to patients depends on the

underlying condition and their causes.

Patients with muscle sprains, strains, or

myofascial pain stand to benefit the most from thermal ultrasound therapy. On the other

hand, patients with pain associated with swelling and carpal tunnel syndrome will

benefit the most from mechanical ultrasound therapy.

Although ultrasound therapy is generally considered safe, it is contraindicated in cases

after immediate injury. Some of its other limitations and drawbacks are:

It may possibly speed up the spread of diseases via the blood, and is therefore

not safe in patients diagnosed with or are suspected of cancer.

It is contraindicated in patients with active infection, bone fractures, and also

during pregnancy.

It is contraindicated on sensitive body parts such as eyes and sex organs

It should not be used in children since the sound waves can adversely affect the

growth plates.

It should be avoided in patients with pacemakers.

It should not be used over broken skin, lesions, and healing fractures.

A study conducted in Iran in 2012 recruited 50 patients suffering from non-specific

chronic lower back pain. The patients were randomized into two groups and underwent

combination therapies consisting of ultrasound with exercise, and placebo ultrasound

with exercise. The treatments were given alternatively, switching treatments between

days, three times a week for four weeks for a total of ten sessions. Although beneficial


effects were seen in both groups, it was found that patients receiving ultrasound therapy

in addition to exercise showed a significant improvement in terms of functionality,

lumbar flexion, extension ROM, and endurance time [127].

PHARMACOLOGY TREATMENTS

Over the counter (OTC) drugs for low back painOver the counter (OTC) pain medications are used to provide symptomatic pain relief.

Examples include NSAIDs such as ibuprofen, acetaminophen, mefenamic acid,

diclofenac, and aspirin.

Non-Steroidal Anti-inflammatory Drugs (NSAIDs)

Clinical trials have found that non-selective NSAIDs show superior efficacy in the

treatment of acute lower back pain treatment without the need for additional analgesics

(137). Ibuprofen was found to be especially effective in the treatment of chronic lower

back pain (132). Other studies claim effectiveness of NSAIDs in the treatment of back

pain with sciatica (137).

Mechanism of action:

NSAIDs relieve nociceptive pain due to tissue

damage and inflammatory mechanisms. These

drugs inhibit the enzyme, cyclooxygenase (COX)

resulting in decreased synthesis of pro-

inflammatory prostaglandins from arachidonic

acid in the central nervous system and the

peripheral sites in the body. Non-selective

NSAIDs inhibit both the COX-1 or COX-2

enzymes. COX-1 is involved in pain mechanisms

as well as the normal functioning of the gastrointestinal tract, platelets, and kidneys

while COX-2 does not. Cox-2 is particularly active in reducing inflammatory responses

(134).


Side effects of NSAIDs:

NSAIDs are associated with various risk factors. The toxicity associated with the use of

both selective COX-2 inhibitors and non-selective inhibitors are similar. Their most

common adverse effects known are listed below (134):

Cardiovascular system:

Rise in blood pressure, fluid retention, myocardial infarction

Neurological system:

Headaches, confusion, hallucinations, depression, tremor, meningitis, tinnitus,

vertigo, neuropathy

Gastrointestinal system:

Nausea, vomiting, dyspepsia, diarrhea, constipation, gastric mucosal irritation,

peptic ulcers, esophagitis, gastrointestinal hemorrhage

Hematological system:

anemia, bone marrow depression, reduced platelet aggregation

Hepatic system:

hepatotoxicity

Renal system:

nephritis, changes in renal blood flow, edema, inhibition of renin release

Others:

precipitation of asthma, skin rashes

Selection of NSAIDs:

The selection of the most appropriate NSAID is an important step in successfully

treating pain symptoms. Clinicians agree that some patients respond to some drugs

better than others. Whichever is the NSAID of choice the drug must only be used for the

shortest time possible. With chronic conditions, the drug can be used for up to 2 to 4

weeks since their maximum effect may be delayed. Before prescribing any NSAID,

clinicians need to consider non-drug treatment as well as the risk-benefit profile (134).

Topical NSAID formulations:

NSAIDs in topical and transdermal formulations are widely used in the treatment of local

musculoskeletal disorders. Examples include diclofenac, ibuprofen, ketoprofen, and


piroxicam. NSAID gels are frequently used for muscular aches and pains. They are

considered to be great alternative to oral NSAIDs, especially when rapid and local pain

relief is required. They are also advantageous because they do not cause gastric

irritation, unlike many of its oral NSAID counterparts (134).

Examples of NSAIDs:

Aspirin

Aspirin acts by irreversibly blocking the enzyme cyclooxygenase-1, thereby reducing the

production of inflammatory substances, prostanoids (134).

Patients with history of hypersensitivity to any NSAID should not take aspirin. Likewise,

those suffering from peptic ulcer should avoid it because of its adverse effects on the

gastric mucosa. It should not be used in children under the age of 12 because of its

propensity to cause Reye’s syndrome. Patients who are taking Ginkgo biloba along with

aspirin may sometimes exhibit spontaneous bleeding.

Aspirin is used as an anti-platelet, analgesic, antipyretic, and anti-inflammatory drug at

various doses. It can cause gastrointestinal and cerebral hemorrhage. Its dosage for

anti-platelet therapy, though minimal, can also cause minimal adverse reactions.

Diclofenac

Diclofenac sodium is an analgesic-antipyretic and anti-inflammatory drug. Like other

NSAIDs, it inhibits prostaglandin synthesis. It reduces neutrophil chemotaxis and

superoxide production at the site of inflammation. It is well absorbed after oral

administration and eliminated from the body via urine and bile. It has high tissue

perfusion and thus, able to achieve high concentration in the synovial fluid (136).

Diclofenac is indicated in the pain management of rheumatoid arthritis, osteoarthritis,

bursitis, ankylosing spondylitis, dysmenorrhea, post traumatic and post inflammatory

conditions. It exhibits immediate pain relief after oral administration.


Diclofenac sodium is generally associated with mild epigastric pain, nausea, headache,

dizziness, and rashes. It is also associated with gastric ulceration and bleeding. It can

rarely cause kidney damage and reversible increase in serum aminotransferase.

Ibuprofen

One of the safest drugs, ibuprofen, also blocks the synthesis of prostaglandin, inhibit

platelet aggregation, and prolong bleeding time. It is well-absorbed following oral

absorption and is highly bound to plasma proteins. It is used as an OTC analgesic in

rheumatoid arthritis, osteoarthritis, and other musculoskeletal disorders where pain is

more pronounced than inflammation. It is also useful in soft tissue injuries, fractures,

and vasectomy in alleviating pain, swelling, and inflammation (136).

Ibuprofen is associated with mild side effects such as gastric discomfort, nausea,

vomiting, headache, dizziness, blurred vision, tinnitus, and depression.

Piroxicam

Piroxicam is a long-acting NSAID, and a reversible inhibitor of COX. It lowers

prostaglandin concentration in the synovial fluid, and also inhibits platelet aggregation. It

is very well absorbed after oral administration and almost 99% of it is bound to plasma

proteins. Its metabolites are eliminated from the body via urine and bile (136).

It is associated with common side effects such as heartburn, nausea, and anorexia.

Rashes and pruritus are also seen in rare cases.

It is indicated in both short and long term pain relief in rheumatoid arthritis,

osteoarthritis, ankylosing spondylitis, acute gout, musculoskeletal injuries, dentistry,

episiotomy, and dysmenorrhea.

Acetaminophen/paracetamol

Research evidence is strong on the efficacy of acetaminophen in short-term pain relief

of a variety of pain conditions such as joint pain (133). Unlike other NSAIDs, it lacks anti-

inflammatory effects. Popularly known as paracetamol, it has both analgesic and

antipyretic actions in the central nervous system (135).



Acetaminophen inhibits the enzyme prostaglandin synthetase in the hypothalamus as

well as the synthesis of spinal prostaglandin. Additionally, it also inhibits the synthesis of

nitric oxide in macrophages.

As mentioned previously, it shows negligible anti-inflammatory action in normal

therapeutic doses because of its insignificant inhibition of prostaglandin (135).

Alternatively in conditions where arachidonic acid concentration is low, acetaminophen

weakly inhibits the isozymes COX-1 and COX-2 as well as prostaglandin synthesis,

accounting for its very low and negligible anti-inflammatory effects (135).

Properties:

Acetaminophen is rapidly absorbed, reaching its peak plasma concentration within 10 to

60 minutes following oral absorption. Its analgesic effect is exhibited within 30 minutes

of oral administration and 15 minutes of Intra venous administration. It does not bind to

the plasma proteins, highly lipid soluble, and thus, easily enters the brain by crossing

the blood brain barrier. The analgesic effect is primarily exhibited in the brain. It

undergoes extensive first pass metabolism in the liver and is converted to its

metabolites. Its elimination occurs via the kidneys (135).

Acetaminophen should be used with caution in individuals with hepatic and renal

disorders to avoid toxicity (133).

