Chronic Low Back Pain

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Definitions

IASP Definitions

Main article: Low Back Pain Definitions

Topography

Starting with the wrong definition of low back pain can lead to the wrong diagnosis, and so it is important to be clear here. The IASP taxonomy categorises low back pain into lumbar spinal pain and sacral spinal pain. There is also an overlapping definition called lumbosacral pain. These three categories constitute the colloquial term "low back pain."

Lumbar spinal pain is pain in a region bounded superiorly by an imaginary transverse line through the tip T12, inferiorly by an imaginary transverse line through the tip of S1, and laterally by vertical lines tangential to the lateral borders of the lumbar erectores spinae.

Sacral Spinal Pain is pain in a region bounded superiorly by an imaginary transverse line through the tip of S1, inferiorly by an imaginary transverse line through the posterior sacrococcygeal joints, and laterally by imaginary lines passing through the posterior superior and posterior inferior iliac spines."

Lumbosacral Pain is pain perceived as arising from a region encompassing or centred over the lower third of the lumbar region as described above and the upper third of the sacral region as described above.

Acuity

Chronic pain is pain present for longer than 3 months (91 days). One pragmatic approach is to include in the definition of chronic those patients with acute low back pain who are not improving when it may not be sensible to wait until the 91 day mark, say at two months. However if they have had pain for more than two months and not had evidence based management for acute low back pain then they should have that first. Indeed, following the acute approach may still be appropriate for some patients who have had pain for longer than 3 months.

Referred Pain

Main article: Low_Back_Pain_Definitions#Referred_Pain

Referred pain is "pain perceived as arising or occurring in a region of the body innervated by nerves or branches of nerves other than those that innervate the actual source of pain"

Visceral referred pain is referred pain where the source lies in an organ or blood vessel of the body. With low back pain, the uterus and abdominal aorta are important considerations. Other viscera with higher segmental supply may cause back pain such as pancreatitis, but this may be due to irritation of the posterior abdominal wall, in which case the pain is not truly referred in nature.

Somatic referred pain is referred pain where the source originates in a tissue or structure of the body wall or limbs. A number of structures in the lumbar spine are capable of nociception including the lumbar zygapophysial joints, intervertebral discs, sacroiliac joints, and more.

Radicular pain is a subset of neuropathic pain, and refers to pain that is evoked with stimulation of the nerve roots or dorsal root ganglion of a spinal nerve. In radicular pain, the pain is felt in the peripheral innervation of the affected nerve.

Aetiology (Causes and Sources)

Main article: Causes and Sources of Chronic Low Back Pain

Management

Laerum et al outlined what a "Good Back Consultation" entails, based on three interdisciplinary Norwedgian RCTs for chronic low back pain.

• Take them seriously
• Examination: explanation during the exam (what was being done and what was found)
• Education: Providing an understandable explanation for the pain given with conviction (exact medical diagnosis is not essential) and addressing misconceptions. He uses a disc injury explanation.
• Reassurance: given with conviction, address fears but cognitive reassurance is preferred over emotional which can create dependency.
• Psychosocial discussion: deal with possible correlation (in both directions) between daily life, job, family, coping, quality of life aspects, role function and the LBP
• Treatment: Encourage normal activity and avoiding rest. Empower the patient to take responsibility for their own rehabilitation.