Back pain is the leading cause of loss of people to miss work and also the leading cause of disability worldwide. In the vast majority of cases, the cause of back pain is trivial and settles in a few days or weeks at most. Most people do not even need to see the doctor and analgesia along with physiotherapy help to alleviate symptoms, while long term exercises to strengthen the muscles of the back and core along with weight loss (if obese) prevent recurrences.
Back pain often develops without a precipitating cause and is not always identified on a diagnostic test. However the most common causes are listed below
o Muscle and Ligament strain: This is the most common cause of back pain. Can be caused by fairly trivial actions like bending down to pick up a piece of paper or sitting awkwardly for a few hours or sometimes while trying to lift heavy weights when untrained, unfit and unsupervised. Most symptoms ease with rest and analgesia
o Degenerative disc disease: Discs are fibro-cartilaginous pads that are positioned between each vertebra. They have a fibrous outer ring and a gelatinous middle (much like a filled donut) and help in the forward, backward and side to side bending of the spine. They also like shock absorbers, protecting against sudden jolts while walking or running and with the tough ligaments that run along it, help hold the spine together. With use and age this disc morphology changes from the usual tri-lamellar pattern (the MRI appearance of which is like a light grey sandwich with a dark centre) to a uniform dark grey/black appearance. This can happen gradually over time resulting in back pain (though the exact origin of the pain remains unclear as to whether this arises from the disc or the surrounding structures especially the facet joints at the back) or as an acute episode where the outer rim of the disc ruptures causing the ‘jelly’ to escape into the spinal canal – referred to as a herniated disc or a slipped disc. This compresses the nerves as they leave the spinal canal (the space within the vertebrae through which the spinal cord along with its nerves and coverings pass) causing pain in the legs (loosely referred to as ‘sciatica’) or arm pain (brachalgia). Degenerate discs can over time lead to a permanent sideways ‘bend’ in the spine called adult-onset scoliosis, or along with hypertrophy (increase in size, usually due to arthritis) of the facets (articulations between two vertebrae at the back of the spine) cause a gradual decrease in the diameter of the spinal canal, squeezing the nerves as they journey downwards ie spinal canal stenosis. This usually presents with claudication- difficulty in walking for any length of time without having to stop because of pain in the legs. In extreme circumstances, there is a slippage of one vertebra over another causing severe back pain with the occasional leg pain and claudication. This is called spondylolisthesis which is the most severe form of degenerative spine disease.
These are the times when you need to see the doctor :
The risk factors for backache include :
Back pain may be prevented or significantly reduced by simple day to day activities
Reg Spine Surgery :
A herniated or a slipped disc is caused by the protrusion of the discs in the spine, or by the acute rupture of the outer fibrocartilaginous ring allowing the gel-like center to escape into the spinal canal. Signs and symptoms depend on the level at which the disc is ruptured, the exact location of rupture (whether it is central or to one side), the size of the rent and the space available within the spinal canal. Ruptured discs and true disc herniation is a disease of the young, while the older patients normally present with the other forms of degenerative spine disease.
Every year, approximately 2% of the population will suffer from a herniated disc. Disc herniation is twice as common in men as compared to women and is the most common cause of pain radiating down the arm or the leg. Risk factors for herniated discs include :
The signs and symptoms for a herniated disc varies on several factors- the mobile areas of the spine ie the neck and the lower back are more prone to disc protrusion than the thoracic spine (the upper back) that is relatively immobile as it articulates with the ribs in front.
Back or lumbar spine:
A typical acutely ruptured lumbar disc will cause a sharp sudden pain in the back that radiates down the leg. As rupture of the L4/5 and L5/S1 discs are more common, pain usually radiates down the back of the leg into the foot. There may be numbness in the area that is supplied by that nerve root or at times, a tingling numbness. Sometimes, severe pressure on the nerve root at the L4/L5 disc level may cause a foot-drop or the inability to lift the foot off the floor by dorsiflexing the ankle. This along with retention of urine, incontinence of either urine or stool or numbness in the genital area this constitutes a neurosurgical emergency and must be seen by a doctor immediately.
