The spine is a complex and very important structure, which gives us the ability to ambulate. It comprises 24 bones known as vertebral bodies, stacked on top of each other with 'shock absorbers' in between called discs. At the top of the spine is the skull and at the bottom the pelvis. Very strong ligaments and muscles complete the construction and provide stability.
The spine also has the important function of carrying a column within it, called the spinal canal, which contains within it the spinal cord, which carries signals from the brain for the body to carry out its multiple complex functions.
What is back pain?
Back pain or lower back pain concentrates on the pain experienced in the bottom part of the spine. This is mainly due to the increased flexibility in this region making it more susceptible to injury and 'wear and tear'. It affects most people at least once during their life and although for most it resolves with simple measures, for others it can have a debilitating effect, causing a huge impact on their quality of life.
What causes it?
There are many causes for back pain and these can range from simple strains to significant injury caused by more serious conditions such as cancer and trauma. The character of the pain as well as other associated symptoms and signs will enable the doctor to localise and investigate appropriately to find the cause. It is therefore essential that the patient gives a good history.
Causes:
- Strains
- Trauma
- Degenerative spine (spondylosis)
- Degenerative disc disease
- Cancers/tumours
- Infection
- Psychological factors
Strains
Daily our bodies are put through vigorous stresses and strains. Although they may be minor, repeatedly subjecting the same structures to injury can cause problems in the long term.
An awkward movement that may have caught you off guard, causing pain, may be defined as a strain or sprain. The pain can come from overstretched muscles or ligaments. Many cases of back pain are due to this and resolve spontaneously within a short time.
The simplest way to prevent injury is by maintaining a healthy weight through a balanced diet and regular exercise. Even if an injury does occur, recovery will be rapid. If you exercise, always remember to warm up and wear suitable attire to prevent injury.
Certain occupations carry a higher risk of injury than others. Always ensure correct techniques and equipment is used at all times.
Trauma
This is a common cause of back pain, and may be due to major or minor injuries. In those who already suffer from back pain, symptoms can be exacerbated. Trauma to the back accounts for most causes of acute back injury. As with any other injury the symptoms and signs are due to swelling, bruising or damage to the bones, neural structures or muscles and ligament. Pain can be significant and you may get associated abnormal sensations in the limbs.
The main aim in management is to rule out an unstable injury, such as a fracture of the bone or instability. If undiagnosed the consequences maybe catastrophic. If there is a history of a significant injury, the patient will be treated as an unstable injury until proven otherwise. If suspected, then the patient will be immobilised immediately and spine kept in the neutral position.
Treatment depends on the type of injury. If fracture of a bone is found this may require surgical stabilisation. If nerve root damage is caused due to an acutely slipped disc this may have to be removed as an urgent procedure (cauda equina). If ligaments and muscles are torn or damaged this may require immobilisation.
Torn ligaments may take up to twelve months to heal properly. Overstretching of these ligaments may cause accelerated wear and tear of the spine, leading to problems later in life.
Degenerative spine
Wear and tear of the spine occurs with age. Certain types of jobs, e.g. manual work, and sports may also accelerate this degeneration. Although most areas of the spine can go through this degenerative process, the most often affected is the neck and the lower spine. Arthritis is the main cause and this results in narrowing of the disc spaces and the formation of bony spurs, which also cause the narrowing of the exit canals through which the nerves come through (osteophytes). These combined factors and pathological processes are called lumbar spondylosis.
Lower back pain described as a dull ache, worsening on movement and activity is the main description given. The pain may come on after walking a few metres, and be associated with pain radiating down the legs. It may be resolved by bending forwards and stopping. Called 'neurogenic claudication', this is a progressively worsening condition, caused by the narrowing of the main canal through which the lower part of the spinal cord called the cauda equina (Latin: horse's tail) gets compressed.
Back pain alone during walking, may also be due to a 'slip' where one vertebral body slips forward on the one below it. This is called spondylolisthesis. The muscles that supply the stability of the lower spine may also go into spasm due to the wear and tear also causing pain.
The diagnosis is confirmed initially by a plain x-ray and then an MRI scan of the back. The patient is examined thoroughly for limb weakness and reduced reflexes as well as reduced sensation. It is essential that you mention to the doctor if you have problems with your bowels or bladder as these could indicate a problem which requires urgent surgical treatment (cauda equina syndrome).
If it is just wear and tear that is the main problem, these patients may benefit from local treatment such as injections of local anaesthetic agents to the painful joints, and sometimes steroid injections. They may also benefit from injections of local anaesthetic into the spinal fluid which surrounds the nerves in this area called an 'epidural' to relieve pain (the same type of anaesthetic given to women during labour).
If symptoms progressively worsen they may benefit from an operation to decompress the nerves, called a laminectomy. Most of the time this has no effect on the back pain but will relieve the leg pain.
