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• W70634425 abstract "Humans have always been plagued by low back pain. One would have thought by now that the problem of diagnosis and treatment would have been solved, but the issue remains mysterious and clouded with uncertainty. Part of the reason has been the concept, derived from the first writings of Mixter and Barr,13 that there must be a relationship among the vertebral bodies, the interposed intervertebral disk, the bony arch, pedicles and facets, and the contained nerve root. Many treatises describe low back pain as a herniated disk producing nerve root compression, but nothing can be further from the truth. In fact, the concept of sustained nerve root compression producing pain is not tenable.14 There may be pain on initial impact, but sustained compression leads to a failing nerve, which, if sufficient in degree, goes on to develop sensory, motor, and reflex loss, but there is no pain in the long-term. Therefore, the source of nociception or pain must originate from other structures, although it is agreed that the neural structures are the conduit for transmission of the painful impulse through the neuraxis to conscious recognition by the brain. It is difficult to identify precisely the origin of low back pain because, even when its characteristics may sometimes point to a given structure, the pain often remains nonspecific. In addition, it is generally impossible to corroborate clinical observations through histologic studies because the usual benignity of this form of spinal disorder does not justify removal of tissue, and there are no current diagnostic techniques that image soft tissue with certainty. What tissue needs to be evaluated? The myofascial system truly supports and binds the spinal segments together and is involved without exception when low back pain exists. The focus of medical attention has been so centered on the nerve/disk/bony relationship that little to no attention has been given to the soft tissue integument and support where all of the chemistry can be found that interacts to produce the stimulus of pain. Their clinical manifestations, once recognized, are easy to identify and treat.21 This simplistic concept has not gained wide acceptance and is constantly demeaned when, in fact, all physiologic and clinical findings lead to the conclusion that the myofascial system is the major culprit with respect to producing low back pain and, with it, leg extension or sciatica. The pain is not radiculopathy or disturbance of a nerve root but rather a disturbance of the myofascial system, which may produce referred pain along a route that uses the nerve root for transmission of nociceptive information to the brain. Nowhere is this seen so clearly as in a major treatise involving the study of 45,000 workers with low back pain, known as the Quebec Study.19 The critical path for the management of spinal disorders that emanated from this study begins with patients with back pain and divides the group into those with a nonspecific diagnosis and those with a specific diagnosis (Fig. 1). The specific diagnosis is easy to identify because it is associated with traumatic injury, neoplasm, infection, and significant neurologic deficit. The nonspecific diagnosis is just that: There is a history of pain only, and the physical findings disclose no neurologic deficit. Observers, however, often fail to examine routinely for myofascial abnormalities, which are universally present and are the most frequent source of the painful state. The second major treatise is an American publication in the Clinical Practice Guidelines series from the Agency for Health Care Policy and Research, which reflects similar thinking but does serve the purpose in the initial assessment of patients with acute low back problems of focusing on the detection of red flags, indicators of potentially serious spinal or other nonspinal pathologies.1 Both monographs begin with an assessment that includes an appropriate history and physical examination, with little attention to the myofascia, and both agree that, in the absence of red flags, imaging studies and further testing of patients are not usually helpful during the first 4 weeks of low back symptoms because the majority of patients remit spontaneously during this period of time. Most people report low back problems at some time in their lives, and it is estimated that four out of five individuals have major back pain during their lifetime. National statistics indicate a general yearly prevalence in the US population of 15% to 20% and among working age people, 50% admit to back symptoms each year. In fact, back symptoms are the most common cause of disability for persons younger than age 45. At any given time, about 1% of the US population is chronically disabled because of back problems, and another 1% is temporarily disabled. Annually, approximately 175 million work days are lost per year, with an additional $20 billion loss of productivity. The total cost to society of low back problems is difficult to calculate, but it is estimated that annual societal costs of back pain in the United States range from $20 billion to $50 billion. This estimation does not include nonmonetary costs of low back problems, which can also be substantial. The inability to function normally at work and other daily activities affects both patients and their families. This loss of productivity is not only potentially catastrophic to the individual, but also it clearly affects the gross domestic product from these absent workers. After headache, low back pain is the most common painful condition; back pain is clearly the most expensive. The problem ranks third among the reasons for surgical intervention, which, as seen subsequently, is mostly unwarranted. There is increasing evidence that many patients with activity intolerance as a result of low back symptoms may be receiving care that is inappropriate or, at least, less than optimal. There are marked regional variations in the United States, which suggest a lack of consensus about appropriate assessment and treatment. In addition, some patients appear to be more disabled after treatment than before, with surgery being the most obvious example, so-called failed back surgery. Failed back surgery has led to repeated surgical procedures that rarely improve outcome, and now this is supplemented by other interventional techniques, such as nerve blocks, epidural steroids, spinal implant stimulators, morphine pumps, and epiduroscopy, all of which find little support for their efficacy and add to cost. The extended use of bed rest has been disproved, and the extended use of high-dose opioids prolongs symptoms and further debilitates patients. When the literature has been searched and judged, according to criteria established by consensus panels, scientific evidence for the validity of many assessment techniques and treatment methods fall short of passing muster.1" @default.
• W70634425 created "2016-06-24" @default.
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• W70634425 modified "2023-10-18" @default.
• W70634425 title "LOW BACK PAIN" @default.
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• W70634425 doi "https://doi.org/10.1016/s0025-7125(05)70128-0" @default.
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