Neck or cervical spine:
Acute ruptured discs in the neck will present with neck pain and a sharp, severe shooting pain that radiates into the arm. There may be tingling or numbness in the area supplied by the nerve root. If the compression is severe it may cause weakness of the shoulder, elbow or wrist. In extreme cases it may cause weakness of all four limbs along with bowel and bladder symptoms which constitutes a neurosurgical emergency and needs to be seen by a doctor almost immediately.
The common investigation for the diagnosis of disc disease are
Spinal disc protrusion is not a life threatening disease and so in the vast majority of cases, intervention is required other than rest and analgesics. Long term treatment will include controlling the precipitating factors- cessation of smoking, reduction of weight, core and back strengthening exercises and correction of posture, especially while working at the desk for long hours.
Non steroidal anti-inflammatory drugs like Ibuprofen, Etoricoxib or Aceclofenac when combined with a muscle relaxant like Thiocolchicoside usually works for the pain. This can be combined with rest and some pain relieving physiotherapy. In cases where there is a predominance of electric shock like shooting pain that affects the limbs Gabapentin or Pregabalin may help. A lot of patients with chronic back pain are depressed and an antidepressant must be considered in these patients.
Physiotherapy has two distinct roles in back pain- one in the reduction of pain where hot fomentation, Interferential therapy and Ultrasound help and the other in building of a strong core- where isometric exercises are most useful. Exercises must only be started when the pain subsides as exercising with the pain is often counterproductive. The initial period of exercise is often uncomfortable as so patients may need to take analgesics for the first few days.
Spinal injections, especially epidurals have a role in reducing back pain. This is usually an injection of a locally acting steroid. At times a local anaesthetic can be used, but that has to be done with caution. For pain that is radiating down the arm or the leg a root block may be useful. This is done under local anaesthesia and involves injecting a local anesthetic/ steroid mixture to numb the root and get rid of the inflammation.
If conservative therapies fail or if there are complications related to spinal cord or nerve compression, removal of the disc may be the only option. In the neck, discs can be approached from the front of the neck with a collar line incision. The dissection to the front of the spine is fairly atraumatic and standard practice. The disc is removed, the root or spinal cord is decompressed and usually a ‘spacer’ is placed in place of the disc. If only the root needs decompressing, and the disc is thought to be calcified, a foraminotomy can be done by an approach from the back of the neck. A laminectomy for a disc protrusion is rarely done these days.
In the thoracic and lumbar spine, the approach for a disc is almost always from the back and a small incision is placed. Discs are usually removed either endoscopically or microscopically, with there being very little difference between the two, if performed in the best hands. In many instances, these are now being performed as day cases, or at most involve an overnight stay. This is a disease of the young and going back to a normal life post surgery is pretty common, as long as there are no preoperative neurological deficits.
Spinal canal stenosis is a condition where there is a decrease in the diameter of the spinal canal (the space within each vertebra through which the spinal cord passes) that is limited by the vertebral body in front, the spinal lamina and the spinous processes at the back and the facet joints (articulating joints with the vertebra above) at the sides. Stenosis is usually multifactorial and is caused by a combination of pathologies- chronic degenerative protrusions of the discs backward into the spinal canal along with osteoarthritis, hypertrophy and inflammation of the facet joints and thickened ligaments. At times, degenerative bony spurs are also formed causing further narrowing of the spinal canal.
Spinal canal stenosis is rare before the age of fifty. It may be asymptomatic when nothing needs to be done, and this is usually seen in people who are genetically blessed with a capacious spinal canal. It is commonly seen in patients who are unfit and obese and have had a long history of back pain and is a ‘wear and tear’ disease. In parts of India, where fluorosis is rampant, spinal canal stenosis is seen often. This is due to the Ossification ( bone formation) of the Posterior Longitudinal Ligament (referred to as OPLL), though this condition is also seen without fluorosis.
The characteristic feature of spinal canal stenosis is a cramping pain while walking that settles on sitting or lying down or even leaning forward. Patients also complain of a heaviness or numbness and pins and needles in the legs while walking. At times there may be a sharp shooting pain (sciatica) that mimics acute disc prolapse.
