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

3. 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

4. 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

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

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

8. 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?

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

10. 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

11. 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

12. 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

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