Dr. Evans of Baylor College of Medicine received honorariums from Allergan, Amgen, Avanir, DepoMed, Lilly, and Novartis for speaking engagements and honorariums from Alder and Promius for advisory board membership.)
This article includes discussion of back pain, dolor en la espalda, dorsalgia, dorsodynia, lumbago, lumbalgia, and spondylalgia. The foregoing terms may include synonyms, similar disorders, variations in usage, and abbreviations.
Back pain remains an evolving and controversial topic in modern medicine and a multidisciplinary field that involves specialists in neurology, neurosurgery, orthopedic surgery, rheumatology, physiatry, and occupational medicine. In this article, the author discusses the literature concerning surgery versus nonoperative care for discogenic back pain. In this update, the author discusses the socio-economic impact of failed back syndrome.
• Lumbar pain is multifactorial and entails great societal costs.
• Conservative care including anti-inflammatory therapy and physical therapy should be the first treatment unless trauma, infection, or tumor is suspected.
• Surgical approaches to back pain are controversial unless overt instability is apparent.
Historical note and terminology
Spinal disease was first diagnosed in The Edwin Smith Surgical Papyrus, which dates from the seventeenth century BC. The papyrus refers to lumbar fractures and the pain associated with them (Breasted 1930). Back pain, or low back pain, remains a common complaint of many patients. The annual incidence of back pain is estimated at 15% to 20% along with a prevalence of up to 60% (Atlas and Deyo 2001). Pain is complex, with symptoms being variable and nondescript. Back pain is currently the fifth most common cause of patient visits, associated with costs approximating 38 to 50 billion dollars a year (Atlas and Deyo 2001). Within the group of patients with back pain, 1% have been diagnosed with nerve root symptoms, and it has been found that the vast majority of patients with back pain will find resolution of this pain without any treatment (Greenberg 2000). A patient's symptoms may flare up periodically, becoming intolerable at times, causing the patient to seek treatment (de Vet et al 2002). Patients usually present to their primary care physician but are commonly referred to see a neurologist, neurosurgeon, or orthopedic surgeon. When back pain persists, and if neurologic symptoms develop, the physician must delve into the cause and begin a thorough diagnostic workup. Persistent low back pain should never be ignored, as it may be the first sign of a serious underlying process, ie, cancer.
In early years, pain was treated differently, and the management of acute pain is a newer concept (Gildenberg 1997). In fact, back pain may not originate from the spine but may be referred from hips or abdominal viscera. These characteristics of back pain may make the true diagnosis and treatment difficult at times.
When discussing back pain, specific terms need to be defined to help understand the etiology, diagnosis, and treatment. First, back pain may be mechanical or simply stated as musculoskeletal pain. A patient might have radiculopathy, which refers to pain in the distribution of a nerve root with associated weakness and loss of reflexes. In some cases, a patient may state that they have “sciatica,” which to the physician often refers to radiculopathy. Myelopathy refers to compression of the spinal cord; these patients often have upper motor neuron signs like spasticity and hyperreflexia. Myelopathy will clue the physician in to a cervical or thoracic lesion because the spinal cord ends at L1/2; these patients may still present with back pain. A combination of mechanical back pain with radicular and myelopathic symptoms is not uncommon. Spondylosis is a generic term for stenosis secondary to bony and ligamentous hypertrophy. Spondylolisthesis refers to anterior subluxation of 1 vertebral body on another. Finally, spondylolysis is failure of the pars interarticularis to form, resulting in a spondylolisthesis, classically at L5/S1 level.
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