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Consensus on the Assessment and Management of Chronic Nonspecific Low Back Pain

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Consensus on the Assessment and Management of Chronic Nonspecific Low Back Pain Hindawi Pain Research and Management Volume 2019, Article ID 8957847, 14 pages https://doi.org/10.1155/2019/8957847 Review Article The Chinese Association for the Study of Pain (CASP): Consensus on the Assessment and Management of Chronic Nonspecific Low Back Pain Ke Ma ,1 Zhi-Gang Zhuang,2 Lin Wang,3 Xian-Guo Liu,4 Li-Juan Lu ,5 Xiao-Qiu Yang,6 Yan Lu ,7 Zhi-Jian Fu ,8 Tao Song,9 Dong Huang,10 Hui Liu,11 You-Qing Huang,12 Bao-Gan Peng ,13 and Yan-Qing Liu 14 1Department of Algology, Xinhua Hospital, Shanghai Jiaotong University School of Medicine, Shanghai, China 2Department of Algology, "e Second Affiliated Hospital of Zhengzhou University, Zhengzhou, Henan, China 3Department of Algology, Affiliated Hospital of Guizhou Medical University, Guiyang, Guizhou, China 4Pain Research Center, Department of Physiology, Zhongshan School of Medicine, Sun Yat-Sen University, Guangzhou, China 5Department of Algology Medicine, Nanjing Drum Tower Hospital, "e Affiliated Hospital of Nanjing University Medical School, Nanjing, China 6Department of Algology, "e First Affiliated Hospital of Chongqing Medical University, Chongqing, China 7Department of Algology, Xijing Hospital, Fourth Military Medical University, Xian, China 8Department of Algology, Shandong Provincial Hospital Affiliated to Shandong University, Jinan, Shandong, China 9Department of Algology, "e First Affiliated Hospital of China Medical University, Shenyang, China 10Department of Algology, "e "ird Xiangya Hospital, Central South University, Changsha, China 11Department of Algology, West China Hospital of Sichuan University, Chengdu, China 12Department of Algology, "e Second Affiliated Hospital of Kunming Medical University, Kunming, Yunnan, China 13Department of Spinal Surgery, General Hospital of Armed Police Force, Beijing, China 14Department of Algology, Beijing Tian Tan Hospital, Capital Medical University, Beijing, China Correspondence should be addressed to Ke Ma; [email protected], Bao-Gan Peng; [email protected], and Yan-Qing Liu; [email protected] Received 14 November 2018; Revised 6 June 2019; Accepted 11 July 2019; Published 15 August 2019 Academic Editor: Jacob Ablin Copyright © 2019 Ke Ma et al. 4is is an open access article distributed under the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. Chronic nonspecific low back pain (CNLBP) is defined as pain or discomfort originating from the waist, which lasts for at least 12 weeks, but no radiculopathy or specific spinal diseases. CNLBP is a complicated medical problem and places a huge burden on healthcare systems. Clinical manifestation of CNLBP includes discogenic LBP, zygapophyseal joint pain, sacroiliac joint pain, and lumbar muscle strain. Further evaluation should be completed to confirm the diagnosis including auxiliary examination, functional assessment, and clinical assessment. 4e principle of the management is to relieve pain, restore function, and avoid recurrence. Treatment includes conservative treatment, minimally invasive treatment, and rehabilitation. Pharmacologic therapy is the first-line treatment of nonspecific LBP, and it is most widely used in clinical practice. Interventional therapy should be considered only after failure of medication and physical therapy. Multidisciplinary rehabilitation can improve physical function and alleviate short-term and long-term pain. 4e emphasis should be put on the prevention of NLBP and reducing relevant risk factors. 2 Pain Research and Management 1. Overview 2.4. Sacroiliac Joint Pain. Sacroiliac joint pain is defined as pain originating from the region of the sacroiliac joint, Low back pain (LBP), defined as pain or discomfort in the exacerbated by stress and provocation tests, and relieved by area between the lower ribs and the gluteal folds, is a sacroiliac joint injections with local anesthetic [10]. common and potentially debilitating condition with or without leg pain. Chronic low back pain (CLBP) refers to low back pain lasting for more than 12 weeks. Patients with LBP 2.5. Soft Tissue-Derived LBP. Soft tissues such as ligaments can be placed into one of three categories, i.e., nonspecific and muscles around the lumbar spine play an important role low back pain, low back pain associated with radiculopathy in maintaining the position of the body, as well as enhancing or spinal stenosis, and low back pain associated with specific the stability, balance, and flexibility of the spine. Diseases of spinal disease [1]. Chronic nonspecific LBP (CNLBP) is the soft tissues such as ligaments, fascia, and muscles can defined as pain and discomfort lasting for at least 12 weeks, produce pain, which is called