Lower back pain (LBP) is defined by the location of pain, typically between the lower rib margins and the buttock creases. It is commonly accompanied by pain in one or both legs and some people with low back pain have associated neurological symptoms in the lower limbs.
Guidelines recommend that laboratory tests and imaging should not be routinely used as part of early management, but rather reserved for patients for whom presenting red flags (findings derived from a patient’s medical history and the clinical exam that are usually linked with a high risk of having a serious disorder like an infection, cancer, fracture or rheumatoid disease).
For nearly all people presenting with LBP, the specific source of pain cannot be identified since is most of the time a combination of biophysical, social and psychological aspects. Therefore the majority of the cases is classified non-specific low back pain. One easy classification can be done through the time of the presentation of the symptoms.
Lower Back Pain classification
– Acute lower back pain is defined as LBP for less than 12 weeks and the management recommended in international guidelines are that individuals should be provided with advice and education about the nature of low back pain or radicular pain; reassurance that they do not have a serious disease and that symptoms will improve over time; and encouragement to avoid bed rest, stay active, and continue with usual activities, including work
– Persistent lower back pain is defined as LBP for more than 12 weeks and recommended physical treatments include a graded activity or exercise program that targets improvements and functionality and prevention of worsening disability. Since there is no evidence showing that one form of exercise is better than another, guidelines recommend exercise programs that take individual needs, preferences, and capabilities into account in deciding about the type of exercise.
Pharmacological treatment
Guidelines now recommend pharmacological treatment only following an inadequate response to first-line non-pharmacological interventions. Paracetamol was once the recommended first-line medicine for low back pain; however, evidence of absence of effectiveness in acute low back pain and potential for harm has led to recommendations against its use.
Health professionals are guided to consider oral non-steroidal anti-inflammatory drugs (NSAIDs), taking into account risks, including gastrointestinal, liver, and cardiorenal toxicity, and if using, to prescribe the lowest effective dose for the shortest possible time.
Guidelines generally suggest consideration of muscle relaxants for short-term use, although further research is recommended.
Interventional therapies and surgery
The role of interventional therapies and surgery is limited and recommendations in clinical guidelines vary.
Recent guidelines do not recommend spinal epidural injections or facet joint injections for low back pain but do recommend consideration of epidural injections of local anaesthetic and steroid for severe radicular pain.
Epidural injections are associated with small short-term (4-weeks) reductions in pain, do not seem to provide long-term benefits or reduce the long term risk of surgery, and have been associated with rare but serious adverse events, including loss of vision, stroke, paralysis, and death.
The benefits of spinal fusion surgery for non-radicular low back pain thought to originate from degenerated lumbar discs (known as discogenic) are similar to those of intensive multidisciplinary rehabilitation and only modestly greater than standard non-surgical management.
Surgery is also more costly and carries a greater risk of adverse events than non-surgical management.
UK guidelines for Lower Back Pain Dubai
The UK guidelines recommend that patients are not offered disc replacement or spinal fusion surgery for low back pain, and instead recommend offering fusion surgery only as part of a randomised trial.
Patients with severe or progressive neurological deficits require surgical referral.
Spinal decompression surgery can be considered for radicular pain when non-surgical treatments have been unsuccessful and clinical and imaging findings indicate association of symptoms with herniated discs or spinal stenosis. For a herniated disc, early surgery is associated with faster relief of radiculopathy than with initial conservative treatment with the option of delayed surgery, but benefits diminish with longer (>1 year) follow-up.
For symptoms associated with lumbar spinal stenosis, benefits of surgery over conservative care are not clear but some beneficial effects have been shown.
However, patients tend to improve with or without surgery and, therefore, non-surgical management is an appropriate option for patients who wish to defer or avoid surgery. To learn more about Lower Back Pain, please visit our dedicated page here: Lower Back Pain Dubai
