Lower back pain made simple

Prof GK Prusty, Neurosurgeon, CMRI, Kolkata, gives an outlook on how to prevent back pain Why is back pain important? Lower back pain is one of the most common human afflictions. It may occur for no apparent reason. For example, one may wake up in the morning with back pain and have no idea what […]

Prof GK Prusty, Neurosurgeon, CMRI, Kolkata, gives an outlook on how to prevent back pain

Why is back pain important?

201411boe17Lower back pain is one of the most common human afflictions. It may occur for no apparent reason. For example, one may wake up in the morning with back pain and have no idea what caused it. The pain can develop suddenly after lifting, carrying, pushing or pulling something heavy or twisting the back awkwardly, or it can develop gradually as a result of years of poor posture. The pain may be worse at night, during activity, or after sitting in the same position for a long duration, such as after a long car journey. Back pain can be triggered by everyday activities at home or at work, or it can develop gradually, over time. To list a few, back pain can be due to bending awkwardly or for long periods slouching in chairs, over-stretching, driving in a hunched position or driving for long periods without taking a break, overusing the muscles. The pain may also be felt down the front, side, or back of your leg besides lower back.

Bone, discs, muscles, ligaments, tendons, joints, nerves and various other tissues are arranged to make up the spine. The spinal column, or back bone, consists of 33 bones (vertebrae). Back bone can be divided into five segments, called the cervical, thoracic, lumbar, sacral, and coccygeal sections of the spine. Each of these sections correspond to a particular part of the body. The cervical spine is that part of the spine in the neck, the thoracic spine supports the trunk, the lumbar spine supports the lower back and abdomen, the sacrum supports the pelvis and the coccyx is the tailbone.

What are the risk factors?

Seventy five per cent of adults experience back pain at some point of their lives. The peak incidence is at 20 to 40 years of age, more severe in older people. In 85 per cent of the cases there are no anatomical cause or finding in imaging. Most cases are self limiting with five per cent, which requires serious medical attention.

Certain risk factors increase the chances of developing a back pain. They are: being overweight — the extra weight puts pressure on the spine; smoking, being pregnant — the extra weight of carrying a baby can place additional strain on the back; long-term use of medication such as corticosteroids known to weaken bones, stress and depression.

Where back pain originates?

The complexity of the spine often makes it difficult to pinpoint the exact cause of the pain. It can originate from identified muscle trauma, or an unknown non-traumatic event. Sometimes low back pain can even begin in the nerves or nervous system. Other origins for low back pain are congenital disorders, trauma, infections, degenerative disorders, inflammatory and circulatory disorders. In addition, depression, anxiety, frustration, reinforcement, stress, anger, fear and many other psychological states can help to cause the onset of back pain, can be a reaction to prolonged pain, or exist concurrently with pain. The emotional component can complicate the back pain diagnosis, sometimes resulting in needless surgery and disability and can sometimes mask the underlying physical causes of pain.

Various causes of lower back pain

Sprains and strains in the back or back musculature lead to most acute pain in the back. The pain is usually limited to five or ten days.

The discs are the circular, spongy tissue between the vertebrae that help cushion your spine. A prolapsed disc or disc herniation or slipped disc or ruptured disc is where the hard outer membrane of the disc is damaged, causing the soft, jelly-like fluid inside to leak out. Lumbar disc herniation is a common injury that can cause severe pain and other problems in the legs. Soreness in your lower back, muscle weakness and tight muscles may be caused by a slipped disc. The pain usually radiates down your leg.

Sciatica is the descriptive term for when pain runs from the back or buttocks down the leg and into the foot. Sciatica implies an irritation of nerve root in the lower part of the spine.

The ways in which a slipped disc causes different pain patterns and problems is related to the location of the slipped disc along the lumbar spine, and also to the anatomy of the individual spinal column.

Spondylolysis is a defect in the lamina of the vertebrae. Spondylolysis is a prerequisite for spondylolisthesis which occurs when spondylolysis weakens one of the vertebrae so much one vertebra slips over the other out of place. The condition can also be caused by degenerative disc disease and conditions that affect the vertebral joints. If the vertebrae slip too much and begin to press on nerves, surgery may become necessary.

Lumbar spinal stenosis is a natural product of aging, and the wear and tear on the spine throughout the life. As the body grows older, the ligaments and bones that make up the spine grow thicker and become stiffer. The spinal canal gradually narrows and the spinal cord is slowly compressed. The lack of space interferes with the normal function of the spinal cord and the body becomes unable to function normally. Stenosis produces a dull, aching pain in the lower back when standing or walking. These symptoms usually slowly get worse over time.

Though infections and inflammation of the spine are rare, if they are neglected for a period of time, or if there is a delay in diagnosis, they can become a significant source of pain and disability.

Discitis, is characterised by the slow onset of severe back pain and may or may not be associated with fever or other symptoms. It is a low-grade infection of disc between two vertebrae caused by bacteria, viruses, or other inflammatory processes. Although uncommon, children under ten are usually the ones affected by this condition. Young children with this condition are usually irritable and uncomfortable and refuse to sit up, stand or walk. Surgery is rarely needed.

Spinal infection like tuberculosis or bacterial can lead to back pain.

Ankylosing spondylitis is a rare condition that can cause back and neck pain.

