“Patient did not sleep due to low back pain. Gave fomentation to herniated disc with immediate relief”
Prognosis
Depends on the cause but it must be realized that in most cases of low back ache in general practice there is no specific cause. Most patients recover in 1-4 weeks on conservative therapy. In nonspecific low-back pain, 90%, recover within 3 days to 2 weeks. Bed rest is not recommended for any length of time and a rapid return to normal activities is the best course in low back pain or sciatica. Back exercises are not useful during the acute phase, but help to prevent recurrences and treat chronic pain. Surgery is required for a small number and is most successful for those with sciatica or pseudo-claudication after nonsurgical therapy has been tried.
Treatment
In Acute Pain
Complete Bed Rest. Inj. Voveron 2 cc IM x alternate days x 3 (NSAID). Tab. Voveron 50 1 tds x after food x 7 (Any NSAID e.g Brufen, Arflur, Zolandin, INDOCAP, MEFTAL, DOLONEX, TOBITIL, NIMULID, Zolandin, Sugarnil etc.) Tab. WYSOLONE 5 mg x tds x 5 (Short course steroid). Gelusil MPS 2 tsp tds (Antacid. Acid inhibitor) or Cap. OMEZ 10 mg OD. S.W.D. (Diathermy) for Lumbar spine x 5-10 days. Tab. ALPRAZOLAM 0.25 mg. bd in acute phase.
Once the acute pain subsides.
Tab. Voveron-SR 1 daily x after food. (Maintenance dose of NSAID to 12 e.g. Froben SR, INDOCAP SR, Pirox TOBITIL etc). Tab. Ostocalcium 2 bd x 30. Cap. Autrin 1 OD x 30. Back Exercises: to increase back muscle tone.
Leg raising in dorsal recumbent positions x 10 – 20 times/ day. Push ups. Swimming.
General Instructions: Maintain straight back posture while standing or sitting. Avoid bending forwards and lifting weights. Sleep on hard mattress. Gentle massage with Rubefacient ointments. Use Lumbosacral belt to support the spine and prevent bending.
What investigations to ask for?
Hb% X-ray LS spine- AP and Lateral (for Osteoarthritis, disc prolapse, TB spine, osteoporosis etc.) In females, Refer to Gynaecologist of X-ray is normal to rule out gynaec causes.
When to refer to a Orthopedic surgeon?
If no relief with routine treatment. If pain is very severe or S.L.R test is Positive. If there is any Neurological deficiency in legs, earliest being weakness of dorsiflexion of great toe.
Lack of Exercise and Bad posture cause mot of the backaches in young patient as seen in general practice.
SLR test and EHL weakness must be tested in every case of Backache.
All patients on NSAID’s should be instructed specially to take the drugs after food, and to stop the drug immediately if it causes epigastric burning.
If there is shooting in pain along one leg, these patients will require Pelvic Traction, Epidural injections, Myelography or surgery.
Patient with Low Backache.
Did it start suddenly while lifting weight or bending? N Doctor. Does it radiate along the legs? Yes it goes down the right leg. Is it more in the morning on getting up? Yes.
First inspect the back and the spine. Ask the patient to show the exact site of pain. Look for prominence of spine, and for tenderness by firm palpation for tenderness by firm palpation and gentle hitting.
S.L.R Test: Ask the patient to lie down and lift each leg straight to 90 degrees. Pain at the back (Lumbar spine) similar to the patient’s pain is a positive SLR test.
Test EHL: Ask the patient to dorsiflex the great toe against resistance. Weakness of dorsiflexion is the earliest sign of neurological deficit in compressive lesions of spine.
If pain is sever or chronic, Test deep tendon reflexes, Brisk or exaggerated reflexes indicate pressure on spinal cord. Test the Plantar reflex.
This should be your reflex to ask the following questions before prescribing NSAID’s./ Ask H/o Epigastric burning/ Acidity/ peptic ulcer in the past. Ask H/o Bronchial Asthma. (If yes, sensitivity to NSAID’s) Check blood pressure. (If steroid is given.)
Key points for Backache: Osteoarthritic or Disc prolapse? Local tenderness, SLR test, EHL, weakness wasting.
Action: SWD, Lumbar belt, Bed rest till acute pain subsides. NSAID, calcium,
If no relief, Refer to Orthopedic surgeon, X-ray of the Lumbo-sacral spine, and SOS Myelography or MRI. If there are neurological signs, refer immediately.
2-3 days bed rest at most, but permitting minimal ambulation. Local heat, Ultra short wave diathermy, Interferential massage, back manipulation by Osteopaths, Acupuncture has given good results in some cases. Ergonomic adjustments at the work place may facilitate return to work and prevent recurrences.
Advice to Patient
Protecting the back during daily activities-Not to lift very heavy weights, to use the legs rather than the back when lifting, sleep on a firm mattress, sitting on tall chairs instead of slouching in low sofas, use chair with arm rest, getting off the bed after turning to a side, supportive pillow behind the back on long travels etc;
Follow Up
After 4 weeks by which time the majority have recovered. If pain persists, re-examine and investigate.
Inadequate Response
Patient not taking even minimal rest, or stopping mediation due to side effects, or continued stress to back due to occupation. Re-examine for any missed cause.
