Diagnosis

Mechanisms of Low Back Pain: A Guide for Diagnosis and Therapy

The Chiro.Org Blog

SOURCE:   F1000Res. 2016 (Oct 11); 5. pii: F1000

Massimo Allegri, Silvana Montella, Fabiana Salici,
Adriana Valente, Maurizio Marchesini, Christian Compagnone,
Marco Baciarello, Maria Elena Manferdini, and Guido Fanelli

Department of Surgical Sciences,
University of Parma,
Parma, Italy

Chronic low back pain (CLBP) is a chronic pain syndrome in the lower back region, lasting for at least 3 months. CLBP represents the second leading cause of disability worldwide being a major welfare and economic problem. The prevalence of CLBP in adults has increased more than 100% in the last decade and continues to increase dramatically in the aging population, affecting both men and women in all ethnic groups, with a significant impact on functional capacity and occupational activities. It can also be influenced by psychological factors, such as stress, depression and/or anxiety. Given this complexity, the diagnostic evaluation of patients with CLBP can be very challenging and requires complex clinical decision-making.

Answering the question “what is the pain generator” among the several structures potentially involved in CLBP is a key factor in the management of these patients, since a mis-diagnosis can generate therapeutical mistakes. Traditionally, the notion that the etiology of 80% to 90% of LBP cases is unknown has been mistaken perpetuated across decades. In most cases, low back pain can be attributed to specific pain generator, with its own characteristics and with different therapeutical opportunity. Here we discuss about radicular pain, facet joint pain, sacro-iliac pain, pain related to lumbar stenosis, discogenic pain. Our article aims to offer to the clinicians a simple guidance to identify pain generators in a safer and faster way, relying a correct diagnosis and further therapeutical approach.

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Low Back Pain and Chiropractic Page

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Life-Threatening Lower Back Pain – Decoding the Mystery Step-By-Step

The Chiro.Org Blog

SOURCE:   A Chiro.Org Contribution

David J Schimp DC, DACNB, DAAPM, FICCN and
Stefanie Krupp DC, MS

David J Schimp DC
Schimp Office of Chiropractic Professionals LTD
937 E. Sumner St.
Hartford, WI 53027 USA

This article will help clinicians identify life-threatening conditions that present with lower back pain.

Intra-abdominal bleed (e.g. aortic aneurysm), infection and tumor are the most dangerous causes of lower back pain and carry the potential for devastating consequences.

Table 1 identifies red flags that should raise suspicion of a serious disorder. [1]

Other red flags that are less likely to be associated with a life-threatening condition but that still warrant prompt diagnosis and appropriate management include:

• pain that is worse with coughing
• incontinence of bowel or bladder
• urinary retention (inability to void or empty the bladder completely)
• impotence
• saddle anesthesia
• intractable radicular pain into the lower extremity
• rapidly progressive neurological deficit

The latter findings are common among patients with lumbar nerve root compression or cauda equina syndrome. Although serious, these disorders are seldom life threatening.

Step 1 –   Evaluate for Red Flags*

Table 1:   Red Flags of Low Back Pain   [1]

*   This is a list of red flags that may be associated with a life-threatening disease.

It is not meant to include all the other red flags of lower back pain.

Step 1:   Evaluate for Red Flags   (Discussion)

1. Duration greater than 6 weeks.   Intractable or progressive lower back pain lasting longer than 6 weeks should raise suspicion of a serious underlying condition. Radiographs (lumbar plain film series including coronal, sagittal and spot views) and routine laboratory studies will add a greater level of diagnostic accuracy to the evaluation. Basic laboratory studies to consider include comprehensive metabolic panel, complete blood count (CBC), C-reactive protein(CRP) or high sensitivity CRP (preferred), erythrocyte sedimentation rate (ESR) and urinalysis (UA). [2]If imaging and lab studies are normal and the patient has normal vitals, then serious disease is unlikely. Advanced imaging (MRI or CT) can be utilized if plain film radiography if felt to lack sensitivity. In the absence of serious disease, a mechanical lesion, central sensitization or psychosocial co-morbidities may explain on-going pain over 6 weeks in duration.
2. Age less than 18 years.   Persistent pain in a pediatric patient is a red flag for tumor or infection if symptoms cannot be ascribed to a congenital abnormality or acute injury. Advanced imaging (MRI) and routine laboratory studies as noted above should be considered. 
3. Age greater than 50 years.   Although low back pain is common in this population, clinicians should be particularly alert to the patient that presents with a new onset of low back pain, whether or not a mechanical basis is identified. Intra-abdominal disorders (e.g. abdominal aortic aneurysm) and cancer are more common in this population. Although a mechanical lesion is more likely, older patients require a greater level of diligence to rule out serious disease.(see Table 1)
4. Patient history of cancer.   Neoplasm involving the spine may present as unrelenting pain (i.e. does not improve with rest or analgesia) or pain that is worse at night. Cancer recurrence or metastasis to the spine should be considered when a patient with a prior history of cancer complains of unrelenting back pain. Advanced imaging (MRI) is valuable and early use may be appropriate if the index of suspicion is high. Basic laboratory testing can be helpful (e.g., elevation of alkaline phosphatase on a comprehensive metabolic panel and leukocytosis on a complete blood count). [2] A history of prior malignancy is the most informative of the all the red flags listed in Table 1 and may suggest active neoplasm as the cause of the individual’s back pain. (more…)