Spinal canal stenosis of the cervical or thoracic spine, if symptomatic, will almost invariably lead to weakness of one or more limbs. Patients complain of pain in their arms, weakness in their arms, difficulty in walking and in extreme cases quadriparesis or weakness of both arms and legs. Quadriparesis is a neurosurgical emergency and needs to be seen by a doctor as soon as possible. There is a growing body of evidence that suggests that patients who have decompression sooner have a better chance of recovery.
The common investigation for the diagnosis of disc disease are
Spinal stenosis is not a life threatening disease but can significantly alter lifestyle. In asymptomatic cases nothing needs to be done, or in cases where minor changes in lifestyle alleviates symptoms. However, if there is significant limitation of lifestyle or signs of compression of the spinal cord, decompression of the spinal cord is indicated.
Non steroidal anti-inflammatory drugs like Ibuprofen, Etoricoxib or Aceclofenac when combined with a muscle relaxant like Thiocolchicoside usually works for the pain in the neck or the back. Gabapentin or Pregabalin may help with shooting pain in the arms and legs but almost all these therapies are symptomatic and do not treat the cause.
Physiotherapy has two distinct roles in spinal canal- one in the reduction of back pain before surgery where hot fomentation, Interferential therapy and Ultrasound help and the other in assisting mobility in patients who are unable to walk. The latter is usually started after surgery and is fundamental in improving surgical outcomes.
Spinal injections, especially epidurals (space between the lamina of the vertebra and the dural sac) have a limited role in reducing back pain and cannot be used in patients with cervical canal stenosis for fear of quadriparesis. But in severe lumbar spinal canal stenosis epidural injections carry significant risk. For pain that is radiating down the arm or the leg a root block may be useful. This is done under local anaesthesia and involves injecting a local anesthetic/ steroid mixture to numb the root and get rid of the inflammation. Root blocks and epidurals are usually limited to patients who cannot undergo surgery or are bed bound.
Surgery remains the only option to treat the cause of the stenosis and increase the diameter of the spinal canal. In the lumbar spine this is usually done from the back through a decompressive operation where the lamina of the vertebra is removed entirely (laminectomy), the lamina are scored and opened ( much like opening a book) and fixed in the new decompressed position (laminoplasty). If the compression is deemed to be more to the sides only the existing nerves are decompressed through a foraminotomy (the ‘foramina’ through which the nerves escape are enlarged). Depending on the sagittal alignment, the amount of instability (movement of one vertebra on another) this decompression may be augmented with a fixation- by the use of screws and cages in the lumbar spine. In the cervical spine, this operation from the back is usually a laminectomy or laminoplasty augmented by lateral mass screws. At times the compression is limited to one or two segments of the cervical spine. In the young, this can be dealt with from the front of the neck where the entire vertebral body is removed and replaced with a cage. In certain scenarios, this may have to be augmented with a posterior fusion and decompression by doing a laminectomy and a lateral mass fixation also known as a 360-degree fusion. While the basis of performing the operation remains the same, there are now minimally invasive techniques using microscopes, endoscopes and tubes that may be used to decrease the postoperative recovery period.
Spondylolisthesis can be defined by the slippage of one vertebrae on another. The term spondylosis, though sometimes used interchangeably with spondylolisthesis, is a defect in the spine where the posterior arch ( the pars interarticularis) is either congenitally absent or fractured, which may be a feature of spondylolisthesis.
The major causes of spondylolisthesis include
Spondylolisthesis may occur in 4-6% of the adult population and a majority may be asymptomatic or have very minor symptoms.
Risk factors include
A large proportion of cases are asymptomatic or have minor symptoms. Back pain is the most common symptom. This is aggravated while working or, in severe cases, while standing or walking. Some, especially athletes, complain of tightness in the hamstrings and spasm in the back. A small percent of patients with severe spondylolisthesis present with functional spinal canal stenosis ( as the vertebra slips the diameter of the spinal canal between the vertebrae is reduced), that usually presents with claudication. At times, pain may be due to the direct pressure on a nerve root that presents with sciatica. Bowel and bladder symptoms due to spondylolisthesis is a very rare occurrence and is seen in traumatic spondylolisthesis that is usually accompanied with severe neurological deficits.
The common investigation for the diagnosis of disc disease are
Spondylolisthesis is not a life threatening disease and so in the vast majority of cases, no intervention is required other than rest and analgesics. Long term conservative management mimics the treatment of degenerative back pain and will include controlling the precipitating factors including weight, rest and the use of spinal braces. Back and core strengthening exercises along with stopping smoking also go a long way in reducing the frequency and intensity of the painful episodes.
