Dr. R.S. CHAHAL
M.B.B.S, DNB (ORTHO)
Sir Ganga Ram Hospital, New Delhi
AO Spine fellow, QMC Nottingham, UK
Spine Fellowship, Dartmouth, Hitchcock, USA

Dr. Chahal is an eminent spine surgeon presently working as Vice Chairman, Department of Spine Surgery, Sir Ganga Ram Hospital, New Delhi. He has 18 years of experience and specializes in all kinds of spine surgeries.

Introduction

Low back pain is a common disorder involving the muscles and bones of the back. It affects nearly every human being, at some point in their life.
As the structure of the back is complex and the reporting of pain is subjective and affected by social factors, the diagnosis of low back pain is not straightforward. While most low back pain is caused by muscle and joint problems, this cause must be separated from neurological problems, spinal tumors, fracture of the spine, and infections, among others. There are a number of ways to classify low back pain with no consensus that any one method is best.

What are the common causes of back pain?

There are three general types of low back pain by cause: mechanical back pain (including nonspecific musculoskeletal strains, herniated discs, compressed nerve roots, degenerative discs or joint disease, and broken vertebra), non-mechanical back pain (tumors, inflammatory conditions such as spondyloarthritis, and infections), and referred pain from internal organs (gallbladder disease, kidney stones, kidney infections, and aortic aneurysm, among others).

Mechanical or musculoskeletal problems underlie most cases (around 90% or more), and of those, most (around 75%) do not have a specific cause identified but are thought to be due to muscle strain or injury to ligaments. Rarely, complaints of low back pain result from systemic or psychological problems, such as fibromyalgia and somatoform disorders.

How does a patient with a low backache present?

Most of the patients generally present with non-specific pain. It is diffuse pain that does not change in response to particular movements and is localized to the lower back without radiating beyond the buttocks.

In up to 7% of cases, patients may present with radicular pain. Pain that radiates down the leg below the knee, is located on one side (in the case of disc herniation) or is on both sides (in spinal stenosis), and changes in severity in response to certain positions or maneuvers.
Sometimes the back pain is accompanied by red flags such as trauma, fever, a history of cancer, or significant muscle weakness, this may indicate a more serious underlying problem and needs urgent or specialized attention.
Occasionally obesity, smoking, weight gain during pregnancy, stress, poor physical condition, poor posture, and the poor sleeping position may also contribute to low back pain.

Is low back pain common in women? What are its causes?

Women may have acute low back pain from medical conditions affecting the female reproductive system, including endometriosis, ovarian cysts, ovarian cancer, or uterine fibroids. Nearly half of all pregnant women report pain in the lower back or sacral area during pregnancy, due to changes in their posture and center of gravity causing muscle and ligament strain. Many women also complain of low back pain during menstruation, it is typically muscular in nature and is likely caused by hormone changes. Most of the women correlate back pain with an epidural injection given during the delivery, which has no scientific basis and is purely coincidental.

Can low backache cause sleep disorder?

Chronic low back pain can also be associated with sleep problems, including a greater amount of time needed to fall asleep, disturbances during sleep, a shorter duration of sleep, and less satisfaction with sleep. In addition, a majority of those with chronic low back pain show symptoms of depression or anxiety.

 

What is the role of MRI in backache?

When warranted, imaging such as MRI can provide clear detail about disc related causes of back pain. Imaging is also indicated when there are red flags, ongoing neurological symptoms that do not resolve, or ongoing or worsening pain. In particular, the early use of MRI is recommended for suspected cancer, infection, or cauda equina syndrome.

What are the other tests used in diagnosing causes of back pain?

The straight leg raise test is almost always positive in those with disc herniation. Therapeutic procedures such as nerve blocks can be used to determine a specific source of pain. Some evidence supports the use of facet joint injections, transforaminal epidural injections, and sacroiliac injections as diagnostic tests. For pain that has lasted only a few weeks, the pain is likely to subside on its own.

What is the management of low back pain?

The management depends on which of the three general categories is the cause: mechanical problems, non-mechanical problems, or referred pain. For acute pain that is causing only mild to moderate problems, the goals are to restore normal function, return the individual to work and minimize pain. The condition is normally not serious, resolves without much being done, and recovery is helped by attempting to return to normal activities as soon as possible within the limits of pain. Providing individuals with coping skills through reassurance of these facts is useful in speeding recovery. For those with sub-chronic or chronic low back pain, multidisciplinary treatment programs may help.

