Managing Low Back Pain
A Challenge for the Next Millennium

All of us have benefited in some way from the advances in medical science that have occurred in the twentieth century. Because of improvements in imaging, medications, and surgical techniques and instruments, doctors can more effectively diagnose and treat illness. Despite these advances, low back pain remains a serious health disorder, and, next to the common cold, it remains the most common reason why people seek medical care. During his or her life, about one in five persons will have a serious episode of back pain that will require medical attention.

Low back pain is the most expensive health care problem for people age 20 to 50 years. It also is the most expensive industrial injury, affecting 2% to 5% of the workforce and leading to 1,000,000 workers' compensation claims annually. Most health care dollars allocated to treating this condition are spent on a small percentage of people - those whose low back pain does not go away after surgery. This problem is often called failed back surgery syndrome.

The key to successful management of low back pain is accurate diagnosis and appropriate treatment. In this issue, we discuss the state of the art in managing low back pain, and we look to the future for what the next millennium might offer to people with low back pain.

Current Concepts
Perhaps the most important step in managing low back pain begins with an accurate diagnosis. The doctor makes this diagnosis after obtaining a thorough clinical history and after performing a meticulous physical examination. Recognizing pain-sensitive structures in the spine allows the examiner to search for potential pain generators (Fig. 1).

Most people associate low back pain with a ruptured (or herniated) intervertebral disc. This condition means that the shock-absorbing structure (or disc) between two vertebrae (back bones) is bulging into the spinal canal and pushing on one or more spinal nerves. In reality, a herniated disc is responsible for few cases of low back pain. More common in occurrence are other less well-recognized causes of low back pain that can mimic a herniated disc. These causes can involve the joints that unite the low back vertebrae (lumbar posterior facet joint syndrome), the joints that unite the pelvis and spine (sacroiliac joint syndrome), or the low back muscles and the tissue that covers them (myofascial syndrome).

Advances in spinal imaging have enabled doctors to identify injured structures in the back with greater accuracy. Plain x-rays (which show the vertebrae) are usually not taken when you have acute (recently occurring) low back pain because they rarely show abnormalities or alter treatment. The doctor should take plain x-rays when your symptoms persist for more than four weeks or are the result of trauma (Figs. 2A and 2B).

Magnetic resonance imaging (MRI) is the imaging study of choice to evaluate the low back because it allows the doctor to see the entire lumbar (low back) compartment in a single image and it depicts the bones, discs, soft tissues, and nerves (Fig. 3). Computed tomography, myelography, and discography are other imaging studies that the doctor can use to complement MRI.

The goal in treating low back pain is to select the least invasive treatment that will eliminate your pain and restore you to a normal activity level. There are many treatment options for managing low back pain.

To help relieve symptoms associated with acute low back pain, your treatment may include physical therapy modalities, such as heat, ultrasound and dynawave (stimulation with sound waves), TENS unit (stimulation with electricity), and massage. The doctor may prescribe muscle relaxants, analgesics, and anti-inflammatory medications (e.g., ibuprofen) for short-term use. Long-term use of narcotics should be avoided. Manual (hands-on) and manipulative treatments by spine therapists can help restore normal back function and motion. Performing therapeutic exercises helps you maintain motion and develop strength, protecting your back against future injury. In addition, you may need to wear an orthosis (brace) for a short period to help relieve your pain and support your back.

Diagnostic and therapeutic spinal injections are useful additional treatments for syndromes such as herniated lumbar discs, facet or sacroiliac joint syndromes, and spinal stenosis (narrowing of the space in the spinal column through which nerves pass) (see "Spinal Injections,").

Chemonucleolysis, a once popular, minimally invasive spinal procedure to chemically shrink or dissolve the abnormal disc , is less widely used today because of rarely reported, but serious, complications. Some newer minimally invasive procedures have shown promise in carefully selected patients. These procedures include laser discotomy, intradiscal steroid injection, suction discectomy, cryotherapy, thermal ablation, and percutaneous discectomy. However, open discectomy is still the "gold standard" of treatment for most people who need a disc removed.

With improvements in anesthesia and surgical instruments, spinal surgeons now are able to perform some disc surgeries with minimal blood loss and tissue trauma, allowing patients to spend minimal time in the hospital. In addition, newer surgical devices have improved techniques for fusing the spine (permanently uniting two or more vertebrae).

Finding ways to treat people with failed back surgery syndrome remains a great challenge. Spinal cord stimulation and some devices that deliver medications directly into the spinal canal have a role in these people's treatment. In addition, programs to help restore function and to manage pain provide a wide range of treatments for people with chronic low back pain.

Thomas N. Bernard, Jr., M.D.
Columbus, Georgia