Back Pain
Low Back Pain
Low back pain is pain arising from the spine from below the ribs to the sacrum. This type of back pain is very common and will affect 4 out of every 5 adults at some point during their life, it is the second most common for people to seek medical attention.
The first thing to remember is don’t worry, in the vast majority of patients the back pain has no sinister cause, and does not require surgery. In most patients the pain settles with no specific treatment, or gets better with a combination of painkilling medication and physiotherapy
What Is The Lower Back?
The lower back is is quite complicated structure. It is made up of 5 lumbar vertebrae and the sacrum/ pelvis, as well as intervertebral discs, ligaments, facet joints between the vertebrae, and all of the supporting muscles. This part of your spine provides you with both mobility and strength. The mobility allows movements such as turning, twisting or bending; and the strength allows you to stand, walk and lift. Proper functioning of your lower back is needed for almost all activities of daily living. Pain in the lower back can restrict your activity and reduce your work capacity and quality of enjoyment of everyday living
What Causes low back pain?
Muscular Sprain and Strain
The muscles of the spine provide the power and strength for everyday activities such as standing, lifting, and walking or running. If these muscles are poorly conditioned, or overworked then a muscular strain can occur. The ligaments in the lumbar spine attach muscles to the bones of the spine, and give support and stability to the bones and discs in the spine. A sprain of these ligaments can occur when a sudden forceful movement injures the ligaments which have been previously weakened by poor conditioning or overuse.
This type of back pain usually lasts less than 3 months.
Both of these conditions cause relatively acute back pain without sciatica. The pain almost always settles with painkillers such as diclofenac or ibuprofen, and physiotherapy may help.
The best means of avoiding this type of pain is regular exercise aimed at strengthening the spinal muscles, maintaining a healthy weight, good lifting techniques, and not smoking
‘Wear and Tear’
This is also a very common cause of back pain. The effects of aging on the spine are universal and in many people result in episodes of low back pain. This process is variously called degenerative spinal disease, osteoarthritis of the spine, spinal spondylosis and ‘worn discs’.
The process usually begins at a relatively early age with dehydration of the lumbar discs, this changes how forces are transmitted through the spine and leads to additional forces being put on the facet joints and ligaments. This in turn leads to degeneration of the facet joints and disc spaces with extra bone formation and a reduced range of movement or ‘stiffness’ of the spine. In addition to this the elasticity of ligaments and the tone of spinal muscle decreases with age.
The pain caused by this problem can last much longer than 3 months
If you have pain going into the legs see the section on sciatica, if you get pain in the legs on excercise which recovers with rest you may have lumbar spinal stenosis
Rare causes of back pain
In under 2% of cases back pain is caused by more serious pathology such as infection, a tumour of the spine and after a spinal fracture
Investigation of back pain
Plain Xrays
These may show wear and tear changes, or suggest instability in rare instances. They do not allow the nerves or discs to be seen
CT scan
This is a good way of looking at the bony structures of the spine, and can show disc prolapses and spinal stenosis, MRI however gives a much cleared picture of the non-bony structures
MRI scan
The best way of getting pictures of the spine if nerve compression is suspected
Myelogram
In some where cases an MRI scan may not be possible this may be required, now very rare
Discography
Involves injecting dye into the discs whilst under sedation. The theory is that the back pain can be reproduced by this injection and thus the disc(s) responsible localised. The test is not infallible though and many spinal surgeons think that it can be misleading
Treatment of back pain
The vast majority of people suffering with back pain do not need surgery, sometimes your GP may refer you for assessment in a surgical clinic because you have not responded as well as hoped with the conventional non-surgical treatments. Just because you have been refered to a surgical clinic does not mean you will be having an operation, it may be that you need further investigation, or referal to a more specialised clinic such as a pain managment clinic.
Types of treatment:
Bed Rest: 1-2 days at most
Excercise: Walking, cycling, swimming, yoga and pilates and excercises guided by a physiotherapist
Medication: Non-steroidal medication such as Neurofen, diclofenac, naproxen are all effective. Additional drugs that may aid pain control include paracetalmol/ codeine preparations, tramadol, and muscle relaxants
Manipulation: this can be perfromed by either a chiropractor, osteopath or physiotherapist
Treatment in a Pain Clinic: This involves assessment by a pain specialist, and may lead to novel pain modifying drugs being tried, spinal injections of steroid and local anaesthetic and use of a TENS machine.
Oxford University Hospitals information booklet and exercises
Surgery for Back Pain
This is only needed in a small percentage of patients, and usually only after all of the above treatments have been tried and failed. The role of surgery is hotly debated and remains unclear, some recent data suggests that excercise and physiotherapy is as good as surgery in the long-term.
Traditional indications for surgery include instability after laminectomy, spondylolysthesis, and large disc prolapse.
Things You Can Do To Prevent Back Pain
- Remain as physically active as possible
- Take regular exercise
- Keep your weight down
- Stop smoking