Treatment

Overview

  • Low back pain affects at least 70% of population at some stage during their life
  • In Australia, LBP is the single most frequent presentation to GPs
  • The cause of pain is non-specific in 95% of patients
  • Serious conditions are rare (but obviously need to be identified)
  • Most episodes are self limiting :
    • 90%+ substantially better within 2 weeks
    • Episodes > 2 weeks affect only 14% of the population at some stage during their lifetime
    • Majority of people with LBP make full recovery within 3/12

Cauda Equina Syndrome

  • The spinal cord terminates at the level of T12 / L1 and the cauda equina continues distally
  • The cauda equina (“horse’s tail”) is the collection of lumbar and sacral nerve roots (lower motor neurones)

  • Compression of the cauda equina can lead to Cauda Equina Syndrome, which is a medical emergency
  • Features of Cauda Equina Syndrome include some or all of the following:
    • Urinary retention, faecal incontinence, lax anal sphincter, saddle area numbness
    • Widespread neurological symptoms and signs in the lower limb, including gait abnormality
  • Cause
    • Cauda equina syndrome results from a herniated lumbar disk in 1-15% of cases.
    • Seventy percent of cases of herniated disks leading to cauda equina syndrome occur in people with a history of chronic low back pain and 30% develop cauda equina syndrome as the first symptom of lumbar disc herniation.
    • Males in their 30s and 40s are most prone to cauda equina syndrome caused by disc herniation.
    • Most cases of cauda equina syndrome caused by disc herniation involve large particles of disk material that have completely separated from the normal disk and compress the nerves (extruded disk herniations).
    • In most cases, the disk material takes up at least one-third of the canal diameter.
    • Other causes include:
      • Spinal Canal stenosis
      • Spondylolisthesis (severe)
      • Tumour
      • Infection
      • Severe trauma / swelling
      • Infectious disease
      • Failed surgery

Treatment of Non-Specific Low Back Pain

Medications

  • Usually, the primary reason a patient with LBP seeks assistance is for pain relief
  • To treat a patient with acute LBP and expect to have them pain-free on discharge is as unrealistic as for a patient with an acute ankle sprain
  • We need to reinforce that relief of pain should not be exclusively limited to pharmaceuticals = posture, positioning, relative rest and non-pharmaceutical methods of pain relief should also be utilised
  • All drugs have unwanted side effects and ultimately the body has to heal itself, so general health behaviours are also important
  • SHORT TERM GAIN VERSUS POTENTIAL FOR LONGER TERM PROBLEMS
  • PRESCRIBING GUIDELINES FOR PRIMARY CARE CLINICIANS
    NSW THERAPEUTIC ASSESSMENT GROUP (2003)

 

Levels of evidence

  • Level 1 Evidence obtained from systematic review of relevant randomised controlled trials
  • Level 2 Evidence obtained from one or more well-designed, randomised controlled trials
  • Level 3 Evidence obtained from well-designed, non-randomised controlled trials; or from well designed cohort or case control studies
  • Level 4 Opinions of respected authorities based on clinical experience, descriptive studies, reports of expert committees

NSAIDs

Relative Risk of GI complications from NSAIDS

DrugRelative Risk
Ibuprofen1.0
Diclofenac2.3
Naproxen7.0
Indomethacin8.0
Pirioxicam9.0

BMJ 1996;312:1563-6

  • Mode of delivery does not change potential problems (action is systemic)

NSAID Toxicity

  • U.S. Mortality Data for Seven Selected Disorders in 1997. A total of 16,500 patients with rheumatoid arthritis or osteoarthritis died from the gastrointestinal toxic effects of NSAIDs. Data are from the National Center for Health Statistics and the Arthritis, Rheumatism, and Aging Medical Information System