Spinal disorders

Palmer, K.T. and Greenough, C.G. (2013) Spinal disorders. In, Palmer, Keith T., Brown, Ian and Hobson, John (eds.) Fitness For Work: The Medical Aspects. 5 ed. Oxford University Press, pp. 207-232. (doi:10.1093/med/9780199643240.003.0011).

Abstract

Non-specific low-back pain (LBP) is one of the commonest conditions afflicting adults of working age. It represents a leading cause of disability and a major cause of sickness absence. The problem posed in assessing fitness for work in back pain sufferers is one that all occupational physicians frequently face. Neck pain and its associated disability are scarcely less common. Collectively, therefore, axial pains affecting the spine pose a major challenge to the decision-maker. Commonly, a number of placement and fitness questions arise. In assessing the absent worker with a current episode of pain: When will symptoms improve or resolve? Is this a short- or a long-term problem? Are any further investigations required to exclude serious pathology? Who (among the many with pain) should be referred for such an assessment? At what point should the occupational physician intervene to hasten rehabilitation? And how? Has work contributed to symptom onset? Might it worsen or prolong symptoms? Is it appropriate to return the worker to the same job or does the work need to be modified? When is chronic spinal pain serious enough to declare a person permanently unfit for work? Could more be done to avoid or control the demands of work before that point is reached? Following spinal surgery, when will the patient be fit for work? Should special restrictions be considered and if so when? At the pre-employment stage the issues are no less difficult: Are there any specific inquiries (questions, examination findings, and investigations) predictive of future spinal pain leading to serious disability or sickness absence? How should these be utilized in assessing fitness for work? In particular, how should a past history of spinal pain be regarded? Are any characteristics sufficiently predictive to warrant restrictions? And more generally: What steps can be taken to promote fitness for work and to prevent spinal pain? What obligations exist under health and safety legislation and the Equality Act 2010? Do current policies on back pain promote well-being and avoid needless work restrictions? In attempting to answer these questions it is helpful to appreciate the frequency and natural history of spinal pain, the markers of serious pathology, and the evidence on fitness assessment and preventing disability. It is also important, for simple mechanical LBP, to be aware of evidence-based advances in management and rehabilitation. Adoption of consensus guidelines has led to better coping and faster recovery. Specific guidelines have also been developed for the management of workers and these address, in part, some of the questions posed above. In this chapter we review these initiatives and the problem of assessing fitness for work in those with spinal pain. Emphasis is given to simple non-specific axial spinal pain as this is the commonest presentation. Only rarely does the clinician make a more specific diagnosis; but occasionally serious pathology underlies symptoms and different responses are needed. Some account is provided of more specific spinal pathologies including prolapsed intervertebral disc, spinal stenosis, fusion surgery, ankylosing spondylitis, Scheuermann’s disease, fractures, and spinal cord injury.

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