012501 low back pain

P R I M A R Y C A R E
cause of work-related disability, in terms of workers’compensation and medical expenses.1 Risk factors in-clude heavy lifting and twisting, bodily vibration, obe- LOW BACK PAIN
sity, and poor conditioning, although low back pain iscommon even in people without these risk factors.16 DIAGNOSTIC EVALUATION
Because a precise anatomical diagnosis is elusive, di- agnostic evaluation is often frustrating for both physi- BOUT two thirds of adults suffer from low cians and patients. Rather than perform an exhaus- back pain at some time. Low back pain is sec- tive search, it is generally more useful to address three ond to upper respiratory problems as a symp- questions: Is a systemic disease causing the pain? Is tom-related reason for visits to a physician.1,2 There are there social or psychological distress that may amplify wide variations in care, a fact that suggests there is pro- or prolong the pain? Is there neurologic compromise fessional uncertainty about the optimal approach.3,4 In that may require surgical evaluation? For most patients, addition, there is evidence of excessive imaging and these questions can be answered from a careful histo- surgery for low back pain in the United States,5-8 and ry taking and physical examination, and imaging is of- many experts believe the problem has been “overmed- icalized.”9-11 In recent years, magnetic resonance im- Medical History
aging (MRI) has come to be widely used, the roles ofexercise and bed rest have been clarified, and more in- Clues to underlying systemic disease include the pa- formation has been gained from clinical trials.
tient’s age; a history of cancer, unexplained weight loss,injection-drug use, or chronic infection; the duration CAUSES AND EPIDEMIOLOGIC PATTERNS
of pain; the presence of nighttime pain; and the re- Experimental studies suggest that low back pain may sponse to previous therapy. In many patients whose originate from many spinal structures, including lig- low back pain is due to infection or cancer, the pain aments, facet joints, the vertebral periosteum, the is not relieved when the patient lies down. However, paravertebral musculature and fascia, blood vessels, this finding is not specific for the presence of these the anulus fibrosus, and spinal nerve roots. Perhaps conditions. Inflammatory spondyloarthropathy is most most common are musculoligamentous injuries and common in men under 40 years of age, but clinical age-related degenerative processes in the interverte- and demographic characteristics have limited accura- bral disks and facet joints. Other common problems Inflammatory arthritis of the hips or knees include spinal stenosis and disk herniation. Stenosis is increases the likelihood of spondylitis.
narrowing of the central spinal canal or its lateral re- Neurologic involvement is usually suggested by the cesses, typically from hypertrophic degenerative chang- presence of sciatica or pseudoclaudication (leg pain es in spinal structures (Fig. 1). Table 1 provides a broad after walking that mimics ischemic claudication). The differential diagnosis for low back pain, with estimates leg pain of sciatica or pseudoclaudication is often as- sociated with numbness or paresthesia, and sciatica Perhaps 85 percent of patients with isolated low due to disk herniation typically increases with cough, back pain cannot be given a precise pathoanatomical sneezing, or performance of the Valsalva maneuver.
diagnosis. The association between symptoms and im- Bowel or bladder dysfunction may be a symptom of aging results is weak.15 Thus, nonspecific terms, such severe compression of the cauda equina (cauda equina as strain, sprain, or degenerative processes, are com- syndrome). This rare condition is usually caused by a monly used.2,13 Strain and sprain have never been an- tumor or a massive midline disk herniation. Urinary re- atomically or histologically characterized, and patients tention with overflow incontinence is usually present, given these diagnoses might accurately be said to have often in association with sensory loss in a saddle distri- bution, bilateral sciatica, and leg weakness. Prolonged Low back pain affects men and women equally, with back pain may be associated with the failure of previous onset most often between the ages of 30 and 50 years.
treatment, depression, and somatization. Substance It is the most common cause of work-related disability abuse, job dissatisfaction, pursuit of disability compen- in people under 45 years of age and the most expensive sation, and involvement in litigation may also be asso-ciated with persistent unexplained symptoms.1,19-21 Physical Examination
From the Departments of Medicine and Health Services and the Center for Cost and Outcomes Research, University of Washington, Seattle Fever suggests the possibility of spinal infection.
