Our spine is made up of building blocks called vertebrae. There are 5 lumbar vertebrae in our lower back. They are labeled L 1,2.3 and so on. There is a spongy cushion between the 2 vertebrae called a disc (purple in the above picture). All vertebrae have a central circular hole through which our spinal cord passes. At each level 2 nerves, one to right and one to left emerge from the spinal cord and come out of the vertebra.
A disc between the L4 and 5 vertebras is known as L4-5 disc. Since we all have heard the word "slipped disc" let's understand the disc a bit better. A disc is made up of a soft gel like centre (blue in the next picture) and a tough outer lining (maroon in the picture). It works like a shock absorber in our spine. A tear in the outer tough structure can make the soft gel protrude out which is known as a disc prolapse. Sometimes a portion of the gel comes out and hangs loose in the spinal canal, which is known as a sequestrated disc. The picture below shows various stages of the disc disase. Whenever the outer tough part tears we experience an episode of back pain. If the disease is untreated it can progress to a prolapse and if the disc prolepses then it pinches the exiting nerve as shown below.
The nerves exit the back and from the buttock pass low down into the thigh and then leg and up to the toes. The main nerve is also known as "sciatic nerve" and hence many times a slipped disc is also known as "sciatica".
This picture which gives us a top end view of the disc clearly shows the relationship of the disc and the two nerves on each side (green in colour). Annulus is the tough part we were talking earlier and the nucleus is the soft gel we mentioned earlier. A disc bulge to right will cause right sides leg pain or the classical sciatica.
Now that we have understood the basic anatomy of the disc let us see who can get affected by this disease. Increasing age, Heavy physical work, particularly long static work postures ( secretaries, receptionists, call centre employees), heavy lifting, twisting, and vibration tool operators, Psychosocial factors, including work dissatisfaction and monotonous work ,Depression, Obesity, Smoking, Drug abuse, History of headache (related to psychological causes) are the most common predisposing factors.
The diagram below shows the importance of strong muscles in maintaining a good posture. Fat or obese people or ladies after a delivery have poor abdominal muscle tone i.e. a paunch which increases a risk of disc prolapse.
A study has shown that the disc pressure is highest when we try and lift a weight while bending our back e.g. lifting a heavy bucket and is least while we sleep on the back with knees bent. This explains why most of us get the first attack of backache while doing simple household things like making a bed, lifting a bucket in the bathroom. The first episode of backache usually lasts for a few days and settles on its own. An episode of back pain where the pain goes right down one's leg is the classical slipped disc and one should see his/her doctor immediately.
At this point I would also like to highlight the fact that backaches can be also caused by structures outside the spine. Pain arising due to gynecological problems or coming from kidneys can be mistaken for backache arising from spinal column. It is always prudent to note following things if you are getting an episode of back pain.
Please rush to a doctor immediately if you notice anything abnormal with your toilet habits (bladder and bowel problems). Ladies should inform the doctor about any problems regarding their menstrual cycle. Loss of appetite, loss of weight (unexplained), any fever should be informed to the doctor as early as possible.
Clinical Evaluation at home
Well it is important that we realize how serious the problem is before rushing to a doctor! Any back pain which travels down the leg has to be seen by the doctor immediately. Pain which increases by coughing or sneezing also has to be seen by a doctor. The simple first aid remedy is to lie down flat on your back with knees folded and uses a hot water bag/pad. A painkiller can be taken if available and then a doctor can be called. One can also use a belt or a brace if available while moving around.
Rest is BEST! Most of the patients get better with a few days rest at home. It's a myth that one has to sleep only on a wooden floor or a hard mattress. There is also a view that bed rest is not at all necessary and can lead to muscle wasting. The truth is that a prolonged bed rest i.e. more than 7 days definitely leads to muscle wasting but we are talking about one week's rest which goes a long long way to cure a back problem. It is mandatory that any backache which does not resolve after a week's rest be investigated thoroughly by a specialist.
