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Are you suffering from back pain ? You are not alone!!!.
7/30/2019
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Almost all of us have experienced back pain at least once in our life time. Low back pain is one of the most common reasons people visit their doctors. Around 80% to 90% of people will experience some form of back pain during their lifetime. Fortunately, in about 80 to 90 percent of cases pain improves without surgery. Despite the fact that in most of the cases low back pain are not due to serious causes, proper evaluation by doctors (history and physical examination) is very crucial to elicit warning signals (Red flags), which indicate the need for further work-up and treatment. Early detection and treatment of these sub group of patient is crucial for prevention of disability and better outcome. This article helps you understand about the basics of back pain and its management in general.

What is low back or Lumbar spine?

The lower back (Lumbar spine) consists of five bones (vertebrae) in the lower part of the spine. Spine is supported by muscles and ligaments around the bones and is cushioned by discs located between the vertebra. These discs are flat and round structures containing gel like material at the centre called nucleus polposus which is contained by a tough, outer layer called annulus fibrosus. The nucleus pulposus functions to distribute hydraulic pressure in all directions under compressive loads, hence, acts  as shock absorber. Of the 31 pairs of spinal nerves and roots, five lumbar (L1-L5) and five sacral (S1-S5) nerve pairs emerge from the spinal canal and supply the lower limbs and bowel and bladder.

Signs and symptoms of backpain:

Muscle pain

Shooting or stabbing pain

Pain that radiates down the leg

Pain that worsens with bending, lifting, standing, coughing or walking

Pain that improves when lying down

Diagnosis of Low Back Pain

Diagnosis is made by neurosurgeon based on history, clinical examination and investigations, if necessary. A careful history is requires in the diagnosis of low back pain to determine whether the causes are mechanical, or secondary. Mechanical causes of acute low back pain include dysfunction of the musculoskeletal and ligamentous structures which usually have a favorable outcome while secondary causes are more life threatening and require treatment for the underlying condition. And fortunately, secondary causes of low back pain are much less frequent than mechanical causes.

Commonly performed test for the diagnosis of low back pain are:

X ray

Computed  Tomography (CT Scan) and/or Magnetic Resonance Imaging (MRI)

Nerve conduction studies

 

Causes of low back 

Primary causes

Ligamentous strain

Muscle strain or spasm

Facet joint disruption or degeneration

Intervertebral disc herniation- A herniated disc presses the spinal nerve roots

Spinal stenosis which is the narrowing of the spinal canal with compression of nerve roots

Spondylolisthesis- Forward movement of one vertebra over the one below it leading to traction on the nerve root and narrowing of spinal canal.

 

Secondary causes

Infection

Spinal cancer

Metabolic disease: Osteoporosis

 

RED FLAGS

Age more than 50 years or less than 20 years

Immunosuppression

Intravenous drug use

Unexplained weight loss

Prolonged use of steroids

History of cancer

Major motor weakness

Pain that is increased or unrelieved by rest

Fever

Bladder or bowel incontinence

Trauma

Treatment

Treatment usually consists of pain medications (non-steroidal anti-inflammatory agents or acetaminophen), short time bed rest, physiotherapy and a gradual return to usual activities. With this, pain subsides with in one week in most of the cases.

Conservative Treatment Option

Conservative treatment measures are aimed at relieving the inflammation in the back and irritation of nerve roots. Treatment options include physical therapy, back exercises, weight reduction, nonsteroidal anti-inflammatory medications, steroid injections (epidural steroids), rehabilitation and limited activity. Usually, four to six weeks of conservative therapy is recommended before considering surgery.

When Surgery is needed?

Surgery may be needed when conservative treatment for low back pain does not provide relief. One may be a candidate for surgery if:

Back and leg pain that limits normal activity or impairs quality of life

Leg weakness and/or numbness which are the Progressive neurological deficits

Loss of normal bowel and bladder functions

Difficulty standing or walking

Medication and physical therapy are ineffective

When the patient general health is reasonably good to tolerate surgery

 

If surgery is required, neurosurgeons have a variety of options available to help relieve pressure on the nerve roots.

Microdiscectomy:  Surgeon use microscope to remove the slipped disc though a small skin incision. Most of the patients feel immediate relief after surgery.

Decompression surgery:  Neurosurgeon carefully removes the causes of compression (like hypertrophied ( thick and enlarged) bone and ligaments) which relieves the compression and helps nerve root get its blood supply and regain function.

Spinal Fusion:  If there is degeneration and instability in the spinal column, the unstable segment of the spine has to be fused with instrumentation ( screws, cage and rods) and bone grafts to stabilize the spine . A successful fusion will prevent the movement in the motion segment and also prevents the disc from bulging or herniating again.

 

 

Author

Dr. Prakash Paudel

MBBS (IOM), FCPS (Neurosurgery, Gold Medal 2016),

Neuroendoscopy Fellowship (Germany)

Associate Consultant, Department of Neuroscience

Nepal Mediciti 

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