Approach to Low Back Pain
Dr. Jose Paolo Lorenzo, FPCP, FPRA
Low back pain (LBP) is a common occurrence of the adult population. Approximately 65% to 80% experience LBP in their lifetime. It is commonly due to mechanical causes such as myofascial lumbar strain, degenerative disc disease, flares of spondylosis and facet joint disease. The majority of which or 80% resolve within a month with conservative management and on occasion become a recurrent condition. These may be considered LBP of some concern although to a lesser degree whether consultation with a physician is sought or not.
The differential diagnoses of LBP include mechanical, non-mechanical and visceral causes. There are a few clinical situations, both acute and chronic, which need the immediate and continuing management by a physician. These have been termed the “red flags” of LBP. These include malignancy, infection, vertebral fracture and the cauda equina syndrome. Other “red flags” may be from the viscera such as a dissecting aortic aneurysm or from an inflammatory condition such as ankylosing spondylitis.
To make the correct diagnosis, it is of utmost importance to obtain a good clinical history including the location, onset, duration, intensity, predisposing factors and the events that brought about the LBP. Just as important is a thorough physical and neurological examination of the lower back and the lower extremities. The use of laboratory and imaging studies (radiographs, MRI) may aid in the diagnosis of LBP.
Fibromyalgia: Does it affect Filipinos?
Dr. Auxencio Lorenz A. Lucero, Jr., FPCP, FPRA
Fibromyalgia (FM) is a chronic pain condition characterized by an array of symptoms including pain, tenderness, fatigue, unrefreshed sleep and cognitive dysfunction. People with FM have substantial impairments in both physical and mental health status. Etiology and pathogenesis is still unclear but current research is aimed at understanding genetic underpinnings, immunologic aberrations and the role of environmental stressors. Presently, central sensitization is considered to be the main mechanism involved in heightened pain sensitivity. The global prevalence of FM is 2.7 % and it is more common in women over 50 years of age and in subjects with low education level, low socioeconomic status and divorced. In Asia, prevalence of FM is 2.1% with the Philippines having one of the lowest prevalence at 0.5% based on an urban setting survey. Filipinos with FM usually present with low back pain and take at least 9 to 10 months before they seek consult. However, physician barriers do exist and it takes an average of 2 consults and at least 7 months before a correct diagnosis is made.
Since 1990 the diagnosis of FM has evolved to be more representative of a spectrum of disorders. Recently, two new diagnostic criteria, as proposed by Wolfe et al, no longer requires the presence of tender points but rely on the combined widespread pain index (WPI) and symptom severity (SS) scores. However, prevalence of FM varies with the different diagnostic tools. There is a higher prevalence and more men are identified with the newer diagnostic criteria. Diagnosis remains clinical and is not a diagnosis of exclusion. Diagnosis does not promote illness behavior and eventually results in better patient outcomes and lowering of healthcare resource utilization. Optimal management based on current treatment guidelines recommend a multimodal approach involving multiple pharmacologic and non-pharmacologic options. Long-term follow up shows that remission is rare but 20%–55% of patients report improvement over time providing realistic expectation on the course of FM in routine clinical care.
In the Philippines, there is still a significant gap in research in FM. It is important that a new and more nationwide survey be done, which the recent diagnostic tools allow, to provide a better view of the prevalence and burden of FM on our society.
Surgery for the Back: Indications and Options
Dr. Rafael Bundoc , FPCS, FPOA
Degenerative disorders present one of the broadest spectrums of signs and symptoms that present an ailing spine. In general, the most common of these would be low back pain syndrome, tension or radicular leg pains, and the classic progressive claudicant pain. Basically, compression, instability, deformities, or combinations of these that affect one or more functional unit of the spine can bring about these symptoms.
This lecture will present a clear discussion on the evolution and pathology of a degenerating spine. Latter will provide the rationale of how compression, instability, and deformity come about and how it variably generates the symptoms of pain, tension signs and claudication. Taken as a whole it should dispense the logic for our management and set a limit when conservative management fails and has been fully exhausted. The lecture should clearly state the relative and absolute indications of surgery. It will also present the commonly prescribed surgeries for the pathology of compression, instability and deformity and give the audience a glimpse of the current state of the art management of the degenerating spine when conservative management has failed.