Evaluating and Managing Acute Low Back Pain in the Primary Care Setting radiografia dorsolumbar

Low back pain is managed by many different health care providers. General practitioners, internists, family practitioners, neurologists, rheumatologists, emergency physicians, and orthopedic and neurological surgeons all see patients with back problems. Nonallopathic providers of back care include osteopathic physicians, chiropractors, physical therapists, acupuncturists, and massage therapists. Among patients who use alternative medicine, back problems are the most frequently reported medical condition, 19 and the use of alternative medicine is increasing. 20 given the variety of health care providers who manage low back pain, variation in the evaluation and management of back pain is not surprising. Rates of hospitalization and surgery for low back pain vary widely by geographic region. 21 – 24

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Few studies have compared outcomes and costs of acute low back pain among different providers. Depending upon the provider the patient initially sees, differences in the use of diagnostic technology (plain x-rays, computed tomography [CT], or magnetic resonance imaging [MRI] imaging), treatments, and referral to other professionals providing back care may result. In one large study comparing primary care practitioners, chiropractors, and orthopedic surgeons, diagnostic testing, intensity and nature of treatments, overall cost of care, and patient satisfaction were shown to vary widely among different provider groups. 25 in spite of differences in resource use and satisfaction with care, patient outcomes were remarkably similar among the different practitioner groups.Radiografia dorsolumbar

Even among similarly trained providers, differences in practice style may influence the quality and cost of care for low back pain. In a large health maintenance organization, the practice styles of 44 primary care physicians were categorized by the frequency of pain medication prescriptions and recommendations for bed rest. 26 although long-term outcomes were similar across physicians, lower costs and higher patient satisfaction were associated with physicians who prescribed less medication and bed rest.

Given the frequency of the problem, the variation in its evaluation and treatment, and its generally good prognosis, improving the efficiency of care for patients with back pain in primary care is needed. 27 because the etiology of most acute low back pain remains uncertain, the initial evaluation focuses on excluding rare but potentially serious causes, and identifying patients at greater risk for prolonged symptoms.Radiografia dorsolumbar initial management for most patients includes measures for symptom relief, education, and reassurance about the favorable natural history. For patients with signs of radiculopathy, potentially serious causes of back pain, or risk factors for prolonged symptoms, diagnostic testing, referral, and alternative treatments may be indicated. This review focuses on the majority of patients with acute nonspecific symptoms, but detailed discussions of less common causes of acute low back pain are available. 28 – 32

A wide range of terms are used for nonspecific mechanical causes, including low back pain/strain/sprain, lumbago, facet joint syndrome, sacroiliac syndromes, segmental dysfunction, somatic dysfunction, ligamentous strain, and myofascial syndrome.Radiografia dorsolumbar these typically involve processes in the muscles and/or ligaments that are difficult to reliably identify by physical examination or diagnostic testing. 29 even when back pain is associated with specific imaging findings such as degenerative disk disease, spondylolysis, spondylolisthesis, or osteoporosis, it may be impossible to determine whether the finding is the cause of the patient’s symptom (discussed extensively in the diagnostic testing section). Occasionally, the source may be the hip joint and musculature.

For initial management, the presence or absence of neurological findings may be a more clinically useful distinction than the extensive differential diagnosis presented in table 1. In contrast to nonspecific back pain, the etiology of a radiculopathy is often identifiable, with a herniated intervertebral disk the most common. 32 the peak incidence is from 30 to 55 years of age, with 98% involving the L4-5 (L5 nerve root) or L5-S1 (S1 nerve root) interspaces.Radiografia dorsolumbar in older individuals, radiculopathy may be due to spinal stenosis, a narrowing of the central spinal canal or its lateral recesses that impinges on adjacent nerve roots. Other anomalies, such as scoliosis, facet joint synovial cysts, and spondylolisthesis can cause radiculopathy, as can fractures, tumor, infection, or vascular compromise. 32 occasionally, patients have radicular findings without a clear etiology, which may be due to soft tissue processes irritating nerve roots as they exit the spinal interspaces, or hypertrophic degenerative bony changes that compromise the nerve root canal.

The epidemiology and etiology of acute low back pain indicate that most patients seen by primary care providers have a self-limited, nonspecific mechanical cause.Radiografia dorsolumbar thus, the goal of the evaluation is to efficiently exclude potentially serious causes and to identify patients who may be at higher risk for delayed improvement due to abnormal physical findings or psychosocial issues. The extent to which the clinician searches for a specific diagnosis can be determined largely by the patient’s history and physical exam. 36 although internists have traditionally spent much of the clinical encounter searching for uncommon causes of back pain, the search is rarely fruitful, and leaves little time to educate patients about self-care.

