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The evaluation and management of low back pain

The evaluation and management of low back pain. Asgar Ali Kalla Professor and Head Division of Rheumatology University of Cape Town. Some helpful statistics. Backpain affects two thirds of adults Second to URTI in frequency Affects men and woman equally

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The evaluation and management of low back pain

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  1. The evaluation and management of low back pain • Asgar Ali Kalla • Professor and Head • Division of Rheumatology • University of Cape Town

  2. Some helpful statistics • Backpain affects two thirds of adults • Second to URTI in frequency • Affects men and woman equally • Most common between 30 and 50 years • Expensive cause of work related disability • Uncertainty about optimal approach

  3. 90% of low back pain is mechanical • Musculoligamentous injuries • Age-related degeneration in the intervertebral discs and facet joints • Spinal stenosis • Disc herniation • Osteoporotic compression fractures • Spondylolysis and spondylolisthesis

  4. Natural history • Spontaneous improvement is the rule • 50% better at 1 week • > 90% better at 8 weeks • 7-10% persist beyond 6 months

  5. Medical causes • Uncommon but important not to miss them • Spondylarthropathy • Spinal infection • Osteoporosis • Malignancy • Referred visceral pain • pelvis, renal, aortic aneurysm, pancreatitis

  6. Clinical evaluation • Precise anatomical diagnosis often elusive • Is a systemic disease causing the pain? • Is there neurological compromise that may require surgical evaluation? • Is there social or psychological distress that may amplify or prolong pain?

  7. serious medical serious neurology systemic symptoms BACK PAIN conservative management

  8. Management: Watchful waiting • Patient education • Spontaneous recovery is the rule • Those who remain active despite pain have less future chronic pain • Exercise has prevention power • Rest: 2 days or less • Analgesics to permit activity • Reassess if pain worsens or neurological symptoms develop

  9. Why not get imaging studies? • Imaging can be misleading: many abnormalities as common in pain-free individuals as in those with back pain • If under age 60 • low yield: unexpected Xray findings 1: 2500 • bulging disc in 1 of 3 • herniated disc in 1 of 5

  10. Over age 60 and pain-free • herniated disc in 1 of 3 • bulging disc in 80% • all have age-related disc and apophyseal joint degeneration • spinal stenosis in 1 of 5 cases

  11. BACK PAIN conservative management PERSISTENT PAIN DEVELOPING NEUROLOGY red flags imaging lab tests

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