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NO.2 Low back pain(2)

 I found a good article about the low back pain. Its journal is New England Journal of Medicine that is mostly reliable in the world.
Article  :  Primary care     Low back pain
Author  :  Richard A. Deyo and James N. Weinstein
Journal  :  N Engl J Med (344) 363-370 2001

 Differential Diagnosis of low back pain
Mechanical low back or leg pain (97%)
Lumbar strain, sprain (70%)   <idiopathic low back pain>
Degenerative processes of discs and facets, usually age-related (10%)
  Herniated disc (4%)
  Spinal stenosis (3%)
  Osteoporotic compression fracture (4%)
        Spondylolisthesis (2%)
        Traumatic fracture (<1%)
        Congenital disease (<1%)
        Severe kyphosis       Severe scoliosis            Transitional vertebrae
        Internal disk disruption or diskogenic low back pain
  Presumed instability

  Nonmechanical spinal conditions (about 1%)
        Neoplasma (0.7%)
Multiple myeloma      Metastatic carcinoma       Lymphoma and leukemia
            Spinal cord tumors     Retroperitoneal tumors     Primary vertebral tumors
        Infection (0.01%)
           Osteomyelitis          Septic diskitis              Paraspinous abscess
            Epidural abscess       Shingles
       Inflammatory arthritis (often associated with HLA-B27) (0.3%)
          Ankylosing spondylitis   Psoriatic spondylitis        Reiter`s syndrome
           Inflammatory bowel disease
       Scheuermann`s disease
       Paget`s disease of bone

 Visceral disease (2%)
       Disease of pelvic organs
          Prostatis                Endmetriosis            Chronic pelvic inflammatory diseases
       Renal disease
          Nephrolitiasis           Pyelonephritis            Perinephric abscess
       Aortic aneurysm
       Gastrointestinal disease
          Pancreatitis             Cholecystis               Penetrating ulcer
Representative results of magnetic resonance imaging studies in ASYMPTOMATIC adults                  
                        Herniated disk   bulging disk    DD     stenosis
   Boden   <60yr            22             54          46          1
               ≧60yr            36             79          93         21
Jensen   mean 42yr        28              52         NR         7
Weishaupt mean 35       40              24          72         NR
Stadnik  mean 42           33              81          72         NR

                                                DD=degenerative disk
Herniated intervertebral disks
    Diskectomy produced better pain relief than nonsurgical treatment over a period of 4
years, but it is unclear whether there is any advantage after 10 years.
Sequential MRI studies reveal that the herniated portion of the disk tends to regress with time, with partial or complete resolution in two thirds of cases after six months

Spinal stenosis
Spinal stenosis usually remains stable or gradually worsens. 
15% improve over a period of four years, 70% remain stable, 15% have deterioration 

  For persistent severe pain, decompressive laminectomy is an option. Even with successful surgery, symptoms often recur after several years. At four years of postoperative follow-up, about 30% of patients have severe pain and about 10% have undergone reoperation.

Nonspecific low back pain
Conventional traction, facet-joint injections, and transcutaneous electrical stimulation appear ineffective or minimally effective in randomized trials.

Conclusion : For patients with nonspecific low back pain, a precise pathological diagnosis is often impossible. The role of imaging in other situations is limited because of the poor association between symptoms and anatomical findings.

To sum up, patients with low back pain should be recommended the conservative therapies ; physical therapy, and analgesics. We convince that the arthrokinematic approach-Hakata method is only treatable technique for low back pain.   

















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