BACKACHE
Having so many parts makes it easy to develop a problem into itself. Anything that puts pressure on the back muscles or nerves can cause pain. Any illness or damage to the spine also can cause pain. The cause of most acute back pain is unknown but probably due to minor strains, sprains, and overuse.
Emotional stress may significantly add to the pain since it slows recovery. Other possible causes of back pain include a ruptured intervertebral disc, spinal stenosis, osteoarthritis, ankylosing spondylitis, an injury or accident, rheumatic-related problems or other conditions.
Many problems that cause back pain result from injury and degeneration of the intervertebral disc. Degeneration is a process where wear and tear cause deterioration. The disc is subjected to different types of stress as we use our backs each day. Bending over results in disc compression and may cause the disc to bulge backwards towards the spinal canal and nerves. The facet joints must also shift to allow the bending to occur. Twisting and bending together is perhaps the most significant stress on the parts of the spine, especially the disc.
The earliest changes that occur in the disc are probably tears in the annulus portion of the intervertebral disc. The annulus is a sizeable round ligament, and the tears in the annulus heal the same way as the tears in other ligaments do, that is, by scar formation. Scar tissue is not as muscular as normal tissue. The repeated cycle of many annular tears healing by scar tissue leads to the disc that finally begins to degenerate.
What happens when the disc begins to degenerate?
As the disc degeneration progresses, the nucleus pulposus loses some water content. It becomes stiff and loses the ability to act as a shock absorber. The process may continue until the disc is collapsed. Bone spurs may form as the body’s response to this degeneration. These spurs are thought to be the result of excess motion at the spinal segment. Eventually, bone spurs form around the nerves of the spine as well.
A herniated disc is one of the most dramatic injuries to the lumbar spine. In this injury, a tear in the annular ligament allows the nucleus pulposus to squeeze into the spinal canal. If the disc material compresses the nerve root, there is pain, numbness, and weakness in the areas supplied by the nerve. A considerable amount of evidence suggests that it’s not only the pressure that plays a part in the symptoms of a herniated disc. The nucleus material squeezed out against the nerve seems to create an inflammatory response in the nerves causing pain.
SYMPTOMS
Low back pain can be divided into two main types:
• Mechanical Type pain
• Compressive Type pain
Mechanical-type back pain results from inflammation caused by irritation or injury to the disc, the facet joints, the ligaments or the back muscles. A common cause of mechanical pain is disc degeneration. A typical muscle or lumbar strain can also cause mechanical-type symptoms. Mechanical-type back pain usually starts near the lower spine. Mechanical-type pain may also spread to include the buttock and thigh areas. It rarely extends below the knee.
Compressive or neurogenic (nerve-related) pain occurs when the nerve roots that leave the spine are irritated or pinched. A common cause of compressive pain is a herniated disc. The nerves that leave the lower lumbar spine join to form the sciatic nerve. This nerve provides sensation and controls the muscles of the lower leg. Pressure or irritations on the nerve roots of the lumbar spine that come together to form the sciatic nerve can interfere with the normal function of the sciatic nerve. One of the earliest signs of pressure on a nerve root is numbness in the area supplied by the nerve. Pain is commonly felt in the same area, extending from the knee to the foot. In cases where there is pressure on a nerve root as it comes out of the spine, it is not unusual for the back to be painless. This can sometimes be confusing since there is no back pain, but the problem is in the lumbar spine. Finally, the muscles that the nerve controls may become weak, and the reflexes may disappear. This is because the pressure on the nerve roots interferes with the signals from the brain to the muscles. No signal goes from the brain to the muscle to tell it to contract.
Spinal stenosis can also cause compressive-type pain. In some people, spine degeneration can result in a narrowing of the spinal canal—the skinny tube where the spinal nerves are located. This causes all of the nerves within the spinal canal to become inflamed and fail to work correctly. One problem when the tube is too small is that the nerves can not get enough blood supply to work correctly. The nerves may be expected when the body is at rest, but once it is active, it needs more blood flow to get more oxygen. If the tube is too tight, the blood supply cannot increase. One of the symptoms of this cause is numbness. It may be in one or both legs. The numbness may become worse with activities. The pain can involve both of the lower extremities. The pain worsens on walking and gets better after short rest periods. Weakness of the muscles of both legs may also occur, and again, this may get worse when activity increases.
