INTRODUCTION — Low back pain is one of the most common disorders in all countries of the world . About 80 percent of individuals in the general population will have at least one episode of low back pain during their lifetime. Low back pain occurs most frequently in people between the ages of 20 and 40, but is more severe among older patients. Occupations that increase the risk for this condition are those that involve lifting, twisting, bending, and reaching. Approximatley 90 percent of people who have low back pain recover spontaneously within four weeks, and only 5 percent remain disabled longer than three months. This topic review will focus on recovery within the first one to three months. CAUSES — Low back pain can have many causes. In general, two broad categories of back problems occur:

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Musculoskeletal disease Spinal disease

Lifting or a sudden, awkward movement can trigger either of these problems. However, most attacks occur without any obvious cause. Simple movements can increase pressure within the back, which may be sufficient to set off an attack. Musculoskeletal disease — Most back pain attacks are caused by minor injury to some of

the many muscles, ligaments, and joints in the back. Myofascial pain disorder is the term used to describe the condition in which the muscles and connective tissue of the lower back have been strained or injured. Other factors that can contribute to musculoskeletal back pain include poor posture, unequal leg length, reduced strength of the muscles in the lower torso, lack of oxygen in the back tissues caused by smoking, and psychosocial factors such as stress. Sciatica causes aching pain in the buttock and an uncomfortable feeling of numbness or pain that extends into the back of the upper leg, and sometimes into the calf. Sciatica can be caused by muscle spasms, impairment of the ligaments, or bursitis, which is an inflammation of the tissue surrounding a joint. Spinal disease — There are several conditions of the spine that can cause symptoms of lower back pain, including spondylolisthesis, a herniated disc, and lumbar spinal stenosis. These occur less commonly than musculoskeletal back pain. Rarely, back pain is caused by a potentially serious spinal condition, such as infection, fracture, or tumor, or a disorder called cauda equina syndrome, which is a neurologic condition that causes weakness and bowel or bladder dysfunction as well as back pain. Spondylolisthesis — Spondylolisthesis is a condition in which one of the vertebrae of the lower spine slips forward in relation to another. Spondylolisthesis is usually caused by stress on the joints of the lower back. Although this condition can cause low back pain and sciatica, sometimes it causes no symptoms at all and is identified only on an x-ray done for other reasons. Herniated disc — Between each pair of vertebrae in the spine is a disc composed of a tough outer tissue and a gel-like inner pulp. These discs protect the bones of the spine like cushions. Too much wear and tear on spinal discs can lead to herniation, in which the outer covering is weakened or torn, and the soft inner tissue extrudes (a "slipped disc"). If this bulge in the disc presses on a nerve, it can cause inflammation, pain, and nerve pinching, which typically results in symptoms of sciatica. Sciatic pain is often accompanied by

paresthesia, an uncomfortable sensation of numbness, tingling, or burning. This type of pain usually is worsened by coughing, straining, or standing or sitting in one position too long. Pain related to compression of a nerve is typically relieved by lying down. Lumbar spinal stenosis — Spinal stenosis is a condition in which the vertebral canal, or open space inside the vertebrae, is narrowed. This is often caused by inflammation due to one or more damaged discs, and is particularly common in older patients. Spinal stenosis typically causes pain that runs down the back to the buttocks, thighs, and lower legs, often involving both sides of the body. This kind of pain is called neurogenic claudication, and may cause limping and weakness in the legs. Pain usually gets worse when extending the lower spine, for example when standing or walking, and gets better when flexing the spine by sitting, stooping, or leaning forward. Back pain caused by occupation — Many cases of low back pain in the workplace are due to ergonomic problems. The science of ergonomics has to do with the safety and efficiency of the workplace as it relates to its physical effects on workers. This includes the design of the furniture and tools used in the workplace and the physical effects of the way in which people carry out their responsibilities. Workplace factors or conditions that can contribute to low back pain include posture while sitting or standing, sitting or standing for long periods of time, driving long distances, improper seating, improper lifting techniques, frequent lifting or lifting of too heavy loads. Many people think of heavy lifting as the main cause of low back pain in the workplace, but poor posture while sitting, especially for long periods of time, is just as important. Back pain is as common among clerical workers in jobs requiring prolonged sitting as in workers whose jobs require heavy lifting. Studies have found that many people experience increased levels of anxiety or depression before they develop symptoms of low back pain and other work-related conditions. Psychological factors relating to the workplace can also contribute to low back pain. These include stress, job dissatisfaction,

boredom, tension, and other psychological factors that can affect the way workers physically carry out their responsibilities as well as how the body responds to the everyday physical demands of the job Patients with low back pain must be particularly careful at the workplace to avoid conditions that could exacerbate their condition. In addition to learning and practicing appropriate posture and methods of lifting or carrying, it may be necessary to temporarily or permanently avoid activities that contribute to back pain. EVALUATION — As mentioned above, the vast majority people with back pain improve on their own or with simple measures that can be performed at home. Thus, in many cases, it is not necessary to see a healthcare provider. However, back pain can represent a serious condition. The following signs and symptoms may indicate a more serious condition that requires medical attention:

Pain that does not go away, even at night or when lying down, may indicate the presence of a rare condition, including fracture, infection, or neoplasm (tumor). Weakness in one or both legs and problems with bladder, bowel, or sexual function can be signs of cauda equina syndrome, arising from the nerve bundle at the base of the spine. People who have problems with their immune system, use intravenous drugs, or who have injured their back by falling or other accident may have an infection or fracture causing their pain. Pain that spreads into the lower leg, particularly if accompanied by weakness of the leg, suggests a herniated disc.