(R.A.D.); and the Center for the Evaluative Clinical Sciences and the De- Vertebral tenderness has sensitivity for infection but partment of Surgery, Dartmouth Medical School, Hanover, N.H. (J.N.W.).
not specificity. The finding of soft-tissue tenderness is Address reprint requests to Dr. Deyo at the Center for Cost and OutcomesResearch, University of Washington, Box 358853, Seattle, WA 98195.
not reproducible from one examiner to another. Lim- N Engl J Med, Vol. 344, No. 5 · February 1, 2001 · www.nejm.org · 363
Downloaded from www.nejm.org on March 23, 2008 . Copyright 2001 Massachusetts Medical Society. All rights reserved. The Ne w E n g l a nd Jo u r n a l o f Me d ic i ne Anterior displacementof L5 on sacrum(spondylolisthesis) Figure 1. Common Pathoanatomical Conditions of the Lumbar Spine.
A superior view of a lumbar vertebra with normal anatomy and canal configuration is shown in the upper right. In the superiorview of a lumbar vertebra and intervertebral disk (center right), herniation of the nucleus pulposus into the spinal canal is evident.
The nucleus pulposus has a soft consistency, at least from childhood to middle age, and may protrude through confluent fissuresin the anulus fibrosus. This usually occurs in the lateral part of the spinal canal, as shown. The usual abnormalities that result inspinal stenosis (lower right) include hypertrophic degenerative changes of the facets and thickening of the ligamentum flavum.
These processes may result in a severely narrowed canal, either centrally or in the lateral recesses of the canal. A lateral view ofthe lumbosacral spine, illustrating spondylolysis of the L5 vertebra with associated spondylolisthesis at L5–S1, is shown on theleft. Spondylolysis refers to a defect in the pars interarticularis of the vertebra, which may be congenital or a result of stress fracture.
Spondylolisthesis refers to the anterior displacement of a vertebra on the one beneath it. This may occur as a result of spondylolysisas shown (called isthmic spondylolisthesis) or as a result of degenerative disk disease, usually in the elderly. This process maycontribute to narrowing of the spinal canal in spinal stenosis.
364 · N Engl J Med, Vol. 344, No. 5 · February 1, 2001 · www.nejm.org
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TABLE 1. DIFFERENTIAL DIAGNOSIS OF LOW BACK PAIN.*
MECHANICAL LOW BACK
NONMECHANICAL SPINAL CONDITIONS
OR LEG PAIN (97%)†
(ABOUT 1%)‡
VISCERAL DISEASE (2%)
Inflammatory arthritis (often associated Ankylosing spondylitisPsoriatic spondylitisReiter’s syndromeInflammatory bowel disease Scheuermann’s disease (osteochondrosis)Paget’s disease of bone *Figures in parentheses indicate the estimated percentages of patients with these conditions among all adult patients with low back pain in primary care. Diagnoses in italics are often associated with neurogenic leg pain. Percentages mayvary substantially according to demographic characteristics or referral patterns in a practice. For example, spinal stenosisand osteoporosis will be more common among geriatric patients, spinal infection among injection-drug users, and soforth. Data are adapted from Hart et al.,2 Deyo,12 Deyo et al.,13 and Deyo and Diehl.14 †The term “mechanical” is used here to designate an anatomical or functional abnormality without an underlying ma- lignant, neoplastic, or inflammatory disease. Approximately 2 percent of cases of mechanical low back or leg pain areaccounted for by spondylolysis, internal disk disruption or diskogenic low back pain, and presumed instability.
‡Scheuermann’s disease and Paget’s disease of bone probably account for less than 0.01 percent of nonmechanical spi- §“Strain” and “sprain” are nonspecific terms with no pathoanatomical confirmation. “Idiopathic low back pain” may ¶Spondylolysis is as common among asymptomatic persons as among those with low back pain, so its role in causing ¿Internal disk disruption is diagnosed by provocative diskography (injection of contrast material into a degenerated disk, with assessment of pain at the time of injection). However, diskography often causes pain in asymptomatic adults,and the condition of many patients with positive diskograms improves spontaneously. Thus, the clinical importance andappropriate management of this condition remain unclear. “Diskogenic low back pain” is used more or less synonymouslywith “internal disk disruption.” **Presumed instability is loosely defined as greater than 10 degrees of angulation or 4 mm of vertebral displacement on lateral flexion and extension radiograms. However, the diagnostic criteria, natural history, and surgical indications re-main controversial.
