Backache differently termed by different authors as low backache, sciatica, lumbago, slipped disc etc., is becoming a major health problem. It is more common in modern society with, its sedentary life style being a contributory factor. Backache is defined, as the penalty homosapiens have to pay for verticality. It is difficult to find an individual who never had backache at least once in his lifetime.
Many experienced persons have written many articles about backache. Different preventive measures have also been suggested. Despite all these attempts, the menace of backache continues. We felt this article is the need of the hour & hence this presentation. We will discuss about the structure of backbone, causes for backache, preventive measures & treatment options.
Structure of Backbone
The human backbone (vertebral column) is a biomechanical marvel made up of interconnected system of bones (vertebrae), ligaments, cartilages, muscles, nerves & other connective tissues. The hollowness in the backbone accommodates the spinal cord & its branches. The vertebrae of the backbone are connected through small joints (facet joints) & a shock absorber (intervertebral disc) is interposed between the vertebral bodies. Whole of this structure simulates a pile of building blocks stacked one on top of the other. To offer flexibility to spine movements there are curves & bulges in the column.
When this kind of stable structure goes through any abnormal stress like bad posture, injury, aging, infection, abnormal growth etc, it manifests as backache.
Reasons for Backache
- Musculoligamental - muscle strain or pull due to injury of stress to back.
- Facet joint stress (small joints between vertebral bodies) - one of the most under diagnosed problems.
- Disc prolapse - Shock absorber slipping out of its location & pressing on the spinal cord.
- Age related changes- wear & tear of the structure (osteoarthritis) with weakness of bone.
- Previous back surgery- (osteoporosis) recurring disc prolapse, adhesions to the surrounding structures.
- Less common problem - Infection, other organ problem, cancer etc,
The person might experience a dull ache in the low back to agonizing searing pain. This pain might travel to one or both of the legs. Additionally person might experience tingling / numbness in legs. Walking, sitting, running etc might aggravate this pain. In rare situations there might be loss of sensation, loss of control on urination & clearing bowels. There are some red flags in the history, which suggest the possibility of serious or systemic disease. These patients need to be evaluated on war footing and some times might require immediate surgical referral. The red flags in the history are as follows:
- Bilateral or alternating symptoms
- Constant or progressive pain
- Night time pain
- Morning stiffness, relieved by exercise
- Sudden onset in the elderly
- History of cancer
- Fever or night sweats
- Recent bacterial infection
- Acute neurological symptoms such as painful footdrop, perineal sensory impairment or sphincter disturbance
Unless there is obvious major injury or significant nerve damage, routinely investigations are not done. Only when the backache is of longstanding nature causing disability to the individual, investigations are planned. The imaging modalities are x-rays (to know bone problem), CT & MRI (to know both bone & soft tissue problems.)
Most episodes of short duration backpain of less than few weeks (acute pain) resolves on its own with rest, analgesics & correction of the underlying problems like bad posture, driving on two wheelers on bad roads, lifting of heavy weights, reducing overweight… Pain that has been there for more than four weeks (chronic) might require more evaluation & specific treatment. More than 50% of patients in this group also recover completely by 6 months with simple measures.
It is the 30% chronic backache patients who run from pillar to post for finding relief from backpain. Majority of these patients can be relieved from pain provided proper evaluation is done. None of the structures in the back getup & say that," I am the cause for the pain." It is up to the experienced clinician to pickup the problem. Many abnormal findings might be present in a normal person without backache also. It is to say that obvious abnormality on scanning may or may not be the cause for backpain.
Individuals with chronic backache will require more aggressive management. The reasons for the backpain in this group are various, like chronic muscle & ligament strain, disk prolapse, age related degenerative changes & others. Many of these can be managed with minor interventions like certain injections (epidural, facet joint, trigger point) over back. These minor procedures greatly reduce painkiller intake & hence provide great pain relief, which can last for months to years. If necessary these minor injections used with or without x-ray guidance can be repeated at a later date.
A small percentage of patients with major disc prolapse or bone problems will require surgery to rectify the situation. Surgery is indicated in neurological deficits or obvious backbone problems. Common surgeries performed are discectomy/ laminectomy.
A subgroup of patients who undergo surgery, again develop backache about 8 to 10 years down the lane. This happens because of recurrent injury and surgical scars getting adhered to nerves. These adhesions if released surgically, can get adherent again when the wound is closed. These adhesions can be released with X-ray guidance (decompressive neuroplasty, epidural adhesiolysis) and certain medications. Nearly 50% to 70% of patients improve after this procedure.
To sum up, back pain is second only to common cold as a reason for visiting a physician. Musculoskeletal problem is the commonest cause, eight out of ten individuals experience back pain in their lifetime. Preventive measures, patient education about self-care helps a lot in the long run. Physiotherapy and properly selected physical exercises are helpful adjuncts in back pain management. 90% of patients can be managed without surgery, while 10% will definitely require surgery. Modifications of lifestyle like avoiding bad postures, adjusting working conditions in office, regular physical activity, weight reduction and a host of other simple modifications goes a long way in preventing and managing back pain The recent developments in back pain management have been Spinal Cord Stimulation, intrathecal morphine pump & Spinal Endoscopy. Lot of energy and time has been and is being spent in finding a remedy for this ailment.