Indication:

It is comparably less effective than the nonsteroidal anti-inflammatory drugs in providing

relief from moderate to severe pain. It is the first line of analgesic in the treatment of

mild to moderate pain especially if it is of soft tissue and musculoskeletal origin. It is

also helpful in reducing the daily doses of NSAIDs or opioids, allowing a significant

reduction in their doses and subsequent adverse effects (135).

Other indications of acetaminophen are (135):

Alternative to aspirin


Treatment of mild procedural pain

Management of fever

Paracetamol is safe for use in children. The recommended dose of acetaminophen in

adults is 0.5 to 1 g given every 4 to 6 hours (135).

Adverse effects / toxicity of acetaminophen:

Acetaminophen is very safe to use in therapeutic doses. There is very low risk of side

effects, which includes an increased risk of upper gastrointestinal complications in

increased doses.

Acetaminophen is known to increase the risk of hypertension in women. In very rare

instances, patients may also experience urticarial or erythematous rashes, fever, and

blood dyscrasias as adverse effects (135).

Overdose of paracetamol is associated with potentially life threatening toxicity. The

toxicity can manifest as either hepatotoxicity, hypoglycemia, or acute renal tubular

necrosis.

Formulations:

Acetaminophen is available as immediate release tablets and capsules, oral solutions

and suspensions, chewable tablets, soluble/effervescent tablets and, modified release

tablets. It is available in rectal and injectable formulations (135).

Acetaminophen is also available in several oral preparations in combination with other

medications such as other analgesics, decongestants, antihistamines, and antiemetics.

Anticonvulsant and antidepressant medications for lower back painThe development of newer classes of antidepressants and anticonvulsant drugs in the

recent years expanded their clinical indications, including their off-label use in the

management and treatment of chronic pain. This is achieved by their actions on specific

neurotransmitters and ion channels. These classes of drugs exhibit varying efficacy in

the treatment of different types of pain. They are widely prescribed off label in the

management of neuropathic and non-neuropathic pain (138).


The antidepressants that are used in pain management are the classic tricyclic

antidepressants like amitriptyline, nortriptyline, and desipramine; and novel

antidepressants like bupropion, venlafaxine, and duloxetine. These drugs have been

found to be especially effective in the treatment of neuropathic pain (138).

First generation antiepileptic drugs like carbamazepine, phenytoin, and second-

generation antiepileptic drugs like gabapentin and pregabalin have been effectively

used in the treatment of neuropathic pain (138).

Antidepressant drugs

Antidepressant medications are used in the treatment of pain for the following common

reasons (139):

Psychiatric disorders are common among those suffering from chronic pain

Sleep disturbances are also consistently found among those in chronic pain

Certain antidepressant classes provide pain relief as an independent feature

from relief of depression and other psychiatric symptoms.


Tricyclic antidepressants inhibit the transmission of pain in the spinal cord by blocking

the reuptake of neurotransmitters, serotonin and norepinephrine. These

neurotransmitters are instrumental in several pain pathways. Additionally, tricyclic

antidepressants have high affinity for histamine H1 receptor that may be helpful in

producing pain relief. As such, tricyclic antidepressants are also used in the

management of acute pain (138).

The newer antidepressant drugs like venlafaxine and duloxetine block the reuptake of

serotonin and norepinephrine but do not block other neuroreceptors, which may result in

side effects related with tricyclic antidepressants. Bupropion is thought to exert its

mechanism of action by blocking the uptake of dopamine (138).

Use:

Tricyclic antidepressants are particularly useful in treating symptoms of chronic back

pain. Serotonin norepinephrine reuptake inhibitors (e.g. duloxetine and milnacipran) are


used to treat pain of both neuropathic and non-neuropathic origins. Of the two,

duloxetine is the only one that is FDA-approved for use in musculoskeletal pain (145).

Antidepressants with mixed–receptor and noradrenergic activity exhibits greater efficacy

in the treatment of patients with neuropathic pain (138).

Adverse reactions:

The most common side effects associated with tricyclic antidepressant are dry mouth,

constipation, urinary retention, sedation, and weight gain. The novel antidepressants

bupropion, venlafaxine and duloxetine exhibit side effects such as anxiety, insomnia,

sedation, loss of weight, seizures, head ache, nausea, sweating, hypertension, dry

mouth, constipation, and dizziness (138).

Drug interaction:

There are many clinically significant interactions involving antidepressants. These

include the interaction between fluvoxamine and benzodiazepines, clozapine,

theophylline, and warfarin, wherein it increases their respective plasma concentrations.

Sertraline and fluoxetine can also increase the concentration of benzodiazepines,

clozapine and warfarin (142).

Some antidepressants are substrates of the CYP enzymes and also inhibit the

metabolic clearance of other drugs resulting in significant drug–drug interaction (142).

Examples of antidepressants:

Amitriptyline and trimipramine Amitriptyline and trimipramine are tricyclic antidepressants and nonselective uptake

inhibitor of noradrenaline and serotonin. Following oral administration, they show a high

level of absorption. They are metabolized in the liver into active metabolites. Generally,

amitriptyline or trimipramine are given once daily with definite changes in steady state

plasma concentration. They are known to cause many adverse effects including dry

mouth, blurred vision, constipation, urinary retention, sedation, postural hypotension,

sexual dysfunction, and weight gain. Amitriptyline is one of the most sedating

compounds of the tricyclic antidepressant class. Alcohol has been studied to exacerbate


the effects of amitriptyline. They should be used with caution in children as they can

impair cardiac conduction and even result in fatal arrhythmias. They show interactions

with serotonergic medications leading to serotonin syndrome (140).

Venlafaxine

Venlafaxine is a serotonin reuptake inhibitor. At higher doses it also acts as a

noradrenaline reuptake inhibitor. It is a weak dopamine reuptake inhibitor. Venlafaxine

and its metabolite have both short half-lives, which makes the recommended dose to be

given twice daily. It shows several side effects including nausea, vomiting, anorexia,

headache, increased sweating, rashes, agitation, periodic limb movements of sleep,

sexual dysfunction, hypotension, and hyponatremia. Withdrawal symptoms may also

appear if the drug is stopped suddenly without tapering the dose gradually. It should not

be used in children or adolescents since it has been reported to instigate hostility and

thoughts of suicide (140).

Antiepileptic/anticonvulsant drugs

Anticonvulsant drugs are also used in the treatment of neuropathic pain. They exert

analgesic effects through multiple neuronal mechanisms such as blockade of voltage

gated sodium channels, enhancement of GABAergic neurotransmission, and inhibition

of glutamatergic neurotransmission. These mechanisms of inhibition of neuronal hyper

excitability are also present in neuropathic pain. Modulation of this mechanism is the

target of neuropathic pain therapy with anticonvulsants (139).


Antiepileptic drugs act at several sites, which may be relevant to the perception of pain.

They trigger the inhibition of neuronal excitation, thereby providing pain relief. The major

sites of action of antiepileptic agents in pain relief are voltage gated ion channels

(sodium and calcium), ligand gated ion channels, excitatory receptors for glutamate and

N-methyl-D-aspartate, and inhibitory receptors of GABA and glycine (138).


Use:

Both first generation and second-generation antiepileptic medications are used in the

treatment of pain. However, it is the second-generation medications that exhibit greater

tolerance since they cause lesser sedation and have lower central nervous system

activity.

Antiepileptic drugs are used in the management of neuropathic pain. Carbamazepine is

extensively used in the treatment of trigeminal neuralgia. Occasionally these agents are

also used in the treatment of other types of pain such as lower back pain (145). Phenytoin

is frequently used in the treatment of chronic pain (138).

Second generation antiepileptic drugs have documented efficacy in patients with painful

diabetic nephropathy, and post-herpetic neuralgia (Maizels & McCarberg, 2005). There

is not much evidence to prove their efficacy in the management of lower back pain

which makes them better suited as adjunctive therapy in cases when the first lines of

drugs are ineffective (145).

Adverse reactions:

First generation antiepileptic drugs like carbamazepine and phenytoin are associated

with side effects like dizziness, diplopia, nausea, ataxia, slurred speech, confusion and

rashes (138).

Second generation antiepileptic agents are known to be more tolerated but exhibit

certain side effects such as drowsiness, dizziness, fatigue, nausea, sedation, and

weight gain (138).

Drug interaction:

The plasma concentration of hydantoins is increased in the presence of any drug

metabolized by CYP2C9 or CYP2C10. Carbamazepine is known to enhance the

metabolism of phenytoin and hence their concomitant use results in reduced

concentration of phenytoin. The reverse is also true, i.e. phenytoin may reduce the

concentration of carbamazepine (151).


Examples of anticonvulsants:

Carbamazepine

Carbamazepine is an anticonvulsant, which works by blocking the sodium channels. It is

used in epileptiform conditions of neurological origins. Studies have found strong

evidence of its clinical efficacy in the management of trigeminal neuralgia, and other

neuropathic pain conditions (141).

