Back Pain

By Dr. Harold Gunatillake FRCS
Health Writer
(Senior Registrar in Orthopaedics and subsequently acting consultant, Queen Mary's Hospital, Surrey. England- 1967-69)

Your spine is a most flexible mobilestructure exceptthe thoracic spine, made strong and stable by a chest frame composed of the ribs and the sternal bone (plate) to protect the vital organs. Most flexible segments of the spine in use, where the stress of wear and tear would be most felt areat the junction of the neck and thoracic bones(cervical-thoracic junction) and at the lower end, the segments between lumbar and sacral junction (lumbosacral junction). The sacral segments are also fused together, like in the thoracic cage forming a pelvic basin to protect its vital structures.

The cervical spine composed of seven vertebra and cushioning discs opposing each set of vertebra, is mobile, can be flexed to look down, extend to see the ceiling, turn from side to side as required when reversing your motor vehicle, and even move in a rotatory movement as seen among Kandyan dancers, having a wide range of movements possible.

Cervical spondylosis
With age, one could get some degree of degenerative condition called cervical spondylitis, a situation where the cushioning discs can degenerate and collapse, causepinching of nerves that emanate from the spinal cord bilaterally, behind the discs resulting in uncomfortable restrictive movements.

In this situation the pain may radiate to the shoulder region on rotating the neck, or stretching, sometimes with cracking noise- the doctors call itcrepitus. This is most common among the older people, and those who have had whiplash injuries of the neck, and may needs, traction, local heat and other manipulative therapy for relief. Sometimes, you may need to wear a cervical collar to relieve the discomfort.

The thoracic spine is well stabilized with no movements at the vertebral and disc segments, due to reinforcementby the ribs on the side and the sternal bone in front. The advantage of a stable frame is to protect vital organs within. Even after heavy falls, this segment of the spine is quite stable, even with crush fractures of the vertebrae. Now we come to the troublesome part, the lower segment of the spine called the lumbar spine, the part of the back that gives recurrent annoying problems that affects your daily life and even sleep.

The lumbar spine is fairly mobile to the extent that you could touch your toes by flexing the spine. The strain on such movements will be borne by the lumbar spine and also at the lumbo-sacral junction. Bending your spine without flexing your knees to relax the hamstring muscles at the back of the thighs will cause permanent recurrent lower back problems.

Always bend (flex) your knees before you stoop to pick up or lift objects.

In case you experience sudden onset of a back pain, or a recurrent chronic back pain, you should see your family doctor, within days if there is no improvement.

The doctor will do a preliminary examination of the spine, and request for X-rays of the relevant spine area. Plain X-rays may not give sufficient information, and the family physician will then decide whether further specialized expensive investigations are required.

In Sri Lanka most people I know, love to get more and more investigations done going from doctor to specialist and so on, and not carry out the instructions given by the first doctor. May be there is the psychological feeling that such sojourns help a cure. This practice is common among those in the private sector where the companies bear the bills.

Scans for Back Pain Ineffective
Researchers from Oregon Health and Science University in Portland reviewed six clinical trials comprised of nearly 2,000 patients with lower back pain. They found that back pain patients who underwent scans didn't get better any faster or have less pain, depression or anxiety than patients who weren't scanned. More important, the data suggested that patients who get scanned for back pain may end up with more pain than those who are left alone, according to the report published in the medical journal Lancet.

The problem, say researchers, is that back scans can turn up physical changes in the back that aren't really causing any problem. One well known study from The New England Journal of Medicine put 98 people with no back pain into a magnetic resonance imaging scan. Even though all of them had healthy backs, two out of three of them came back with M.R.I. reports that showed disk problems. (Reportby Tara Parker-Pope)

If the discs are intact, and the vertebral segments are in alignment, the doctor may pinpointa muscular and ligament problem and a therapy regime will be organized without further investigations. If significant nerve damagesymptoms are present from a crushed vertebra and disc protrusion suspected, with pain radiating down a leg (sciatica), then your doctor will request for further investigations like a CT scan or MRI.

In the situation the plain X-rays do not show serious damage to the spine, your doctor will diagnose the condition as "Lumbar- sacral strain". You will then be referred to a physiotherapist for massages, manipulative therapy and short wave diathermy (SWD), and so on. You will be shown erecto-spinae exercises to do daily at home for a while. In most situations you improve within days to a few weeks. Bulging discs and pinched nerves may require traction treatment in addition.

Basic treatment at home
You don't have to rush to hospital with an acute back pain. Try some home remedies first.

