Low Back Pain

Dr (Maj) Pankaj N Surange

MBBS, MD, FIP

Interventional pain and spine specialist

Back pain is a problem which is very often faced by all the human beings at least once in their lifetime. This pain, if not taken seriously can turn in to a deadly disease which can put your life at stake.

Some Important Facts about back pain

· Low back pain is the most common musculoskeletal complaint, with potentially devastating consequences.

· 90% of patients with acute low back pain do not require surgery. Most specialists agree that non-surgical treatment should be tried first.

· Surgery as first line treatment is indicated only in few selected cases. These are medical emergencies such as a broken neck or if you have symptoms such as weakness in the legs that gets progressively worse and/or bladder and/or bowel incontinence caused by the back problem.

· The incidence of back pain is highest between the ages of 35 and 55.

· Disc is not always the culprit. Small joints of spine are the source of pain in majority of patients.

· The pain combined with depression and anxiety in long-term cases places sufferers at risk for suicide.

· People who work at sedentary occupations are at a higher risk of disk injury than those who do moderate amounts of physical work.

· Up to 85 per cent of persons with back pain can’t recall a specific incident that brought on their pain.

· Early interventional treatments in Back pain management have been found to return patients to work and regular activities more rapidly than past conservative therapies.

· Early intervention decreases unnecessary chronic pain, long-term treatments and disabilities.

· Heat and massage therapy cannot cure the disease. These do not provide long term solutions to the problems of back. These are mainly used for managing pain during the recovery period.

Important Causes of back pain

The most common causes of low back pain are:

· Injury or overuse of muscles, ligaments, facet joints, and the sacroiliac joints.

· Pressure on nerve roots in the spinal canal. Nerve root compression can be caused by:

o A herniated disc, often brought on by repeated vibration or motion (as during machine use or sport activity, or when lifting improperly), or by a sudden heavy strain or increased pressure to the lower back.

o Osteoarthritis (joint degeneration), which typically develops with age. When osteoarthritis affects the small facet joints in the spine, it can lead to back pain. Osteoarthritis in other joints, such as the hips, can cause you to limp or to change the way you walk. This can also lead to back pain.

o Spondylolysis and spondylolisthesis, vertebra defects that can allow a vertebra to slide over another when aggravated by certain activities.

o Spinal stenosis, or narrowing of the spinal canal, which typically develops with age.

o Fractures of the vertebrae caused by significant force, such as from an auto or bicycle accident, a direct blow to the spine, or compressing the spine by falling onto the buttocks or head.

o Spinal deformities, including curvature problems such as severe scoliosis or kyphosis.

· Compression fractures. Compression fractures are more common among postmenopausal women with osteoporosis, or in men or women after long-term corticosteroid use. In a person with osteoporosis, even a small amount of force put on the spine, as from a sneeze, may cause a compression fracture.

Less common spinal conditions that can cause low back pain include:

· Ankylosing spondylitis, which is a form of joint inflammation (arthritis) that most often affects the spine.

· Bacterial infection. Bacteria are usually carried to the spine through the bloodstream from an infection somewhere else in the body or from IV drug use. But bacteria can enter the spine directly during surgery or injection treatments, or as the result of injury. Back pain may be the result of an infection in the bone (osteomyelitis), in the spinal discs, or in the spinal cord.

· Spinal tumors, or growths that develop on the bones and ligaments of the spine, on the spinal cord, or on nerve roots.

· Paget's disease, which causes abnormal bone growth most often affecting the pelvis, spine, skull, chest, and legs.

· Scheuermann's disease, in which one or more of the bones of the spine (vertebrae) develop wedge-shaped deformities. This causes curvature of the spine (rounding of the back, or kyphosis), most commonly in the chest region

Newer Developments and Better Understanding in Management of Back pain

A wide range of treatment is available for low back pain, depending on what is causing the pain and how long it lasts. Most people find that their low back pain improves within a few weeks. Chances are good that your pain will go away soon with some basic self-care.

· If you have recently developed low back pain, stay active and consider taking over-the-counter pain medicines .

· Staying active is better for you than bed rest. In fact, staying in bed more than 1 or 2 days can actually make your pain worse and lead to other problems such as stiff joints and muscle weakness.

· If your low back pain has lasted longer than 3 months, you will probably benefit from more intensive treatment.