Ideally, screening for rare underlying diseases should be sensitive enough to identify all cases (true positives), while being specific enough to avoid identifying a large number of individuals who will turn out to have a nonspecific mechanical cause (false-positives). 37 there is an inherent tradeoff between increasing sensitivity and decreasing specificity.Radiografia dorsolumbar because the prevalence of potentially serious causes of acute low back pain is very low in the primary care setting, most patients with suggestive history or examination findings will prove to have a nonspecific mechanical cause on further testing (low positive predictive value).

Recent guidelines for acute low back pain assist with this process of efficiently evaluating patients. 27 the history and physical examination can identify patients at risk for serious causes of low back pain and those with neurologic compromise who warrant more detailed evaluation and treatment. 36 additionally, the history and physical exam can identify factors that may influence choice of therapy or may amplify or prolong pain. For most patients, the history and physical exam is sufficient to exclude the “red flags” that suggest serious disorders ( table 3).Radiografia dorsolumbar

The intent of the guidelines is to improve the appropriateness of diagnostic testing in the initial evaluation of acute low back pain, but rigid adherence may increase diagnostic testing compared to what clinicians otherwise do on their own. 38 , 39 we recommend that guidelines be used to augment clinical skills and insight rather than be applied rigidly.

A history of cancer, unexplained weight loss, age over 50 years, or failure of conservative therapy are risk factors for low back pain due to cancer ( table 3). 40 most cancer involving the spine is metastatic from the breast, lung, or prostate. Factors associated with spinal infections include a history of recent or ongoing urinary or skin infections, indwelling catheter, or injection drug use. Fever is not a common symptom or finding (low sensitivity), but when present increases the chance of an infectious etiology.Radiografia dorsolumbar compression fractures of the spine are associated with significant trauma, age over 50 years (though age over 70 years is more specific), corticosteroid use, or osteoporosis. Ankylosing spondylitis is suggested by morning stiffness, improvement with exercise, onset at age less than 40 years, slow onset, and pain for at least 3 months. 41 , 42 other factors such as symptoms unrelated to activity, pain that is worse when lying down, presence of atherosclerosis risk factors, and gastrointestinal or genitourinary symptoms can be helpful in suggesting other underlying visceral or systemic etiologies.

The history and physical exam are also helpful in identifying patients at high risk for persistent symptoms because of social or psychological stressors.Radiografia dorsolumbar A history of previous back pain, depression or other measures of psychological distress, substance abuse, pending or past litigation or disability compensation, low socioeconomic status, and work dissatisfaction have been shown to increase the likelihood of persistent low back pain. 46 – 49 the physical exam may also be helpful in identifying patients who are more likely to have persistent symptoms. Waddell reported on certain physical findings in patients with chronic low back pain that predicted poor response to subsequent treatment ( table 5). 50

Use of radiography among physicians is highly variable. 59 to improve appropriate diagnostic testing, clinical guidelines for the use of radiographs have been developed, 27 , 56 but it is unclear whether they will improve appropriateness or decrease overall utilization. 38 , 39 , 56 , 60

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Studies such as CT or MRI should be obtained in patients with a history, examination, or prior tests that strongly suggest a serious cause for back pain, such as cauda equina syndrome, infection, or tumor. For patients with sciatica likely due to a herniated disk or spinal stenosis, unless major neurologic abnormalities are identified, early imaging is unnecessary because many patients will improve with conservative treatment. 32 , 61 if such patients do not improve with a course of conservative care, imaging studies are appropriate. However, primary care providers may reasonably refer patients who may be surgical candidates (see referral section) to orthopedic or neurological surgeons prior to obtaining a study, as surgeons may wish to order a specific test to assist with surgical planning.Radiografia dorsolumbar

Evidence supporting one advanced imaging technique over another for disk herniation is lacking. 62 computed tomography (without contrast) may be the preferred test if: (1) there is a need to evaluate bones (i.E., if suspect fracture, facet joint abnormality, severe degenerative changes); (2) a metallic object in patient precludes use of MRI; or (3) the patient has severe claustrophobia. Magnetic resonance imaging may be the preferred test if the patient has had previous noninstrumented spine surgery (with gadolinium) or there is a history and examination suggestive of spinal stenosis, osteomyelitis, epidural abscess, tumor, or recent nondisplaced fracture. 63 magnetic resonance imaging has the advantage of not using ionizing radiation and providing better resolution.Radiografia dorsolumbar radionuclide bone scans can be used to evaluate for infection or fracture not noted on plain radiographs. However, MRI provides similar or better diagnostic accuracy without radiation exposure. 64 myelography has few indications and should generally not be ordered by primary care providers. 62

