Aust Fam Physician
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Chronic low back pain presents a major challenge for general practitioners and is a significant drain on community resources. Patients often feel frustrated by modern medicine's apparent failure to validate their symptoms with a specific diagnosis and management plan. ⋯ Modern imaging techniques rarely determine the cause of pain. The GP must look for 'red flag' clues in the history. Management of low back pain includes NSAIDs, simple injections of plain local anaesthetic without adrenalin or cortisone, referral to a masseuse, cortisone, physiotherapist and/or a musculoskeletal pain physician. Specific management includes medial branch and sacroiliac joint blocks, and radiofrequency neurotomy. Patients with long term pain may be referred to a psychologist for cognitive behavioural therapy.
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Radicular pain is caused by irritation of the sensory root or dorsal root ganglion of a spinal nerve. The irritation causes ectopic nerve impulses perceived as pain in the distribution of the axon. The pathophysiology is more than just mass effect: it is a combination of compression sensitising the nerve root to mechanical stimulation, stretching, and a chemically mediated noncellular inflammatory reaction. ⋯ Lumbar radicular pain is sharp, shooting or lancinating, and is typically felt as a narrow band of pain down the length of the leg, both superficially and deep. It may be associated with radiculopathy (objective sensory and/or motor dysfunction as a result of conduction block) and may coexist with spinal or somatic referred pain. In more than 50% of cases, LRP settles with simple analgesics. Significant and lasting pain relief can be achieved with transforaminal epidural steroid injection. Surgery is indicated for those patients with progressive neurological deficits or severe LRP refractory to conservative measures.
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Back pain is a common presentation associated with opioid seeking behaviour. ⋯ Back pain, with or without opioid dependence, is commonly encountered in general practice. General practitioners frequently find themselves caught between the desire to treat and relieve symptoms, and not wanting to cause or exacerbate dependence. Clear guidelines and access to support are often lacking.
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The term 'doctor' comes from the Latin 'docere' meaning 'to teach'. Although few general practitioners have formal teaching skills or qualifications, we are all involved in teaching patients every day. The importance of our role as educators has been recognised for a long time, with the first statements of the Hippocratic Oath dealing with respect for our teachers and our duty to pass our knowledge on to others.