ited spinal motion is not strongly associated with any raising has sensitivity but not specificity for a herni- specific diagnosis, but this finding may help in plan- ated disk, whereas crossed straight-leg raising (with the ning or monitoring physical therapy.13 Chest expansion symptoms of sciatica reproduced when the opposite of less than 2.5 cm has specificity, but not sensitivity, leg is raised) is insensitive but highly specific.13,22 The remainder of the neurologic examination should fo- Among patients with sciatica or pseudoclaudication, cus on ankle and great-toe dorsiflexion strength (the a straight-leg–raising test should be performed, with L5 nerve root), plantar flexion strength (S1), ankle and the patient supine and the examiner’s hand holding the knee reflexes (S1 and L4), and dermatomal sensory leg straight and cupping the heel with the other hand.
loss. The L5 and S1 nerve roots are involved in approx- However, the test is often negative in patients with spi- imately 95 percent of lumbar-disk herniations.12,13 nal stenosis. An elevation of less than 60 degrees isabnormal, suggesting compression or irritation of the nerve roots. A positive test reproduces the symptoms Plain radiography should be limited to patients with of sciatica, with pain that radiates below the knee, not clinical findings suggestive of systemic disease or trau- merely back or hamstring pain. Ipsilateral straight-leg ma. Guidelines recommend plain radiography for pa- N Engl J Med, Vol. 344, No. 5 · February 1, 2001 · www.nejm.org · 365
Downloaded from www.nejm.org on March 23, 2008 . Copyright 2001 Massachusetts Medical Society. All rights reserved. The Ne w E n g l a nd Jo u r n a l o f Me d ic i ne tients with fever, unexplained weight loss, a history Evaluation of Older Adults
of cancer, neurologic deficits, alcohol or injection-drug Among patients over 65 years of age, the diagnos- abuse, an age of more than 50 years, or trauma.23 tic probabilities shown in Table 1 change. Cancer, com- Strict adherence to these criteria might increase the pression fractures, spinal stenosis, and aortic aneurysms use of plain radiographs,24,25 and some observers there- become more common. Osteoporotic fractures may fore argue for further refinement of the criteria. Fail- occur even in the absence of recognized trauma. Be- ure of the pain to improve after four to six weeks cause hormone-replacement therapy and other med- should prompt radiography, because improvement oc- ications may prevent further fractures, early radiog- curs in most patients in the absence of infection, can- raphy is recommended for older patients.
cer, or inflammatory disease.23 Plain radiography is not Spinal stenosis due to hypertrophic degenerative highly sensitive for early cancer or infection, and there- processes and degenerative spondylolisthesis is more fore ancillary tests, such as measurement of the eryth- common in older than in younger adults. Pseudoclau- rocyte sedimentation rate and a complete blood count, dication is the classic symptom of central-canal steno- sis. The symptoms of stenosis are often diffuse, because Computed tomography (CT) and MRI are more the disease usually is bilateral and involves several ver- sensitive than plain radiography for the detection of tebrae.31 Pain, numbness, and tingling may occur in early spinal infections and cancers. These imaging one or both legs. The symptoms are usually relieved by techniques also reveal herniated disks and spinal ste- spinal flexion, so that patients report less pain when nosis, which plain radiography cannot. Early or fre- they are sitting32 or pushing a grocery cart. Pain is quent use of these tests is discouraged, however, be- often increased by extension of the lumbar spine.32,33 cause disk and other abnormalities are common The diagnosis can usually be made on the basis of CT among asymptomatic adults (Table 2).26-29 Degener- or MRI, although electromyography or measurement ated, bulging, and herniated disks are frequently in- of somatosensory evoked potentials may help define cidental findings, even among patients with low back the extent of neurologic involvement31,33 and differ- pain, and may be misleading. Incidental findings may entiate this condition from peripheral neuropathy.
