Lumbar Disc Disease Management

Aka: Lumbar Disc Disease Management, Low Back Pain Management

1. See Also
   1. Low Back Rehabilitation
   2. Low Back Muscle Fusion Rehabilitation
   3. Return to Work in Lumbar Back Pain
   4. Lumbar Disc Disease
   5. Sciatica
   6. Low Back Pain
   7. Lumbar Spine Anatomy
   8. Low Back Pain History
   9. Low Back Pain Red Flags
   10. Low Back Exam
   11. Low Back Imaging
   12. Differential Diagnosis of Low Back Pain
   13. Rheumatologic Conditions affecting the Low Back
   14. Low Back Pain in Children
   15. Low Back Pain in Teen Athletes
2. Management: General Measures
   1. Ice or heat applied to affected area
      1. Initial interval: 20-25 minutes per hour
      2. Later interval: three times daily
   2. Position of comfort
      1. Flexion relieves pressure on posterior columns
      2. Extension relieves pressure on anterior columns
   3. Body mechanics
      1. Ease transfers out of bed
      2. Ease moves to chair, car, toilet, and bathtub
   4. Stay active
      1. Early mobilization activities
         1. Slowly walk every 30 minutes
         2. Consider pool walking
      2. Improves outcomes
         1. Speeds recovery
         2. Reduces chronic Disability
         3. Reduces time off work
      3. Avoid exacerbating activities
         1. See Return to Work in Lumbar Back Pain
         2. Avoid prolonged standing or sitting
         3. Avoid forward flexion at waist (especially while lifting)
         4. Avoid prolonged bed rest (slows recovery)
            1. If absolutely needed, then limit to no more than 2 days
   5. Massage
      1. No affect on pain, functional status or mobility
   6. Physical Therapy
      1. See Low Back Rehabilitation
      2. See Low Back Muscle Fusion Rehabilitation
      3. Consider if no improvement in 2 to 4 weeks
      4. Consider traction or inversion table
   7. Corset
      1. Stabilizes spine but does not immobilize back
      2. May allow patient to continue to work
      3. Reduces Exercise benefit of daily activities
3. Management: Acute Pain Control
   1. NSAIDs
      1. Effective for short-term symptomatic relief
      2. Griffin (2002) Am Fam Physician 65(7):1319-21
   2. Narcotics
      1. Use sparingly for refractory Acute Low Back Pain
      2. Limit to very short course
      3. Patients improve faster without Narcotics
   3. Muscle relaxants
      1. Efficacy studies
         1. Reduces Acute Low Back Pain
         2. Does not impact outcome
      2. Entire class acts centrally and causes Sedation
      3. Greatest benefit may be at night to assist sleep
   4. Epidural Corticosteroid Injection
      1. Indicated for Lumbar Disc Herniation with moderate to severe radiculopathy not improving after 2-3 weeks conservative therapy
      2. Typically directed by MRI, however classic symptoms and signs may direct ESI to best level when imaging is not possible
      3. Discuss significant neurologic deficits with spine surgery prior to epidural steroid injection
   5. Systemic Corticosteroids
      1. No proven benefit over NSAIDs
      2. May reduce radicular pain
      3. Treat for seven day course on fast taper
4. Management: Spinal manipulation
   1. Manipulation may improve Low Back Pain in up to 85% of patients when 2 criteria met
      1. Acute Low Back Pain less than 16 days and
      2. No symptoms distal to the knee
      3. Fritz (2005) BMC Fam Pract 6(1): 29
   2. Effective in acute and chronic Low Back Pain
      1. (2005) Best Pract Res Clin Rheumatol 19(4):639-54
   3. Equivalent efficacy to other conservative measures
      1. Analgesics
      2. Physical therapy
      3. Back school
      4. Assendelft (2003) Ann Intern Med 138:871-81
5. Management: Chronic Pain Control
   1. Acetaminophen (Tylenol) 1000 mg PO qid
   2. NSAIDs
      1. Less effective for long-term pain relief
      2. Risk of Peptic Ulcer Disease and renal injury
   3. Tricyclic or Tetracyclic Antidepressant (e.g. Elavil)
      1. Related to Norepinephrine reuptake inhibition
      2. Reduces back pain symptoms
      3. SSRI medications do not appear to be effective
      4. Staiger (2003) Spine 28:2540-5
   4. Trigger Point Injection
      1. No proven benefit in Low Back Pain
      2. Modalities
         1. Local anesthetic injections
         2. Spray or ice followed by stretch
   5. Behavior Therapy
      1. Improves pain and Disability in chronic Low Back Pain
      2. Modifying attitude toward pain reduces Disability
         1. Normal functioning possible despite back pain
         2. Pain does not cause harm, and activity may hurt
         3. Goal is return to function, not eliminating pain
         4. Dramatically reduces time to return to work
         5. Staal (2004) Ann Intern Med 140:77-84
   6. Avoid measures without benefit
      1. Facet Joint Injections offer no proven benefit
      2. Sacroiliac Joint Injections are rarely indicated
      3. Narcotics should be avoided for chronic back pain
   7. Exercises and Therapy
      1. Perform daily back Exercises
      2. Consider multidisciplinary treatment program
6. Prognosis: Factors associated with Chronic Pain (more factors increase risk)
   1. Affect
      1. Anxiety Disorder
      2. Major Depression
      3. Feeling of Uselessness
   2. Behavior
      1. Adverse coping strategies
      2. Impaired sleep
      3. Passive role
   3. Beliefs
      1. Belief that pain is harmful and must be eliminated
   4. Social
      1. Drug Abuse, physical abuse or sexual abuse
      2. Poor social support
   5. Work
      1. Anticipating that pain will increase with work
      2. Pending litigation
   6. References
      1. Last (2009) Am Fam Physician 79(12):1067-1074.
7. References
   1. Atlas (2001) J Gen Intern Med 16:120-31
   2. Tulder (2002) Am Fam Physician 65(5):925-8