It is remarkable in its ability to induce its own metabolism, which is started within 3 to 5

days of initiation of therapy and completed in 3 to 4 weeks. It also interacts with other

drugs like corticosteroids, cyclosporine, oral contraceptives, other antiepileptic drugs,

and warfarin.

It shows many dose-related side effects, namely:

Sedation

Headache

Ataxia

Dizziness

Nausea

Visual symptoms like diplopia

Skin rash

Diarrhea and,

Hepatitis

Gabapentin

Gabapentin is structurally similar to GABA. Its mechanism of action is rooted in its ability

to inhibit glutamate synthesis and increase GABA concentration in the brain. It acts

upon the calcium-gated ion channels to bring about its effects (141).

It is widely prescribed to treat neuropathic pain. It acts on the spinal cord to interact with

neuronal calcium channels to decrease neurotransmitter release and increase the

synthesis of GABA. It has been documented to reduce neuropathic pain by almost 50%.


It is absorbed via the amino acid uptake system in the gastrointestinal tract, with its

bioavailability decreasing with a corresponding increase in dose. It interacts with

antacids. It remains unchanged in the urine when eliminated. Among its most common

adverse effects are somnolence, dizziness, and ataxia.

Phenytoin

Phenytoin inhibits the voltage-gated sodium channels. It is highly bound to albumin, with

its unbound portion exhibting pharmacological activity. Phenytoin is associated with a

plethora of adverse effects, which may be dose-related or idiosyncratic in nature.

Examples include neurotoxic symptoms such as drowsiness, dysarthria, tremor, ataxia,

diplopia, and cognitive difficulties. It may also result in gum hypertrophy, acne,

hirsutism, and facial coarsening. Phenytoin shows a wide range of interactions with

major drug classes. It has very poor water solubility. Its intra muscular injection should

be completely avoided (141).

Pregabalin

Pregabalin is an analogue of gamma–aminobutyric acid, with both anticonvulsant and

analgesic properties. It blocks calcium channels and reduces the release of

neurotransmitters such as glutamate, noradrenaline and substance P (141).

It is well absorbed orally and eliminated from the body via urine. It has not shown any

clinically significant drug interactions. The side effects related to its use are

somnolence, dizziness, blurred vision, weight gain, peripheral edemas, and increased

creatine kinase levels (141).

Comparative account of anticonvulsant and antidepressant drugs

The antidepressant and anticonvulsant drugs have shown comparable efficacy in the

management of pain of neuropathic origin, but there are profound differences in the

safety profiles, drug tolerance, and side effect associated with specific drug classes.

According to certain clinical trials, SSRI’s are found to be most effective in treating

neuropathic pain when compared to tricyclic antidepressants, sodium channel blocking

antiepileptic drugs, and gabapentin. In the treatment of non-neuropathic pain, tricyclic


antidepressants are the only class of drugs that has well documented efficacy in the

treatment of pain.

A research meta-analysis in patients with chronic back pain has shown that

antidepressants exhibit significant, albeit small, decrease in pain. But the improvement

in pain has not been associated with an improvement in day-to-day quality of life.

Antidepressants that showed serotonergic activity showed even lesser efficacy in

reducing pain (152).

Opioid AnalgesicsOpioid analgesics are still the mainstay in pain management and treatment since the

first discovery of their parent compound, opium, hundreds of years ago. The opioid

analgesics are drugs used especially in the treatment of moderate to severe pain in

post-operative and cancer patients. Their analgesic effects are attributed to their ability

to reduce the pain sensation. The most significant feature of this class of drugs is its

sensory role in inhibiting responses to painful stimuli, regulating the gastrointestinal,

endocrine and anatomic functions. These drugs are also addictive and play an

important role in cognition and memory (155,154).

Endogenous opioid peptides

Peptides can be classified in three different families:

Enkephalins

Endorphins

Dynorphins

All three families of opioids are derived from natural precursors; prepro-

opiomelanocortin (POMC), preproenkephalin, and dynorphins, respectively. The main

opioid peptide, which has been derived from POMC is β-endorphins (155).

Opioid receptors

There are three classical opioid receptors classified as μ, δ and κ. The opioids, which

are used for clinical purpose are selective for and activate μ receptors. Some drugs also

change their receptor selectivity at high doses while others act on more than one


receptor; being an agonist for one receptor while being an antagonist for another.

Morphine and most of the clinical opioid drugs exert their action by acting on the μ

receptors (155).

Effects of clinically used opioids

The opioid analgesics have been known to exert their effects on a wide range of

physiological systems. Their actions include production of analgesia, affect mood and

change the respiratory, cardiovascular, gastrointestinal and neuroendocrine function.

Delta (Δ) opioids have also been useful in some cases to alleviate pain. Studies on

animals have also shown that κ-opioid receptors are most effective in the spinal region

(155).

Morphine like drugs produces analgesia, drowsiness, mood changes and mental

clouding. Another significant feature is that pain is relieved without causing

unconsciousness (155).


Opioid analgesics interact with one or more opioid receptors (including μ, δ, κ) at the

supraspinal, spinal and peripheral regions to result in analgesia. The opioid analgesics,

which are currently in use, are μ agonists but some δ and κ agonists also produce

analgesia. The opioid receptors exist as heterodimers and respond in more a complex

and elaborate manner to different combination of drugs (155).

Opioids inhibit the presynaptic release of neurotransmitters from the C-fiber terminals,

promote postsynaptic activity in the nociceptive pathways, and trigger the disintegration

of other pathways involved in nociceptive regulation. Opioid analgesics classified as

pure agonists of opioid receptors or mixed agonist-antagonist drugs act at specific

receptors (154).

Use of opioids for treatment of acute pain:

Morphine and fentanyl are clinically used to relieve severe acute pain. Since opioid

overdose is associated with increasing risk of toxic effects such as respiratory


depression, rapid dosage increments are not advisable. Essentially, rapid dosage

increments disrupt the balance between analgesia and safety. Its administration usually

starts with a low dose with repeat doses given at approximately 5-minute intervals to

achieve the required analgesic effects (155).

Adverse effects of opioids:

Opioids are associated with many adverse or side effects on various body systems

including cardiovascular, neurological, dermatological, gastrointestinal, musculoskeletal,

neuroendocrine, respiratory, and urinary systems. The withdrawal symptoms of opioids

are manifested as body aches, diarrhea, loss of appetite, ‘goose flesh’, loss of appetite,

restlessness or nervousness, runny nose, squeezing, tremors, stomach cramps,

nausea, and loss of sleep, diaphoresis, asthenia, tachycardia or fever (154).

The adverse effects of opioids are listed below (154):

Cardiovascular system:

Bradycardia, release of histamine resulting in vasodilation and hypotension;

Neurological system:

Mental clouding dependent on dose, delirium, sedation, nausea and vomiting,

apnoea, spinal and epidural morphine may also reactivate herpes simplex, but

the central adverse effects are much delayed following an intraspinal

administration of morphine;

Dermatological system:

sweating, flushing, urticarial and pruritus;

Gastrointestinal system:

Vomiting, anorexia, reduction in gastric motility, delayed gastric emptying, biliary

colic, slowed digestion, increased time for intestinal transit, increased anal

sphincter tone, constipation;

Musculoskeletal system:

myoclonus, chest wall rigidity;

Neuroendocrine system:

hypothalamia resulting in reduced gonadotrophins, adrenocorticotrophic

hormones, beta endorphin, testosterone and cortisol and increased prolactin;


Respiratory system:

respiratory depression which is directly related to the dose, bronchospasm;

Urinary system:

Urinary retention, difficulty with micturition, increased tone of external sphincter,

decreased muscle tone of detrusor muscle, antidiuretic effect.

It should be noted here that most of the adverse effects could be reversed with the use

of naloxone, which is an opioid antagonist. Its use will also reduce the analgesic effects.

Interactions and precautions with opioids:

Opioids may interact with other medicines, which is why they should be used with

caution and only under medical advice and supervision. The health care practitioner

should always confirm with the patient if he is using any other prescription medications,

OTC medications, complementary and alternative medicines, and illicit compounds (154).

Opioids should not be used within 14 days of the use of monoamine oxidase inhibitors

(MAO) such as pethidine or tramadol since serious adverse reactions may occur.

Opioids should be used with caution when given with other central nervous

system depressant drugs such as sedatives, hypnotics, antipsychotics,

antidepressants, anesthetics or alcohol as the sedative and antidepressant

effects of opioids may be exacerbated.

When given with anticholinergic drugs, the patient should be made aware of an

increased chance of developing constipation or urinary retention.

Partial opioid agonist such as buprenorphine may decrease the analgesic effects

produced by morphine and may even initiate the withdrawal symptoms.

Drugs affecting the hepatic cytochrome system may also alter the blood level of

opioids, which may either result in toxicity or decreased effectiveness.

There is a risk of arrhythmia when opioid are given with drugs like methadone.

