Mr S, a 50-year-old man, has long-standing low back pain. His pain began more than 20 years earlier with a lumbar disk herniation and has persisted despite diskectomy. He has undergone numerous treatments, but he remains disabled with ongoing pain. His treatment course is used to frame the epidemiology and pathophysiology underlying acute and chronic lumbosacral and radicular pain. The roles of neuropathic pain medications, chronic opioid therapy, physical therapy, spinal manipulation, and multidisciplinary pain treatment programs are reviewed. The indications for and outcomes associated with interventional pain treatments, including epidural steroid injection, facet blocks and radiofrequency treatment for facet-related pain, intradiskal electrothermal therapy, spinal cord stimulation, and intrathecal drug delivery, are discussed. Clinicians are given an evidence-based approach to using available treatment options for low back pain.
A, Sagittal T2-weighted image near midline demonstrating advanced degenerative disk disease at the L3-4, L4-5, and L5-S1 levels. Note presence of a Schmorl node (black arrowhead). White lines indicate levels of axial images. B, Axial T2-weighted image at the L3-4 level demonstrating degenerative disk changes and a diffuse disk bulge (yellow arrowheads) resulting in mild stenosis of the central spinal canal. C, Axial T2-weighted image at the L4-5 level demonstrating degenerative disk changes and right-sided postoperative changes with indentation of the thecal sac (white arrowhead). D, Axial T2-weighted image at the L5-S1 level demonstrating degenerative disk changes and prior right hemilaminotomy (blue arrowhead). Overall, there were no significant changes in this MRI study compared with an earlier study performed in September 2003.
A, “Low back pain” is more precisely termed lumbosacral spinal pain, which encompasses both lumbar spinal pain (L) and sacral spinal pain (S). Lumbosacral spinal pain is pain in either or both regions and constitutes “low back pain.” B, Radicular pain is caused by stimulation of a spinal nerve and describes pain that is referred to the lower extremity along the corresponding dermatome.
The basic unit of the spine, the functional spinal unit, is composed of 2 adjacent vertebral bodies with 2 posterior facet joints, an intervertebral disk, and surrounding ligamentous
structures. See online interactive supplement.
Patterns of pain associated with specific degenerative changes are shown in red. A, Early degenerative changes of the functional spinal unit include loss of hydration of the nucleus pulposus accompanied by mild loss of height of the intervertebral disk. Internal disk disruption (left) begins with radial and/or concentric fissures that extend from the periphery of the nucleus pulposus into the annulus fibrosus. Extension of these fissures or of material from the nucleus pulposus to the peripheral portion of the annulus fibrosis can produce lumbosacral pain mediated by the sinuvertebral nerve. Extension of material from the nucleous pulposus posterolaterally outside the annulus fibrosis (herniated nucleus pulposus, right) can produce an intense inflammatory reaction surrounding the spinal nerve leading to radicular pain. B, Advanced degenerative changes include complete loss of hydration of the nucleus pulposus, marked loss of height of the intervertebral disk, osteophyte formation, and thickening of ligaments. Central canal stenosis results from the combined effects of facet hypertrophy and thickening of the ligamentum flavum and posterior longitudinal ligaments. These degenerative changes can produce neurogenic claudication. Progressive degeneration of the disk or facets can produce chronic lumbosacral pain. Facet hypertrophy can produce stenosis of the lateral recess of the spinal canal and the intervertebral foramen, which may result in radicular pain.
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Anatomy of the L4-L5 Functional Spinal Unit and Associated Neural Structures
Anatomy of the L4-L5 Functional Spinal Unit and Associated Neural Structures (enhanced interactive)
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The Rational Clinical Examination
Make the Diagnosis: Will This Patient Develop Disabling Back Pain?
The Rational Clinical Examination
Original Article: Will This Patient Develop Persistent Disabling Low Back Pain?
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