What is Backpain?
Back pain is one of the commonest symptoms that patients complain when they see their doctors which lead to taking time off work. Very often back pain is self-limiting and get better without any active treatment. With rest and some easy self-treatment, our body takes care of the back pain naturally.
Back pain becomes significant if the symptom persists beyond 2 weeks. Most back pain occurs when we over strain our back. By doing that, we cause muscle, ligament or tendon injury. We also can cause joint inflammation of the facets in our back if we do repetitive bending or rotation of my back. These causes are common and with reduction of level of activities, simple stretching and use of over-the-counter medication, the duration of symptoms can be curtailed and return of normal function is the usual expectation.
When is back pain a significant symptom
and requires urgent attention?
The following are features that should alert you that the back pain is not the usual strain: -
Back pain lasting longer than 2 weeks
Severe back pain particularly after a fall or trauma leading to difficulty to ambulate
Back pain associated with pain radiating down the lower limbs (sciatica)
Back pain associated with feeling of heaviness and weakness in the lower limbs
Back pain that is throbbing that keeps you awake at night
Back pain with fever
Back pain with lower limb weakness and inability to control bladder and bowel
When you see the specialist, the doctor will take a thorough history of the back pain
These are the usual questions he will have for you.
History of trauma, like a fall or lifting incident
2Precipitating, aggravating factors and relieving factors
3Associated with radiating pain down the legs with altered sensation in the lower limbs
4
Bladder and bowel control
5Past history of cancers
After the history taking is complete, a thorough examination of the spine and the neurological assessment of the lower limbs will be conducted. Based on the findings, the specialist will recommend radiological imaging of the spine based on the most likely or suspected diagnosis/condition.
Medical Screening for Back Pain
X-rays of the spine is generally suitable for suspected trauma, degenerative condition and looking for overall spinal alignment. A magnetic resonance imaging scan (MRI) is superior to x-rays in terms of giving a detailed assessment as it is able to pick up the following
Detecting subtle hairline fractures
2Detailing ligament, muscles and tendon injury
3Evaluating disc degeneration including bulging and herniation
4Nerve root or spinal cord entrapment
5Detection of cancer or cancer spread
6Infection in the spine
Computerised Tomography scan (CT) and magnetic resonance imaging scans (MRI) are also commonly used modes of imaging to help in diagnosis, assessment of severity and confirmation of more complex spinal conditions. For example, spondylolysis, a condition where there is a subtle breakage of part of the vertebra can be better highlighted using a CT scan or MRI. X rays can help diagnose about 80% of spinal conditions but supplemented with an MRI scan, the rate increases to as high as 95%. Furthermore, an MRI scan is safe and does not use any form of radiation. While Xray can be performed immediately, MRI scans often need appointment and hence the results are not immediate. MRI scans are more expensive compared to x rays.
Once a diagnosis has been made, your doctor will usually discuss the full spectrum of treatment options available to you. This will include the following:
Medications in the form of painkillers, anti-inflammatory, muscle relaxants and nerve desensitiser
2
Rest and reduction of physical activities
3Simple modalities like hot or cold compress
4Self-stretching exercises
5Physiotherapy
Injections in the form of hydrocortisone and lignocaine, epidural steroids, facet blocks
7
Nerve ablation procedures using radiofrequency
8Nucleoplasties
9Surgery options
Back Pain Treatments (Conservative Management)
Stretching
Most back pain need conservative management. They are self-limiting and the duration of recovery can be shortened with logical reduction of activities. Judicious use of anti-inflammatory can also help shorten the recovery period.
Self-imposed bed rest should not exceed 48 hours as studies have shown that muscles deconditioning start to occur after 48 hours of bed rest. Most back pain is accompanied by stiffness of the back due to the spasm of the back muscles.
Often this is more debilitating compared to the back pain itself. Hence hot packs and stretching of the back muscles are advised to reduce these muscular spasms. Gradual return to normal activities should be advocated. Return to physical activities should only be done when the symptoms completely abate.
Physiotherapy
Return to normal function can also be enhanced with physiotherapy. Physiotherapy uses modalities like hands on manipulation of the back, reduction of muscular spasms with heat therapy, eletromodulation and interferential as well as stretching exercises. Once the symptoms improve, the next phase would be core muscle strengthening to better support the spine and prevent future episodes of back pain.
Back Pain Treatments (Surgery)
Steroid injection
In prolonged cases of back pain where conservative treatment fails, then more invasive procedures may be needed. However, these procedures can be recommended only if the source of the back pain can be elucidated. If a nerve root is compressed or inflamed, targeted steroid injection around the nerve root can be done under CT guidance.
In the case of inflamed facet joints, similarly CT guided facet blocks can be done to relieve the pain. In cases where the intervertebral disc is degenerated and bulging without extrusion, nucleoplasty can be performed. This procedure uses very fine catheter introduced into the disc space guided using x rays or CT scan.
This catheter is connected to a radiofrequency machine which generate energy to vaporise water molecules to cause scarring and hence firming up the disc to better support the spine. The scarring can also cause retraction of the disc bulging in some instances.
Surgery
In about 10% of cases of low back pain may end up with surgery. Surgery is performed in the instances where all conservative measures have failed. Usually, the most common surgery formed to the spine is to relieve the nerve root of the pressure of a herniation in the disc.
This is discectomy when herniated fragment is removed. In the case where the pressure on the nerve is due to formation of bone spurs, then decompression laminectomy is done to relieve the pressure on the nerve.
In some instances, where removal of bone spurs and elements that make up the support of the spine is removed, a fusion surgery may need to be performed.
This often involves the insertion of titanium screws and rods including using interbody cages to join the 2 vertebral bones together. This is essentially reconstructing the spine for better support.