Degenerative disc
As we grow older, the discs between the vertebral bodies which act as shock absorbers undergo change. They become dehydrated and may rupture, during which the contents may spill into the spinal canal causing symptoms by pressing on the nerves. This is known as a 'slipped disc'. Even a bulge may cause the same symptoms. This protrusion will cause symptoms and signs which can enable the doctor to localise the level at which it has slipped.
The symptoms may include pain in the back and leg. There may also be numbness or sensations of 'pins and needles' in the legs.
Most slipped discs do not require surgical treatment, and the symptoms resolve with rest and analgesia. Surgery may be needed if the pain in the leg and back take a long time to resolve, affecting the quality of life and if there is weakness in the legs which is progressively worsening. Then an operation called a discectomy where the disc fragment which is prolapsed is taken out is done.
There is, however, a situation where urgent surgical intervention is required, when the prolapsed disc causes numbness in the groin area, with associated problems with difficulty passing urine or opening bowels. This is called Cauda equina syndrome and is a surgical emergency. The disc should be removed to avoid a permanent problem with bladder and bowel function.
Cancers/Tumours
Tumours which are within the bone and growing into the spinal canal may cause back pain. If they spread from other areas of the body these are then called secondaries. They may arise from any of the structures composing the spine. Secondary tumours are generally malignant and may affect the bone or the soft tissues. As the presence of these tumours in the bone causes weakening the patients may also present with fractures. Tumours, which arise from the structures of the spine may be benign or malignant, and their presentation, depends on the size, the location and nature of the tumours.
The pain maybe localised to a level and there maybe tenderness. Depending on the size and extent, the symptoms and signs may vary. Most people presenting with tumours of the spine complain of pain that is continuous and worse at night. There may be associated altered sensation, and even problems in bladder and bowel function.
What is the treatment? If it is a secondary tumour causing pain and weakness in the limbs and affects only one level and the patient has at least six months to live, a decompression may be offered. This resolves the compression caused by the tumour. This is mainly a palliative procedure to reduce the pain. The spine at this level may also have to be stabilised.
If the source of the tumour is unknown then a small piece of tissue may also be taken at this point to send to the laboratory. The operation is normally followed by radiation treatment to this area. If the appearance on the scan indicates a benign tumour the principle is to take it out, especially if it is causing worsening symptoms and signs.
Infections
The elderly, diabetics and those whose immunity is compromised have an increased risk of developing spinal infections. A localised collection of infection, pus, is called an abscess. These normally spread via the blood to the spine, but may also occur by direct spread from a source. This is a neurosurgical emergency especially if patients have severe pain associated with weakness of the limbs.
The operation is carried out for two reasons, to isolate the bug that is causing the abscess and to decompress the spine at this level to stop permanent damage by compression.
In developing countries, TB is also a significant cause of spinal infection. This is diagnosed by special blood tests. Management is the same.
Psychological factors
Stress is a cause of many pain syndromes. Psychological stress, anxiety, anger and distress can affect the rate of recovery from back pain. Worrying that it maybe due to a sinister cause, the inability to carry out normal day-to-day activities affecting the quality of life all have a profound effect on quality of life. It is very important that this group of patients, after a serious cause has been ruled out, continue with rehabilitative care and reassurance. The main management strategy is to return them to a normal daily routine as soon as possible.
It is very important that from a young age we look after our backs. Here are some basic methods and advice to follow:
- Exercise and control your diet to maintain ideal body weight
- Keep healthy in mind as well as body
- Good posture management
- Lift and carry heavy weights carefully
- Seek medical advice if pain persists and progressively worsens
There are also 'red flag' factors to be wary of. If any of these occur on a background of back pain it is essential that you seek urgent medical attention.
'Red flags' for possible serious
spinal conditions
- Presentation less than age 20 or onset over age 55 years
- Violent trauma: e.g. fall from a height, RTA
- Constant, progressive, non-mechanical pain
- Thoracic pain
- Past medical history of tumours
- Systemic steroids
- Drug abuse, HIV
- Systemically unwell
- Weight loss
- Persisting severe restriction of lumbar flexion
- Cauda equina syndrome/widespread neurological disorder
- Difficulty with passing urine
- Loss of anal sphincter tone or faecal incontinence
- Saddle anaesthesia about the anus, perineum or genitals
- Widespread (>one nerve root) or progressive motor weakness in the legs or gait disturbance
- Sensory level
- Inflammatory disorders (ankylosing spondylitis and related disorders)
- Gradual onset before age 40
- Marked morning stiffness
- Persisting limitation of spinal movements in all directions
- Peripheral joint involvement
- Iritis, skin rashes (psoriasis), colitis, urethral discharge
- Family history
Other conditions may cause back pain. For instance, a sudden enlargement of a main blood vessel called the aorta may present with excruciating pain. Infection or inflammation of certain organs such as the pancreas and the kidneys may also cause back pain. Thus a thorough medical examination must be carried out by your doctor, and detailed investigations done to confirm the right diagnosis.
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