In very few cases, a disc herniation can be so significant that it fills the entire spinal canal. The immediate pressure on the nerves in the spine may cause paralysis of the muscles that control the bowels and bladder. When control over the bowels or bladder is lost, it is better to contact the physician immediately. If any of the following accompanies the back pain, the doctor should be consulted:
• Weakness or numbness in one or both legs.
• Pain going down one leg below the knee.
• Back pain from a fall or injury.
• Back pain accompanied by fever.
• Pain that continues to interrupt sleep after three nights.
• Back pain that remains after six weeks of home treatment.
DIAGNOSIS
To enable the doctor to diagnose the problem correctly, a complete history of back pain should be provided. The doctor may ask several questions as listed below:
• What are the symptoms?
• What kinds of aches or pains?
• Where exactly is the pain?
• Where is the pain the most severe?
• When did the pain begin?
• How long it lasts?
• Did something specific cause back pain, such as an accident or injury?
• What home treatments are undertaken?
• Was there any additional stress when the pain began?
• Is there any other health problems?
• What kind of work does the patient do?
• Types of recreational activities in which the patient participates?
Next, the doctor will make a clinical/physical examination. During this, the doctor may perform any of the following:
• Observe the muscles and joints.
• Ask to sit and lie down.
• Ask to move the back in different positions.
• Observe the most painful area.
• Check if other body areas are tender or painful (such as the kidneys, intestines, or other organs).
If the doctor can identify the likely cause of the back pain, at this point, no further tests will be needed. If the doctor needs more specific information, the following tests may be advised:
X-RAY
Studies show that X-rays may not initially be necessary in many cases of recurring back pain. However, the signs and symptoms will determine what type of study should be done. In some instances, X-rays might indicate that the pain is due to:
• Injury in one or more of the backbones.
• A tumour in the spine.
• A deformity in the spine.
• Ankylosing spondylitis.
CAT SCAN (COMPUTERIZED AXIAL TOMOGRAPHY)
Only a few people with lower back pain need a CAT scan. If the doctor advises one, a particular machine takes an X-ray scan of the area. A computer turns this scan into a three-dimensional view of the back. This helps the doctor see if a ruptured disc can’t be seen on regular X-rays; a CAT scan also helps detect spinal cord stenosis, tumours and infections.
MRI (MAGNETIC RESONANCE IMAGING)
MRI is another way to make clear pictures of parts of the spine. The MRI does not use X-rays or radioactive dyes. It can provide more explicit pictures of soft tissues such as muscles, cartilage, ligaments, tendons, blood vessels, and bone structure. The body must be moved slowly through a tube containing mighty magnets in the machine’s centre to take an MRI picture. People who are claustrophobic or whose bodies contain certain kinds of metal objects may not be able to tolerate the procedure.
The MRI scanner shows the nerves and disc quite clearly. No special dyes or needles are necessary. The MRI scan is, perhaps, too good at showing the anatomic details of the spine. A growing body of evidence suggests that not all abnormalities that show up on the MRI scan are the cause of the individual patient’s problem related to back pain. Abnormalities, such as bulging discs, appear frequently in average persons who have never had back problems. Hence, it should be remembered that an MRI scan is a great test to show the lumbar spine anatomy and must be correlated carefully with the symptoms so that the findings aren’t blown out of proportion.
TYPES OF BACK PAIN
Back pain may be acute (generally severe and short-lived), subacute or chronic (long-lasting or occurring often).
ACUTE BACK PAIN
• Pain usually lasts from one to seven days.
• Pain may be mild or severe.
• An accident or injury may occasionally cause pain.
• About 80 per cent of all back pain is acute.
SUBACUTE BACK PAIN
• Pain usually lasts from seven days to seven weeks.
• Pain usually is mild and occasionally severe.
• Pain generally is unrelated to other illnesses.
• About 10 to 20 per cent of all back pain is subacute.
CHRONIC BACK PAIN
• Pain usually lasts more than three months.
• Pain may be mild or severe.
• Pain may be related to other illnesses or have no identifiable cause.
• About five to 10 per cent of all back pain is chronic.
