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LOW BACK PAIN

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Low back pain is the most common musculoskeletal disorder and the most common reason for patients to seek medical attention after the common cold. It is the #2 cause of missed work and the #1 cause of disability in patients younger than 45. Four out of five people will experience back pain in their lives. 

 

SEVERITY OF BACK PAIN

 

There are many risk factors which include smoking, posture, genetics, body habitus, and work conditions. Previously, surgical decompression and fusion of the spine has been the default option for such patients. However in the recent years, patients have the option of minimally invasive percutaneous spinal procedures likened to angioplasty of heart vessels, done as day surgery with less side effects or complications. Ironically, the severity of the pain is often unrelated to the extent of physical damage. Muscle spasm from a simple back strain can cause excruciating back pain that can make it difficult to walk or even stand, whereas a large herniated disc or completely degenerated disc can be completely painless. Muscle sprain may often mimic nerve impingement symptoms, presenting with back pain and `nerve root' leg pain. The causes of low back pain can be very complex, and there are many structures in the lower back that can cause pain.

 

CAUSES AND TREATMENT OF LOW BACK PAIN

 

The following are possible sites and mechanisms of low back pain:

 

Non-mechanical back pain

 

This accounts for 60% - 70% of all acute back pain. As this term describes, it is not a structural problem requiring surgery.  It refers to either muscles or ligaments.

 

Acute muscle sprain or injury can be secondary to either acute loading or repetitive strain. Poorly conditioned muscles undergoing a particular action that it is not used to. For example, lifting a heavy luggage during a holiday, can result in acute pain. Fortunately most of these are self-limiting and 90% of them will recover in 2 weeks. Medications and increased exercise tolerances form the cornerstone of treatment. On the contrary, studies have shown that excessive bed rest and avoidance of movement may be counter-productive for the back pain. Other chronic disorders of the muscle, fascia, ligaments, and supporting structures include: 
 

 

Myofascial pain syndrome and Fibromyalgia . They often appear as stiffness of muscle with localized or radiating pain in the legs or arms. Numbness may even be the predominant symptoms. These types of pain can be extremely disabling. Significant risk factors include female gender, stress, hormonal disorder and deconditioned muscles. Local injection of Botox or steroid into the trigger points can provide good relief.
 

 

Mechanical back pain

 

The remaining 30% - 40% may be treated with minimally invasive pain procedures/injections as an alternative to open surgery. These structural problems may even require open surgery to correct those very severe mechanical nerve compression.
 

 

1. Fractures of the vertebral body Compression fractures of the vertebral body can result in loss of height and additional stress on the surrounding facet joints.

 

2. Impingement of spinal nerve roots This impingement may be due to protruding disc or enlarging facet joints, encroaching into the spinal canal, resulting in narrowing of the space (spinal stenosis) and nerve entrapment. 
For patients who are afraid of surgery or not a candidate for open surgical decompression, we can offer canal scar lysis and ballooning of the spine or endoscopic needles to burr and file the bone spur. This will dilate and open up space for the surrounding impinged nerves.


 

3. Intervertebral Disc It may be a disc herniation or slipped disc, resulting in protrusion of disc material into the spinal canal, causing nerve irritation and impingement. Treatments which are minimally invasive, interventional pain procedures include Disc Decompression . These procedures may use a spinal laser wand to enter the disc and vaporize 1ml of the disc, generating 1cc of vacuum. This vacuum will shrink and draw the bulging disc inward, relieving the pressure effect on the impinged nerve. Alternatively, we can use endoscopic ports/needles to suck and extract larger herniated slipped disc.

 

4. Facet Arthropathies/Spondylosis

 

Facetal pain can be secondary to acute inflammation or degeneration. Additional physical stress may pose on the facet joints if it is compounded with scoliosis or kyphosis of the spine. Radiofrequency ablation of the painful nerves can give relief to patients who do not want to undergo surgery on their spine.

 

TYPES OF LOWER BACK PAIN THAT INDICATE A SURGICAL EMERGENCY

 

There are a few symptoms that are possible indications of a serious medical condition requiring surgery, and patients with these symptoms should seek medical attention immediately. These symptoms include:
 

 

- Sudden bowel and/or bladder incontinence (cauda equina syndrome)
 

- Progressive weakness in the legs (cauda equina syndrome)
 

- Serve, continuous abdominal and low back pain (possible abdominal aortic aneurysm)
 

- Fever and chills (those who have a history of cancer with recent weight loss, or who have just suffered a severe trauma should also seek immediate medical attention). 
 

 

OTHER THERAPIES

 

Many doctors may recommend physiotherapy. The therapist will perform an in-depth evaluation; which combined with the doctor's diagnosis, will dictate a treatment specifically designed for patients with lower back pain. This may include pelvic traction, gentle massage, ice and heat therapy, ultrasound, electrical muscle stimulation, and stretching exercises. Pain medication and muscle relaxants may also be beneficial in conjunction with the physical therapy.

 

MEDICATIONS

 

Mild to moderate back pain is commonly treated with nonsteroidal anti-inflammatory drug (NSAID), such as Nurofen . This first line of medication is useful as it has both anti-inflammatory effects as well as analgesic properties. Nurofen has the longest history for its use in low back pain treatment with good effectiveness and minimal side effects.
 

They should be taken early  once the back pain sets in. After the first 24 to 48 hours of medication, returning to normal activities as tolerated is advisable. These medications should reduce inflammation and reduce the pain. Concurrently, the use of ice packs and compression (pressure) massage, together with limited bed rest is useful in reducing pain and spasm. In severe back pain, other medications such as morphine/tramadol and anti-convulsant drugs may be added to alleviate the pain. 
 

 

OTHER THERAPIES

 

Many doctors may recommend physiotherapy. The therapist will perform an in-depth evaluation; which combined with the doctor's diagnosis, will dictate a treatment specifically designed for patients with lower back pain. This may include pelvic traction, gentle massage, ice and heat therapy, ultrasound, electrical muscle stimulation, and stretching exercises. Pain medication and muscle relaxants may also be beneficial in conjunction with the physical therapy.
 

 

PROGNOSIS

 

The prognosis is excellent for a complete recovery from a lumbar strain or sprain injury.  More than 90 percent of patients completely recover from an episode of lumbar muscle strain or sprain within one month. Heat and ice treatment are indicated on an as needed basis at home to treat sudden flare-ups of low back pain, along with anti-inflammatory medications, such as Nurofen. 
 

 

In refractory persistent low back pain, one should seek a specialist who will look deeper into the different causes of low back pain, to arrive at a better diagnosis. These can be treated to avoid developing into a chronic pain condition.


Source: Prime Magazine Aug - Sep 2017 Issue. Reproduced with permission.


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