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KMID : 0614720070500060507
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Journal of Korean Medical Association
2007 Volume.50 No. 6 p.507 ~ p.522
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NonsurgicalManagementofChronicLowBackPain
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Park Jung-Yul
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Abstract
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Chronic low back pain (CLBP), defined as low back pain persisting more than 3 months, develops in about 5~7% of those who experience low back pain anytime during the lifetime. It is associated with not only substantial functional disability in each patient, but also a great socioeconomic burden. The etiology of CLBP is usually multifactorial. Also, known risk factors related to the development of CLBP are diverse, including age, sex, genetic factors, environment, previous trauma, dissatisfaction from work, etc. The more common causes of CLBP encounteredin clinical settings are disorders related to intervertebral disc, spinal stenosis, spondylolisthesis, compression fracture related to osteoporosis, pain originating from zygapophysial, and sacroiliac joints. Less common but other important causes include metastatic lesions, infection, and myofacial pain syndromes. Here, an evidence-based literature review on nonsurgical management of CLBP is presented with a special attention focused on various therapeutic approaches based on etiologic processes and clinical resentations. Nonsteroidal anti-inflammatory drugs, alone or in combination with muscle relaxants, relieve pain and improve overall symptoms of acute low back pain, but do not usually play a role in CLBP. Tricyclic antidepressants play a role in CLBP with its analgesic effect and sleep improvement. Tramadol, a centrally acting analgesic, also provides effects on moderate to severe CLBP but careful considerations, as with opioids, are necessary to prevent side effects and should be rescribed in refractory patients. Exercise therapy has strong evidence in the management of CLBP. Moderately strong evidence upports the use of manipulation in acute back pain but not in CLBP. Evidence for epidural steroid is strong for short-term relief of CLBP and is moderate to strong for long-term relief, especially with radicular pain, when performed nsforaminally. Medial branch block (MBB) has moderate effects on facet-related pain and mechanical LBP, and the radiofrequency
medial branch neurotomy has strong evidence of long-term effects when done properly in patients responsive to MBB. The use of facet injections, orthoses, traction, magnets, prolotherapy, trigger point injection, or acupuncture in the agement of CLBP, unlike in acute LBP, is not supported by evidence for the long-term effectiveness. Sacroiliac joint injections are not indicated in the routine management of low back pain but show moderate effects in selected patients with CLBP. Conflicting evidence exists regarding the use of transcutaneous electrical nerve stimulation. For primary care providers and for those who specialize pain management, every effort should be made to contemplate all possible factors that might have played roles in generating the chronic pain and inform the patients of the natural course of various roblems causing CLBP. Also, whatever management is chosen, the decision should be based upon the clinical presentation that closely correlates with definitive findings from studies best available whenever possible to provide the best treatment possible, not only to relieve the pain but also to provide functional capability to return previous social status as well as to prevent further development of disability and chronicity with refractory pain syndromes.
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KEYWORD
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Chronic low back pain, Etiology, Riskfactor, Diagnosis, Conservative, Treatment
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