Uncategorized · December 21, 2020

Backache – Ignore or panic?

Dr. Rohit Bhayana

Independent International Healthcare Management Expert

MBBS – Pt BDS Postgraduate Institute, Rohtak

D.Ortho, DNB (Ortho)

MRCS – Royal College of Surgeons of Edinburgh

MBA – International Healthcare Management from Frankfurt, Germany

Dr. Rohit did his MBBS and Diploma in Orthopedics from Pt BDS Postgraduate Institute, Rohtak. During his DNB (Ortho) in Delhi, he was the Founder Chairman of the DNB doctors forum and helped in securing salaries for DNB postgraduates in Delhi. He went to the UK in 2005, working at various levels there, and secured his MRCS from the Royal College of Surgeons of Edinburgh. He chaired the Trent JDC wing of the British Medical Association and held a number of other medico-political positions at regional and national (UK) level. Thereafter he shifted his focus to broad-based healthcare concepts and did his MBA in International Healthcare Management from Frankfurt, Germany. Dr. Rohit has lectured and presented at multiple locations around the world including hospitals, healthcare establishments, and healthcare and management associated firms and academic institutions, in England, Scotland, Germany, India, Singapore, USA, Canada, UAE, Switzerland, etc. He did his research on Primary Healthcare – “Does the Primary Healthcare Sector in India need a complete changeover?” – drawing inspiration for India from healthcare sectors of about 35 countries in the world.
Currently, Dr. Rohit is an Independent International Healthcare Management Expert and is happily disseminating his knowledge and advice to various hospitals, peoples, society, and governments, as gratitude and giving back to society. His current interest is COVID-19 – it’s policy, lockdowns, research, and vaccination. He will be happy to answer your questions about these areas.

 

Introduction

Backache or Back pain – whatever we may call it – is an extremely common condition. In fact, most, if not all of us would encounter it at some point in our lives. Population data indicates its incidence (number of new cases per year) at around 1-4%. The number of people who may have backache at any given time in any community (Prevalence) ranges from 5-10% of the population, with a lifetime prevalence of around 75-85%.

Background

 

The classical teaching has been that most backaches (more than 80-90%) will resolve within 2-3 weeks. However, current knowledge is that that may not be true. Backaches typically show a pattern of remissions and relapses, and a large number of people may still have it even after a year or more, especially if the condition does not resolve itself in the first six to eight weeks.

Backache is the leading cause of job-related disability, and since a large part of the affected population is in an economically productive age-group, it leads to a huge economic strain on societies.

A backache is called “Acute” if it lasts three weeks or less, or “Chronic” if it lasts more than three months. An intermediate form lasting between six to twelve weeks is called “Subacute”.

Backache can originate from any of the structures – ligaments, muscles, bones (vertebrae), cartilages, Intervertebral discs, nerves, or blood vessels.

However, backache can be a symptom of something more sinister underlying.

When do I need to see a doctor?

Most back pains gradually improve over a matter of 2-3 weeks on their own. However, see your doctor if the backache:

  • Persists after three weeks.
  • Is severe enough to immobilize you or severely restrict your daily activities, showing no improvement with rest.
  • Spreads down your legs – one or both, especially if they graduate below the knees.
  • Is accompanied by unexplained weight loss.
  • Is accompanied by urinary or bowel retention or loss of bowel or bladder control (incontinence).
  • Is accompanied by unexplained fever, night sweats, loss of appetite.
  • Has resulted after a severe fall or blow to your back.
  • Is accompanied by swelling, deformity, or hump in the back.
  • Abnormal sensations, numbness, weakness, tingling on one side of the body.
  • Impaired balance and co-ordination.
  • Loss of sensation in a limb or legs.
  • Persistent muscle weakness in the arms or legs.
  • Unresolved Neck pain.
  • Weakness (loss of strength) in the body.

Causes of Backache

We often get backache from common causes as:

  • Poor posture – home, work, or driving.
  • Repeatedly doing the same motion or overdoing it.
  • Pushing, Pulling, Lifting without due care.
  • Obesity.
  • Poor general physical condition.
  • Pregnancy.

Most often backache is without any identifiable cause and may not require any tests or imaging study. However, the common conditions causing backache in daily practice are:

  • Muscle or Ligament strain: Repeated heavy lifting, poor posture, or a sudden awkward movement can strain back muscles and spinal ligaments. Poor general health often aggravates the pain.
  • Intervertebral Disc disease: Discs are soft pulpy cushions between the bony vertebra typically meant to act as “shock absorbers” of the spine. The soft material inside the disc can rupture or bulge out, sometimes causing back pain, or may press upon a nerve causing symptoms in the legs. However, not all disc bulges cause pain or symptoms and maybe purely an incidental finding on imaging.
  • Arthritis: Osteoarthritis can affect any joint, so the spine. In some cases, the spinal canal can get narrowed causing spinal stenosis in severe cases.
  • Osteoporosis: Soft bones, low in calcium and mineral deposits can cause painful compression vertebral fractures.
  • Spondylolisthesis: In this condition, one vertebra slips over the adjacent one, causing severe pain at times due either to instability or nerve compression.
  • Deformity: Normal Spinal curvature can be deformed resulting in Kyphosis and Scoliosis due to congenital reasons, or trauma, or disease. The resultant breakdown of discs, joints, ligaments, or narrowing can result in a painful back.
  • Trauma: Ranging from a simple twist, or slip, or fall, to a severe fall from height or a direct blow, or a motor vehicular accident, trauma is a leading cause of backache. Often we don’t even remember the incident which triggered it. Trauma may result in a number of conditions ranging from a simple muscle strain, ligament stretch to vertebral fractures and dislocations, and spinal compression. It is important that all cases of trauma to back be properly examined by a trained doctor.
  • Sacroiliac joint problems: This is a low-motion joint connecting the sacrum at the bottom of the spine to the pelvis. Its inflammation (sacroiliitis) or dysmotility (too little or too much movement) can cause backache.
  • Degenerative disc disease: The soft discs are full of water at birth. With age, they desiccate, lose water, and become degenerative.
  • Infection: Bacterial or Tubercular infection of the vertebra, intervertebral discs (Discitis), or structures around the vertebra can cause painful back along with other symptoms like fever, night sweats, swelling, discharge, neurological symptoms, etc. It is imperative that a doctor be seen urgently both to treat as well as to prevent long term complications.
  • Tumor: A spine is commonplace for metastatic cancers. Breast, Prostate, Kidney, Thyroid, Lung, and some other cancers freely metastasize to the spine, causing pain and weight loss, besides symptoms of primary cancer. One must see the doctor if this is suspected. Primary tumors of the spine and surrounding soft tissues are a less common cause.
  • Autoimmune Diseases: Conditions like ankylosing spondylosis, rheumatoid arthritis, lupus, Crohn’s disease, fibromyalgia, and some other autoimmune diseases can involve the spine. If you happen to have any of these and develop backache, do get in touch with your doctor.
  • Other causes:
    • Ectopic pregnancy.
    • Abscess.
    • Gallstones.
    • Kidney stones.
    • Pyelonephritis (infection of kidneys).
    • Stress

Other symptoms that may appear with backache

If there are any underlying diseases or conditions or if the backache is more extensive than a “simple pain”, you may experience other symptoms, like:

  • Buttock or hip pain.
  • Changes in the curvature of the spine – commonly signify muscle spasm.
  • The weakness of leg or foot, or foot drop (feeling of the foot slapping the ground).
  • Heel pain.
  • Muscle spasm.
  • Muscle weakness.
  • Shoulder pain.
  • Stiffness in the spine decreased mobility or difficulty in bending or straightening.
  • Swelling in the shoulder, knee, or ankle joints.
  • Balancing problems.
  • Headache, particularly in the back of the head.
  • Nerve problems causing tingling, numbness, pain in an arm, buttock, shoulder, or leg.
  • Paraesthesias – stinging, burning, tingling, sensation of insects crawling on the skin.
  • Inflammation of the eye (s) – Uveitis.
  • Loss of appetite.
  • Fever – commonly low grade, but could be high grade.

 

Potential complications of Backache and its causes:

  • Permanent or Chronic pain or discomfort – months, years, or lifelong.
  • Reduced mobility and flexibility.
  • Loss of bowel and bladder control.
  • Paralysis.
  • Permanent loss of sensation.
  • Permanent physical disability.
  • Progressive weakness.
  • Spread of cancer.
  • The spread of infection.

Risk factors

Anyone can develop backache – from a child to the oldest. However, certain factors are associated with a greater chance of backache:

  • Age: Incidence and Prevalence both increase with increasing age, especially after 30.
  • Lack of exercise: Weak, unused muscles in the back and abdomen can lead to backache.
  • Overweight: Increasing weight puts increased strain on the back and causes the back curvature to change (Lordosis) putting further strain.
  • Diseases: Arthritis, Cancer, Infection, etc all contribute as stated above.
  • Improper lifting: Using your back instead of your legs to lift can cause backache.
  • Psychological conditions: People living in stressful lifestyles and those suffering from, or prone to, depression and anxiety appear to have a higher incidence of backache.
  • Smoking: Smoking causes smokers cough and other lung conditions causing an excessive cough, which can lead to herniation of discs. Smoking can cause decreased blood flow to the spine, and an increased risk of osteoporosis.

Prevention

Most of us will have backache sometime in our lifetime. However, we can limit its severity, and improve our chances of returning to normal life by decreasing recurrence, if we follow certain simple steps to improve our general well being and by practicing proper body mechanics.