STRUCTURE OF BACK
The back is held upright by muscles attached to the backbone. Doctors often refer to the backbone as the spine, spinal column, or backbone and find the discs between each vertebra. These discs are made of cartilage, which is a soft, elastic material. Discs act as cushions or shock absorbers. Their main job is to protect the joints from wearing out. Most joints contain a slippery synovial fluid that keeps them moving smoothly. The spinal cord is essential because it transmits electrical signals between the brain and the nerves in the legs, arms, back and other body parts. The spinal cord runs through a hole in each vertebra of the upper and middle parts of the backbone, much like a piece of string through a beaded necklace. The space it runs through is called the spinal canal. At times, a message might cause pain or discomfort. The pain signal is important because it tells that some body part needs attention.
A severe neck or upper back injury risks damaging the spinal cord, causing paralysis of the parts of the body below the injury. It should be noted that the spinal cord is not present in the lower part of the backbone. Here the spinal canal contains a sack of nerves, the cauda equina. The backbone, with all its parts, cannot hold itself upright. It needs strong muscles, tendons, and ligaments for support. Muscles help to move or hold the position. Tendons fasten muscles to bones, and ligaments stretch from one bone to another to hold bones together.
MYELOGRAM
During a myelogram, a special liquid dye called a contrast medium is injected into the spinal canal then X-rays are taken of the area. The contrast medium can make problem areas appear more clearly on the X-ray. A myelogram may be ordered to detect problems such as spinal stenosis or spinal cord tumours. If surgery is being considered, particularly for a person with a severe back injury, many neurosurgeons will require a myelogram beforehand.
BONE SCAN
During a bone scan, a minimal amount of radioactive liquid is injected into a vein that concentrates in the bones briefly. A particular radioactive detecting machine scans the area of concern to produce a picture. Occasionally, bone scans look for damage or tumours in the bones themselves. However, back pain is rarely due to diseases of the bones.
ELECTRODIAGNOSTIC STUDIES
Electrodiagnostic studies are used to help confirm the presence of nerve compression in the spine. An electrodiagnostic study consists of two tests. One is an electrical test, which is designed to study nerve conduction. In this test, the nerve is given an electrical stimulation, and the speed of the impulse is measured. The other test is a needle test called an electromyogram, or EMG. This test aims to study the muscles for primary disease or the effect of nerve compression on the muscle. The compression is especially seen in herniated discs or spinal stenosis.
BLOOD TESTS
If the doctor orders blood tests, a laboratory technician will carefully draw a small amount of blood from a vein in the arm, which will be tested in the laboratory. Anyone of the following blood tests may be advised:
• Erythrocyte sedimentation rate (sed rate)
• Haematocrit and haemoglobin
• White blood cell count
• HLA B-27 test
• Chemical profile (SMAC)
TREATMENT
Back pain treatment ranges from simple reassurance that nothing is wrong to extremely delicate surgery. Each case is different, and treatment must be individualized to meet the circumstances. Treatment falls into two major categories:
Conservative treatment includes exercise, medications, physical therapy and other non-operative therapy. Surgical treatment includes laminectomy, diskectomy and spinal fusion in selected conditions.
Treatment for any back condition should involve two goals:
• To relieve the immediate problem.
• To reduce the risk of re-injury.
Exercise plays a vital role in achieving both of these goals. More than 85 per cent of people with lower back pain improve with minimal treatment in a matter of days. However, if back problems persist, doctors generally prescribe one or more treatments. For some back conditions, the doctor may refer the patient to another specialist such as an orthopedist, rheumatologist, physical or occupational therapist, psychologist, psychiatrist or surgeon.
REST
The most common treatment doctors recommend for severe back pain is bed rest. Different people require different amounts of rest. Usually, two to three days of staying in bed, except to go to the bathroom, will be enough to ease the back pain. The doctor may be consulted to know if special pillows or devices are necessary to support the neck, back, or feet.
HEAT AND COLD
Many people have found that hot and cold treatments help relieve back pain. It is advisable to try both to find out which of the two works best.
Heat relaxes muscles and soothes painful areas. There are many ways to apply heat. Some people like hot showers or baths, while others prefer heat lamps, heating pads or warm compresses. For persons having arthritis, heating the muscles first might make it easier to do back exercises. Care should be taken not to fall asleep while using heat.
Cold has a numbing effect. This often helps relieve pain. One of the following methods may be tried for applying cold:
• An ice bag
• A large ice cube used to massage the area
• Frozen package of vegetables (peas work best)
• A commercially made cold pack
Be sure not to leave ice on after the skin becomes numb, which could lead to localized frostbite. Persons sensitive to ice or having decreased circulation or sensation should not use cold treatment.