Patient expectations may be another reason to consider performing a diagnostic test. However, this is rarely a good indication unless efforts by the physician are not able to dissuade the patient. Information about why such a test is not indicated is usually sufficient for most patients. 65 for patients insistent on an advanced imaging study, referring the patient to a conservative specialist may be an appropriate alternative. Patients with acute low back pain with pending litigation or disability compensation may request certain imaging procedures.Radiografia dorsolumbar because of the poor association between symptoms and findings noted previously, the ordering of imaging studies for medicolegal reasons when the clinical evaluation does not support such testing should be documented in the clinical note.

Since the 1950s, bed rest has been one of the cornerstones of low back pain treatment based largely on expert opinion 72 and on physiologic studies showing that disk pressures are minimized in the supine position. 73 by the early 1980s, bed rest recommendations were being questioned. 74 randomized trials have tested the effect of varying recommendations for bed rest in patients with acute low back pain without radicular leg symptoms. Two versus 7 days of recommended bed rest resulted in similar outcomes, except those patients recommended 2 days of bed rest returned to work sooner. 75 subsequent trials have compared no formal bed rest recommendation to days of bed rest. 76 – 78 these studies have shown improved outcomes, especially decreased work loss, are associated with recommending usual activity as opposed to 2 to 4 days of bed rest.Radiografia dorsolumbar thus, clinical trials have tested the effect of progressively less bed rest. Continuation of usual activity with no formal recommendation for any bed rest appears to be associated with better outcomes.

For patients with sciatica, bed rest remains a common recommendation. 32 A recent randomized trial of 2 weeks of recommended bed rest versus maintaining activity as tolerated (bed rest not prohibited) found similar outcomes through 12 weeks. 79 pending additional studies, limiting bed rest to periods of severe pain, encouraging early ambulating, and avoiding activities that provoke pain appear reasonable.

Nonsteroidal anti-inflammatory drugs (nsaids) and acetaminophen are the medications of choice for treating acute low back pain. 27 , 84 acetaminophen and nonsteroidal agents have been shown to be equally efficacious in treating knee osteoarthritis, 85 but no similar studies have been performed for back pain.Radiografia dorsolumbar nonsteroidal agents are most commonly prescribed, 86 but acetaminophen is preferred in those with dyspepsia or known intolerance to aspirin or other nonsteroidal agents.

Muscle relaxants and opioids are commonly prescribed for low back pain, but have not been shown to be more effective than acetaminophen and nsaids in well-controlled studies. 84 , 86 for patients without severe pain, muscle relaxants (drugs like diazepam or cyclobenzaprine) and narcotic painkillers (acetaminophen with codeine or oxycodone) offer few advantages and have more side effects. When muscle relaxants and opioids are used, they should be prescribed for short, clearly defined periods (typically up to 1 to 2 weeks). For more severe pain that prevents restful sleep, sedatives, including antihistamines such as diphenhydramine, can be helpful.Radiografia dorsolumbar muscle relaxants that cause sedation can also help with nighttime discomfort, and narcotic painkillers may be prescribed for short periods on a regular basis, especially for people with pain that radiates into the leg.

Because low back pain is self-limited in most primary care patients, an important goal is to establish reasonable patient expectations. Patient interest in alternative medicine providers may reflect concerns about the adequacy of care in the primary care setting. Besides offering different treatments, many alternative providers make very specific diagnoses and communicate this certainty to patients. This may account for greater satisfaction among patients of chiropractic compared with patients of primary care allopathic clinicians. 25 , 88

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It is important to provide the patient with clear, concise information that emphasizes treatment as being time to heal and reassurance that the pain will improve. Education should include information on causes of back pain, pain resolution, why testing is rarely needed, usual activity/work and other treatment recommendations, when to contact the clinician, when referral is appropriate, and prevention ( table 7). Written material can reinforce verbal information. Despite the common sense view that patient education can improve outcomes, rigorous studies have been disappointing. 97 – 99 however, for patients with sciatica considering surgery, those randomized to view an educational videodisc felt better informed, had equally good outcomes and were less likely to choose surgery than patients who received usual care. 100 , 101