  • Exercise: Regular, low-impact aerobics – without straining or jolting the back. Walking and swimming are good choices.
  • Muscle strength and flexibility: Abdominal and back muscle exercises to strengthen your core can help.
  • Weight watching: Maintaining a healthy weight in BMI within the range of 18.5 to 25 gives a healthy weight. BMI (Basal Metabolic Index) is calculated by dividing your weight in Kilograms by the square of your height in meters. Formula: Weight (kg) / [height(m)]2. For more information search “BMI calculator” or talk to your doctor.
  • Quit smoking: Risk is directly proportional to the number of cigarettes smoked per day, and decreases after quitting.
  • Avoid movements that jerk or twist your body.
  • Stand Smart: Don’t slouch. If you need to stand for long periods, place one foot on a low footstool to take some load off your back, alternating the feet every 15-30 minutes. Good posture reduces strain on the back.
  • Sit smart: Have seats with good lower back support, arm-rest, and a swivel base. Placing a pillow or a towel rolled in the small of your neck can maintain its normal curvature. Keep your knees and hips at the same level. Change your position every half-hour.
  • Lift Smart: Avoid heavy lifting, if possible. If you do lift, keep your back straight – don’t twist, and bend only at knees. Hold the load close to your body, and ask for help.

 

 

Diagnosis:

A good examination by a trained doctor can help a lot. Assessment of gait, back, posture, legs, the quantum of pain, the neurological and vascular status of legs and arms, your general health, evidence of infection, other underlying conditions, etc, all need to be evaluated.

The following tests may be ordered by your doctor depending upon the results of his clinical examination:

  • X-ray: Bony structures and their integrity will be visible. Any misalignment, fractures, severe arthritis can be picked up.
  • MRI: MRI and CT can help in picking up disc herniation and ruptures, infection, and involvement of spinal cord and soft tissues, infection of bones, tumors, problems in muscles, tendons, ligaments.
  • Blood Tests: Infections and other underlying conditions like Ankylosing spondylosis can be picked up
  • Bone scan: Compression fractures, bone tumors, osteoporosis can be picked up
  • Nerve studies: Electromyography (EMG) can measure electrical impulses generated by the nerves. If a nerve is compressed by disc protrusion, spinal stenosis, or tumor, EMG can point out

Treatment

It is a real possibility that your backache may get better or even disappear in a matter of 3-4 weeks unless it is due to some underlying condition that requires attention. However, this is not a rule and everyone is different, some may experience pain for months without any identifiable cause.

The foremost remedy is pain killers available over the counter – either oral or topical (ointments or sprays) or a combination of both. Bed rest is not usually helpful unless there’s a history of trauma where initial bed rest and graduated return to mobility within the limits of pain may be helpful. If activity increases pain, try avoiding it, but also try avoiding being immobile.

You may choose to see your doctor early to ensure nothing is being missed, or you may wait for 2-3 weeks to see if the pain settles with home remedies.

Medications:

The possible options are:

  • NSAIDs: Ibuprofen, Diclofenac, Paracetamol, or naproxen may help. Usually, they can be procured over-the-counter (OTC).
  • Muscle Relaxants: These would need prescribing by your Doctor if the pain is not getting relieved by simple pain-killers.
  • Topical pain relievers: Creams, Gels, Ointments, Sprays are commonly available OTC.
  • Narcotics: Medicines containing codeine and opioids like oxycodone are commonly available on prescription.
  • Antidepressants: Some antidepressants like Duloxetine and Amitryptaline have been shown to have a role in intractable chronic backache independent of their effects on depression. However, you should consult your doctor to discuss if you will need it.

Physical Therapy:

A physiotherapist is a key person in backache management. They may assist you to achieve flexibility, strengthen your back and abdominal muscles, and improve your posture. This can especially help in preventing recurrence.

Interventional procedures:

Surgery and some other interventions can help if the above fail. However, they must be done only by a trained doctor under full precautions and asepsis:

  • Steroid Injections: Hydrocortisone or another steroid may be injected along with an anesthetic drug into the epidural space (surrounding your spinal cord). This may also be injected in or around the facet joint of the vertebrae to relieve arthritis. However, the relief is temporary, lasting for 4 to 8 weeks and these may need to repeat regularly.
  • Radiofrequency nerve ablation: The nerves delivering pain signals from the affected area to the brain are destroyed by a radiofrequency signal delivered with the help of a fine needle inserted through the skin under local anesthesia. This interferes with the delivery of the pain signals to the brain.
  • Nerve Stimulators: Nerves can also be blocked by impulses generated through implantable devices thereby interfering with the delivery of pain signals to the brain.
  • Surgery: Surgery should be performed as a last resort and not as a treatment of the first choice unless there is compression of nerve or cord or abscess (which needs draining) or fracture or instability which needs fixing. Other indications for surgery are severe spinal stenosis, disc herniation causing nerve compression, etc.

Take-Home Message

Backache is not something to panic, however, it is also not something to be ignored. We can easily manage it at home by the above remedies unless there are red flags as listed above, in which case it is advisable to see your doctor to prevent recurrence and lasting damage.