Low Back Pain_A Conservative Approach

This is a very difficult topic to traverse, most people don’t know where to turn and a simple google search will give you a million different options. It has been reported that 43% of people seek out care only to be reassured that what they are experiencing and is not that of something more sinister.(1) Sometimes some of the tools that are used to assess for abnormalities can propagate a “I’m broken” mentality that is carried to every aspect of someone's life. I don’t want to downplay low back pain or anything that you might be experiencing, but what I would like to do is reassure you that you are resilient and movement is medicine and that hurt doesn’t always equal harm. To do this, I’m going to discuss three different areas that maybe aren't talked about much. First, I would like to discuss the different types of low back pain, what MRI and radiological findings you can have and what they mean, and criteria on when surgery should be considered as an option. 

It has been estimated that low back pain will occur in 35-40% of the population in a years’ time and 60-80% of the population in a lifetime!(2) That’s a lot of people suffering from back pain. Out of this population, 2% are found to have serious pathology (infection, cauda equina, cancer, etc), 10% having nerve root compression and the other 85-90% are mechanical in origin (3). For the sake of this article, we are going to specifically focus on nerve root compression and mechanical low back pain. This is a vulnerable time for people, and while being in this position it’s incredibly important from a management perspective to appropriately diagnose and treat these conditions. Mismanagement runs the risk of any episode of back pain becoming a chronic issue, which leads to other things, such as, deconditioning and disability.

The first line of defense for most professions is to have diagnostic imaging done with the intentions of “figuring out what structures are damaged.” More times than not, people who have an episode of low back pain do not suffer an overly traumatic incident. It comes as a result of insignificant movement, like bending over to pick up something or what could be considered to be a non-challenging task. This in itself automatically rules out beginning with advanced imaging as a screening tool. The reason for this is because the findings on an X-ray or an MRI are incredibly sensitive for detecting abnormalities. The likelihood of discovering “pathology” or structural abnormalities is extremely high. In fact, 28-50% of asymptomatic people will have at least one disc herniation in the low back.(4) Similar findings can be found in the neck with up to 75% of asymptomatic people having disc herniations.(5) Likewise with findings of degenerative joint disease (DJD), prevalence of these findings in asymptomatic patients is between 46-93%.(7) X-rays and MRI’s are the equivalent to taking a picture of a phone, you don’t know whether or not that phone is ringing; same thing with common findings such as disc herniations and DJD. We don’t know if these findings are a direct cause of the pain and more times than not they are not related. This is why we cannot presume these findings to be associated with the origin of pain. Even though the findings are there, it is irresponsible to render these abnormalities to be significant in the vast majority of patients. Believe it or not, a history and physical exam has been shown to be 99% sensitive in filtering out serious pathology as the underlying cause of pain. This means that with a majority of patients, we can rule out serious pathology with a thorough history and exam.(9) There is a time and a place for these forms of imaging, such as, traumatic indicidences, unresolved functionality and disability from injury, neurological symptoms resulting in limb weakness, etc; again, this represents only about 2-10% of the population with back pain. 

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Figure 1: Abnormal findings in asymptomatic people (6)

 

Now that we have categorized back pain, given epidemiological occurrence of back pain, and the low occurrence of serious pathology, we can discuss different treatments associated with mechanical low back pain and patients presenting with neurological symptoms. Research is heavily in favor of conservative care as a first line of defense for anybody experiencing back pain. But what about surgery? In the majority of cases, surgery should come as a result of unresolved symptoms following conservative care. “Surgery should be reserved for patients for whom function cannot be satisfactorily improved by a physical rehabilitation program. Failure of passive non-operative treatment is not sufficient for the decision to operate.”(8) Exceptions to this rule are major neurological findings, such as, Cauda equina syndrome or paresis (that is rapidly progressing).