Should a patient with backache undergo rigorous exercises?

No individual with backache should avoid rigorous physical exercises. Increasing general physical activity has been recommended, but no clear relationship to pain or disability has been found when used for the treatment of an acute episode of pain. For acute pain, low to moderate-quality evidence supports walking. There is tentative evidence to support the use of heat therapy for acute and sub-chronic low back pain but little evidence for the use of either heat or cold therapy in chronic pain. Weak evidence suggests that back belts might decrease the number of missed workdays, but there is nothing to suggest that they will help with the pain.

Is exercise therapy effective in decreasing pain?

Exercise therapy is effective in decreasing pain and improving function for those with chronic low back pain. It also appears to reduce recurrence rates for as long as six months after the completion of the program and improves long-term function. There is no evidence that one particular type of exercise therapy is more effective than another.
 
The multifidus muscles run up and down along the back of the spine and are important for keeping the spine straight and stable during many common movements such as sitting, walking, and lifting. A problem with these muscles is often found in someone with chronic low back pain because the back pain causes the person to use the back muscles improperly in trying to avoid the pain. The problem with the multifidus muscles continues even after the pain goes away and is probably an important reason why the pain comes back. Teaching people with chronic low back pain how to use these muscles is recommended as part of a recovery program.

What is the role of pain medication in managing low back pain?

The management of low back pain often includes medications for the duration that they are beneficial. With the first episode of low back pain, there is a hope of complete cure; however, if the problem becomes chronic, the goals may change to pain management and the recovery of as much function as possible. As pain medications are only somewhat effective, expectations regarding their benefit may differ from reality, and this can lead to decreased satisfaction. The medication typically recommended first is acetaminophen (paracetamol) or NSAIDs and these are enough for most people. Standard doses of acetaminophen are very safe; however, high doses may cause liver problems and very high doses can be fatal.NSAIDs are more effective for acute episodes than acetaminophen; however, they carry a greater risk of side effects including kidney failure, stomach ulcers, and possibly heart problems. Thus, NSAIDs are a second choice to acetaminophen, recommended only when the pain is not handled by the latter. For older people with chronic pain, opioids may be used in those for whom NSAIDs present too great a risk, including those with diabetes, stomach, or heart problems. They may also be useful for a select group of people with neuropathic pain.

Antidepressants may be effective for treating chronic pain associated with symptoms of depression, but they have a risk of side effects. Although the antiseizure drugs gabapentin and carbamazepine are sometimes used for chronic low back pain and may relieve sciatic pain, Systemic oral steroids have not been shown to be useful in low back pain. Facet joint injections in non-radiating pain may help both as a diagnostic as well as therapeutically, Epidural, and transforaminal injections however, they may be considered for those with persistent sciatic pain.

What is the role of surgery in managing low backache?

Surgery may be useful in those with a herniated disc that is causing significant pain radiating into the leg, significant leg weakness, bladder problems, or loss of bowel control. It may also be useful in those with spinal stenosis. In the absence of these issues, there is no clear evidence of a benefit from surgery.
For those with pain localized to the lower back due to disc degeneration, fair evidence supports spinal fusion as equal to intensive physical therapy and slightly better than low-intensity nonsurgical measures. Fusion may be considered for those with low back pain from acquired displaced vertebra that does not improve with conservative treatment, although only a few of those who have spinal fusion experience good results. There are a number of different surgical procedures to achieve fusion, with no clear evidence of one being better than the others.

How is the prognosis of back pain?

Overall, the outcome for acute low back pain is positive. Pain and disability usually improve a great deal in the first six weeks, with complete recovery up to90%. In those who still have symptoms after six weeks, improvement is generally slower with only small gains up to one year. At one year, pain and disability levels are low to minimal in most people. Following the first episode of back pain, recurrences occur in more than half of people.

For persistent low back pain, the short-term outcome is also positive, with improvement in the first six weeks but very little improvement after that. At one year, those with chronic low back pain usually continue to have moderate pain and disability. People at higher risk of long-term disability include those with poor coping skills or with fear of activity (2.5 times more likely to have poor outcomes at one year), those with a poor ability to cope with pain, functional impairments, poor general health, or a significant psychiatric or psychological component to the pain.

This information is for general guidance and reflects the opinions and experience of the author. It is not intended to replace specialist consultation or provide treatment advice for specific cases.

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