Lower back pain, buttock pain, neck pain and stiffness and pain in the sacroiliac joint (the joint that connects the pelvis to the spine) are all possible symptoms of ankylosing spondylitis. Patients often have early morning stiffness. One feels better with light exercise and warm shower.

Tumours of the spine and spinal cord are relatively uncommon. The most common initial symptom that patients with a spinal tumour is pain. The term ‘benign’ indicate that a particular tumour is unlikely to spread to others parts of the body. Benign tumours can still be a significant problem however, depending upon their location, size, adjacent structures, blood supply and other factors.

Malignant lesions indicate that a particular tumour or a cancer often spreads to other parts of the body and can be difficult to cure or treat.

Any one involved in an accident could have damaged his back. Even after medical evaluation the injury may not be detected. The symptoms for spinal cord injuries may be missed at the initial examination and thus need to be examined repeatedly.

In osteoporosis the amount of calcium decreases in the bones. The weakened spine fails to support the weight of the body and may break. When this happens, people usually suffer from sharp back pain and they often become shorter or have a ‘hunched over’ posture.

When to visit doctor for back pain?

Most cases of back pain can be treated by taking proper rest, painkillers and self-care.

However, one should visit the doctor if he is worried about the condition or struggling to cope with the pain. With back pain lasting for more than six weeks or longer, paralysis, urinary incontinence; one should consult specialist trained in providing a particular treatment

Diagnosing back pain

A doctor usually assesses the patient’s ability to sit, stand, walk and lift legs, as well as testing the range of movement in the back. He may ask about any illnesses or injuries one may have had, the type of work one does and about lifestyle. Additionally, the doctor would like to know: When did the back pain start? Which are the site of pain? Past history of back problems, the nature of pain, what makes it better or worse. Depending on the clinical observations further tests like blood, X-ray , CT scan and MRI scan will be considered.

Prevention strategy for lower back pain include — weight loss, strengthening exercises, improvement in strenuous and stressful working condition, cessation of smoking. Back braces are ineffective in prevention but useful to remind the sufferer to be cautious.

The goals of management for patients with low back pain are to decrease the pain, restore mobility and hasten recovery so that the individual can resume normal daily activities as soon as possible. Treatments vary depending on duration, severity of pain, individual needs and preferences.

Short-term back pain

90 per cent of back pain that last no longer than six weeks can be treated with painkillers and home treatments like application of pain balm, hot and cold compress, a hot bath or a hot water bottle placed on the affected area helps ease the pain. Cold, such as an ice pack or a bag of frozen vegetables, placed on the painful area is also effective. Do not put the ice directly on to the skin because it might cause a cold burn. Wrap the frozen pack in a wet cloth before applying it to the affected area.

Another option is to alternate between hot and cold using ice packs and hot compression packs or a hot water bottle. Changing in sleeping position can take some of the strain off the back and ease the pain. If one sleeps on his side, he should draw his legs up slightly towards his chest and put a pillow between legs. If he sleeps on his back, placing a pillow under the knees will help maintain the normal curve of his lower back. Trying to relax is a crucial part of easing the pain because muscle tension caused by worrying about ones condition can make things worse. Research suggests that people who manage to stay positive despite the pain tend to recover quicker and avoid long-term back pain.

Exercise and lifestyle have a greater role to play. Regular exercises and being active on a daily basis will help keep the back strong and healthy. Activities such as walking, swimming and yoga are popular choices. One must try to address the causes of back pain to prevent further episodes.

Long-term back pain for more than six weeks (known as chronic back pain), specific exercises to improve muscle power and posture, manual therapy like massage for upto 12 weeks, nerve root block, facet joint block and antidepressant medicines can be tried.

Counselling while the pain in the back is very real, how the individual thinks and feels about his condition can make it worse. Cognitive behavioural therapy (CBT) works by helping one to manage his back pain better by changing how he thinks about his condition.

A number of other treatments such as low level laser therapy, interferential therapy (IFT), therapeutic ultrasound, transcutaneous electrical nerve stimulation (TENS), lumbar supports are sometimes used to treat long-term back pain.

Surgery for back pain is usually only recommended when all other treatment options have failed.

Surgery may be recommended if the back pain is so severe or persistent that the individual is unable to sleep or carry out his day-to-day activities and or due to severe or increasing neurological deficits like paralysis foot drop, urinary symptoms, spondylolisthesis with stenosis or severe pain and sciatica syndrome for more than 12 months. The type of surgery will depend on the type of back pain and its cause. For example, a procedure known as a discectomy may be used for prolapsed disc. A discectomy involves removing the damaged part of the disc through an incision made in back. It is now possible for surgeons to carry out the procedure using a very small incision and a microscope or magnifying lenses or endoscope to find the damaged disc. This minimises the amount of trauma to the surrounding tissue, reduces pain and discomfort in the affected area and results in a smaller scar. Spinal fusion surgery is a less common surgical procedure where the joint that is causing pain is fused to prevent it moving. This involves fixing the spine with various metallic implants like screw, rod, artificial disc etc.

Most spinal surgeries are performed safely with good success. Before you agree to have surgery to treat back pain, you should fully discuss the risks and benefits of the procedure being recommended with your surgeon.

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