Low back pain. Evaluation and management in the primary care setting.

摘要: Humans have always been plagued by low back pain. One would thought now that the problem of diagnosis and treatment solved, but issue remains mysterious clouded with uncertainty. Part reason has concept, derived from first writings Mixter Barr, 13 there must be a relationship among vertebral bodies, interposed intervertebral disk, bony arch, pedicles facets, contained nerve root. Many treatises describe pain as herniated disk producing root compression, nothing can further truth. In fact, concept sustained compression is not tenable. 14 There may on initial impact, leads to failing nerve, which, if sufficient in degree, goes develop sensory, motor, reflex loss, no long-term. Therefore, source nociception or originate other structures, although it agreed neural structures are conduit for transmission painful impulse through neuraxis conscious recognition brain. It difficult identify precisely origin because, even when its characteristics sometimes point given structure, often nonspecific. addition, generally impossible corroborate clinical observations histologic studies because usual benignity this form spinal disorder does justify removal tissue, current diagnostic techniques image soft tissue certainty. What needs evaluated? The myofascial system truly supports binds segments together involved without exception exists. focus medical attention so centered nerve/disk/bony little integument support where all chemistry found interacts produce stimulus Their manifestations, once recognized, easy treat. 21 This simplistic gained wide acceptance constantly demeaned when, physiologic findings lead conclusion major culprit respect and, it, leg extension sciatica. radiculopathy disturbance rather system, which referred along route uses nociceptive information Nowhere seen clearly treatise involving study 45,000 workers pain, known Quebec Study. 19 critical path management disorders emanated begins patients divides group into those nonspecific specific (Fig. 1). associated traumatic injury, neoplasm, infection, significant neurologic deficit. just that: history only, physical disclose Observers, however, fail examine routinely abnormalities, universally present most frequent state. second an American publication Clinical Practice Guidelines series Agency Health Care Policy Research, reflects similar thinking serve purpose assessment acute problems focusing detection red flags , indicators potentially serious nonspinal pathologies. 1 Both monographs begin includes appropriate examination, myofascia, both agree that, absence flags, imaging testing usually helpful during 4 weeks symptoms majority remit spontaneously period time. Most people report at some time their lives, estimated four out five individuals lifetime. National statistics indicate general yearly prevalence US population 15% 20% working age people, 50% admit each year. common cause disability persons younger than 45. At any time, about 1% chronically disabled problems, another temporarily disabled. Annually, approximately 175 million work days lost per year, additional $20 billion loss productivity. total cost society calculate, annual societal costs United States range $50 billion. estimation include nonmonetary also substantial. inability function normally daily activities affects families. productivity only catastrophic individual, gross domestic product these absent workers. After headache, condition; expensive. ranks third reasons surgical intervention, subsequently, mostly unwarranted. increasing evidence many activity intolerance result receiving care inappropriate or, least, less optimal. marked regional variations States, suggest lack consensus treatment. appear more after before, surgery being obvious example, so-called failed surgery. Failed led repeated procedures rarely improve outcome, supplemented interventional techniques, such blocks, epidural steroids, implant stimulators, morphine pumps, epiduroscopy, find efficacy add cost. extended use bed rest disproved, high-dose opioids prolongs debilitates patients. When literature searched judged, according criteria established panels, scientific validity methods fall short passing muster.