lead to overdiagnosis, anxiety on the part of patients, Aortic aneurysm should be suspected among old- dependence on medical care, a conviction about the er adults with coronary artery disease or multiple risk presence of disease, and unnecessary tests or treat- factors. Some aneurysms are detected by physical ex- ments. CT and MRI should be reserved for patients amination, although ultrasonography, CT, or MRI is for whom there is a strong clinical suggestion of un- derlying infection, cancer, or persistent neurologicdeficit. These tests have similar accuracy in detecting NATURAL HISTORY
herniated disks and spinal stenosis,30 but MRI is Recovery from nonspecific low back pain is gen- more sensitive for infections, metastatic cancer, and erally rapid. In one study, 90 percent of patients rare neural tumors. These tests have largely supplant- seen within three days of onset recovered within two ed myelography, although CT myelography is some- weeks.20 However, in cross-sectional studies, which times performed for the planning of surgery.
oversample patients with multiple visits, the progno- TABLE 2. REPRESENTATIVE RESULTS OF MAGNETIC RESONANCE IMAGING STUDIES
SUBJECTS
ANATOMICAL FINDINGS
Stadnik et al.29 Patients referred for head or 366 · N Engl J Med, Vol. 344, No. 5 · February 1, 2001 · www.nejm.org
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sis is less favorable. These studies may best reflect the effective in randomized trials. Bed rest does not in- experience of primary care physicians. They suggest crease the speed of recovery from acute low back pain that a third of patients are substantially improved at and sometimes delays recovery.43-45 If a patient obtains one week and two thirds at seven weeks.21,34 Recur- symptomatic relief from bed rest, it can be recom- rences are common, affecting 40 percent of patients mended for a day or two, with reassurance that it is within six months.35 Most recurrences are not dis- safe to get out of bed even if pain persists. Back exer- abling, but the emerging picture is that of a chronic cises are also not helpful in the acute phase, although problem with intermittent exacerbations, analogous to they are useful later for preventing recurrences and asthma, rather than an acute disease that can be cured.
for treating chronic low back pain.39,45-47 Convention- The natural history of herniated disks is also favor- al traction, facet-joint injections, and transcutaneous able. Improvement is the norm, although it is often electrical nerve stimulation appear ineffective or min- slower than improvement in low back pain alone. Only imally effective in randomized trials.48-50 about 10 percent of patients have sufficient pain after The most popular alternative therapies for low back six weeks that surgery is considered. Sequential MRI pain are spinal manipulation, acupuncture, and mas- studies reveal that the herniated portion of the disk sage.51 Although clinical trials suggest that spinal ma- tends to regress with time, with partial or complete nipulation has some efficacy, systematic reviews have resolution in two thirds of cases after six months.36,37 found little support for acupuncture.41,42,52 Massage In contrast, spinal stenosis usually remains stable or has rarely been studied, but promising preliminary gradually worsens. In this indolent condition, symp- results of clinical trials suggest that research on mas- toms evolve gradually. About 15 percent of patients sage therapy should be assigned a high priority.53,54 improve over a period of four years, 70 percent re- There is no evidence from clinical trials or cohort main stable, and 15 percent have deterioration.38 studies that surgery is effective for patients who have Return to work after an episode of low back pain low back pain unless they have sciatica, pseudoclau- is influenced by clinical, social, and economic factors.
Low back pain is rarely permanently disabling. Patientswith herniated disks who undergo surgery do not re- Herniated Intervertebral Disks
turn to work earlier than those who receive nonsur- In the absence of the cauda equina syndrome or gical therapy, although they have better symptomatic progressive neurologic deficit, patients with suspect- ed disk herniation should be treated nonsurgically forat least a month. Early treatment resembles that for nonspecific low back pain, although the safety andefficacy of spinal manipulation remain unclear. Nar- Nonspecific Low Back Pain
cotic analgesics may be necessary for pain relief, but There are few large, randomized trials of therapy they should be used only for limited periods. Bed rest for nonspecific low back pain. Recommendations does not accelerate recovery.56 Epidural corticosteroid have been derived from small studies of variable meth- injections offer temporary symptomatic relief for some odologic quality.23,39 Nonsteroidal antiinflammatory patients.57 If severe pain or neurologic deficits persist, drugs (NSAIDs) are effective for symptom relief, as CT or MRI and consideration of surgery are appro- are some muscle relaxants. Clinical trials do not clear- ly identify which patients benefit from muscle relax- Diskectomy produced better pain relief than non- ants, and side effects, especially sedation, are common.
