Low back pain and the lumbar intervertebral disk: Clinical considerations for the doctor of chiropractic

Background: Low back pain exists in epidemic proportions in the United Stat es. Studies that demonstrate innervation to the intervertebral dial; provid e evidence that may account for instances of discogenic low back pain encou ntered in general medical and chiropractic practice. Many patients and heal th care practitioners believe that intervertebral disk lesions require surg ery as the only method of treatment that will result in satisfactory outcom e. Surgery rates vary widely across geographic regions. Only one randomized prospective study exists that compares surgical and nonsurgical treatment; it demonstrated essentially equal outcomes in the long run. Objective: To review specific aspects of the examination, history, imaging, and treatment of patients with suspected intervertebral disk lesions and t o provide guidelines for conservative management, imaging, and relative and absolute indications for surgical referral. Data Sources: Review articles, texts, and original articles from indexed re fereed sources that discuss the lumbar intervertebral disk in regard to pat ient history, physical examination, imaging, treatment, and referral for su rgery. Results: Patients with low back pain who do not present with so-called red flags (fever, history of cancer, unexplained weight loss, urinary tract inf ection, intravenous drug use, saddle anesthesia, or prolonged use of cortic osteroids) may be treated initially with conservative methods. Imaging stud ies are helpful in determining the patient's diagnosis, and comput ed tomog raphy, magnetic resonance imaging, or other special imaging studies should be ordered judiciously. The only prospective, randomized study of conservat ive versus surgical management of herniated lumbar intervertebral disk lesi ons indicates both methods provide adequate outcome in the long run. Little consensus exists on the best method of management of herniated lumbar inte rvertebral disk lesions without absolute indications for surgery. Conclusion: Patients should be screened for "red flags" to determine whethe r they are candidates fur conservative treatment. Magnetic resonance imagin g is perhaps the most practical imaging study for evaluation of lumbar disk lesions because it involves no use of ionizing radiation and because magne tic resonance imaging has other advantages over computed tomographic scanni ng such as excellent delineation of soft tissue structures, direct multipla nar imaging, and excellent characterization of medullary bone. Provocation computed tomography-diskography is an invasive procedure and should be rese rved for patients with normal magnetic resonance imaging findings and conti nuing severe pain who have not been helped by conservative treatment attemp ts and fur whom surgical intervention is contemplated. Both conservative an d surgical interventions have been shown to be effective in the treatment o f discogenic and radicular pain syndromes.