Wrap ice cubes in a damp tea towel and place it on the painful area of the spine for 20 minutes every two hours to reduce the traumatic inflammation. Avoid massaging at this stage. After 24 hours application of heat packs help ease much of the discomfort. Hot baths and hot water bottles help to ease muscle discomfort.

Rest your back as most cases of back pain is due to muscle strain and further irritation can cause more damage. Bed rest is fine, so long as this only lasts two or three days. Prolonged bed rest may actually lead to more persistent pain. When resting lie down on your back, or sideways supported by pillows

Avoid much in sitting position.
Travelling in a car place a rolled towel or pillow behind at the lumbar region (small of your back)
To reach your feet (for example, to tie your shoes), sit on a chair and cross one foot at a time over the opposite knee, or stand with one foot on a stool.

Lifting an object can be problematic. If possible, first get down on one knee and lift the object to your waist; then stand up, holding it close to your body.

When carrying packages, use two bags with handles packed as evenly as possible, and carry one bag in each hand. If you have recently had a vertebral fracture, limit the weight you carry to 10 pounds.
Walk as little as you can, and gradually you can increase the distance

Take some pain killer like paracetamol and codeine combination. Diazepam relaxes the back muscles.

After the muscle spasms have subsided exercises will be important to stretch and strengthen the back muscles. These exercises are referred to as "erectospinae exercises." A physiotherapist will demonstrate these strengthening exercises.

Lie on your back with knees bent, and feet flat. Place a small pillow under your head. Tighten your abdominal muscles by pulling your pelvis and ribs together while flattening your lower back towards the floor. Repeat this exercise daily for about 10 times. Avoid those infamous stomach "crunches" and toe touches and any exercise or activity that involves twisting the spine or bending forward from the waist with straight legs. Do all your exercises in lying down position on a firm mattress when the spine is free to accept any movement.

In the erect position, stand up straight. Good posture — proper alignment of body parts when you stand, sit or walk — reduces stress on the spine. Lift your breastbone, and keep your head erect and shoulders back, all the while gently tightening abdominal muscles and maintaining a small hollow in your lower back.

In most countries, including Sri Lanka more money are spent over to treat spine problems, but their backs aren't getting any better. The Journal of the American Medical Association in a report has revealed that over nearly $ 86 billion have been spent for the treatment of back problems in 2005. The report says,"It's not clear why more people appear to be suffering from back and neck pain. It could be that rising obesity rates are taking an added toll on the spine, researchers suggested. Or it could be that excessive treatment of back problems is leading to more problems."

Coping skills are extremely important in the chronic back pain treatment. Chronic back pain directly affects all areas of your life. Pain affects mood,and your mood affects your ability to cope with pain. Pain also affects how you interact with other people. For this reason,learning appropriate coping skills for dealing with anxiety,depression,irritability and frustration can be invaluable. Visiting a trained pain specialist,psychologist or psychiatrist greatly enhances the Chronic back pain treatment. Procedures ranging from minimally invasive injections to surgery may be used in chronic back pain treatment. Sometimes,implantable devices are beneficial in treating chronic back pain.

In most situations, a local cortisone based injection gives at least 6 months relief in recurrent chronic nonspecific back problems. This is normally suggested by the doctors as a last resort before surgery is contemplated, when all other options have been tried. In most situations it works like magic. The injection needs to be given to the right spot for temporary relief. I would suggest- go for it. I personally have treated most of my patients in Sydney likewise, over hundreds, and most satisfying outcomes.

When chronic back pain with disc protrusions is neglected, you may end up with thigh and leg muscle wasting and weakness, loss of sensation and even difficulty in walking. Even laminectomy and decompression procedures may be too late and the surgeon and the procedure get the bad name. So decide on surgery early, if indicated. Most candidates in this plight, at this stage contemplate having conservative therapies, such as acupuncture, herbal applications, chiropractic procedures, meditation, yoga, and so on. It is a fact that you may be unsuitable for surgery if indicated, after going through these regimes.

Spinal Stenosis
This article would be incomplete if some salient points on Spinal Stenosis are not detailed. This could occur in the neck region (cervical spine), thoracic spine and the lower back (lumber region)
Spinal Stenosis is a condition due to narrowing in and around the spinal canal causing nerve pinching which leads to persistent back pain, pain in the buttocks, limping, lack of feeling in the lower extremities, and decreased physical activity. There are several different types of spinal stenosis affecting all regions of the spine (cervical, thoracic and lumbar spine).

The specialist will suggest surgery to decompress the region to release pressure on the cord and nerves. Back pain is a vast subject. This article is very brief. Always do the right thing, take the right steps at the right time, understand the problems and take the right decisions. After all you need your spine till you last, as much as a healthy heart.

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