Non steroidal anti-inflammatory drugs like Ibuprofen, Etoricoxib or Aceclofenac when combined with a muscle relaxant like Thiocolchicoside usually works for the pain. However, these must be avoided in the long term as this may affect the kidneys. If there is pain that radiates into the buttock, leg or foot, gabapentin or pregabalin may help in the short term. A lot of patients with chronic back pain are depressed and an antidepressant may be considered in patients with refractory pain.
Physiotherapy has two distinct roles in back pain- one in the reduction of pain where hot fomentation, Interferential therapy and Ultrasound help and the other in building of a strong core- where isometric exercises are most useful in all conditions of the back. Exercises must only be started when the pain subsides as exercising with the pain is often counterproductive. The initial period of exercise is often uncomfortable as so patients may need to take analgesics for the first few days. Bracing and the use of a well fitted lumbar corset may help with the pain, though biomechanically it makes very little impact.
Spinal injections, especially epidurals have a role in reducing back pain. This is usually an injection of a locally acting steroid. At times a local anaesthetic can be used, but that has to be done with caution. For pain that is radiating down the arm or the leg a root block may be useful. This is done under local anaesthesia and involves injecting a local anesthetic/ steroid mixture to numb the root and get rid of the inflammation.
If conservative therapies fail to control the pain, surgery may be the only option. Surgery often involves decompression of the spinal nerves and stabilization of the spine using a cage, rods and screws. In the majority of cases, this is done through an approach on the back of the spine, but at times an opening on the flank or the front of the abdomen may be required. Traditionally, the larger incisions for this procedure have been replaced by minimally invasive techniques that only entail much smaller stab incisions. The use of spinal robots have further improved the accuracy of the procedure.
Adult onset scoliosis is the abnormal sideways curvature of the bony spine that occurs after puberty. This is different from the scoliosis that affects children and young adults. The cause of adult onset scoliosis is degenerative spine disease where the vertebrae rotate and slip disrupting the almost vertical spinal axis.
Back pain is the most common symptom, though a percentage of patients will remain asymptomatic and the diagnosis is made incidentally. In some patients there may be a ‘hump’ at the back- but this is more common in adolescent scoliosis as the thoracic spine is usually not involved in adult onset scoliosis. In some patients there may be height loss due to the collapse of the vertebrae or weakness and numbness of the legs due to the pressure on the nerves as they exit the spinal foramina.
The common investigation for the diagnosis of disc disease are
Spinal disc protrusion is not a life threatening disease and so in the vast majority of cases, intervention is required other than rest and analgesics. Long term treatment will include controlling the precipitating factors- cessation of smoking, reduction of weight, core and back strengthening exercises and correction of posture, especially while working at the desk for long hours.
Pain is typically treated with non-steroidal anti-inflammatory medicines like Ibuprofen, Etorcoxib, or Aceclofenac in combination with a muscle relaxant like Thiocolchicoside. Rest and a little physiotherapy for pain relief can be added to this. Gabapentin or Pregabalin may be beneficial in situations when there is a predominance of electric shock-like shooting pain that affects the limbs.
Physiotherapy has a distinct role in back pain- where hot fomentation, Interferential therapy and Ultrasound help. A combination of this along with rest and analgesia are usually enough to tide over acute exacerbations of pain.
Spinal injections especially epidurals have a role in reducing back pain alone and is usually a mixture for a local anaesthetic and a steroid. Nerve or root blocks are effective for radiating sciatic type pain.
Even though surgery is not usually advised, some patients find the symptoms of their spinal deformity intolerable. Their spinal misalignment also has an impact on daily activities and general well-being. In some situations, surgery is the only solution. In younger persons, the cosmetic abnormality may play a significant role in the choice to have surgery, but this is typically not the case in older adults. Depending on the circumstances of each instance, there are many spinal surgery possibilities. Surgery is typically performed to stabilise the spine, regain balance, and release nerve pressure. In order to hold the spine in place, metal implants are placed after bone grafts are used to fuse the spine’s bones together.
In spine surgery