Common Symptoms in the Ambulatory Setting , An Issue of Medical Clinics, E-Book (eBook)

Common Symptoms in the Ambulatory Setting , An Issue of Medical Clinics, E-Book

Douglas Paauw (Autor)

eBook Download: PDF | EPUB

2014 | 1. Auflage
100 Seiten
Elsevier Health Sciences (Verlag)
978-0-323-29716-5 (ISBN)

Infos

This issue of the Medical Clinics of North America, edited by Douglas Paauw, is devoted to Common Symptoms in the Ambulatory Setting. Articles in this issue include: Evaluation and treatment of chronic cough; Evaluation and treatment of lower back pain; Lower extremity symptoms; Common dermatologic problems; Evaluation and treatment of shoulder pain; Headache; Evaluation and treatment of colonic symptoms; Dyspepsia; Insomnia; Dizziness; Fatigue; Common anal problems; Involuntary Weight Loss; Evaluation and treatment of neck pain; and Multiple unexplained symptoms.

Textauszug

Low Back Pain

Anna L. Golob, MDab∗ [e-mail] and Joyce E. Wipf, MDab,     aDepartment of Medicine, University of Washington, Box 356420, 1959 NE Pacific Street, Seattle, WA 98195-6420, USA; bVA Puget Sound Healthcare System, General Medicine Service, S-123-PCC, 1660 South Columbian Way, Seattle, WA 98108, USA

∗Corresponding author. VA Puget Sound Healthcare System, General Medicine Service, S-123-PCC, 1660 South Columbian Way, Seattle, WA 98108.

Low back pain is one of the most frequent complaints for which patients are seen in primary care. Low back pain has a substantial economic impact, estimated at $100 billion per year including direct and indirect costs. The evaluation of low back pain involves a thorough history and physical examination. Imaging is only indicated when a more serious underlying cause or neurologic abnormality is suspected. Abnormalities detected on imaging do not strongly correlate with symptoms. Generally, a specific underlying cause for low back pain is not identified. Treatment consists of a multidisciplinary approach with goal to maintain function and minimize disability.

Keywords

Acute low back pain

Chronic low back pain

Risk factors

Cause

Diagnosis

Imaging

Treatment

Sciatica

Key points

• Low back pain is a common, frequently recurring condition that often has a nonspecific cause.

• History and physical examination should focus on evaluation for evidence of systemic or pathologic causes.

• Imaging is only indicated when there is evidence of neurologic deficits or red flags to suggest fracture, malignancy, infection, or other systemic disease, or when symptoms do not improve after 4 to 6 weeks.

• Most nonspecific low back pain will improve within several weeks with or without treatment.

• Back pain that radiates to the lower extremities, occurs episodically with walking or standing erect, and is relieved by sitting or forward spine flexion is typical of neuroclaudication and suggests central spinal stenosis.

• All patients with acute or chronic low back pain should be advised to remain active.

• The treatment of chronic nonspecific low back pain involves a multidisciplinary approach targeted at preserving function and preventing disability.

• Urgent surgical referral is indicated in the presence of severe or progressive neurologic deficits or signs and symptoms of cauda equina syndrome.

Introduction

Low back pain affects a significant proportion of the population.1–5 The precise incidence and prevalence of low back pain are difficult to characterize due to significant heterogeneity in the epidemiologic studies. In a survey of Saskatchewan adults, 84% of participants reported experiencing at least one episode of back pain in their lifetime.6 A 2002 US National Health Interview Study found that 26.4% of the 30,000 participants had experienced at least one full day of back pain in the past 3 months.7 A 2010 review article reported 1-year incidences of first time, any time, and recurrent low back pain episodes as ranging from 1.5% to 80%, and the 1-year prevalence of low back pain ranging from 0.8% to 82.5%.8 These findings are summarized in Table 1.

Table 1

Incidence and prevalence of low back pain episodes

Low Back Pain (LBP) Episode

Incidence or Prevalence

1-y incidence of first ever LBP episode

6.3%–15.4%

1-y incidence of any LBP episode

1.5%–36%

1-y incidence of recurrent LBP episode

24%–80%

Point prevalence of LBP episodes

1.0%–58.1% (mean 18.1%, median 15.0%)

1-y prevalence of LBP episodes

0.8%–82.5% (mean 38.1%, median 37.4%)

Data from Hoy D, Brookes P, Blyth F, et al. The epidemiology of low back pain. Best Pract Res Clin Rheumatol 2010;24(6):769–81.