surgical treatment over a period of 4 years, but it In general, medication for symptomatic relief should is unclear whether there is any advantage after 10 be prescribed on a regular schedule rather than on an years.55,58,59 The effectiveness of microdiskectomy, as-needed basis.40 Spinal manipulation and physical which is performed through a small incision with the therapy are alternative treatments for symptomatic re- aid of magnifying lenses, is similar to that of stand- lief among patients with acute or subacute low back ard diskectomy, but two newer techniques, automated pain, but their effects are limited.41,42 In general, we percutaneous diskectomy and laser diskectomy, are less recommend delaying referral for manipulation or phys- effective than standard diskectomy.55 For selected pa- ical therapy until an episode of pain has persisted for tients, arthroscopic diskectomy is promising, and its three weeks, because half of the patients spontane- effectiveness may be similar to that of standard dis- ously improve within this period.21 For most patients, the best recommendation is a rapid return to normalactivities, with neither bed rest nor exercise in the acute Spinal Stenosis
phase.43-45 This recommendation must be tempered Evidence regarding nonsurgical therapy for spinal by consideration of the patient’s usual job or life de- stenosis is sparse. Avoidance of alcohol and sedatives mands. Heavy lifting, trunk twisting, and bodily vibra- and strengthening of the legs may reduce the risk of tion should be avoided in the acute phase.
falls. Use of an exercise bicycle or walking is recom- Several common treatments have not been found mended, with brief rest when pain occurs.33 Analge- N Engl J Med, Vol. 344, No. 5 · February 1, 2001 · www.nejm.org · 367
Downloaded from www.nejm.org on March 23, 2008 . Copyright 2001 Massachusetts Medical Society. All rights reserved. The Ne w E n g l a nd Jo u r n a l o f Me d ic i ne antidepressants may be more effective for treating pain TABLE 3. INDICATIONS FOR SURGICAL REFERRAL AMONG PATIENTS
in patients without depression than selective seroto- nin-reuptake inhibitors.70 Long-term opioid therapyfor patients with persistent pain has been proposed, SCIATICA AND PROBABLE HERNIATED DISKS
and a small, randomized trial showed that opioidshave a greater effect on pain and mood than NSAIDs.
The cauda equina syndrome (surgical emergency): characterized by bowel or bladder dysfunction (usually urinary retention), numbness in the However, opioids did not improve activity levels, and perineum and medial thighs (i.e., in a saddle distribution), bilateral leg in a third of subjects they caused side effects such as drowsiness, headache, constipation, and nausea.71 Un- Progressive or severe neurologic deficitPersistent neuromotor deficit after 4–6 weeks of nonoperative therapy til further evidence of their safety and efficacy is avail- Persistent sciatica (not low back pain alone) for 4–6 weeks, with consistent able from clinical trials, we do not advocate the long- clinical and neurologic findings (in this circumstance, and for persistent neuromotor deficit, surgery is elective, and patients should be involved Referral to a multidisciplinary pain center may be appropriate for some patients with chronic low back SPINAL STENOSIS
pain. Such centers typically combine cognitive–behav- Progressive or severe neurologic deficit, as for herniated disks ioral therapy, patient education, supervised exercise, Back and leg pain that is persistent and disabling, improves with spine flex- ion, and is associated with spinal stenosis on imaging tests; surgery is selective nerve blocks, and other strategies to restore elective, and patients should be involved in decision making functioning. Complete relief of symptoms may be un-realistic, and therapeutic goals may need to be refo- SPONDYLOLISTHESIS
cused on optimizing daily function. Multiple surgical Progressive or severe neurologic deficit, as for herniated disks Spinal stenosis with referral indications as aboveSevere back pain or sciatica with severe functional impairment that persists PREVENTION