The first important line is the traditional anti-inflammatory like diclofenac (Voveran). There is an important role of skeletal muscle relaxants when there is an associated spam. Chlorzoxazone like drugs are not preferred because of heaptotoxocity (liver damage). We now have a series of excellent drugs available which include Thiocolchicoside (Myoril), Tizanidine (Tizan), Carisoprodol (Carisoma), Metaxolone (Flexura), methacarbamol (Robinax), Baclofen. Most of these are also available conveniently in a combination with NSAID's or painkillers. Some are also available an injectable form (Robinax, Myoril).There are a few known side effects of these skeletal muscle relaxants which one should be aware in practice. Most of the skeletal muscle relaxants cause drowsiness. Metaxolone causes nausea, Thiocolchicoside causes diarrrhoea in addition. Tizanidine has an important gastro protective action which does help patients who suffer from acidity.
Patients with disturbed sleep do get adequate relief from short acting sedatives. We do use drugs like Gabapentin (routinely used in Epilepsy) in chronic cases and also in patients with radicular pains (pain traveling along a nerve).
In severe radicular pain steroids are regularly used either in oral or in intravenous forms. Amitryptiline is used in cases where associated depression is also present. Amitryptiline (a popular anti-depressant) is also an excellent drug for chronic neuropathic (pain originating from the nerves) pain.
Local gels which give a sense of heat when applied have a role to play though it's limited. A detailed discussion on drugs is beyond the scope of this article.
However it is worth mentioning that the drug regimen has to be very selective based on the patient's etiology and psychological profile. Calcitonin (available in nasal spray form and comes by the brand name Miacalcic) is the preferred pain killer in a patient with osteoporotic (soft or brittle bones) fracture of the spine leading to an acute onset back pain. I may add here that a single drug can be used to treat many conditions and I have seen patients getting upset having been told by their chemist that you have been prescribed an anti-depressant! Please understand that amitryptiline for example is a known antidepressant but is used in neurological pain syndrome quite frequently!
90% patients with back pain tend to get better with rest and pain killers in 10 days time! Yes, that's the truth and therefore there is no need to rush for X-rays immediately. All patients who suffer an episode of back pain and get better quickly need counseling. Counseling means teaching the patient importance of a good posture while working and then teaching them simple exercises to strengthen their back and abdominal muscles.
Here is an example of how we teach secretaries or employees who have a sedentary sitting job, the importance of posture.
This lady has a good posture! Note that she is sitting right at the back of her chair and her back is well supported. There is a small green pillow which sits in the hollow of her back. There is a 90 degree angle between her torso and her thighs and the same angle is there between her thighs and her legs and again between her legs and both feet. The feet rest on the floor firmly, which indicates that the height of the chair is perfect. Short stature people who have their legs dangling in the air can use a wooden plank to rest their feet. Note that the abdomen is very close to the desk and hence the elbows and the wrist rest on the desk which eases off the pressure form her neck.
Here is guide as to which the best ways to sleep are or ways to avoid stress on the back while performing simple activities of daily living i.e. brushing your teeth!
Once a patient understands the importance of a good posture the next important thing is to emphasize the need for regular exercises. Any trained physiotherapist will be able to help you with exercises. Swimming, Yoga and regular walking always help your back.
In selected cases injecting a combination of local anesthetic and long acting steroids helps to avoid surgery. The decision to inject depends on lot of factors and only the treating surgeon can decide whether one is suitable for such therapy.
All back pain suffers will tell you that they receive free advice from almost everybody on the street as to which alternative remedy to use and this may range from scientific methods like acupressure to a proverbial "laath" in the back side! It has been scientifically proved that apart from Yoga none of the other therapies have any role to play in treatment of backaches, and this includes the use of magnetic belts and the kerala ayurvedic massages.
