In the authors’ clinical experience, chronic low back pain, discussed below, has been less successfully treated by manipulative procedures, but there are some patients who testify to improvement in their clinical state and admittedly the medical profession has little to offer in most cases and the rate of spontaneous improvement is high. The results for acute and chronic back pain with another popular approach, acupuncture, have been even less beneficial, most studies showing it to be no more effective than sham needle treatment (Tudler et al).
Chronic and recurrent low back syndrome Often the symptoms of low back strain are recurrent and more chronic in nature, being regularly exacerbated by bending or lifting, suggesting that postural, muscular, and arthritic factors play a role. This is the most common syndrome seen in spine clinics, more often in men than in women.
Insidiously, or after some unusual activity, raising the question of trauma, especially if it happens in the work-place, the patient develops aching pain in the low back, increased by certain movements and attended by stiffness. The pain may additionally have a restricted radiation into the buttocks and posterior thigh, thereby simulating root compression. There are no motor, sensory, or reflex abnormalities. Imaging usually reveals some combination of osteoarthropathy, changes in vertebral discs, osteoarthritic changes in apophyseal joints, and sometimes osteoporosis or slight spondylosis, or they may be entirely normal. Treatment with short-duration bed rest, analgesics, and physiotherapy, as outlined for acute strains, helps to relieve the symptoms, and the majority of patients recover within a few weeks, only to have a recurrence of similar pains in the future.
Recurrent attacks are typical of degenerative spine disease that affects the vertebrae and facet joints. Chiropractic manipulation has the same uncertain effect as for acute low back symptoms. Usually the origin of the pain cannot be assigned with certainty to spinal, joint, or muscular injury, but direct percussion tenderness of one vertebral segment always raises concern of metastatic disease as noted above. Quite often, changing the firmness of the mattress (in either direction) is helpful. Compensation relating to injuries at work or to an accident and related legal matters often prolong and intensify the reported disability, but there are, of course, many legitimate injuries that occur in these circumstances.
Vertebral fractures Fractures of lumbar vertebral bodies are usually the result of flexion injuries. Such trauma may occur in a fall or jump from a height (if the patient lands on his feet, the calcanei may also be fractured) or as a result of an auto accident or other violent impact. If the injury is severe, it may cause a fracture dislocation, a “burst” fracture of one or more vertebral bodies, or an asymmetrical fracture of a pedicle, lamina, or spinous process; most often, however, there is asymmetrical loss of height of a vertebral body (compression fracture), which may be extremely painful at the onset. When compression or other fractures occur with minimal trauma (or spontaneously), the bone has presumably been weakened by some pathologic process. Most of the time, particularly in older individuals, osteoporosis is the cause of such an event, but there are many other causes, including osteomalacia, hyperparathyroidism, prolonged use of corticosteroids, myeloma, metastatic carcinoma, and a number of other conditions that are destructive of bone. Spasm of the lower lumbar muscles, limitation of all movements of the lumbar section of the spine, and the radiographic appearance of the damaged lumbar portion (with or without neurologic abnormalities) are the basis of clinical diagnosis. The pain is usually immediate, although occasionally it may be delayed for hours or exceptionally, days after injury.