Opioid use in the elderly:

Older adults are more sensitive to the analgesic and other effects of opioids, which is

why lower doses are generally more appropriate for this particular subset of population


group. Lower doses produce an equivalent analgesia in the elderly when compared to

higher doses in adults. Additionally, due to the elderly’s greater likelihood of reduced

renal function, the risk of accumulation of active opioid metabolites is also greater along

with increased brain sensitivity leading to respiratory depression or nausea (156).

Opioid drugs:

Morphine

The prototype of this group, morphine, is an agonist for all opioid receptors, specially

the μ receptor. Morphine is well absorbed following oral use but almost 30% of it is

metabolized during first pass hepatic metabolism. The metabolites of morphine are

morphine-3-glucuronide and morphine-6-glucuronide. Morphine is eliminated via renal

excretion in the form of its metabolites (156).

The duration of morphine action is 3 to 6 hours. It is administered via oral,

subcutaneous, intramuscular, intravenous, epidural, intrathecal and

intracerebroventricular routes with the preferred mode of administration being oral.

Morphine is used in the treatment of chronic pain, cancer pain, and also non-cancer

pain. It is also used for pain management in palliative care such as terminally ill

patients. Tolerance to morphine develops rapidly.

Oxycodone

Oxycodone has greater bioavailability compared to its other opioid counterpart,

morphine, which makes it twice more potent. It undergoes metabolism to form the

metabolite, oxymorphone, through the action of the hepatic enzyme, CYP2D6. The

efficacy profile of oxycodone is similar to morphine. It is also available in an oral

modified release formulation, which brings about early onset of analgesia lasting almost

12 hours.

Buprenorphine

Buprenorphine is a partial opioid agonist at μ receptors and an antagonist at κ

receptors. It has a prolonged duration of action. It is available as sublingual, parenteral,


and transdermal preparations of which the sublingual preparation is indicated for use in

acute and chronic pain, cancer pain, and opioid detoxification (153).

It is metabolized by the cytochrome P450 3A4. It is worth mentioning that

buprenorphine can lead to respiratory depression, which is unresponsive to the reversal

effects of naloxone. It is not recommended for use in palliative care. The transdermal

patches are not effective for acute pain or in cases where the need for analgesic effects

varies constantly.

It is used in the treatment of opioid overdose.

Fentanyl Fentanyl is a very potent opioid, which is synthesized in the lab. It has a short duration

of action. It has been indicated for use in both management of acute and chronic pain. It

is administered orally, parenterally as intramuscular, intra venous, sub cutaneous,

intrathecal or epidural, and transdermal patch (154).

It is metabolized in the liver to form inactive metabolites. It is suitable for patients with

compromised renal system and those who are hemodynamically compromised. Its

adverse effects are similar to that of morphine but with lesser frequency of constipation

and confusion.

COGNITIVE BEHAVIORAL THERAPY

Cognitive Behavior therapy or CBT is a type of psychological therapy that involves

engaging the patient in dialogue to change existing thoughts and behavior. It helps

patient tackle a number of problems in a more positive way.

Cognitive behavior therapy is routinely done by psychiatrists, psychologists and other

professionals trained in the treatment of mental illnesses such as anxiety, depression,

post-traumatic stress disorder, and personality disorders, to name a few. Evidence-

based studies suggest its role in the management of chronic painful conditions such as

lower back pain, irritable bowel syndrome (IBS) and arthritis.


Cognitive behavior therapy tends to focus on changing the patient’s way of dealing with

problems. It focuses on changing the way a patient thinks and behaves, allowing and

welcoming a completely different response to difficult situations than previously

exhibited. It helps improve the patient’s state of mind. It does not provide a solution to

the problems; however, it equips the patient with new behavior and thoughts to

overcome negative thinking and manage existing problems.

A recent systematic review conducted in Belgium assessed the use of cognitive

behavior therapy in patients with acute and sub-acute chronic back pain. The review

suggested the incorporation of operant conditioning, a CBT-based strategy, into

ambulatory physiotherapy practice to manage chronic back pain symptoms [161].

BiofeedbackBiofeedback is a technique that enables patients to control their sympathetic responses

to various injuries and trauma. It can help patients control various body functions and

responses such as heart rate and pain perception. As such, it is often advocated as an

important relaxation technique.

During the treatment process, patients are connected to an external sensor device,

which provides the feedback used to control sympathetic responses. It brings about

subtle changes such as relaxation of specifically targeted muscles and subsequent pain

relief.

Biofeedback is a noninvasive treatment modality and carries very minimal and

insignificant risks, if any. It may be used in a number of conditions especially in cases

where pain relief is an immediate need. It is also a treatment option in patients who are

not keen to take medications (possibly due to side effects and allergies) and exhibited

refractory pain following conventional treatments.

The use of biofeedback in the treatment of chronic back pain is intensely being studied

worldwide. There are multiple trials that advocate the use of Biofeedback in patients

with no specific chronic lower back pain. For example, a study conducted at the

University of Limerick, Ireland in 2013 involving 24 participants concluded that postural


biofeedback that is appropriately matched to specific clinical presentations of patients

could significantly help in reducing lower back discomfort even with a single session

[162].

Another fairly recent scientific paper published in June 2013 reviewed the available

existing literature regarding biofeedback techniques and their clinical effectiveness in

physical rehabilitation. The review suggested that EMG (electromyogram) biofeedback

could be beneficial in relieving pain associated with musculoskeletal conditions and

cardiovascular accident. Additionally, the review also highlighted the fact that real time

ultra sonography (RTUS) biofeedback could potentially prove to be effective in treating

patients with chronic low back pain [163].

Aside from alleviating chronic back pain, biofeedback is also most useful in conditions

such as constipation, incontinence, and irritable bowel disease.

SUMMARY

The spine is a complex region of the body whose major function is to provide skeletal

support and structure. It is made up of bones, tough cartilages and ligaments, joints,

and highly sensitive nerve roots that supply sensations to all parts of the body. Trauma,

deformities, degeneration, metastases, and infections can all undermine the spine’s

major function. A case of lower back pain is usually an indication of a disease process

in any of the spinal structures that warrants an immediate medical assessment.

Lower back pain is a general symptom that is associated with various medical

conditions; some of which are benign and easy to treat (e.g. overexertion, minor sports

injuries) and some, which have high morbidity and life-threatening implications (e.g.

spinal stenosis, cauda equine syndrome).

The diagnosis of lower back pain, both acute and chronic, require careful review of

medical history, physical examination, and results of diagnostic imaging and specialized

techniques. The most commonly ordered imaging modality in spinal disorders involving

lower back pain is spinal x-ray of the lumbar and sacro-iliac regions. It is cheap,


universally available and delivers quick images. On the other hand, it is limited to the

visualization of bones since it does not capture clinically useful images of soft tissues

such as muscles and nerves, making it useless in identifying conditions such as nerve

impingement, muscle sprains, and strains. Other imaging modalities provide superior

visibility of soft tissue structures such as the CT and MRI scans. As such, they are more

expensive and not as universally available and accessible as x-ray machines. Other

diagnostic tools such as ultrasound and bone scan are also useful in diagnosing causes

of back pain.

The treatment approaches to back pain, both acute and chronic, depends largely on the

symptoms, patient history, physical health, and suspected underlying causes. Because

the causes of back pain are generally difficult to pinpoint, the clinician usually starts with

common OTC pain-relievers until further tests and evaluation have provided sufficient

evidence to suggest interventional therapies such as surgery and steroid injections.


References:

1) American Academy of Orthopedic Surgeons. Low back pain. Retrieved from

http://orthoinfo.aaos.org/topic.cfm?topic=a00311.

2) Science based medicine. Low back pain: causes, care and consequences. Retrieved

from http://www.sciencebasedmedicine.org/low-back-pain-causes-care-and-

consequences/.

3) anatomyEXPERT. (n.d.). Lumbar vertebrae. Salt lake city, Utah. Retrieved from

anatomyEXPERT.

4) Drake, R., Vogl, W., & Mitchell, A. (2009). Gray's anatomy for medical students (2nd

ed.). New York: Churchill Livingstone.

5) Gray, H. (1918). Anatomy of the human body. Philadelphia: Lea and Febiger.

Retrieved from Bartleby.com

6) Kishner, S., Moradian, M., & Morello, J. K. (2012). Lumbar spine anatomy. Retrieved

from Medscape: http://emedicine.medscape.com/article/1899031-overview#aw2aab6b3

7) Moore, K., & Dalley, A. (2006). Back. In K. Moore, & A. Dalley, Clinically oriented

anatomy. Baltimore: Lippincott Williams and Wilkins.

8) Moulton, A. (2013). Understanding spinal anatomy- overview of the spine. Retrieved

from andrewmoultonmd.com: http://www.andrewmoultonmd.com/spine-anatomy.php

9) Frymoyer, J., Clements, J. H., Wilder, D. G., MacPherson, B., & Ashikaga, T. (1983).