· Must visit Interventional pain and spine specialist :-

· if you have moderate to severe low back pain that lasts more than a couple of days;

· if you have back or leg symptoms that have gotten worse;

· if your symptoms have not gone away after 2 weeks of home treatment;

· or if improved symptoms flare up again.

· A physical examination by pain specialist and possibly an imaging(x-ray/MRI) test may produce new information about your condition and help direct your treatment decisions.

· Physical Therapy: TENS, Ultrasound, Heat and Cryotherapy:

o These Modalities should always be considered an adjunct to an active treatment program in the management of acute low back pain.

o They should never be used as the sole method of treatment.

Interventions: Minimally invasive non surgical procedures for management of Back Pain

For back pain sufferers, interventional pain management techniques can be particularly useful. In addition to a thorough medical history and physical examination, interventional pain management physicians have a wide array of treatments that can be used including the following:

Epidural injections (in all areas of the spine):

The use of anesthetic and anti-inflammatory medications injected into the epidural space to relieve pain or diagnose a specific condition.

Nerve, root, and median branch blocks:

Injections done to determine if a specific spinal nerve root is the source of pain. Blocks also can be used to reduce inflammation and pain.

Facet joint injections:

An injection used to determine if the facet joints are the source of pain. These injections can also provide pain relief.

Discography:

An "inside" look into the discs to determine if they are the source of a patient's pain. This procedure involves the use of a dye that is injected into a disc and then examined using x-ray or CT Scan.

Pulsed Radiofrequency Neurotomy (PRFN):

A minimally invasive procedure that disables spinal nerves and prevents them from transmitting pain signals to the brain.

Rhizotomy:

A procedure in which pain signals are "turned off" through the use of heated electrodes that are applied to specific nerves that carry pain signals to the brain.

Spinal cord stimulation:

The use of electrical impulses that are used to block pain from being perceived in the brain.

Intrathecal pumps:

A surgically implanted pump that delivers pain medications to the precise location in the spine where the pain is located.

Percutaneous Discectomy / Nucleoplasty:

A minimally invasive day care procedure in which tissue is removed from the disc with the help of decompressor through a very minute hole ,in order to decompress and relieve pressure on the spinal nerves.

Ozoneucleolysis or Ozone discectomy:

Has emerged as an affordable, least invasive approach and costs 2/3 of the price of conventional surgery. Ozone injected inside the affected intervertebral disc under c- arm guidance, causes shrinkage of disc and thus reducing the volume and lessening the pressure on nerves.

Intradiscal Electrothermoplasty (IDET)
This procedure involves the insertion of a needle into the affected disc with the guidance of an x-ray machine. A wire is then threaded down through the needle and into the disc until it lies along the inner wall of the annulus. The wire is then heated which destroys the small nerve fibers that have grown into the cracks and have invaded the degenerating disc.

These techniques are exciting. They offer the possibility of treating low back pain and sciatica with much less trauma and risk than surgery.

Quick tips to a healthier back

· Following any period of prolonged inactivity, begin a program of regular low-impact exercises.

· Speed walking, swimming, or stationary bike riding 30 minutes a day can increase muscle strength and flexibility.

· Yoga can also help stretch and strengthen muscles and improve posture

· Always stretch before exercise or other strenuous physical activity.

• Don’t slouch when standing or sitting. When standing, keep your weight balanced on your feet. Your back supports weight most easily when curvature is reduced.
• At home or work, make sure your work surface is at a comfortable height for you.
• Sit in a chair with good lumbar support and proper position and height for the task. Keep your shoulders back. Switch sitting positions often and periodically walk around the office or gently stretch muscles to relieve tension. A pillow or rolled-up towel placed behind the small of your back can provide some lumbar support. If you must sit for a long period of time, rest your feet on a low stool or a stack of books.
• Wear comfortable, low-heeled shoes.
• Sleep on your side to reduce any curve in your spine. Always sleep on a firm surface.
• Ask for help when transferring an ill or injured family member from a reclining to a sitting position or when moving the patient from a chair to a bed.
• Don’t try to lift objects too heavy for you. Lift with your knees, pull in your stomach muscles, and keep your head down and in line with your straight back. Keep the object close to your body. Do not twist when lifting.
• Maintain proper nutrition and diet to reduce and prevent excessive weight, especially weight around the waistline that taxes lower back muscles.
• If you smoke, quit. Smoking reduces blood flow to the lower spine and causes the spinal discs to degenerate.