Back Pain - Sciatica
- Diagnosis, Imaging, Screening
- General Information
- Guidelines
- Internet Sites
- Risk Factors
- Risk Reduction
- Treatment
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Back Pain - Sciatica
NIH - What Is Back Pain? “What Are the Causes of Back Pain? There are many causes of back pain. Mechanical problems with the back itself can cause pain. Examples are: • Disc breakdown • Spasms • Tense muscles • Ruptured discs Injuries from sprains, fractures, accidents, and falls can result in back pain. Back pain can also occur with some conditions and diseases, such as: • Scoliosis • Spondylolisthesis • Arthritis • Spinal stenosis • Pregnancy • Kidney stones • Infections • Endometriosis • Fibromyalgia Other possible causes of back pain are infections, tumors, or stress.”
NIH - Medical Encyclopedia Back pain - low "The specific structure in your back responsible for your pain is hardly ever identified. Whether identified or not, there are several possible sources of low back pain: • Small fractures to the spine from osteoporosis • Muscle spasm (very tense muscles that remain contracted) • Ruptured or herniated disk • Degeneration of the disks • Poor alignment of the vertebrae • Spinal stenosis (narrowing of the spinal canal) • Strain or tears to the muscles or ligaments supporting the back • Spine curvatures (like scoliosis or kyphosis) which may be inherited and seen in children or teens • Other medical conditions like fibromyalgia."
Highlighted Articles
Prolonged conservative care versus early surgery in patients with sciatica caused by lumbar disc herniation: two year results of a randomised controlled trial (BMJ 2008) “Conclusions Early surgery achieved more rapid relief of sciatica than conservative care, but outcomes were similar by one year and these did not change during the second year.”
Evidence-informed management of chronic low back pain with watchful waiting (The Spine Journal 2008) "After the common cold and other upper respiratory issues, LBP is the most common reason why medical attention is sought in the United States. The lifetime prevalence of LBP is estimated at 60% to 80% in industrialized nations. However, the presence of LBP does not necessarily require medical attention. Most cases occur without an obvious or diagnosable cause, and are self-limiting. Absent certain red flags indicative of serious pathology, care for LBP should generally begin with the least invasive option, as there is no evidence that more invasive approaches are more effective for nonspecific LBP."
Treatment of acute sciatica. (Am Fam Physician. 2007) "Acute sciatica is lower back pain with radiculopathy below the knee and symptoms lasting up to six weeks. … caused by a variety of conditions: disk herniation, lumbar spinal stenosis, facet joint osteoarthritis or other arthropathies, spinal cord infection or tumor, or spondylolisthesis. … Clinical Commentary: An efficient clinical history and thorough physical examination of a patient with suspected sciatica is needed to rule out urgent conditions like cauda equina syndrome, infection, or cancer, and to determine the need for diagnostic tests. After the acute episode, emphasis is placed on activity, back exercises, behavioral techniques, ergonomics education, and close clinical monitoring. Educating patients on self-care and establishing reasonable expectations usually increase patient compliance with therapy and improve satisfaction."
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Notes
The Guidelines section will contain 2008 and some 2007 updated published guidelines. To view Guidelines from previous years, view the Guideline sections or the Article sections or our Monthly Online Newsletter (under the Guidelines section).
Back Pain - Sciatica
Daily Treatment Report
Cognitive Therapy-CBT-Psychotherapy
Evidence-informed management of chronic low back pain with cognitive behavioral therapy (The Spine Journal 2008) "The major goal of cognitive behavioral therapy (CBT) is to replace maladaptive patient coping skills, cognitions, emotions, and behaviors with more adaptive ones. From a biopsychosocial perspective, CBT alone does not address all of the important variables potentially contributing to chronic low back pain (CLBP) (eg, biological factors) but may improve care for patients with psychological comorbidities. The addition of even a very brief schedule of CBT to usual care from primary care physicians has been shown to reduce pain and anxiety, though such effects may not last over time [1] and [2]. CBT is often a component of multidisciplinary pain programs and patients sometimes find it difficult to perceive the utility of CBT as the sole treatment for CLBP [3]."