muscle pain clinically. but no radiculopathy, specific spinal disease, or nerve root pain. 4e current practice of diagnosis and treatment of LBP 2.6. Epidemiology of CNLBP. CNLBP is a serious medical is often empirical, but not based on scientific methodology. and social problem, which often leads to the loss of labor It is time for our experts to convene, discuss, and formulate force. Although many of the studies in the literature have consensus for the diagnosis and treatment of CNLBP in focused on the incidence and prevalence of CNLBP, there is China. It is also necessary to refer to existing evidence on the a lack of accurate data on the incidence of the disease be- topic and international consensus for the diagnosis and cause the consensus on its definition has not been estab- treatment of LBP. 4e knowledge in this field has been lished so far [11]. In 2012, a systematic survey of the global combined with the conclusions drawn from some good adult population showed that the point prevalence, 1-month clinical studies carried out in China. We believe that the prevalence, 1-year prevalence, and lifelong prevalence of consensus will be of great significance for pain management CNLBP were 12%, 23%, 38%, and 40%, respectively [12–18]. in China and will be of great reference value for other In China, CNLBP is the most common disease in De- national pain experts in the world. partments of Orthopedics, Rehabilitation Medicine and Pain Medicine, accounting for 1/3 of daily outpatient visits, 2. Etiology and Epidemiology of CNLBP second only to upper respiratory tract infections. At present, the medical cost for CNLBP is greater than that of coronary 2.1. Common Causes of CLBP. Based on etiology, CLBP is heart disease, diabetes, arthritis, and cerebrovascular disease often classified into two categories: specific and nonspecific [19, 20]. CNLBP is no longer a simple medical problem, and CLBP. Specific CLBP has obvious causes such as infection, it can cause complicated psychological problem and serious tumor, fracture, or inflammatory disease. However, 80%– social medical economic burden on patients [21–24]. 90% of CLBP is nonspecific, intractable, and difficult to cure [1–4]. It is a great challenge to clarify the specific causes of CLBP. With the development of technologies and diagnostic 3. Pathogenesis of CNLBP tests (local anesthetic injection or discography), etiologic A large number of basic and clinical studies have shown that factors can be identified in 90% of patients with CLBP [5]. A CNLBP presents not only nociceptive pain, but also neu- study by DePalma et al. [5] on patients with nonspecific ropathic pain, usually accompanied by central and pe- CLBP showed that prevalence of zygapophyseal joint pain, ripheral sensitization [25, 26]. sacroiliac joint pain, and discogenic pain was 31%, 18%, and 42%, respectively. 3.1. Discogenic LBP. 4e painful disc is characterized his- 2.2.DiscogenicLBP. Discogenic LBP is not caused by lumbar tologically by formation of a zone of vascularized granu- intervertebral disc herniation. It is defined as pain caused by lation tissue in the posterior part of the disc, with infiltration changes in the internal structure of lumbar discs, despite of macrophages and mast cells [27]. Macrophages are not intervertebral discs of normal morphology. 4e pathologic only the main phagocytic cells in the inflammation but also feature is the formation of zones of vascularized granulation secrete a large number of growth factors and cytokines. 4e tissue with extensive innervation in fissures extending from aggregation of mast cells in the painful disc may be closely the outer part of the annulus to the nucleus pulposus [6]. related to the formation of new blood vessels in the disc and Peng [7] divided discogenic LBP into two types based on the fibrosis of the disc tissue [7]. Meanwhile, discogenic LBP discography findings: internal annular disruption (IAD) and has also the characteristic of visceral pain [6, 28]. At present, internal endplate disruption (IED). the main pathological features of discogenic LBP are the annulus fibrosus tearing, vascularized granulation tissue gradually growing from the outer part of the annulus into 2.3. Zygapophyseal Joint Pain. Zygapophyseal joint pain is the nucleus pulposus and the degenerative annulus fibrosus, identified as pain arising from any structures of the lumbar and nucleus pulposus releasing inflammatory mediators. facet joints, including bony articulations, hyaline cartilage 4ese inflammatory mediators sensitize nociceptors, which surfaces, the synovial membranes, and the fibrous capsules causes LBP [27]. Internal endplate disruption is a form of [8, 9]. discogenic LBP. Endplate injury can be subdivided into two Pain Research and Management 3 types: formation of Schmorl’s nodules and endplate de- 4.2. Zygapophyseal Joint Pain.
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