Risk factors in low-back pain. An epidemiological survey. The journal of bone and joint

surgery, 65(2), 213-218.


http://www.sciencebasedmedicine.org/low-back-pain-causes-care-and-consequences/

http://www.sciencebasedmedicine.org/low-back-pain-causes-care-and-consequences/

10) Harreby, M., Nygaard, B., Jessen, T., Larsen, E., Storr-Paulsen, A., Lindahl, A.,

Laegaard, E. (1999). Risk factors for low back pain in a cohort of 1389 Danish school

children: an epidemiologic study. European spine journal, 8, 444-450.

11) Hochschuler, S. H. (2008). Back pain risk factors: What can increase the potential

for back problems. Retrieved from Spine-health:

http://www.spine-health.com/conditions/lower-back-pain/back-pain-risk-factors-what-

can-increase-potential-back-problems

12) Lefevre-Colau, M.-M., Fayad, F., Rannou, Fermanian, J., Coriat, F., Mace, Y.

Poiraudeau, S. (2009). Frequency and interrelations of risk factors for chronic low back

pain in a primary care setting. PLoS ONE, 4(3). doi:10.1371/journal.pone.0004874

13) Smedley, J., Egger, P., Cooper, C., & Coggon, D. (1995). Manual handling activities

and risk of low back pain in nurses. Occupational and environmental medicine, 52, 160-

163.

14) Sterud, T., & Tynes, T. (2013). Work-related psychosocial and mechanical risk

factors for low back pain. Occupational and environmental medicine, 70(5), 296-302.

15) Tucer, B., Yalcin, B. M., Ozturk, A., Mazicioglu, M. M., Yilmaz, Y., & Kaya, M.

(2009). Risk factors for low back pain and its relation with pain related disability and

depression in a Turkish sample. Turkish Neurosurgery, 19(4), 327-332.

16) Borenstein, D. (2004). Does osteoarthritis of the lumbar spine cause chronic low

back pain? Current Rheumatology reports, 6(1), 14-29.

17) Center for Neuro and Spine. (2013). Low back pain. Retrieved from Center for

Neuro and Spine: http://www.centerforneuroandspine.com/conditions/spine-conditions/

lumbar-spine-conditions/low-back-pain/default.aspx


18) Cleveland Clinic. (2008, October 24). Back strains and sprains. Retrieved from

Cleveland clinic: http://my.clevelandclinic.org/orthopaedics-rheumatology/diseases-

conditions/back-strains-and-sprains.aspx

19) Ray, C. D. (2005, June 7). Osteoarthritis of the spine. Retrieved from spine-health:

http://www.spine-health.com/conditions/arthritis/osteoarthritis-spine

18) Shiel, W. C. (2012, March 12). Low back pain. Retrieved from MedicineNet.com:

http://www.medicinenet.com/low_back_pain/page2.htm

20) Simon, H., & Zieve, D. (2012, May 3). Back Pain and Sciatica. Retrieved from

University of Maryland Medical System:

http://umm.edu/health/medical/reports/articles/back-pain-and-sciatica

21) Teitel, A. D., & Zieve, D. (2012, February 2). Fibromyalgia. Retrieved from

MedlinePlus: http://www.nlm.nih.gov/medlineplus/ency/article/000427.htm

22) Ullrich, P. F. (1999, September 8). Fibromyalgia: Overview. Retrieved from spine-

health: http://www.spine-health.com/conditions/fibromyalgia/fibromyalgia-overview

23) Ullrich, P. F. (2012, March 22). Pulled muscle and lower back strain. Retrieved from

spine-health: http://www.spine-health.com/conditions/lower-back-pain/pulled-back-

muscle-and-lower-back-strain.

24) Shiel, W. C. (2012, March 12). Low back pain. Retrieved from MedicineNet.com:

http://www.medicinenet.com/low_back_pain/page2.htm

25) Boden, S. D. (2005, May 11). When back pain is a spine compression fracture.

Retrieved from spine-health:

http://www.spine-health.com/conditions/osteoporosis/when-back-pain-a-spine-

compression-fracture


http://www.spine-health.com/conditions/lower-back-pain/pulled-back-muscle-and-lower-back-strain

http://www.spine-health.com/conditions/lower-back-pain/pulled-back-muscle-and-lower-back-strain

26) Hicks, R. (2012, May 17). Pain management guide. Retrieved from WebMD:

http://www.webmd.boots.com/pain-management/guide/back-pain-osteoporosis-bone-

fractures?page=2

27) Middleton, K., & Fish, D. E. (2009, June). Lumbar spondylosis: clinical presentation

and treatment approaches. Current reviews in musculoskeletal medicine, 2(2), 94-104.

28) Nakamura, T. (2003). Low back pain accompanying osteoporosis. The Journal of

Japanese Medical Association, 46(10), 445-451.

29) National Institute of Neurological Disorders and Stroke. (2003, July). Low back pain

fact shift. Retrieved from NAtional Institutes of health.

30) Ribeiro, C., Fernandes, P., & Reis, F. (1998, June). The Maffucci syndrome with

axial bone lesions. A rare cause of low back pain. Acta Med Port, 11(6), 559-562.

31) Sama, A. A. (2012, August 17). Spinal tumors. Retrieved from Medscape:

http://emedicine.medscape.com/article/1267223-overview

32) Texas Oncology. (2013). Bone metastases.

33) Ullrich, P. F. (2008, May 7). Spondylosis: What it actually means. Retrieved from

spine-health: http://www.spine-health.com/conditions/lower-back-pain/spondylosis-what-

it-actually-means

34) Walker, K. A. (2012, December 12). Spinal osteoarthritis (Spondylosis). Retrieved

from Practical Pain Management:

http://www.practicalpainmanagement.com/patient/conditions/osteoarthritis/spinal-

osteoarthritis-spondylosis


35) Yuan, Y.-C., Huang, C.-T., Lin, Y.-T., Lai, Y.-T., & Wu, I.-H. (2011). Osteoporosis

with low back pain. Fu-Jen journal of medicine, 9(4), 207-214.

36) Adams, M. A., & Roughley, P. J. (2006). What is intervertebral disc degeneration,

and what causes it? Spine, 31(18), 2151-2161.

37) Mayo Clinic Staff. (n.d.). Pain management Back pain.

38) Morgan, F. P., & King, T. (1957). Primary instability of lumbar vertebrae as a

common cause of low back pain. The journal of bone and joint surgery, 39 B(1), 6-22.

39) Panjabi, M. M. (1992, January). The stabilizing system of the spine. Part I. Function,

dysfunction, adaptation and enhancement. Journal of spinal disorders and techniques,

5(4), 383-389.

40) Porter, R. W. (1996). Spinal stenosis and neurogenic claudication. Spine, 21(17),

2046-2052.

41) Ullrich, P. F. (1999, September 8). Lumbar spinal stenosis: a definitive guide.


http://www.spine-health.com/conditions/spinal-stenosis/lumbar-spinal-stenosis-a-

definitive-guide

42) Ullrich, P. F. (2006, November 6). Lumbar degenerative disc disease (DDD).

Retrieved from spine-health: http://www.spine-health.com/conditions/degenerative-disc-

disease/lumbar-degenerative-disc-disease-ddd

43) WebMD Medical Reference. (2010, April 15). WebMD Back pain health center.

Retrieved from Lumbar spinal stenosis: an overview: http://www.webmd.com/back-

pain/tc/lumbar-spinal-stenosis-topic-overview


44) Weinstein, J. N., Tosteson, T. D., Lurie, J. D., & Tosteson, A. N. (2008). Surgical

versus nonsurgical therapy for lumbar spinal stenosis. The New England Journal of

Medicine, 358, 794-810.

45) Anderson, P. (2013, May 8). Low back pain linked to bacterial infection. Retrieved

from medscape: http://www.medscape.com/viewarticle/803858

46) Badshah, C. (2005, May 2). Shingles. Retrieved from Health Central:

http://www.healthcentral.com/encyclopedia/408/138.html?ic=506048

47) Baker, A. S., Ojemann, R. G., Swartz, M. N., & Richardson, E. P. (1975, September

5). Spinal epidural abscess. The New England journal of medicine, 293(10), 463-468.

48) Fowler, C. J. (1999). Cauda Equina Disorders. In C. J. Fowler, Neurological bladder,

bowel and sexual dysfunction (pp. 63-74). London: Butterworth-Heinemann.

49) Huang, J. (2002, July 10). Potential causes of back pain in children and teens.


http://www.spine-health.com/conditions/lower-back-pain/potential-causes-back-pain-

children-and-teens

50) Kenny, T., & Knott, L. (2013, April 5). Nonspecific lower back pain ina dults.

Retrieved from patient.co.uk: http://www.patient.co.uk/health/nonspecific-lower-back-

pain-in-adults

51) Schofferman, L., Schofferman, J., Zucherman, J., Gunthorpe, H., Hsu, K., Picetti,

G., White, A. (1992). Occult infections causing persistent low-back pain. Spine, 17(7).

52) Siemionow, K., Steinmetz, M., Bell, G., Ilaslan, H., & Mclain, R. F. (2008).

Identifying serious causes of back pain: Cancer, infection, fracture. Cleveland clinic

journal of medicine, 75(8), 557-566.