History and physical examination — For those with concerning signs and symptoms associated with back pain, as well as those who do not improve after conservative treatment, a complete medical history and physical

examination are needed. X-rays — Back x-rays are not useful in most patients with acute low back pain; x-rays do not show a herniated disc or spinal stenosis, and x-ray findings do not always correlate with a person's pain. Magnetic resonance imaging (MRI) and computed tomography (CT) show the structures of the back more accurately than xray. One of these tests may be recommended if surgery is planned or if the cause of pain cannot be determined with other methods. However, for most people with low back pain, CT and MRI are not needed. TREATMENT — Unless back pain is caused by a serious medical condition, a rapid recovery is possible, even if there are signs or symptoms of a pinched nerve. In the latter circumstance, the body breaks down bulging disks and disposes of the offending material, taking pressure off the nerve. Care of an attack of low back pain includes several simple elements, many of which can be done by the patient: Find a comfortable position. For some people, this is in bed with knees bent. Any position that works is fine. A medium-firm bed mattress may be better than a firm mattress.

Some people may need to stay home from work if their occupation does not allow them to sit or stand comfortably. If the job requires prolonged standing, stepping on a block of wood with one foot (and periodically alternating which foot is on the block) may be helpful. Avoid heavy lifting or sudden, awkward movements. Take a pain medication such analgesic Stronger pain medications, such as narcotics, are rarely needed. It is usually more effective to take a dose on a regular basis, rather than waiting for pain to become bothersome. Muscle relaxants are sometimes helpful

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In the first few days of the attack, try applying cold and heat 15 to 20 minutes every two to three hours. Bed rest is only recommended for those with severe, debilitating back and leg pain, and it should not be used for more than two to three days. Movement helps to relieve muscle spasm and prevents loss of muscle strength.

Exercise — Exercise can begin as soon as it is comfortable to sit. Recommended activities include walking, swimming, stationary bicycle, and low-impact aerobics. Avoid activities that involve twisting, bending, are high impact, or that make the back hurt more. Some specific exercises may help strengthen the muscles of the lower back. People with frequent attacks of low back pain should continue these exercises indefinitely to prevent new attacks. Other treatments — Some physicians recommend injection of the soft tissues of the back for pain and stiffness in these areas. However, this treatment is not recommended by all experts. Other treatments that may be considered include the following:

Lumbar Corsets and braces can sometimes be used . Used preventively, however, lumbar corsets may reduce time lost from work in patients who perform jobs that involve frequent heavy lifting. Acupuncture involves placing small needles into specific points on the body. This treatment is used with a wide variety of physical conditions. Although many patients with low back pain report that acupuncture helps relieve their symptoms, there are not enough data from well-designed clinical studies to prove the effectiveness of this treatment. Acupuncture does not appear to be harmful in any way.

SURGERY — Only a small minority of patients suffering from low back pain will require surgery. Surgery is only considered if imaging studies show one or more lesions that match the clinical findings, or if there is evidence of nerve root compression, cauda equina, or

conus medullaris (problems with the nerves at the base of the spinal cord). Referral to an orthopedic surgeon or neurosurgeon may be recommended under the following circumstances:

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Increasing neurologic problems (measurable weakness) Sensory loss and bladder and bowel symptoms Failure to respond to four to six weeks of conservative management, with persistent and severe sciatica and evidence of nerve root involvement

Many surgical procedures are available depending upon the lesion found on testing and the experience of the surgeon. Patients having surgery for lower back pain usually stay in the hospital for a few days after the operation, and can resume sedentary work within three to six weeks. Serious complications during surgery are rare, but can include hemorrhage, nerve root injury, and infections. About 5 to 7 percent of patients who undergo back surgery will experience a recurrence of their herniated disc. One of the most common causes is bending over to pick something up from the floor too soon after surgery. PREVENTING BACK PAIN — There are a number of ways to prevent the recurrence of low back pain. Perhaps the most important are exercise and physical conditioning. Regular exercise that improves cardiovascular fitness can be combined with specific exercises to strengthen the muscles of the hips and torso. Back exercises or stretching routines should not be used during an attack of back pain. These activities can worsen pain and further damage protruding (herniated) discs. However, after symptoms have subsided, there is significant benefit from a program of exercises to increase back flexibility and strengthen the muscles that support the back. A healthcare provider may recommend working with a physical therapist to learn appropriate ways of sitting, standing, and moving. Many such therapists offer "back school" programs that combine stretching and strengthening exercises with education about the back and

how to care for it to prevent further problems. Patients who smoke and have low back pain should consider stopping smoking which has long been recognized as a risk factor for back pain. :

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