The incidence of low back pain peaks in the third decade of life. The prevalence increases until age 60 to 65 and then gradually declines.

Commonly reported risk factors for low back pain include physical, psychological, social, and occupational factors and are summarized in Table 2.2,6

Table 2

Risk factors for development of low back pain

Older age

Depression

Low educational achievement

Physically or psychologically strenuous work

Female gender

Anxiety

Increased life stress

Sedentary work

Obesity

Somatization disorder

Whole body vibration

Smoking

Low social support in the workplace

Job dissatisfaction

Workers compensation insurance

Low back pain has an enormous social and economic impact. It is a leading cause of work absenteeism globally and the second most common cause of missed work days in the United States.9,10 Direct medical costs attributed to the evaluation and treatment of low back pain are estimated to exceed $33 billion annually in the United States. When the indirect costs of missed work and decreased productivity are added, the total costs exceed $100 billion each year.2

Primary care providers play a key role in the evaluation and treatment of low back pain. Indeed, low back pain is the chief complaint in about 2.3% of all ambulatory physician visits, representing about 15 million office visits per year, and is second only to upper respiratory symptoms as a symptom prompting office evaluation.7

Pathophysiology

Anatomy

There are 5 lumbar vertebrae, each of which is composed of a vertebral body, 2 pedicles, 2 lamina, 4 articular facets, and a spinous process. Between each pair of vertebrae are the foramina, openings through which pass the spinal nerves, radicular blood vessels, and sinuvertebral nerves. The spinal canal is formed anteriorly by the posterior surface of the vertebral bodies, intervertebral discs, and posterior longitudinal ligament, laterally by the pedicles, and posteriorly by the ligamentum flavum and lamina (Fig. 1).

Fig. 1 Anatomy of the lumbar spine. (A) Cross-sectional view through a lumbar vertebra. (B) Lateral view of the lumbar spine. (From Firestein GS, Budd RC, Gabriel SE, et al. Kelley’s textbook of rheumatology. Philadelphia: Saunders; 2013. p. 666; with permission.)

In the normal spine, the anterior structures including the vertebral bodies and intervertebral discs perform weight-bearing and shock-absorbing functions. The posterolateral structures, including the vertebral arches, lamina, transverse, and spinous processes, provide protection for the spinal cord and nerve roots. Balance, flexibility, and stability are provided by the facet joints and paraspinous muscles and ligaments.

Physiology

Low back pain is often characterized in terms of radiologic findings (spondylosis, spondylolisthesis, spondylolysis) and clinical and neurologic findings (lordosis, kyphosis, radiculopathy, sciatica). These terms are defined in Table 3.

Table 3

Commonly used terms in low back pain

Term	Definition

Spondylosis

Osteoarthritis of the spine; evidenced by disc space narrowing and/or arthritic changes of the facet joints on radiographs

Spondylolisthesis

Anterior displacement of a vertebra in relation to the one beneath it. Displacement is graded 1–IV as follows: Grade I: 1%–25% slip; generally nonsurgical Grade II: 26%–50% slip; generally nonsurgical Grade III: 51%–75% slip; may be surgical Grade IV: 76%–100% slip; may be surgical

Spondylolysis

Fracture in the pars interarticularis of the vertebral arch (the joining of the vertebral body to the posterior structures), usually at L5. This is a congenital variant in 3%–6% of people

Spinal stenosis

Local, segmental, or generalized narrowing of the central spinal canal by bone or soft tissue elements, usually bony hypertrophy of the facet joints or thickening of the ligamentum...

Produkt-Details

• Erscheint lt. Verlag: 28.5.2014
• Sprache: englisch
• Themenwelt: Medizin / Pharmazie ► Medizinische Fachgebiete
• Themenwelt: Studium ► 2. Studienabschnitt (Klinik) ► Anamnese / Körperliche Untersuchung
• ISBN-10: 0-323-29716-1 / 0323297161
• ISBN-13: 978-0-323-29716-5 / 9780323297165