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injuries the examiner must be careful to avoid further damage All movements must be kept to a minimum until an approximate diagnosis has been made and adequate measures have been instituted for the proper care of the patient If the patient complains of pain in the back and cannot move the legs, the spine may have been fractured and the cord or cauda equina compressed or crushed The neck should not be manipulated, and the patient should not be allowed to sit up (See Chap 44 for further discussion of spinal cord injury) Acute Sprains and Strains The terms lumbosacral strain, sprain, and derangement are used loosely by most physicians, and it is probably not possible to differentiate them What was formerly referred to as sacroiliac strain or sprain is now known to be due, in many instances, to disc disease The term acute low back strain is preferable for minor, self-limited injuries that are usually associated with lifting heavy loads when the back is in a mechanically disadvantaged position, or there may have been a fall, prolonged uncomfortable postures such as air travel or car rides, or sudden unexpected motion, as may occur in an auto accident The discomfort of acute low back strain is often severe, and the patient may assume unusual postures related to spasm of the lower lumbar and sacrospinalis muscles The pain is usually con ned to the lower part of the back, in the midline or just to one side or other of the spine The diagnosis of lumbosacral strain depends on the description of the injury or activity that precipitated the pain; the localization of the pain; the nding of localized tenderness; the augmentation of pain by postural changes eg, bending forward, twisting, or standing up from a sitting position; and the absence of signs of radicular involvement In more than 80 percent of cases of acute low back strain of this type, the pain resolves in a matter of several days or a week even with no speci c treatment Sacroiliac joint and ligamentous strain is the most likely diagnosis when there is tenderness over the sacroiliac joint and pain radiating to the buttock and posterior thigh, but this always needs to be distinguished from the sciatica of a ruptured intervertebral disc (see further on) Strain is characteristically worsened by abduction of the thigh against resistance and is also felt in the symphysis pubis or groin It, too, responds within days or a week or two to conservative management Treatment of Acute Low Back Strain The pain of muscular and ligamentous strains is usually self-limited, responding to simple measures in a relatively short period of time The basic principle of therapy in both disorders is to avoid reinjury and reduce the discomfort of painful muscles Rest, in a recumbent position, for one or several days has been the traditional treatment, but several clinical trials over the years have questioned this dictum (see Vroom and colleagues) Nonetheless, lying on the side with knees and hips exed or supine with a pillow under the knees are the favored positions for relief of pain With strains of the sacrospinalis muscles and sacroiliac ligaments, the optimal position is hyperextension, which is effected by having the patient lie with a small pillow under the lumbar portion of the spine or by lying face down Physical measures such as application of ice in the acute phase and, later, heat diathermy and massage can be tried, but these are of limited value beyond several days Nonsteroidal anti-in ammatory drugs (NSAIDs) should be given liberally during the rst few days Muscle relaxants are of little use, serving mainly to make bed rest more tolerable The same can be said of traction, formerly a popular treatment When weight bearing is resumed, discomfort.

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may be diminished by a light lumbosacral support, but many orthopedists refrain from prescribing this aid As a result of several studies that have failed to demonstrate a bene t of bed rest, recent practice has been to mobilize patients as soon as they are able and to prescribe corrective exercises designed to stretch and strengthen trunk (especially abdominal) muscles, overcome faulty posture, and increase the mobility of the spinal joints Despite this modern approach, the authors can af rm from personal experience that some injuries produce such discomfort that arising from a bed or chair is simply not possible in the early days after injury The use of spinal manipulation practiced by chiropractors, osteopaths, and others has always been a contentious matter in the United States, partly because of unrealistic therapeutic claims made in treating diseases other than low back derangements By contrast, in certain parts of Europe, orthopedists often incorporate manipulative procedures into conventional practice A type of slow muscle stretching and joint distraction (axial traction on a joint) administered by physiatrists and physical therapists is quite similar It must be recognized that many patients seek chiropractic manipulation on their own, often before seeing a physician, and may not disclose this information to the physician When the supporting elements of the spine (pedicles, facets, and ligaments) are not disrupted, chiropractic manipulation of the lumbar spine has provided acute relief to a considerable number of our patients with low back strain or facet pain; at issue is the durability of the effect, even with repeated so-called spinal adjustments A randomized British trial has shown manipulation to be superior to analgesics and bed rest in returning patients to work after minor back injury (Meade et al) Some other trials have corroborated this nding (Hadler et al), while others have not, or, most often, the results have been ambiguous In the study by Cherkin and colleagues comparing chiropractic, physical therapy (McKenzie method), and simple instruction to the patient from a booklet, manipulation yielded a slightly better outcome at the end of a month Despite several hypotheses offered by practitioners of spinal manipulation, the mechanism of pain relief is not known The sound created by rapid and forceful distraction of the facet joints, similar to cracking the knuckles, seems not to be necessary for pain relief Whether all forms of low back pain represent minor subluxations, as claimed by chiropractors, is undocumented and seems unlikely Chronic low back pain has, in the authors experience, 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 many of these patients The results with another popular approach, acupuncture, have been even more uncertain for acute or chronic back pain, most studies showing it to be no more effective than a sham treatment (Tudler et al) It should be added, however, that the commitment of patients to a regimen of NSAIDs for many months or to narcotic analgesics is a hazard always to be avoided The Degenerative 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 orthopedic clinics, more in men than in women After some unusual activity, raising the question of trauma, especially if it happens in the workplace, the patient develops deep 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.

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