Which Patient With Low Back Pain has a good chance of getting better?

Low back pain is very common, and the majority of the patients get better with time. Few patients don’t get better, and they will need more time, more care, more studies, and more treatment. Who is the patient with low back pain that will get better with time? Which patient is ideal for simple treatment of low back pain? The ideal patient has low back pain that may be severe, and it may be incapacitating. The patient may have limited lumbar range of motion but there’s no radiation below the knee and there is no history of trauma. The ideal patient has no fever or chills or weight loss, no bladder or bowel dysfunction, no neurological deficits, and no pathological reflexes. The patient typically improves with rest. In order to optimize recovery, management of the patient should consist of early return to activity as tolerated, as the symptoms allow. In fact, the best treatment for low back pain is probably return to work. You will give the patient reassurance with limited analgesia, early range of motion, and muscle relaxants (it is a symptomatic treatment). A healthy patient with an acute onset of non-traumatic low back pain, you do not need early diagnostic imaging before proceeding with the therapeutic treatment. Diagnostic imaging is not necessary unless the initial treatment is unsuccessful, and the symptoms are prolonged. X-rays may not be needed in the first six weeks unless there is a reason for it, such as red flags. In fact, the use of x-rays can lead to better patient satisfaction (you make the patient feel better) but doesn’t necessarily lead to better patient outcome. An MRI is not needed early in the management of the patient, unless there are red flags in the history or in the exam, such as things that point to trauma, tumor, or infection. X-rays and MRIs may show changes in the intervertebral discs and may be associated with the patient’s pain, but these changes are also commonly seen in cross-sectional studies of asymptomatic people. About 30% of abnormal discs are seen in its asymptomatic subjects less than 40 years old, so there is a lot of false positive MRIs. About 90% of patients above 60 years of age will have MRI changes. There are a lot of false positive MRIs, and you need to correlate the MRI findings with the clinical findings. Don’t rely on the MRI alone! Just because you have MRI changes or disc protrusion, it does not mean that you need surgery! A nonspecific pain does not require surgery; therefore, it does not require further work-up. There are risk factors associated with low back pain that includes Poor physical fitness; Smoking; History of repetitive bending or stooping on the job and whole body vibration exposure. X-rays may show instability, severe deformity, lumbar stenosis, or spondyloarthropathy. These findings are associated with low back pain. You need to see if there is a straight leg raise, because this mans that there might be a disc herniation in about 66% of the time. In the straight leg raise, you will find pain when the patient raises his lower extremity with the knee extended. If you add the imaging to the straight leg raise, this will give you 86% accuracy in the diagnosis of disc herniation. If you have neurological deficit, straight leg raise and MRI imaging, that will make the incidence of disc herniation and improvement from surgery is about 95% of the time. You need to connect the MRI with the tension sign, which is the straight leg raise, and with the neurological deficit (can be just sensory changes, reflexes or decreased strength). If the patient has a simple low back pain, 50% of the patients resolve their pain in one week. Resolution of the acute back pain occurs in 90% of the patients within one month. If the patient has more back pain than leg pain, then you can successfully treat the patient conservatively. If you have a nerve irritation and radiculopathy, and the back pain is shooting down the buttock and the leg, then it is really more complex than if you have low back pain by itself. If the patient has leg pain greater than back pain, then the patient has sciatica. Leg pain can mean that the patient has a disc herniation. Sciatica can be self-diagnosed by the patient. Sciatica means nerve root irritation, probably due to a herniated disc. Pain in disc herniation will be worse with sitting, coughing, sneezing and forward flexion.