53) Steere, A. C., Schoen, R. T., & Taylor, E. (1987). The clinical evolution of Lyme

arthritis. Annals of Internal medicine, 107(5), 725-731.

54) Steere, A. D., Bartenhagen, N. H., Craft, J. E., Hutchinson, G. J., Newman, J. H.,

Rahn, D. W., Malawista, S. E. (1983). The early clinical manifestations of Lyme disease.

Annals of Internal medicine, 99(1), 76-82.

55) Teitel, A. D. (2012, February 2). Rheumatoid arthritis. Retrieved from MedlinePlus:

http://www.nlm.nih.gov/medlineplus/ency/article/000431.htm

56) Ullrich, P. F. (1999, September 8). Rheumatoid arthritis in the spine. Retrieved from

spine-health: http://www.spine-health.com/conditions/arthritis/rheumatoid-arthritis-spine

57) University of Maryland Medical Center. (2013, June 17). Ankylosing spondylitis A

patient's guide to ankylosing spndylitis. Retrieved from spine center umm.edu:

http://umm.edu/programs/spine/health/guides/ankylosing-spondylitis

58) Vaccaro, A. R. (2000, April 15). Osteomyelitis, a spinal infection. Retrieved from

spine-health: http://www.spine-health.com/conditions/lower-back-pain/osteomyelitis-a-

spinal-infection.

59) Villavicencio, A. (2011, January 6). Cauda equina syndrome. Retrieved from spine-

health: http://www.spine-health.com/conditions/lower-back-pain/cauda-equina-

syndrome.

60) Vorvick, L. J., & Benjamin, C. (2012, June 29). Low back pain-acute. Retrieved from

MedlinePlus: http://www.nlm.nih.gov/medlineplus/ency/article/007425.htm.

61) Ben-yishay, A. (2007, June 12). When back pain may be a medical emergency.




http://www.spine-health.com/conditions/lower-back-pain/when-back-pain-may-be-a-

medical-emergency

62) Bratton, R. L. (1999, November 15). Assessment and management of acute low

back pain. American Family Physician, 60(8), 2299-2306.

63) Coleman, R. (2001, June). Metastatic bone disease: clinical features,

pathophysiology and treatment strategies. Cancer treatment reviews, 27(3), 165-176.

64) Coleman, R. E. (1997, October 15). Skeletal complications of malignancy. Cancer,

80(8), 1588-1594.

65) Deyo, R. A., Rainville, J., & Kent, D. L. (1992, August 12). What can the history and

physical examination tell us about low back pain. JAMA, 268(6), 760-765.

66) Kennedy, J., Soffe, K., McGrath, A., Stephens, M., Walsh, M., & McManus, F.

(1999). Predictors of outcome in cauda equina syndrome. European journal of spine, 8,

317-322.

67) Levis, J. T. (2009). Cauda equina syndrome. Western Journal of emergency

medicine, 10(1), 20-22.

68) Rigler, M. L., Drasner, K., Krejcie, T. C., Yelich, S. J., Scholnick, F. T., DeFontes, J.,

& Bohner, D. (1991). Cauda equina syndrome after continous spinal anesthesia.

Anesthesia analgesia, 72, 275-281.

69) Shephard, R. (1959, Decemebr 26). Diagnosis and prognosis of Cauda equina

syndrome produced by protrusion of lumbar disc. British medical journal, 1434.

70) Spector, L. R., Madigan, L., Rhyne, A., Darden, B., & Kim, D. (2008). Cauda equina

syndrome. Journal of the American Academy of Orthopedic Surgeons, 16(8), 471-479.


71) National Institute of Health and Care Excellence. Low Back Pain (early

management): overview. Retrieved from http://pathways.nice.org.uk/pathways/low-

back-pain-early-management/low-back-pain-early-management-

overview#content=view-node%3Anodes-advice-information-and-promoting-self-

management

72) Forseen, S., & Corey, A. (2012). Clinical Decision Support and Acute Low Back

Pain: Evidence-based order sets. Journal of the American College of Radiology, 9 (10),

704-712.

73) French, S.D., Cameron, M., Walker, B.F., Reggars, J.W., & Esterman, A.J. (2006).

A Cochrane review of superficial heat or cold for low back pain. Spine, 31(9):998-1006.

74) Petering, R., & Webb, C. (2011). Treatment options for low back pain in athletes.

Sports Health, 3(6), 550-555.

75) Hagen, K.B., Hilde, G., Jamvedt, G., & Winnem, M. (2010). WITHDRAWN: Bed rest

for acute low-back pain and sciatica. Cochrane Database Systematic Review,

(6):CD001254. doi: 10.1002/14651858.CD001254.pub3.

76) National Health Society. Exercises for lower back pain. Retrieved from

http://www.nhs.uk/Livewell/Backpain/Pages/low-back-pain-exercises.aspx.

77) Masharawi, Y., & Nedal, N. (2013). The effect of non-weight bearing group-

exercising on females with non-specific chronic low back pain: A randomized single

blind controlled pilot study. Journal of Back and Musculoskeletal Rehabilitation.

Retrieved from http://www.ncbi.nlm.nih.gov/pubmed/23948819.

78) Larivière C, DA Silva RA, Arsenault AB, Nadeau S, Plamondon A, Vadeboncoeur R.

(2010). Specificity of a back muscle exercise machine in healthy and low back pain


http://www.ncbi.nlm.nih.gov/pubmed/23948819

http://www.nhs.uk/Livewell/Backpain/Pages/low-back-pain-exercises.aspx

subjects. Medicine and Science in Sports Exercise, 42(3):592-9. doi:

10.1249/MSS.0b013e3181b96029.

79) Kuczynski, J., Schwieterman, B., Columber, K., Knupp, D., Shaub, L. & Cook, C.

(2012). Effectiveness of physical therapist administered spinal manipulation for the

treatment of low back pain: a systematic review of the literature. International Journal of

Sports Physical Therapy, 7(6): 647–662. PMCID: PMC3537457.

80) Cleland, J.A., Fritz, J.M., Kulig, K., Davenport, T.E., Eberhart, S., Magel, J., &

Childs, J.D. (2009). Comparison of the effectiveness of three manual physical therapy

techniques in a subgroup of patients with low back pain who satisfy a clinical prediction

rule: a randomized clinical trial. Spine, 34(25):2720-9. doi:

10.1097/BRS.0b013e3181b48809.

81) Bronfort, G., Haas, M., Evans, R.L., & Bouter, L.M. (2004). Efficacy of spinal

manipulation and mobilization for low back pain and neck pain: a systematic review and

best evidence synthesis. Spine Journal, 4(3):335-56.

82) Dagenais, S., Gay, R.E., Tricco, A.C., Freeman, M.D., & Mayer, J.M. (2010). NASS

Contemporary Concepts in Spine Care: spinal manipulation therapy for acute low back

pain. Spine Journal, (10):918-40. doi: 10.1016/j.spinee.2010.07.389.

83) Senna, M.K., & Machaly, S.A. (2011). Does maintained spinal manipulation therapy

for chronic nonspecific low back pain result in better long-term outcome? Spine,

36(18):1427-37. doi: 10.1097/BRS.0b013e3181f5dfe0.

84) Assendelft, W.J., Morton, S.C., Yu, E.I., Suttorp, M.J., Shekelle, P.G. (2003). Spinal

manipulative therapy for low back pain. A meta-analysis of effectiveness relative to

other therapies. Annals of Internal Medicine, 138(11):871-81.


85) Johns Hopkins Medicine. Laminectomy. Retrieved from

http://www.hopkinsmedicine.org/healthlibrary/test_procedures/orthopaedic/

laminectomy_92,P07681/.

86) Jones, A.D., Wafai, A.M., & Easterbrook, A.L. (2013). Improvement in low back pain

following spinal decompression: observational study of 119 patients. European Spine

Journal.

87) Mirza, S.K., & Deyo, R.A. (2007). Systematic review of randomized trials comparing

lumbar fusion surgery to nonoperative care for treatment of chronic back pain. Spine,

32(7):816-23.

88) National Health Society. Acupuncture. Retrieved from

http://www.nhs.uk/conditions/Acupuncture/Pages/Introduction.aspx.

89) National Center for Complementary and Alternative Medicine: “Acupuncture for

Pain.”

90) Chou, R., Baisden, J., Carragee, E.J., Resnick, D.K., Shaffer, W.O., & Loeser, J.D.

(2009). Surgery for low back pain: a review of the evidence for an American Pain

Society Clinical Practice Guideline. Spine, 1;34(10):1094-109. doi:

10.1097/BRS.0b013e3181a105fc.

91) Carreon, L.Y., Glassman, S.D., & Howard, J. (2008). Fusion and nonsurgical

treatment for symptomatic lumbar degenerative disease: a systematic review of

Oswestry Disability Index and MOS Short Form-36 outcomes. Spine Journal, 8(5):747-

55.

