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Back Pain

Back Pain

Back pain is a very common problem. Most of us have experienced back pain at some point in our lives. It can be of acute onset lasting from few days to weeks or it can be a chronic problem lasting months It can happen due to a multitude of causes and usually recovers with adequate rest and time; but in certain situations back pain can be due to a problem for which consulting a doctor could be helpful

Various factors can be related to back pain like

  • Age : As we grow older there is a generalised loss in bone strength and muscle mass along with some wear and tear (degeneration) in the discs between two vertebrae. The purpose of the disc is to provide flexibility to our spine. But as we grow older they tend to become less flexible and can be one of the factors related to back pain.
  • Posture : Having a proper posture is very important in properly balancing our spine and to evenly distribute the load on the spine. It includes both sitting as well as standing posture. People who tend to slouch have a higher incidence of back pain. Posture not only affects back pain but is also related to development of neck pain.
  • Physical fitness / lifestyle : Sedentary lifestyle and lack of exercises can lead to decreased tone of muscles and can also lead to weight gain and obesity. If our core muscles are not exercised regularly then it adds to the stress on our spine, which can cause back pain.
  • Smoking : It has been shown in various studies that smoking causes early degeneration (wear and tear) of discs thereby increasing the probability of having back pain due to degenerated discs.
  • Obesity : indirectly affects the spine by putting extra load on to the spine. Obesity is usually associated with poor abdominal muscle tone which can be a contributing factor to back pain.
  • Occupational hazards : Back pain is more common in individuals involved in heavy work such as lifting and pulling heavy objects.
  • Genetics : This is also a contributing factor in certain situations like early degeneration (wear and tear) of discs and arthritis of the spine.
  • Osteoporosis : can also cause back pain as it affects the bony architecture

Specific causes of back pain include

  • Degenerative disc disease (DDD) : It’s a very common cause related to back pain. It basically means loss of flexibility of the discs, which act as cushions between the adjacent vertebrae. It can be age related or due to smoking, occupation/lifestyle or even genetics.
  • Slipped disc / Herniated disc (Prolapsed Intervertebral Disc) : this is caused by a tear in the outer portion of the disc due to which the inner gelatinous material leaks out causing irritation of the nerves thereby causing back pain and radiating leg pain or sciatica. In severe cases it can cause weakness in leg muscles and numbness.
  • Sciatica : It is the term used for radiating hip and leg pain associated with tingling and numbness along the course of the sciatic nerve, which is a major nerve of the leg supplying all the muscles and skin over the thigh and leg.
  • Spinal stenosis : this is a condition in which the space for the spinal cord and the nerves leaving the spine gets narrowed thereby causing irritation of the nerves. Clinically it causes decreased efficiency of the involved nerves which results in fatigue symptoms in the legs like calf pain, numbness in legs and feet after walking for a long distances (claudication). It is commonly age related and caused by height loss of discs with bulging (degeneration), thickening of ligaments around the spinal cord and arthritic changes in the small joints of the back (facet joints).
  • Spondylitis : It is inflammation of the joints of the back which can lead to chronic back pain. Common causes include rheumatological problems, infection.
  • Instability back pain : It happens when the spine (back) is not stable at one of the segments due to which there is extra mobility at that level causing back pain. It happens when along with degeneration of the disc there is arthritis of the small joints of the back (facet joints) affecting the stability of the spine at that level.
  • Back pain due to injuries of the spine like fractures or ligament injuries.
  • Osteoporotic compression fractures : Back pain can occur due to osteoporosis which commonly affects the spine or vertebrae. It results in weakness of the bones and they can become very soft. Even minor injury can cause the soft bone to collapse on itself resulting in a compression fracture.

Diagnosis

Evaluating your back pain is very important for its proper diagnosis and accordingly tailoring the treatment. Your doctor will help you in the diagnosis with a proper clinical history and medical examination and if required certain investigations.

Investigations commonly done to evaluate the source of back pain include :

  • X-rays : Most common investigation ordered. Ideally standing X rays are more important and in certain situation your doctor might even ask for forward and backward bending X rays.
  • MRI : It is ordered to clearly evaluate the status of spinal cord and nerves, whether they are compressed or not and also to evaluate the overall structure of the spine. It involves magnetic and radio waves with no exposure to radiation. It takes around 30 to 45 minutes for the complete study and patients who are uncomfortable with closed spaces should clearly mention it to their doctor.
  • EMG/NCV (Muscle and nerve conduction studies) : This test is sometimes advised by your doctor to see the functioning of muscles and nerves. It involves placing small needles in specific muscles and passing a low grade electric impulse through it. It can also differentiate between pinching of the nerve in the spine or somewhere else.
  • CT : It is sometimes advised by your doctor to get a better picture of bones and joints.
  • DEXA Scan : This test is advised to grade the status of osteoporosis and accordingly planning the treatment.

Treatment Options

Based on the diagnosis and cause of back pain treatment is tailored. Overall for most types of back pain conservative therapy is the first line of treatment and surgery is limited to those patients who have a structural or a surgically correctable problem and have failed trials of other treatment with no relief.

Conservative Treatment

It is the first line of treatment for most types of back pain. In acute onset low back pain with spasm of back muscles rest is initially advised for a few days. Long-term rest is not recommended as it further de-conditions the back muscles.

Other modalities include

  • Pain Medications : They are sometimes given for short durations to control the pain. Sometimes combination of painkillers with muscle relaxants is advised. It is not recommended to take these medicines for a longer duration as they have many side effects.
  • Physical Therapy : This is the mainstay of conservative therapy for managing back pain both of short and long durations. It basically involves strengthening the core muscles. They are the main muscles which support the back. Its normally recommended to start physiotherapy in a graded manner depending on ones capability. Different regimens are followed based on the indication and mostly done under the vigilance of a trained physiotherapist in the beginning and then followed regularly at home for long lasting benefits.
  • Activity / Lifestyle Modifications : This constitutes an important part of the management. Maintaining proper posture is very important for evenly distributing the load to the spine. When at workplace proper ergonomic considerations should be made. Brisk walking is advisable for endurance training. If comfortable with swimming then it is considered to be a complete whole body work up.
  • Behavioural modifications like healthy diet, quitting smoking and getting regular sleep.
  • Weight Control / Obesity Management : This is an important aspect as it reduces the load coming on to the spine and also has indirect advantage of improving cardiovascular fitness.
  • Spinal Injections : In some situations certain type of spinal injection can be of help for reducing the back pain and disability associated with it and before starting graded physiotherapy.
  • Alternative Therapies : like TENS, Pilates, Acupuncture and Acupressure.

Surgical Treatment

Surgery is rarely the first choice of treatment when managing back pain. Your doctor might advise you surgery if pain is not responding to conservative options and is affecting your sleep or daily activities. In certain situations before going ahead with surgery your doctor might advise for some diagnostic spinal injections to localize the source of pain and to determine whether surgery would benefit in such conditions.

Common medical conditions that might require surgery include :

  • Slipped disc / herniated disc
  • Spinal stenosis
  • Instability back pain (Spondylolisthesis)
  • Vertebral fractures

Your doctor will help in deciding which option is best for you depending on the specific circumstances after having a good discussion with you.