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26 January 2022

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6 minute read

The Truth About Back Pain

By Dr. Gunaseelan A/l Ponnusamy

If you have lower back pain, you are not alone. Back pain is one of most common reasons people see a doctor or miss days at work. Even school-going children can have back pain.

Back pain can range in intensity from a dull, constant ache to a sudden, sharp or shooting pain. It can begin suddenly as a result of an accident or by lifting something heavy, or it can develop over time as we age. Getting too little exercise followed by a strenuous workout can also cause back pain.

There are two types of back pain:

  • Acute, or short-term back pain that lasts a few days to a few weeks.
  • Chronic back pain is defined as pain that continues for 12 weeks or longer. About 20 percent of people affected by acute low back pain develop chronic low back pain with persistent symptoms in a span of one year.

What causes lower back pain?

Most acute low back pain is mechanical in nature, meaning that there is a disruption in the way the components of the back (the spine, muscle, intervertebral discs, and nerves) fit together and move. Some examples of mechanical causes of low back pain include:

Congenital

  • Skeletal irregularities such as scoliosis (a curvature of the spine), lordosis (an abnormally exaggerated arch in the lower back), kyphosis (excessive outward arch of the spine), and other congenital anomalies of the spine.
  • Spina bifida which involves the incomplete development of the spinal cord and/or its protective covering. This can cause problems involving malformation of vertebrae and abnormal sensations and even paralysis.

Injuries

  • Sprains (overstretched or torn ligaments), strains (tears in tendons or muscle), and spasms (sudden contraction of a muscle or group of muscles).
  • Traumatic Injuries from playing sports, car accidents, or a fall that can injure tendons, ligaments or muscles, causing the pain, as well as compress the spine and cause discs to rupture or herniate.

Degenerative problems

  • Intervertebral disc degeneration which occurs when the otherwise rubbery discs wear down as a normal process of aging and lose their cushioning ability.
  • Spondylosis is the general degeneration of the spine associated with normal wear and tear that occurs in the joints, discs, and bones of the spine as people get older.
  • Arthritis or other inflammatory disease in the spine, including osteoarthritis and rheumatoid arthritis as well as spondylitis, an inflammation of the vertebrae.

Nerve and spinal cord problems

  • Spinal nerve compression, inflammation and/or injury
  • Sciatica (also called radiculopathy), caused by something pressing on the sciatic nerve that travels through the buttocks and extends down the back of the leg. People with sciatica may feel shock-like or burning low back pain combined with pain through the buttocks and down one leg.
  • Spinal stenosis, the narrowing of the spinal column that puts pressure on the spinal cord and nerves
  • Spondylolisthesis, which happens when a vertebra of the lower spine slips out of place, pinching the nerves exiting the spinal column
  • Herniated or ruptured discs can occur when the intervertebral discs become compressed and bulge outward
  • Infections involving the vertebrae, a condition called osteomyelitis; the intervertebral discs, called discitis; or the sacroiliac joints connecting the lower spine to the pelvis, called sacroiliitis
  • Cauda equina syndrome occurs when a ruptured disc pushes into the spinal canal and presses on the bundle of lumbar and sacral nerve roots. Permanent neurological damage may result if this syndrome is left untreated.
  • Osteoporosis (a progressive decrease in bone density and strength that can lead to painful fractures of the vertebrae)

Non-spine sources

  • Kidney stones can cause sharp pain in the lower back, usually on one side
  • Endometriosis (the build up of uterine tissue in places outside the uterus)
  • Fibromyalgia (a chronic pain syndrome involving widespread muscle pain and fatigue)
  • Tumors that press on or destroy the bony spine or spinal cord and nerves or outside the spine elsewhere in the back
  • Pregnancy (back symptoms almost always completely go away after giving birth)

What are the risk factors for developing low back pain?

Anyone can have back pain. Factors that can increase the risk for low back pain include:

Age: The first attack of low back pain typically occurs between the ages of 30 and 50, and back pain becomes more common with advancing age. Loss of bone strength from osteoporosis can lead to fractures, and at the same time, muscle elasticity and tone decrease.