Device Therapy
Lumbar supports for prevention and treatment of low back pain. (Cochrane Database Syst Rev. 2008)
Drug Side-Effects and Interactions
Drugs
NSAIDs and Manipulation Ineffective for Acute Low Back Pain: A Best Evidence Review (Medscape Family Medicine. 2008)
Non-steroidal anti-inflammatory drugs for low back pain. (Cochrane Database Syst Rev. 2008)
NSAIDs No Better for Low Back Pain "When it comes to treating low back pain, non-steroidal anti-inflammatory drugs (NSAIDs) such as naproxen and ibuprofen are no more effective than acetaminophen. That's the conclusion of researchers who reviewed more than 65 studies that included more than 11,000 people with low back pain. The review authors concluded that NSAIDs are "slightly effective" for short-term symptomatic relief in patients with acute and chronic low back pain without sciatica. But they said it's unclear whether NSAIDs work better than simple analgesics or other drugs. No kind of NSAID was obviously better than another."
Evidence-informed management of chronic low back pain with adjunctive analgesics (The Spine Journal 2008) "In individuals progressing from acute low back pain to CLBP, adjunctive analgesics appear to have grown in popularity in recent years given that traditional analgesics are not always able to achieve complete pain relief in all patients. The use of adjunctive analgesics is based on the etiology of CLBP, which can be divided into nocioceptive (pain stemming from tissue injury) and neuropathic (pain stemming from nerve injury). Most CLBP is considered nocioceptive but may nevertheless refer pain to the leg. True neuropathic radicular pain stems from nerve root injury or irritation. This distinction is important to avoid the indiscriminate use of adjunctive analgesics for nocioceptive pain, when they have a much stronger theoretical basis for use in neuropathic pain."
Evidence-informed management of chronic low back pain with nonsteroidal anti-inflammatory drugs, muscle relaxants, and simple analgesics (The Spine Journal 2008) "Nonsteroidal anti-inflammatory drugs (NSAIDs) are medications that provide anti-inflammatory and analgesic effects and which include common products such as ibuprofen and naproxen. Older NSAIDs are sometimes termed nonselective NSAIDs because they inhibit both the cyclooxygenase (COX)-1 and COX-2 enzymes. Newer NSAIDs are commonly known as selective NSAIDs, coxibs, or COX-2 inhibitors because they block only the COX-2 isoenzyme involved in inflammation. Muscle relaxants are drugs used to relax skeletal muscle, usually for the purpose of analgesia when related to chronic low back pain (CLBP). . "
Evidence-informed management of chronic low back pain with opioid analgesics (The Spine Journal 2008) "Opioid analgesics have become an integral part of the sophisticated management of patients. In 2001, a large insurance plan reported that 55% of patients with low back pain received analgesics, 38% of whom received opioids [6]. Of those receiving opioids, 9% received more than a 180-day supply. In specialty spine practices, opioids were part of the plan after a single visit for 3.4% of more than 25,000 patients, 75% of whom had pain for longer than 3 months [5]. In a university orthopedic spine clinic, opioids were prescribed for 66% of patients and 25% received LTO treatment [4]."
Exercise
Relieve Back Pain With Core Strength Training: Exercise may be a better option for back pain than surgery.“Back pain can be relieved by many different types of exercises. For instance, a knees-to-chest exercise can be a big help if your pain is due to spinal stenosis, a narrowing of areas in the spine that can put pressure on the nerves. That’s because lying on your back and pulling the knees to the chest for about 60 seconds opens up the disc space in the back, which relieves pressure on the nerves, says Kelly.”
Sciatica and Low Back Pain: Does Physical Therapy Provide Long-Term Benefits? A Best Evidence Review (Medscape Family Medicine. 2008)
The impact of aerobic fitness on functioning in chronic back pain. (Eur Spine J. 2007)
Evidence-informed management of chronic low back pain with lumbar extensor strengthening exercises (The Spine Journal 2008)
General Information
Rehabilitation after lumbar disc surgery. (Cochrane Database Syst Rev. 2008)
Back pain eased by good posture
Predictors of Physical Therapy Clinic Performance in the Treatment of Patients With Low Back Pain Syndromes. (Phys Ther. 2008)
Prolonged conservative care versus early surgery in patients with sciatica caused by lumbar disc herniation: two year results of a randomised controlled trial (BMJ 2008) “Conclusions Early surgery achieved more rapid relief of sciatica than conservative care, but outcomes were similar by one year and these did not change during the second year.”