The myth of spondylit
A recent American study showed that at age 49, 60% of women and 80% of men have osteophytes and other changes indicating early spondylosis (in simple terms age related changes in the spine akin to your hair growing gray). There is a poor correlation between the presence of spondylosis on x-rays of the lumbar spine and back pain
Most of the patients require a simple set of x-rays as mentioned earlier. Patients who don't respond to the initial treatment of rest and painkillers need further evaluation. Depending up on the clinical case scenario blood tests may be ordered. The most important investigation of choice is a MRI scan. MRI scan is frequently ordered by a non treating doctor or even by a family physician, a practise that has to be criticized. MRI is a very sensitive investigation and should always be seen with a co relation to patient's specific complaints. Also it is important to observe the clinical rule while ordering an investigation "order an investigation only if it is going to tell you something which you do not know and will alter the treatment regimen". MRI therefore should be ordered by an orthopedic surgeon only. Many patients go to MRI centers offering cheap rates and this is one thing which should be avoided. A good quality MRI is important and not a cheap one. I would ask all patients to follow a simple rule of getting a MRI done on a 1.5 tesla machine nearest to you. MRI machines of higher tesla value will be soon available in the city of Mumbai.
Elderly patients also suffer from a condition called "lumbar canal stenosis". The hole though which our spinal cord passes narrows down over a period due to age related changes. In some patients this narrowing is so much that after walking for some distance they feel a sense of heaviness in their legs or feel a sensation of "tingling/numbness" in their legs. These patients have to sit down after walking a specific distance and can walk further after a rest period. They do not have any symptoms while sitting or lying down. Most of these patients end up having a surgery done and generally do very well after the surgery.
A safe generalization is that patients with "uncomplicated" low back pain with or without radiating pain into the lower extremity in the absence of physical findings on examination can be observed without diagnostic testing
Many patients have a feeling that "back pain" is synonymous with "sciatica" or "slipped disc" or "spondylitis". It is important to realize that there are other important causes like infection (tuberculosis of spine is very very common in India ); inflammatory disorders like various arthritis's, osteoporosis and so on. Let's look at the most common causes apart from the disc disease.
Tuberculosis is rampant in our country. Patients who have severe unremitting back ache with other signs like unexplained weight loss, appetite loss; low grade fever especially in the evening may be suffering from tuberculosis. MRI is the most important investigation in such patients. Most of the tuberculosis patients are treated with drugs and achieve a full, functional recovery.
Simply put this means soft bones. All ladies after menopause suffer from this condition. Occasionally if untreated or undiagnosed the first symptom of the disease is a fracture of the vertebra leading to sudden onset back pain. This is easily treatable and even reversible.
There are inflammations of spine like ankylosing spondylitis ..a disease which classically affects young adult males. There are various disorders which can be diagnosed easily by doing a few simple blood tests. All these conditions require medication in the short term and physiotherapy in the long term.
In elderly patients spread of cancer from various sites like prostate or breast or lungs to the spine can first present as back pain and hence back pains in patients above 65 years is often investigated aggressively to eliminate this dreadful complication.
There is probably no surgery surrounded by myths more than the back surgery. Here are few golden facts:
- Only 5 % of back pain patients end up having a surgery.
- Surgery is always a last resort except a very few emergency situations.
- The most important indication for surgery is "failed" conservative treatment.
- With technological advances anesthesia and the surgery have brought down the so called complications to single digit numbers.
And here are a few things we do routinely which we should not attempt to do
Remember to bend your knees while bending forward and do not bend the back!
The take home message
- Simple rest at home cures most of the backapin episodes.
- 95% of back pain patients get better with "non-Surgical" methods.
- Paying attention to your posture at home and at office helps!
- Exercising daily is the best preventive measure to avoid backaches!
- Exercise is free and available everywhere and has no side effects!
- If you are developing a paunch start exercising immediately.
- Do not rush to get multiple investigations done.
- Back pain in patients above 50 should be investigated more aggressively.
- If indications are right DO NOT delay surgery.
- Surgeries are now very safe and devoid of complications.
- The low back exercise program is a series of stretching exercises and strengthening exercises prescribed by your physician. The purpose of this exercise program is to improve the flexibility and strength of your back muscles essential for your low back care.
- By following this program on a regular basis, you will see improvements in your posture, capacity to work. The exercises in this booklet will not irritate your back or neck when done properly. Perform each exercise at a slow pace at least once a day, every day. If there is pain, stop.
- Carefully follow the instructions and do only those exercises that have been recommended to you.
If you experience any discomfort other than muscles soreness, slow down the pace or decrease the number of repetitions. Should pain persist, discontinue exercises and contact your physician immediately.
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