Fitness level: Back pain is more common among people who are not physically fit. Weak back and abdominal muscles may not properly support the spine. “Weekend warriors”—people who go out and exercise a lot after being inactive all week—are more likely to suffer painful back injuries than people who make moderate physical activity a daily habit. Studies show that low-impact aerobic exercise can help maintain the integrity of intervertebral discs.

Weight gain: Being overweight, obese, or quickly gaining significant amounts of weight can put stress on the back and lead to low back pain.

Genetics: Some causes of back pain, such as ankylosing spondylitis (a form of arthritis that involves fusion of the spinal joints leading to some immobility of the spine), have a genetic component.

Job-related factors: Having a job that requires heavy lifting, pushing, or pulling, particularly when it involves twisting or vibrating the spine, can lead to injury and back pain. Working at a desk all day can contribute to pain, especially from poor posture or sitting in a chair with not enough back support.

Mental health: Anxiety and depression can influence how closely one focuses on their pain as well as their perception of its severity. Pain that becomes chronic also can contribute to the development of such psychological factors. Stress can affect the body in numerous ways, including causing muscle tension.

Backpack overload in children: A backpack overloaded with school books and supplies can strain the back and cause muscle fatigue.

How is low back pain diagnosed?

A complete medical history and physical exam can usually identify any serious conditions that may be causing the pain. Neurologic tests can help determine the cause of pain and appropriate treatment. Imaging tests are not needed in most cases but may be ordered to rule out specific causes of pain, including tumors and spinal stenosis. Occasionally the cause of chronic lower back pain is difficult to determine even after a thorough examination.

Tests include:

  • Blood tests 
  • Bone scans
  • Discography
  • Electrodiagnostics :
    • Electromyography (EMG)
    • Evoked potential studies
    • Nerve conduction studies (NCS)
  • Diagnostic imaging tests allow specialists to see into the body without having to perform exploratory surgery. Imaging includes:
    • Computerized tomography (CT) can show soft tissue structures that cannot be seen on conventional x-rays, such as disc rupture, spinal stenosis, or tumors.
    • Magnetic resonance imaging (MRI) creates a computer-generated image of bony structures and soft tissues such as muscles, ligaments, tendons, and blood vessels. An MRI may be ordered if a problem such as infection, tumor, inflammation, disc herniation or rupture, or pressure on a nerve is suspected
    • X-ray imaging can show broken bones or an injured or misaligned vertebra.
  • Myelograms

How is back pain treated?

Acute back pain usually gets better on its own. Acute back pain is usually treated with:

  • Medications designed to relieve pain and/or inflammation
    • Analgesics such as acetaminophen and aspirin
    • Non-steroidal anti-inflammatory drugs (NSAIDs) such as ibuprofen and naproxen may be sold over the counter; some NSAIDS are prescribed by a physician 
    • Muscle relaxants are prescription drugs that are used on a short-term basis to relax tight muscles
    • Topical pain relief such as creams, gels, patches, or sprays applied to the skin stimulate the nerves in the skin to provide feelings of warmth or cold in order to dull the sensation of pain. Common topical medications include capsaicin and lidocaine.
  • Heat and/or ice may help ease pain, reduce inflammation, and improve mobility for some people
  • Gentle stretching (not vigorous exercise) upon advice by your healthcare professional

Exercising, bed rest, and surgery are typically not recommended for acute back pain.
Chronic back pain is most often treated with a stepped care approach, moving from simple low-cost treatments to more aggressive approaches. Specific treatments may depend on the identified cause of the back pain.

Step 1: Early treatments

Medications may include:

  • Analgesics and NSAIDS
  • Opioid drugs prescribed by a physician (opioids should be used only for a short period of time and under a physician’s supervision, as opioids can be addictive, aggravate depression, and have other side effects)
  • Anticonvulsants—prescribed drugs primarily used to treat seizures—may be useful in treating people with sciatica
  • Antidepressants such as tricyclics and serotonin, and norepinephrine reuptake inhibitors have been commonly prescribed for chronic low back pain (prescribed by a physician)

Self-management:

  • Hot or cold packs
  • Resuming normal activities as soon as possible may ease pain; bed rest is not recommended
  • Exercises that strengthen core or abdominal muscles may help to speed recovery from chronic low back pain. Always check first with a physician before starting an exercise program and to get a list of helpful exercises.