92) Saltychev, M., Eskola, M., & Laimi, K. (2013). Lumbar fusion compared with

conservative treatment in patients with chronic low back pain: a meta-analysis. Internal

Journal of Rehabilitation Research.


http://www.nhs.uk/conditions/Acupuncture/Pages/Introduction.aspx

http://www.hopkinsmedicine.org/healthlibrary/test_procedures/orthopaedic/laminectomy_92,P07681/

http://www.hopkinsmedicine.org/healthlibrary/test_procedures/orthopaedic/laminectomy_92,P07681/

93) O'Sullivan, K., O'Sullivan, L., O'Sullivan, P., & Dankaerts, W. (2013). Investigating

the effect of real-time spinal postural biofeedback on seated discomfort in people with

non-specific chronic low back pain. Ergonomics, 56(8):1315-25. doi:

10.1080/00140139.2013.812750. Epub 2013 Jul 5.

94) National Library of Medicine. (2011). Kyphoplasty. Retrieved from

http://www.nlm.nih.gov/medlineplus/ency/article/007511.htm.

95) Hemmings, D. (2012). Discectomy. Health Grades. Retrieved from

http://www.healthgrades.com/procedures/discectomy?

96) National Library of Medicine. (2012). Foraminotomy. Retrieved from

http://www.ncbi.nlm.nih.gov/pubmedhealth/PMH0004637/

97) The British Acupuncture Council. (2011). Back pain. Retrieved from

http://www.acupuncture.org.uk/a-to-z-of-conditions/a-to-z-of-conditions/back-pain.html

98) Thomas, K.J., MacPherson, H., Ratcliffe, J., Thorpe, L., Brazier, J., Campbell, M.,

Fitter, M., Roman, M., Walters, S., & Nicholl, JP. (2005). Longer term clinical and

economic benefits of offering acupuncture care to patients with chronic low back pain.

Health Technology Assessment, 9(32):iii-iv, ix-x, 1-109.

99) Yuan J, Purepong N, Kerr DP, Park J, Bradbury I, McDonough S. (2008).

Effectiveness of acupuncture for low back pain: a systematic review. Spine,

1;33(23):E887-900. doi: 10.1097/BRS.0b013e318186b276.

100) Shin, J.S., Ha, I.H., Lee, J., Choi, Y., Kim, M.R., Park, B.Y., Shin, B.C., & Lee,

M.S. (2013). Effects of motion style acupuncture treatment in acute low back pain

patients with severe disability: a multicenter, randomized, controlled, comparative

effectiveness trial. Pain, 154(7):1030-7. doi: 10.1016/j.pain.2013.03.013. Epub 2013

Mar 15.


101) Itoh, K., Katsumi, Y., Hirota, S., & Kitakoji, H. (2006). Effects of trigger point

acupuncture on chronic low back pain in elderly patients--a sham-controlled randomised

trial. Acupuncture Medicine, 24(1):5-12.

102) Itoh, K., Katsumi, Y., & Kitakoji, H. (2004). Trigger point acupuncture treatment of

chronic low back pain in elderly patients--a blinded RCT. Acupuncture Medicine,

22(4):170-7.

103) Hochschuler, S. (2008), Back Pain Diagnosis: Diagnostic Tests for

Indicators of Back Pain. Retrieved from http://www.spine-health.com/conditions/lower-

back-pain/back-pain-diagnosis-diagnostic-tests-indicators-back-pain.

104) National Institute of Health. (2003). Low Back Pain Fact Sheet. Retrieved from

http://www.ninds.nih.gov/disorders/backpain/detail_backpain.htm.

105) Johns Hopkins University: Health Library. X-rays of the Spine, Neck, or Back

(Cervical, Thoracic, Lumbar, Sacral, or Coccygeal X-ray Studies) Procedure overview,

Guide to the diagnosis, treatment and prevention of conditions from A to Z. Retrieved

from http://www.hopkinsmedicine.org/healthlibrary/test_procedures/orthopaedic/x-

rays_of_the_spine_neck_or_back_92,P07645/.

106) American College of Radiology. Myelography of spine, Retrieved from

http://www.radiologyinfo.org/en/psa/index.cfm?pg=psa_pc

107) American College of Radiology. Computed Scan of Spine. Retrieved from


108) American College of Radiology. MRI Scan of Spine. Retrieved from



109) Agranoff, A.B., Andary, M.T., & Moberg-Wolff, E. (2013). Electrodiagnosis.

Medscape. Retrieved from http://emedicine.medscape.com/article/307096-overview

110) National Institute of Health. (2011). Bone scan. Retrieved from


111) Sync Medical. Back Pain. Retrieved from http://www.syncmedical.co.uk/back-

pain.htm.

112) Quante, M., Lorenz, J., & Hauck, M. (2010). Laser-evoked potentials: prognostic

relevance of pain pathway defects in patients with acute radiculopathy. European Spine

Journal, 19(2): 270–278. PMCID: PMC2899816

Retrieved from http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2899816/.

113) National Institute of Health. Vertebroplasty. Retrieved from

http://www.nlm.nih.gov/medlineplus/ency/article/007512.htm.

114) Radiological Society of North America. Vertebroplasty and kyphoplasty. Retrieved

from http://www.radiologyinfo.org/en/info.cfm?pg=vertebro

115) Adam, D., Pevzner, E., & Gepstein, R. (2013). Comparison of percutaneous

nucleoplasty and open discectomy in patients with lumbar disc protrusions. Chirurgia

(Bucur), 108(1):94-8.

116) Gerges, F.J., Lipsitz, S.R., & Nedeljkovic, S.S. (2010). A systematic review on the

effectiveness of the Nucleoplasty procedure for discogenic pain.

117) Arthrocare spine. Nuceloplasty. Retrieved from

http://www.nucleoplasty.com/phyNucleoplasty.aspx.


http://www.nucleoplasty.com/phyNucleoplasty.aspx


118) American Academy of Physical Medicine and Rehabilitation. Intradiscal

electrothermal therapy. Retrieved from

http://www.aapmr.org/patients/conditions/msk/spine/Pages/IDET.aspx.

119) Maurer, P., Block, J.E., & Squillante, D. (2008). Intradiscal electrothermal therapy

(IDET) provides effective symptom relief in patients with discogenic low back pain.

Journal of Spinal Disorders and Techniques, 21(1):55-62. doi:

10.1097/BSD.0b013e31812f4f29.

120) Kloth, D.S., Fenton, D.S., Andersson, G.B., & Block, J.E. (2008). Intradiscal

electrothermal therapy (IDET) for the treatment of discogenic low back pain: patient

selection and indications for use. Pain Physician, 11(5):659-68.

121) National Health Society. Traction. Retrieved from

http://www.nhs.uk/conditions/traction/Pages/Introduction.aspx.

122) Wegner, I., Widyahening, I.S., van Tulder, M.W., Blomberg, S.E., de Vet, H.C.,

Brønfort, G., Bouter, L.M., & van der Heijden. G.J. (2013). Traction for low-back pain

with or without sciatica. Cochrane Database Systematic Review, 19;8:CD003010. doi:

10.1002/14651858.CD003010.pub5.

123) Keskin, E.A., Onur, O., Keskin, H.L., Gumus II, Kafali, H., & Turhan, N. (2012).

Transcutaneous electrical nerve stimulation improves low back pain during pregnancy.

Gynecologic and Obstetric Investigation, 74(1):76-83. doi: 10.1159/000337720. Epub

2012 Jun 21.

124) Buonocore, M., Camuzzini, N., Cecini, M., Dalla Toffola, E. (2013). High-frequency

transcutaneous peripheral nerve stimulation induces a higher increase of heat pain

threshold in the cutaneous area of the stimulated nerve when confronted to the

neighbouring areas. Biomed Research International, 2013:464207. doi:

10.1155/2013/464207. Epub 2013 Aug 6.


125) Buonocore, M., & Camuzzini, N. (2007). Increase of the heat pain threshold during

and after high-frequency transcutaneous peripheral nerve stimulation in a group of

normal subjects. Europa Medicophysica, 43(2):155-60. Epub 2006 Oct 3.

126) Laser spine institute. Ultrasound therapy for back pain. Retrieved from

http://www.laserspineinstitute.com/beendoctors/section/other/26/ultrasound/183/.

127) Ebadi. S., Ansari, N.N., & Fallah, E. (2012). The effect of continuous ultrasound on

chronic non-specific low back pain: a single blind placebo-controlled randomized trial.

BMC Musculoskeletal Disorder, 13:192. Published online 2012 October 2. doi:

10.1186/1471-2474-13-192

128) Ebadi, S., Ansari, N.N., Naghdi, S., Fallah, E., Barzi, D.M., Jalaei, S., & Bagheri, H.

(2013). A study of therapeutic ultrasound and exercise treatment for muscle fatigue in

patients with chronic non specific low back pain: a preliminary report. Journal of Back

and Musculoskeletal Rehabilitation, 1;26(2):221-6. doi: 10.3233/BMR-130380.