The Evidence About Epidural Steroid Injections and Opioid Use for Low Back Pain
Local corticosteroid injections for low back pain and sciatica. (Joint Bone Spine. 2008)
Management of Chronic Low Back Pain (US Pharm. 2008)
Individual patient education for low back pain. (Cochrane Database Syst Rev. 2008)
SPORT lumbar intervertebral disk herniation and back pain: does treatment, location, or morphology matter? (Spine. 2008)
Evidence-informed management of chronic low back pain with watchful waiting (The Spine Journal 2008) "After the common cold and other upper respiratory issues, LBP is the most common reason why medical attention is sought in the United States. The lifetime prevalence of LBP is estimated at 60% to 80% in industrialized nations. However, the presence of LBP does not necessarily require medical attention. Most cases occur without an obvious or diagnosable cause, and are self-limiting. Absent certain red flags indicative of serious pathology, care for LBP should generally begin with the least invasive option, as there is no evidence that more invasive approaches are more effective for nonspecific LBP."
A supermarket approach to the evidence-informed management of chronic low back pain (The Spine Journal 2008) "Patients with chronic low back pain (CLBP) are finding it increasingly difficult to make sense of the growing list of treatment approaches promoted as solutions to this widespread problem. Their confusion is compounded by the financial and emotional cost of previous failed attempts. This frustration is felt not only by patients, but by all interested stakeholders, including clinicians trying to offer accurate advice and provide the most effective treatment to their patients, and third-party payers responsible for providing access to reasonable and necessary care. All share a common goal and wish to use limited healthcare resources to support those interventions most likely to result in clinically meaningful improvements in symptoms and functional capacity. The current approach to the management of CLBP makes this goal virtually unobtainable."
Evidence-informed management of chronic low back pain with physical activity, smoking cessation, and weight loss (The Spine Journal 2008)
What have we learned about the evidence-informed management of chronic low back pain "Although readers may be tempted to examine only those articles describing their favorite (or least favorite) treatments to find evidence that simply affirms their beliefs, it is highly recommended that the entire special focus issue be perused to compare and contrast the theories and evidence supporting all approaches. This can help overcome our natural tendencies to support only those treatments with which we are most familiar and dismiss those about which we know little. Only when reasonably informed about all available treatments will purchasers (eg, patients, insurers) and providers of care truly understand the current state of the science and art and be in a position to compare and make decisions concerning the treatment options for CLBP. This article will attempt to facilitate this task by summarizing some of the pertinent information from each of the articles presented in this special focus issue"
Guidelines
Low Back Pain Guidelines Expanded to Include Interventional Procedures
Internet Sites
Treatment Information
Drug-Food-Supplement Information
DrugDigest (drug interactions)
FDA - Drug Interactions: What You Should Know
NIH - Botanical Dietary Supplements: Background Information
NIH - Drug, Supplements, and Herbal Information
NIH - Herbal Supplements: Consider Safety, Too
NIH - Vitamin and Mineral Supplement Fact Sheets
Nutrition
Other
Other Treatments
Transcutaneous electrical nerve stimulation (TENS) versus placebo for chronic low-back pain. (Cochrane Database Syst Rev. 2008)
Massage for low-back pain. (Cochrane Database Syst Rev. 2008)
Injection therapy for subacute and chronic low-back pain. (Cochrane Database Syst Rev. 2008)
Evidence based medicine in the use of botulinum toxin for back pain. (J Neural Transm. 2008)
Psychological predictors of substantial pain reduction after minimally invasive radiofrequency and injection treatments for chronic low back pain. (Pain Med. 2008)
The Basis for Recommending Repeating Epidural Steroid Injections for Radicular Low Back Pain: A Literature Review (Archives of Physical Medicine and Rehabilitation 2008) "There does not appear to be any evidence to support the current common practice of a series of injections."