Step 2: Complementary and alternative techniques include:

  • Acupuncture is moderately effective for chronic low back pain. It involves inserting thin needles into precise points throughout the body and stimulating them (by twisting or passing a low-voltage electrical current through them), which may cause the body to release naturally occurring painkilling chemicals.
  • Transcutaneous electrical nerve stimulation (TENS) involves wearing a battery-powered device which places electrodes on the skin over the painful area that generate electrical impulses designed to block or modify the perception of pain
  • Physical therapy programs to strengthen core muscle groups that support the low back, improve mobility and flexibility, and promote proper positioning and posture are often used in combination with other interventions
  • Spinal manipulation and spinal mobilization are approaches in which doctors of chiropractic care use their hands to mobilize, adjust, massage, or stimulate the spine and the surrounding tissues. Manipulation involves a rapid movement over which the individual has no control; mobilization involves slower adjustment movements. 

Spinal injections include: Trigger point injections can relax knotted muscles (trigger points).

Epidural steroid injections, Pain relief associated with the injections tends to be temporary and the injections are not advised for long-term use.

Radio frequency ablation involves inserting a fine needle into the area causing the pain through which an electrode is passed and heated to destroy nerve fibers that carry pain signals to the brain. 

Step 3: More advanced care options

Surgery
When other therapies fail, surgery may be considered to relieve pain caused by worsening nerve damage, serious musculoskeletal injuries, or nerve compression. Specific surgeries are selected for specific conditions/indications. However, surgery is not always successful. It may be months following surgery before the person is fully healed and there may be permanent loss of flexibility. Surgical options include:

  • Vertebroplasty and kyphoplasty
  • Spinal laminectomy
  • Discectomy and microdiscectomy
  • Foraminotomy
  • Nucleoplasty
  • Radio frequency denervation, destroys part of the target nerves and offers temporary pain relief.
  • Spinal fusion is used to strengthen the spine and prevent painful movements in people with degenerative disc disease or spondylolisthesis (following laminectomy). The spinal disc between two or more vertebrae is removed and the adjacent vertebrae are “fused” by bone grafts and/or metal devices secured by screws.
  • Artificial disc replacement is an alternative to spinal fusion for treating severely damaged discs. 
  • Interspinous spacers are small devices that are inserted into the spine to keep the spinal canal open and avoid pinching the nerves.
  • Rehabilitation programs
    The programs are designed to help the individual reduce pain and reliance on opioid pain medicines. Programs last usually two to three weeks and can be done on an in-patient or out-patient basis.

Can back pain be prevented?

Recurring back pain resulting from improper body mechanics may be prevented by avoiding movements that jolt or strain the back.
Recommendations for keeping one’s back healthy:

  • Exercise regularly to keep muscles strong and flexible. Consult a physician for a list of low-impact, age-appropriate exercises that are specifically targeted to strengthening lower back and abdominal muscles.
  • Maintain a healthy weight and eat a nutritious diet with sufficient daily intake of calcium, phosphorus, and vitamin D to promote new bone growth.
  • Use ergonomically designed furniture and equipment at home and at work. Make sure work surfaces are at a comfortable height.
  • Switch sitting positions often and periodically walk around the office or gently stretch muscles to relieve tension. A pillow or rolled-up towel placed behind the small of the back can provide some lumbar support. Put your feet on a low stool or a stack of books when sitting for a long time.
  • Wear comfortable, low-heeled shoes.
  • Sleeping on one’s side with the knees drawn up in a fetal position can help open up the joints in the spine and relieve pressure by reducing the curvature of the spine. Always sleep on a firm surface.
  • Don’t try to lift objects that are too heavy. Lift from the knees, pull the stomach muscles in, and keep the head down and in line with a straight back. When lifting, keep objects close to the body. Do not twist when lifting.
  • Quit smoking. Smoking reduces blood flow to the lower spine, which can contribute to spinal disc degeneration. Smoking also increases the risk of osteoporosis and impedes healing. Coughing due to heavy smoking also may cause back pain.

This article first appeared in The Star, 5 December 2021.

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26 January 2022

•

6 minute read

The Truth About Back Pain

By Dr. Gunaseelan A/l Ponnusamy

Dr. Gunaseelan A/l Ponnusamy

Orthopedic

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