129) Stelzer, W., Aiglesberger, M., Stelzer, D., & Stelzer, V. (2012). Use of cooled

radiofrequency lateral branch neurotomy for the treatment of sacroiliac joint-mediated

low back pain: a large case series. Pain Medication, 14(1):29-35. doi:

10.1111/pme.12014. Epub 2012 Dec 28.

130) Kapural, L., Nageeb, F., Kapural, M., Cata, J.P., Narouze, S., & Mekhail, N.

(2008). Cooled radiofrequency system for the treatment of chronic pain from sacroiliitis:

the first case-series. Pain Practice, 8(5):348-54. doi: 10.1111/j.1533-

2500.2008.00231.x.

131) Ferrante, F.M., King, L.F., Roche, E.A., Kim, P.S., Aranda, M., Delaney, L.R.,

Mardini, I.A., & Mannes, A.J. (2001). Radiofrequency sacroiliac joint denervation for

sacroiliac syndrome. Regional Anesthesia and Pain Medicine, 26(2):137-42.


132) Berry, H., & Hutchinson, D. (1998). Tizanidine and ibuprofen ina cute low back

pain:results of a double -blind multicenter study in general practice. Journal of

International Medical Research, 16, 83-91.

133) Chou, R., & Huffman, H. L. (2007). Medications for acute and chronic low back

pain: a review of the evidence for an American pain society /American college of

physicians clinical practice guideline. Annals of Internal Medicine, 147, 505-514.

134) Nonsteroidal anti-inflamamtory drugs expert group. (2007). Nonsteroidal anti-

inflammatory drugs. In N. a.-i. group, eTG23[CD-ROM]. Therapeutic Guidelines.

135) Paracetamol Expert Group. (2007). Paracetamol. In P. E. Group, eTG23 [CD-

ROM]. Therapeutic Guidelines Ltd.

136) Tripathi, K. (2008). NSAIDs and antipyretic-analgesics. In K. Tripathi, & 6th (Ed.),

Essentials of MEdical Pharmacology. New Delhi: JAYPEE Publishers.

137) Vroomen, P., deKrom, M., slofstra, P., & Knottnerus, J. (2000). Conservative

treatment of sciatica: a systematic review. Journal of Spinal disorders, 13, 463-469.

138) Maizels, M., & McCarberg, B. (2005). Antidepressants and antiepileptic drugs for

chronic non-cancer pain. American Family Physician, 71(3):483-90.

139) Sullivan, M.D., & Robinson, J.P. (2006). Antidepressant and anticonvulsant

medication for chronic pain. Physical Medicine and Rehabilitation Clinics of North

America, 17(2):381-400, vi-vii.

140) Antidepressant Drug Expert group. (2007). Antidepressant drugs. Melbourne:

Therapeutic guidelines limited.

141) Antiepileptic Drug Expert Group. (2007). Antiepileptic drugs. Melbourne:

Therapeutic guidelines limited.


142) Baldessarini, R. J. (2006). Drug therapy of depression and anxiety disorders. In L.

L. Brunton, J. S. Lazo, & K. L. Parker, Goodman & Gilman's the Pharmacological BAsis

of therapeutics (11th ed.). New York: McGraw Hill.

143) Barlow, P. (2012). A practical review of the Glasgow Coma Scale and Score. The

Surgeon, 10(2), 114-119.

144) Chamoun, R. B., Robertson, C. S., & Gopinath, S. P. (2009). Outcome in patients

with blunt head trauma and a Glasgow Coma Scale score of 3 at presentation. Journal

of Neurosurgery, 111(4), 683-687.

145) Chou, R. (2010). Pharmacological management of low back pain. Drugs, 70, 387-

402.

146) Eken, C., Kartal, M., Bacanli, A., & Oktay, E. (2009). Comparison of the full outline

of unresponsiveness score coma scale and the glasgow coma scale in an emergency

setting population. European journal of emergency medicine, 16(1), 29-36.

147) Fischer, M., Ruegg, S., Czaplinski, A., Strohmeier, M., Lehmann, A., Tschan, F.,

Marsch, S. C. (2010). Inter-rater reliability of the full outline og unresponsiveness score

and the glasgow coma scale in critically ill patients : a prospective observational study.

Critical care, 14(R64).

148) Grote, S., Bocker, W., Mutschler, Bouillon, B., & Lefering, R. (2011). Diagnostic

value of the Glasgow coma scale for traumatic brain injury in 18,002 patients with

severe multiple injuries. Journal of neurotrauma, 28, 527-534.

149) Holmes, J. F., Palchak, M. J., MacFarlene, T., & Kuppermann, N. (2008).

Performance of the paediatric Glasgow Coma Scale in children with blunt head trauma.

Academic emergency medicine, 12(9), 814-819.


150) Matis, G., & Birbilis, T. (2008). The Glasgow Coma Scale-a brief review past,

present, future. Acta Neurol Belg, 108, 75-89.

151) McNamara, J. O. (2006). Pharmacotherapies of the epilepsies. In L. L. Brunton, J.

S. Lazo, & K. L. Parker, Goodman & Gilman's the pharmacological basis of therapeutics

(11th ed.). New York: McGraw-Hill Medical publishing division.

152) Salerno, S.M., Browning, R., & Jackson, J.L. (2002). The effect of antidepressant

treatment on chronic back pain: a meta-analysis. Archives of Internal Medicine,

14;162(1):19-24.

153) Buprenorphine : an alternative to methadone. (2003). The Medical letter on drugs

and therapeutics, 45(1150), 13-5.

154) Expert group for therapeutic guidelines: Analgesic. (2006, January). Therapeutic

guidelines. In Expert group for therapeutic guidelines: Analgesic, eTG complete [CD-

ROM]. Melbourne, Australia.

155) Gutsein, H. B., & Akil, H. (2006). Opioid analgesics. In L. L. Brunton, J. S. lazo, &

K. L. Parker, Goodman & Gilman's the pharmacological basis of therapeutics. New

York: McGraw-Hill.

156) Morrison, R., magaziner, J., Gilbert, M., Koval, K., McLaughlin, M., & Orosz, G.

(2003). Relationship between pain and opioid analgesics on the development of

delirium following hip fracture. The Journals of gerontology Series A: Biological sciences

and medical scinces, 58(1), 76-81.

157) American Academy of Orthopedic Surgeons. (2009). Interventional therapies,

surgery, and interdisciplinary rehabilitation for low back pain. Retrieved from

http://www.aaos.org/news/aaosnow/sep10/cover1_t1.pdf.


http://www.aaos.org/news/aaosnow/sep10/cover1_t1.pdf

158) Peh, W.C.G. (2011). Image-guided facet joint injection. Biomedical imaging and

interventional journal. Retrieved from

http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3107686/.

159) Childers, M. (2012). Botulinum toxin in pain management. Medscape. Retrieved

from http://emedicine.medscape.com/article/325574-overview#a30.

160) Waseem, Z., Boulias, C., Gordon, A., Ismail, F., Sheean, G., & Furlan, A.D. (2011).

Botulinum toxin injections for low-back pain and sciatica. Cochrane Database of

Systematic Reviews,1. Art. No.: CD008257. DOI: 10.1002/14651858.CD008257.pub2.

161) Brunner, E., De Herdt, A., Minguet, P., Baldew, S.S., & Probst, M. (2012). Can

cognitive behavioural therapy based strategies be integrated into physiotherapy for the

prevention of chronic low back pain? A systematic review. Disability and Rehabilitation,

35(1):1-10. doi: 10.3109/09638288.2012.683848. Epub 2012 May 21.

162) O'Sullivan, K., O'Sullivan, L., O'Sullivan, P., & Dankaerts, W. (2013). Investigating

the effect of real-time spinal postural biofeedback on seated discomfort in people with

non-specific chronic low back pain. Ergonomics, 56(8):1315-25. doi:

10.1080/00140139.2013.812750. Epub 2013 Jul 5.

163) Giggins, O.M., Persson, U.M., & Caulfield, B. (2013). Biofeedback in rehabilitation.

Journal of Neuroengineering and Rehabilitation, 18;10:60. doi: 10.1186/1743-0003-10-

6.


http://emedicine.medscape.com/article/325574-overview#a30

http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3107686/

The information presented in this course is intended solely for the use of healthcare professionals taking this course, for credit, from NurseCe4Less.com.

The information is designed to assist healthcare professionals, including nurses, in addressing issues associated with healthcare.

The information provided in this course is general in nature, and is not designed to address any specific situation. This publication in no way absolves facilities of their responsibility for the appropriate orientation of healthcare professionals.

Hospitals or other organizations using this publication as a part of their own orientation processes should review the contents of this publication to ensure accuracy and compliance before using this publication.

Hospitals and facilities that use this publication agree to defend and indemnify, and shall hold NurseCe4Less.com, including its parent(s), subsidiaries, affiliates, officers/directors, and employees from liability resulting from the use of this publication.

The contents of this publication may not be reproduced without written permission from NurseCe4Less.com.


lower back pain - nursece4less.com · web viewlower back pain results from abnormal mechanics of...

Documents