Low back pain

Introduction

Low back pain is one of the commonest complaints seen in the pain clinics. According to a survey, low backache affects about 540 million people globally at any point of time. Almost everyone would have had low back pain at some point in their lives. It can affect anyone at any age and its incidence is increasing. The disability due to back pain has risen by more than 50% since 1990. Low back pain is becoming more prevalent in low and middle income countries rapidly as compared to high income countries (Lancet 2018).

Causes of Low back pain

There are various causes of low back pain. Many people and even clinicians have a misconception that low back pain is mostly due to disc bulge or disc prolapse. There are many anatomical structures in the spine (lumbar spine) including the vertebral bone, muscles of the back, ligaments, spinal nerves, inter-vertebral disc and small joints called the facet joints. In fact, low back pain can be caused by pain originating from any of these structures.

Many people use vague terms like “sciatica”, “lumbar sprain”, “Lumbago” etc as their diagnosis. And many patients get frightened and confused by their scan reports showing terminologies like “spondylosis” and “spondylitis”. Let us know these terms in little detail.

Sciatica- is the term often used interchangeably with nerve irritation. But it is just a term used to describe the pain which goes down along the back of the thigh and calf. So it is just a descriptive term and not a diagnosis.

Spondylosis- It is a radiological term which indicates degeneration in any part of the spine. It can be made out only after taking x-ray or MRI scan of the spine and it is not a clinical diagnosis. Spondylosis is a normal age related change and rarely leads to low back pain.

Spondylitis- refers to inflammation in any part of the spine. It can be a cause of low back pain.

Common causes of low back pain

In elderly age

  1. Facet joint arthritis- Most common cause in elderly age group. As a rule of thumb, low back pain after the age of 50 is due to facet joint pain unless otherwise proved.
  2. Sacroiliac joint arthritis
  3. Lumbar canal stenosis- narrowing of the spinal canal
  4. Osteoporotic vertebral fracture
  5. Myofascial pain
  6. Infection in the spine
  7. Malignancy or cancerous growth in the spine

In young age

  1. Discogenic pain (not disc prolapse) – this is caused by degenerative tears in the disc.
  2. Lumbar nerve root irritation- due to disc bulge causing pressure and pinching of the nerves.
  3. Sacroiliac joint pain- mostly in females after child birth.
  4. Spondylitis
  5. Infection in the spine

Infection, tumor/ malignancy and trauma can be the cause in both age groups and are more serious conditions.

Infection (fever, sweating, loss of weight), tumor (severe pain not responding to medicines, night pain), trauma, neurologic deficits (loss of bowel and bladder control, loss of muscle power, weakness in your legs) are regarded as red flag signs. These cases will need urgent surgical management. Hence if you have any of these symptoms, u will have to meet the doctor without any delay.

Risk factors

Following are the risk factors which will increase the chance of you getting back pain

  1. Over weight/ obesity– The important function of spine is to transmit the upper body weight to the lower limbs and increase in body weight will put extra load on the back bone.
  2. Lack of exercise– The abdominal and back muscles are the major supporters of the back bone. Sedentary lifestyle will lead to weakening of back and abdominal muscles thus decreasing the support to the back.
  3. Smoking– smoking causes early wear and tear which leads to back pain.
  4. Diseases like diabetes, certain immunologic conditions like ankylosing spondylitis.
  5. Occupation– like software engineers who sit for long time bending forwards,tailors, weight lifters or any occupation which needs lifting heavy objects.

Diagnosis

During your visit to the pain clinic, the doctor will examine you thoroughly and ask you to do various movements like sitting, standing, twisting and leg lifting movements to provoke your pain. The doctor may also do some special clinical tests which will help in making the diagnosis. Depending on the clinical diagnosis he  may ask you to get some special radiological and laboratory tests.

  1. X-ray– This is a simple and inexpensive investigation. This will show if there is any abnormality in the bones. It does not detect abnormalities in the soft tissue like disc, muscles, spinal cord, nerves.
  2. MRI scan– It is the most common test requested for back pain in order to detect soft tissue problems.
  3. CT scan– This is asked if you have a metal implant in your body which is a contraindication for the MRI scan.
  4. Nerve conduction tests– Electromyography (EMG) and Nerve conduction velocity (NCV) tests measure the electrical impulses in the nerves and muscles.
  5. Blood tests– Simple blood tests can help to detect infection which may be a cause of your back pain.

Treatment

In majority of the cases, the acute low back pain is self limited and gets better within few days to weeks unless you have the red flag symptoms (refer above). All you have to do is to consult the doctor, take care of the pain with simple pain killers for a week to ten days and continue your daily activities.

Do’s and Don’ts in acute Low backache

  • Do’s
  1. Take pain killers- Over the counter medicines like plain paracetamol will ease your pain.
  2. Take rest for one or two days
  3. Continue routine activities, light exercise like walking
  4.  physiotherapy
  • Don’ts
  1. Prolonged bed rest for weeks
  2. Using lumbar support belts
  3. Taking stronger medicines and narcotics without consulting doctor
  4. Getting MRI scans without advice
  5. Getting alternative treatments like massages, acupuncture or any other treatments with fancy devices.

If your pain doesn’t go away within a week or ten days, then probably you may seek for more help from your doctor who will now ask for special test including MRI scan, blood tests, and nerve tests to diagnose / confirm the cause of your back pain. He will now suggest you to take stronger medicines or take injections in to your spine.

Interventions/ Spinal injections

These are minimally invasive procedures where the doctor injects a mixture of numbing medicine and anti-inflammatory cortisone in to various parts of the spine from where the pain is originating. These injections are done under the image guidance (either x-ray or ultrasound) and with sterile precautions. All these injections are done under local anaesthesia with minimal discomfort. You will experience pain relief immediately after the injection. Most of these injections are done on day-care basis and you will be discharged on the same day.

Surgical treatment– Rarely you may need surgery for your low back pain. When the pain is due to infection, tumor or if you have weakness in the legs, loss of bowel or bladder control, when the spinal injection fail to give you pain relief, then you may be referred to spine surgeon for the surgical management.

Myths about low back pain

Some of the common myths prevalent among the people are-

  1. Prolonged strict bed rest is advised in low backache- Prolonged bed rest is not advised as it will lead to muscle wasting and reduce the nutrition to the spine. Instead one or two days rest is recommended.
  2. Lumbar belt helps to reduce the low back pain- Lumbar belt will worsen the pain by weakening the back muscles.
  3. MRI scan will help in diagnosis of the back pain- MRI scan is not useful in diagnosing all causes of back pain. There is a poor correlation between the MRI findings and low back pain. Many of the findings in MRI are asymptomatic and are not the cause for your backache. Hence it is not recommended in acute low back pain without any red flag signs.
  4. Surgery is necessary whenever the MRI shows a disc bulge or slipped disc- As previously mentioned, MRI finding hardly correlates with your back pain. Your MRI scan may show multiple level disc bulges. This doesn’t mean that you should immediately undergo surgical treatment. Surgery is needed only if you have red flag/ danger signs.

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