Evidence-informed management of chronic low back pain with prolotherapy (The Spine Journal 2008)
Evidence-informed management of chronic low back pain with epidural steroid injections (The Spine Journal 2008) "Conventional medicine has commonly upheld the notion that 80% to 90% of low back pain (LBP) cases are because of an unknown etiology. This belief is mostly based on the early work of Dillane et al. who could not detect an identifiable cause of LBP in 79% of males and 89% of females in a general clinical practice [1] and [2]. . Studies using fluoroscopically guided, diagnostic spinal procedures have attempted to differentiate the various sources of LBP and reported that 39% (95% confidence interval 30%-50%) of LBP is because of internal disc disruption syndrome [8], 13% to 19% can be attributed to SIJ dysfunction [11] and [12], and 15% to 17% are related to painful z-joint(s) [13]. Their results suggest that 67% to 75% of LBP cases can be accurately diagnosed as discogenic-, sacroiliac-, or z-joint-mediated pain, a stark contrast to earlier findings [1], [2], [3] and [4]. .Injection of corticosteroids into the anterior epidural space has long been used to bathe the posterolateral periphery of the annulus with discogenic CLBP to help curtail the biochemical stimulation of the intervertebral disc. The main goals of this approach are to improve pain and function and allow the patient to participate in a comprehensive physical therapy program addressing biomechanical deficiencies after this reduction of hyperalgesia. Before using epidural steroid injections (ESIs), the target disc must be confirmed as the source of pain. To ensure the success of this approach, the appropriate therapeutic medication deposited into the anterior epidural space must also gain access to sensitized nerve endings."
Experimental
Radiotherapy
Supplements-Vitamins-CAM
Effect of short-term intensive yoga program on pain, functional disability and spinal flexibility in chronic low back pain: a randomized control study. (J Altern Complement Med. 2008)
Vitamin D A Surprising Champion Of Back Pain Relief, Report Says “According to Stewart B. Leavitt, MA, PhD, editor of Pain Treatment Topics and author of the report, "our examination of the research, which included 22 clinical investigations of patients with pain, found that those with chronic back pain almost always had inadequate levels of vitamin D. When sufficient vitamin D supplementation was provided, their pain either vanished or was at least helped to a significant extent." … -- Vitamin D is essential for calcium absorption and bone health. Inadequate vitamin D intake can result in a softening of bone surfaces, or osteomalacia, that causes pain. The lower back seems to be particularly vulnerable to this effect. -- In one study of 360 patients with back pain, all of them were found to have inadequate levels of vitamin D. After taking vitamin D supplements for 3 months, symptoms were improved in 95% of the patients. All of them with the most severe vitamin D deficiencies experienced back-pain relief. -- The currently recommended adequate intake of vitamin D up to 600 IU per day is outdated and too low. According to the research, most children and adults need at least 1000 IU per day, and persons with chronic back pain would benefit from 2000 IU or more per day of supplemental vitamin D3 (also called cholecalciferol). … In conclusion, Leavitt stresses that vitamin D should not be viewed as a cure for all back pain and in all patients. It also is not necessarily a replacement for other pain treatments. "While further research would be helpful," he says, "current best evidence indicates that recommending supplemental vitamin D for patients with chronic back pain would do no harm and could do much good at little cost."”
Complementary therapies in the management of low back pain: A survey of reflexologists. (Complement Ther Med. 2008)
Reflexology in the management of low back pain: A pilot randomised controlled trial. (Complement Ther Med. 2008)
Evidence-informed management of chronic low back pain with herbal, vitamin, mineral, and homeopathic supplements (The Spine Journal 2008)
Surgery
A brief overview of evidence-informed management of chronic low back pain with surgery (The Spine Journal 2008) "Because physical examination and detailed imaging techniques have failed to delineate a clear pathoanatomic cause for patients with CLBP, it is difficult to identify those individuals who would benefit from surgical intervention, and the type of intervention that is most suitable to a particular patient. Not surprisingly, this lack of consensus had lead to huge geographical variations in use of surgery for LBP across the United States [31]. In addition to uncertainty regarding the efficacy of surgery for CLBP, it should also be noted that the potential harms and costs associated with these interventions are substantial. There are generally two schools of thought on the clinical approach to CLBP in the absence of serious structural disease: 1) pain generator approach and 2) psychosocial/economic approach."
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