Back Pain is one of the most common causes of morbidity worldwide. Most people suffer from back pain at least once in his or her lifetime. As you grow older, you are more likely to experience back pain. The incidence of low back pain is low in children and adolescence but the incidence is increasing. Sometimes episodic back pain becomes chronic pain.
Fortunately, most of the episodes of pain will resolve on their own. There are many steps you can take to prevent back pain like daily stretches, yoga, and strength training. It can help make your back and core muscles stronger and maintains flexibility. Weight control and balanced diet rich in vitamin D and calcium also keep your back stronger. If you are suffering from repeated episodes of pain, you should consult an orthopedic surgeon or pain clinic. Most of the back pain resolves with physiotherapy, lifestyle modification, and medication. Surgery may be required as a treatment option rarely.
- Strain due to lifting heavy weight or repeated twisting and bending of the trunk
- Vitamin D deficiency
- Prolonged sitting
- Sedentary lifestyle
- Highly physically demanding jobs
- Extreme tallness
Less common causes
- Disc herniation
- Degenerative spine
- Osteoporotic fractures
- Fracture and trauma
- Deformity of spine
Symptoms of Back Pain
Symptoms can vary from dull aching pain to a stabbing or shooting pain. Pain may radiate down to the leg or foot. You might not be able to stand and walk in severe pain. Stiffness of back is almost always present and sometimes may only be a presenting symptom. Onset of pain may be sudden (acute) or may develop gradually over time. Back pain due to strain or muscle fatigue may be relieved in a couple of days by rest and simple medications.Some of the symptoms of pain could be alarming. You should seek immediate orthopedic consultation if one or more of following symptoms are associated with back pain:-
- Numbness, tingling or weakness of lower limb
- High fever
- Unexplained weight loss
- Causes new bladder or bowel problems like incontinence of stool or urine
- Pain suddenly increasing on standing
- Discharge of fluid or pus from back
- If pain is severe and doesn’t improve with rest and medications
- Back pain for the first time if you are above the age of 50 years and if there is a history of cancer, or osteoporosis or steroid use.
Diagnosis of Back Pain
The diagnosis of back pain starts with the symptoms you have. Your doctor will do through clinical examination like your ability to flex your spine, bending forward and sides, and straight leg raise test. Further laboratory and the radiological test are advised depending upon your clinical examinations. Common tests for the diagnosis of back pain are the following:-
Lab tests:- common lab tests performed are complete blood counts, ESR, CRP, Serum Vit. D, Calcium, B12 to see your nutritional status and to exclude infection. Other tests may be advised according to your clinical examination.
X-ray:- X-ray is the most commonly performed test for the diagnosis of back pain. It may show fracture, spondylolisthesis, decrease disc space, arthritis or degenerative spine if present.
MRI:- MRI scans reveal herniated disks or other problems of bones like infection and malignancy. It also gives valuable information regarding the condition of muscles, tissue, tendons, nerves, ligaments, and blood vessels. CT- Scan and Bone scan is sometimes performed.
Nerve studies:- Nerve conduction velocity(NCV) and Electromyography (EMG) is sometimes performed to diagnose nerve compression due to herniated disc or lumbar canal stenosis(LCS)
Treatment of Back Pain
Treatment of back pain depends upon the severity and duration of pain. Most episodes of acute low back pain are usually relieved by rest and topical analgesic agents. The more specific cause needs detailed evaluation and treatment. Let us first discuss the prevention and treatment of common forms of back pain. The more specific cause of pain like a herniated disk, degenerative spine, infection, and tumors will be discussed later in this article.
Lifestyle modifications:-Lifestyle modification is the single most effective way for the prevention and treatment of back pain. Modify your day to day activities to decrease stress on the back are important to resolving or controlling pain and sciatica. Healthy lifestyle changes can avoid future episodes of pain. Some of the recommendations are:-
- Balance diet: – Your diet should be rich in protein, calcium, vitamin D, and anti-oxidants. These help to maintain bone and muscle strength. The deficiency of vitamin D causes muscle fatigue which results in chronic back pain and stiffness.
- Regular exercise: – Regular exercise help to maintain the flexibility of your back and it also strengthens your back muscles. Best exercises for back pain are Knee-to-chest, Trunk rotation, Bridges, partial sit-ups, hamstrings stretches, pelvic tilts and low impact aerobic exercises. Stretching exercises help to reduce tension and stiffness of back muscles and also improves range of motion and overall mobility. Low impact aerobic exercises like walking, elliptical trainer, static bicycling, and swimming help to improve blood circulation and also help to burn calories. At least 20-30 minutes of aerobic exercises 3-5 times a week is recommended. Some of the exercises to avoid in back pain are complete sit-up, straight leg raises, and toe touches. Weight lifting should be done under proper guidance.
- Maintain ideal weight:- Obesity leads to increased pressure over low back and can lead to repeated episodes of pain. Regular exercise and balanced diet help to maintain the ideal body weight.
- Posture correction:- You need to learn correct postures for sitting, standing, sleeping, and lifting objects from the ground. Please click on the following link to learn about correct posture:- https://my.clevelandclinic.org/health/articles/4485-back-health-and-posture
- Quit Smoking:- Smoking leads to decreased blood flow in the lower spine and can affect the nutrition of intervertebral disk, bones, and muscles of the low back.
