Seminars in Pain Medicine最新文献

Low back pain is a symptom affecting millions of adults annually. The etiology of low back pain may be difficult to determine at times because of the number of diverse anatomic structures located in or near the low back region. These structures may be causing direct or referred pain patterns. An accurate diagnosis is essential for both acute and chronic low back pain conditions. The discussion in this article is extensive but not all-inclusive, and the clinician should consult other sources for more detailed description of the less common differential diagnoses.

The physiatric approach to low back pain is functional and interdisciplinary. Physiatry approaches the patient from the physical, psychological, and social perspectives to obtain a thorough understanding of his or her goals and needs. Once the assessment is complete, treatment focuses on reducing pain; restoring ability to participate in activities of daily living, work, and recreation; achieving patient independence with care; and reducing dependence on the health care system. This treatment is achieved through the use of a cognitive-behaviorally based interdisciplinary rehabilitation approach, which combines the use of therapeutic exercise, body mechanics and ergonomics, biofeedback, modalities, medications, and vocational counseling.

Analgesics are important in the management of low back pain, but their role is currently limited by the efficacy of available pharmacological options. Recent progress in pain research has greatly increased understanding of the pathophysiology of pain and the mechanisms of actions of analgesic agents, but the translation of research progress into new clinical treatments has been slow. Nonetheless, currently available agents (nonopioid, opioid, and adjuvant analgesics) have established utility in the management of moderate and severe pain. While awaiting new research developments, clinicians can improve symptom control and patient care in persons with low back pain now by optimizing use of available pharmacologic options.

Proper treatment of low back pain requires a good understanding of anatomical structures of the lumbar spine, paraspinal muscles, and neurological structures. Clinical judgment, examination, and a detailed history of the initial causative event and progression of the low back pain can help determine the possible pain generator in many cases. There are several other modalities that may further enhance the accuracy of the diagnosis. Although radiological examinations have been known to specifically diagnose most of the structural abnormalities of the lumbar spine, there are some conditions that may require other types of diagnostic interventions, such as facet, selective nerve root, disc, and epidural/spinal injections, and even spinal endoscopy (epiduroscopy). This article will attempt to outline and describe most of these modalities to help a practicing physician identify the most likely pain generator in the lower back and determine the most effective treatment plan to achieve the intended goal.

The dysfunction of the lumbar spine has a pivotal role in etiology of low back pain. A thorough knowledge of the functional anatomy of the lumbar spine is needed to aid in understanding the mechanisms that lead to low back pain and to provide rationale of management. This article reviews functional anatomy of the lumbar spine involving the bony structures, articulation, ligaments, muscles, blood supply, and neural structures.

The use of interventional techniques to treat spine-related pain syndromes is becoming more common in the United States and abroad. This growth is related to several factors, including improved patient awareness, education of referring physicians, improved training of interventional pain specialists, and advances in equipment and technology. The spectrum of interventional techniques ranges from simple trigger-point injections to implantation of sophisticated devices to modulate the nervous system. The challenges of treating these patients involve the need to make a diagnosis, the choice of an appropriate technique, and the performance of that technique in an acceptable manner. The pain specialist should also be able to recognize the complications of these techniques and make good decisions in responding to adverse outcomes. Several chapters would be required to comprehensively cover interventional techniques for the treatment of pain of spinal origin. It is the objective of this article to cover the most commonly performed procedures in regard to the patient selection, procedure selection, techniques, and complication management.

This work reviews the evidence for the efficacy of cognitive behavioral and behavioral interventions for chronic low back pain. Several meta-analyses of randomized control studies indicate that behavioral and cognitive behavioral approaches are effective in the treatment of chronic low back pain. Furthermore, there is evidence that patients who receive both medical and psychological treatment not only improved their functional capacity but also spend fewer health care dollars after their treatment has ended. Patients who received medical treatment alone not only got worse but spent more money after post treatment.

Myofascial pain syndrome (MPS) is a musculoskeletal pain disorder with a high prevalence in low back pain complaints. However, because of its complex and confusing nature, MPS is commonly misdiagnosed and overlooked by clinicians who are unfamiliar with this pain syndrome. However, with proper knowledge, MPS can be identified and effectively treated. This article discusses the current diagnostic and treatment modalities regarding MPS in the low back.