Exercise programs that combine aerobic condition- ing with specific strengthening of the back and legscan reduce the frequency of recurrence of low back sics, NSAIDs, physical therapy, and epidural cortico- pain.46 The use of corsets and education about lift- steroids may be useful, although there are no data from ing technique are generally ineffective in preventing clinical trials. For persistent severe pain, decompressive low back problems.46,72,73 Epidemiologic studies sug- laminectomy is an option. If degenerative spondy- gest that weight loss and smoking cessation may have lolisthesis contributes to the stenosis, adding spinal preventive value, but no intervention trials involving fusion to decompression may improve the outcomes these approaches have been conducted. There are, over those with decompression alone.55,61 Cohort stud- of course, other compelling reasons to recommend ies suggest that surgery results in better pain relief and weight loss and smoking cessation. Ergonomic rede- functional recovery than nonsurgical treatment, at least sign of strenuous job tasks may facilitate return to work for a few years.62,63 Even with successful surgery, symp- toms often recur after several years. At four years ofpostoperative follow-up, about 30 percent of patients CONCLUSIONS
have severe pain and about 10 percent have undergone For patients with nonspecific low back pain, a pre- cise pathoanatomical diagnosis is often impossible,which leads to various imprecise diagnoses (e.g., sprain Chronic Low Back Pain
or strain). The natural history of low back pain is fa- Many patients with chronic low back pain have no vorable, and patients need this reassurance. The fa- radiculopathy or anatomical abnormalities that clearly vorable natural history may partly explain the prolif- explain their symptoms. Recent evidence of neuroplas- eration of unproved treatments that may seem to be ticity suggests that central nervous system changes — effective. The use of plain radiography can be limited including neuronal hyperactivity, changes in mem- to patients with clinical findings suggestive of under- brane excitability, and expression of new genes — may lying systemic disease, and more advanced imaging perpetuate the perception of pain in the absence of can be reserved for potential candidates for surgery.
The role of imaging in other situations is limited be- Intensive exercise reduces pain and improves func- cause of the poor association between symptoms and tion in patients with chronic low back pain.39,66,67 anatomical findings. Bed rest is not recommended for However, maintaining adherence to the sort of exercise the treatment of low back pain or sciatica, and a rapid regimen that is required for long-term benefits is of- return to normal activities is usually the best course.
ten difficult. Antidepressant-drug therapy is useful for Back exercises are not useful for the acute phase but the one third of patients with low back pain who also help to prevent recurrences and treat chronic pain. Sur- have depression. There is conflicting evidence regard- gery is appropriate for a small proportion of patients ing patients without clinical depression.68,69 Tricyclic with low back symptoms; it is most successful for those 368 · N Engl J Med, Vol. 344, No. 5 · February 1, 2001 · www.nejm.org
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with sciatica or pseudoclaudication that persists after radiographs for the early diagnosis of low back pain: proposed guidelines would increase utilization. JAMA 1997;277:1782-6.
25. Deyo RA, Diehl AK. Lumbar spine films in primary care: current use
and effects of selective ordering criteria. J Gen Intern Med 1986;1:20-5.
26. Boden SD, Davis DO, Dina TS, Patronas NJ, Wiesel SW. Abnormal
Supported in part by grants from the National Institutes of Health magnetic-resonance scans of the lumbar spine in asymptomatic subjects: (AR45444-01) and from the Agency for Healthcare Research and Quality a prospective investigation. J Bone Joint Surg Am 1990;72:403-8.
27. Jensen MC, Brant-Zawadzki MN, Obuchowski N, Modic MT, Malka-
sian D, Ross JS. Magnetic resonance imaging of the lumbar spine in people
We are indebted to Pam Hillman for assistance with the prepara- without back pain. N Engl J Med 1994;331:69-73.
tion of the manuscript and to Douglas Paauw, M.D., Daniel Cher- 28. Weishaupt D, Zanetti M, Hodler J, Boos N. MR imaging of the lum-
kin, Ph.D., Robert Keller, M.D., Jon Lurie, M.D., and John Loeser, bar spine: prevalence of intervertebral disk extrusion and sequestration, M.D., for their helpful reviews of earlier drafts. nerve root compression, end plate abnormalities, and osteoarthritis of the facet joints in asymptomatic volunteers. Radiology 1998;209:661-6.
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