Physiotherapy:- Physiotherapy has a definite role in the treatment of back pain. Physiotherapy is helpful even if you are not sure of the cause of pain. Physiotherapists can guide you regarding which exercises will help you to get rid of back pain. He can advise you regarding posture correction and about what kinds of everyday activities will help or hurt your back. Some of the modalities used in back pain are:-
- Heat and cold application
- TENS Ultrasonic therapy
The most commonly prescribed medicine for the treatment of back pain is NSAIDs like diclofenac, ibuprofen, etoricoxib etc, but long term use may lead to renal failure. Paracetamol alone or with tramadol is also prescribed in chronic diabetics and geriatric patients to avoid renal complications. Topical analgesics in the form of gel or spray are highly useful. Sometimes muscle relaxants are also added if muscle spasm is present. Calcium and vitamin D are added as nutritional supplements as their deficiency may cause chronic pain. Sometimes an antidepressant is also prescribed in chronic pain or in sciatica.
Treatment for specific causes:-
1) Herniated disc:- PIVD or herniated disc is a well-known cause of back pain and radiating pain to the lower limb. Intervertebral disc provides structural integrity and flexibility to the spine. It can be ruptured due to acute trauma like lifting a heavy object. Disc material is pushed back into the spinal canal where it put pressure over the spinal cord or nerve root. The pain usually starts as acute pain which gradually starts radiating to lower limb in a couple of days. Pain due to a herniated disc is managed conservatively by rest, physiotherapy, and medication. The diagnosis is confirmed by an MRI scan because the disc is not visible on plain x-rays. If pain does not respond to conservative management surgery may be required. A nerve block or epidural injections can also be tried before surgery.·
2) Degenerative spine disease:- It is a common name for the vast majority of spine disorders like arthritis or spondylosis, multi-level disc disease, spondylolisthesis, lumbar canal stenosis, etc. It usually presents as chronic low back pain and sciatica. Plain x-ray or sometimes MRI is required for the diagnosis. Exercise and physiotherapy is the mainstay of treatment. Surgery in the form of decompression and stabilization is sometimes required when there is significant nerve or cord compression is present. Fixation and fusion is sometimes performed in spondylolisthesis, if not responding to conservative management.·
3) Spinal fractures:- spinal fractures result from significant trauma and cause severe acute back pain. These fractures are usually associated with compression of the spinal cord and may result in weakness of both lower limb(paraparesis) or both upper and lower limb(quadriparesis). If the fracture is stable and no weakness is present, the fracture can be managed by rest and braces. Sometimes these fractures are associated with weakness of limb and are unstable. Unstable fractures need surgery for fixation and decompression.
4) Osteoporotic fractures:- Osteoporotic fractures need a special mention here. Spine (vertebra) becomes very weak due to osteoporosis. As a result of trivial trauma or sometimes just lifting weight is enough to cause a fracture. These fractures are painful and can be multilevel fractures. The diagnosis is done by plain X-ray and MRI. Pain can be managed by analgesics and rest and braces can be used for mobilization. Oxytocin nasal spray is very effective in pain control. These patients need long term treatment for osteoporosis to prevent further fractures and collapse of the spine. Bone cement augmentation of vertebral fractures (vertebroplasty or kyphoplasty) is sometimes required for control of pain and to maintain the normal contour of the spine.
5) Spinal tuberculosis:- Tuberculosis of the spine is common in India. Back pain is usually first symptom. Pain is worst in night and the patient may get up from sleep due to pain. It may present with swelling in the lower back (cold abscess). Delayed cases may present with weakness of both lower limb (paraplegia) with or without bowel and bladder involvement. Diagnosis is confirmed by plain X-ray, MRI and Lab investigations. Patients of spinal tuberculosis are managed with analgesics, rest and antitubercular drugs (ATT). Surgical decompression and stabilization may be required in late cases or if not responding to ATT.·
6) Tumours:- Primary tumour of the spine is relatively rare. Metastatic tumors are more common in spine. It usually presents with pain which is worst at night. Late cases may present with paraplegia. Detailed investigations are required to find the primary tumor. Treatment is aimed for the primary tumor. Stabilization of spine may be required in selected cases. Zoludronic acid infusion may be required to prevent spinal fracture and collapse..
7) Congenital Abnormalities:- Congenital means conditions that existing from birth as a result of abnormal growth of the fetus. Common congenital abnormalities causing back pain are scoliosis and spina bifida. Scoliosis is a lateral (sideway) curvature of the spine. Children with significant scoliosis may require treatment with bracing. Surgery may be required in selected cases. Adults infrequently Spina bifida is the defect in the bony vertebral arch over the spinal canal with the absence of the spinous process. This birth defect most commonly affects the lowest lumbar spine and the upper sacrum. Abnormal tufts of hair on the skin over the involved area are usually present. Spina bifida can be a minor bony abnormality without symptoms. Sometimes the condition can also be accompanied by serious nervous abnormalities of the lower limb.·
8) Back pain in pregnancy:- Back pain during pregnancy could be due to weight gain, hormonal changes, change in posture, or stress. Learn to improve your body posture to avoid back pain. Analgesics are usually avoided during pregnancy to avoid congenital abnormalities. You can apply heat or cold and can also apply topical analgesic gels.·
9) Referred pain:- Referred pain is pain perceived at a location other than the site of the painful stimulus. The Source of pain is located away from or adjacent to the spine. Sometimes kidney stones, urinary tract infections, ovarian cyst or tumours etc can present as back pain. Treatment should be aimed towards treating the underlying cause.