A common symptom accompanying low back back is symptoms into the leg. This is termed sciatica. It can have numerous causes. Research shows that a good majority of patients who are experiencing sciatica will resolve over time. Now, with that being said, a discectomy has been shown to be incredibly effective with disc herniations, with a 46-90% improvement with carefully selected patients with a strict criteria, including unresolved symptoms following conservative care. On the flip side of that coin, 36% of patients who did undergo conversative care reported good to excellent outcomes.(12) With properly selected stenosis patients, there was no difference in a 10 year study looking at patient outcomes compared to patients who underwent surgery and those who went through conservative care.(10) There was no difference in patients who opted to delay surgery by undergoing a trial of conservative care. The point being that conservative care should be at the forefront of the decision making process, to see if it can be managed without surgical intervention. There is lack of evidence regarding surgery and degenerative joint disease in the low back at this time. However, with disc herniations, the larger the disc herniation the greater the surgical outcome, 57% of patients who underwent surgery for a disc herniation less than 6 mm reported poor outcomes and only 2% of patients having a herniation greater than 9 mm reported poor outcomes.(13) The strict Danish criteria that has been set for patients with disc herniations to be designated surgical candidates are: ineffectual 4-6 week conservative care, positive correlation between clinical findings and imaging reports, progressive leg weakness, and severe leg symptoms in spite of medication. 

Surgery indeed has a time and place, as long as the patient meets the criteria that has been set, which includes a trail of conservative care. Strict guidelines are set in place to create the best outcome for the patients. When we try and maximize function and correct motor control issues (movement perception) we give ourselves a fighting chance to reduce stress on sensitive tissue and stop overusing or misusing structures. This is why visiting a qualified chiropractor can be a great entry point into the healthcare system, we regularly refer patients out to respected healthcare professionals. This is a result of proper history and physical exam, which we can use to rule in and rule out diagnosis that conservative care can be effective with and what might be better managed by other professionals. Every situation is different, this article is to be used as a reference only.   

 

References:

  1. Klassen AC, Berman ME. Medical care for headaches. A consumer survey. Cephalgia . 1991;11(suppl 11):85-86.

  2. Vos T, Flaxman AD, Naghavi M, Lozano R, Michaud C. Years lived with disability (YLDs) for 1160 sequelae of 289 diseases and injuries 1990–2010: a systematic analysis for the Global Burden of Disease Study 2010. Lancet . 2012;380:2163-2196.

  3. Qaseem A, Wilt TJ, McLean RM, et al. Noninvasive treatments for acute, subacute, and chronic low back pain: A clinical practice guideline from the American College of Physicians. Ann Intern Med. 2017; 166(7):514-530

  4. Boden SD, Davis DO, Dina TS, Patronas NJ, Wiesel SW. Abnormal magnetic-resonance scans of the lumbar spine in asymptomatic subjects. J Bone Joint Surg Am. 1990;72:403.

  5. Boden SD, McCowin PR, Davis Do, Dina TS, Mark AS, Wiesel S. Abnormal magnetic-resonance scans of the cervical spine in asymptomatic subjects. J Bone Joint Surg Am . 1990;72A:1178-1184.

  6. Borenstein DG, O’Mara JW, Boden SD, et al. The value of magnetic resonance imaging of the lumbar spine to predict low-back pain in asymptomatic subjects. J Bone Joint Surg Am . 2001;83-A:1306-1311. (PICTURE)

  7. Jarvik JG, Deyo RA. Imaging of lumbar intervertebral disc degeneration and aging, excluding disc herniations. Radiol Clin North Am. 2000;38:1255-1266.

  8. Saal JA, Saal JS. Nonoperative treatment of herniated lumbar intervertebral disc with radiculopathy. Spine . 1989;14:431.

  9. McGuirk B, King W, Govind J, Lowry J, Bogduk N. Safety, efficacy and cost-effectiveness of evidence-based guidelines for the management of acute low back pain in primary care. Spine . 2001;26:2615-2622.

  10. Amundsen T, Weber H, Nordal HJ, Magnaes B, Abdelnoor M, Lilleas F. Lumbar spinal stenosis: conservative or surgical management? A prospective 10-year study. Spine . 2000;25:1424-1436.

  11. Caragee E, Alamin T, et al. Can MR scanning in patients with sciatica predict failure of open limited discectomy? Presented at: The Annual Meeting of the International Society for the Study of the Lumbar Spine, 2001; Edinburgh, Scotland.

  12. Gibson JN, Grant IC, Waddell G. Surgery for lumbar disc prolapse (Cochrane review). Cochrane Library. 2004;3.

  13. Caragee E, Alamin T, et al. Can MR scanning in patients with sciatica predict failure of open limited discectomy? Presented at: The Annual Meeting of the International Society for the Study of the Lumbar Spine, 2001;

Curt Kippenberger