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:
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:
Computed Tomography (CT Scan) and/or Magnetic Resonance Imaging (MRI)
Nerve conduction studies
Causes of low back
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.
Metabolic disease: Osteoporosis
Age more than 50 years or less than 20 years
Intravenous drug use
Unexplained weight loss
Prolonged use of steroids
History of cancer
Major motor weakness
Pain that is increased or unrelieved by rest
Bladder or bowel incontinence
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.
Dr. Prakash Paudel
MBBS (IOM), FCPS (Neurosurgery, Gold Medal 2016),
Neuroendoscopy Fellowship (Germany)
Associate Consultant, Department of Neuroscience