LECTURE ON LOWER BACKACHE 

             Despite the advances in diagnostics and treatment in the past two decades, low back pain remains a challenging health disorder. Next to common cold, it remains the most common reason why people seek medical care, said Dr Sanjay Wadhwa, head of physiotherapy, PGI, Chandigarh. Dr Wadhwa was delivering a lecture on combating low backache in the auditorium of Advanced Paediatric Centre of the PGI here on Friday where other PGI experts, including Dr Babita Ghai, department of anaesthesia, and Prof Raj Bahadur, department of orthopaedics, spoke.

            Low backache affects up to 90 per cent of people at some stage and is considered as a medical disaster of the 21st century and leads to major loss of job hours.

            Dr Wadhwa said there were many causes (more than 100, according to an estimate) of low back pain. However, few people who felt pain in their low back had a serious medical problem. “One should see a specialist immediately if there is severe pain extending down your leg or the leg pain increases when you lift your knee to your chest or bend over,” said Dr Wadhwa. Dr Wadhwa said one must focus on exercises that work the lower abdominals, obliques and the quadratus muscles. Right posture while standing, sitting, moving heavy items, lifting, carrying and sleeping was also important. Prof Raj Bahadur said the best treatment was prevention, which included taking good care of your back. However there were three reasons why you might need surgery: When the pain is too severe to cope with in the short term and you need hospitalisation; the pain is persisting for too long, interfering with your quality of life; and when you have significant muscle weakness from pressure on a nerve which causes bladder and bowel incontinence.

             Dr Babita Ghai said patient education on the choice of treatment and the expected treatment outcomes seemed to be the key factors to success.

         Men and women are equally affected by lower back pain, and most back pain occurs between the ages of 25 and 60. Approximately 12% to 26% of children and adolescents suffer from low back pain. Fortunately most low back pain is acute, and will resolve itself in three days to six weeks with or without treatment. If pain and symptoms persist for longer than 3 months to a year, the condition is considered chronic. The back is the POWERHOUSE for the entire body, supporting our trunks and making all of the movements of our head, arms, and legs possible.

Causes of spinal pain

 

  •    Structural abnormalities
  •    Inflammation
  •    Infection
  •    Neoplastic
  •    Metabolic
  •    Visceral
  •    Idiopathic

 

 DISC PROLAPSE

Disc Prolapse happens when the soft inner material of the vertebral disc bulges or bursts through the outer lining of cartilage and puts pressure on the spinal nerve.

This irritation causes constant back and leg pain.Muscle spasms also occur when the spinal nerves are irritated.

Metabolic conditions

Mechanical or sinister pain

 

  • Osteoporosis
  • Osteomalacia
  • Hyperparathyroidism
  • Paget’s disease

 

Visceral pain

Referred pain

 

  • Pyelonephritis
  • Peptic ulcer, pancreatitis, pancreatic tumour
  •  Aortic aneurysm
  • Retroperitoneal neoplasm
  • Large bowel malignancy
  • Genital tract

 

In addition, depression, anxiety, frustration, reinforcement, stress, anger, fear and many other psychological states can help to cause the onset of or complicate back pain.The emotional component can complicate the back pain diagnosis, sometimes resulting in needless surgery and disability.

Commonest conditions by age & sex

  •  Young working men          acute disc prolapse                 
  • Middle age                       chronic disc disease

          (female>male)                  apophyseal joint OA      

  • Very young/old                  infection

                                                 malignancy

                                                 metabolic         

What are the symptoms?

Pain across the lower part of the back that sometimes radiates into the buttocks, the back of the thigh or to the groin.(sciatica) The pain is usually worse on movement.
Limitation in movement of the spine - especially bending forward and leaning back.

Tense spasm of the muscles surrounding the spine and causing a stiff back. With severe pain and spasm, the back may TILT to one side causing a change in posture. The pain is sometimes accompanied by a tingling sensation or numbness in the back or buttocks or leg.

What are the danger signs?

If you suddenly find out that you are unable to control your bladder or bowel movements or if the area of the lower back or legs turns numb, contact a doctor or Accident and Emergency department immediately. If you suffer from backaches and notice reduced strength or muscle bulk in one or both legs, contact a doctor. These warning signs indicate compression of the spinal cord and its branches and early treatment is essential if permanent damage is to be avoided.
Investigations

     X-rays of the back: to look for:

–     Spinal alignment

–     Fractures

–     Tumors

–     Osteoporosis

Discography

MRI

    Highlights soft tissues better than a CT scan

     Useful for seeing:

–      Disc protrusions

–      Tumors

–      Infections

–     Spinal cord compression

CT Scan

  Highlights bone better than a MRI scan

   Useful for seeing:

–     Fractures

–     Canal Stenosis

 

Other investigations

  •   Blood tests e.g. HLA-B27 for ankylosing spondylitis 
  •    Bone scan 
  • Bone Density Analysis 

TREATMENT

  •    The best treatment is prevention - i.e. taking good care of your back.
  •    Pressure in the disc is least when you lay flat, higher when you stand and, surprisingly, highest when you sit, and obviously higher if you carry a weight. Thus, standing is usually better than sitting if you have a painful disc.  

The three reasons why you might need surgery are:

  •  the pain is too severe to cope with in the short term - e.g. you need hospitalization
  •  the pain is persisting for too long, interfering with your quality of life
  • if you have significant muscle weakness from pressure on a nerve which causes bladder and bowel incontinence

SURGERY  !!!

  • Surgery can adequately correct only a fraction of all back problems.
  • The key is to become educated on your diagnosis, to get more than one opinion and to make sure you know all the facts including risks before you elect for surgery.
  • Keep in mind that even if you do elect for surgery, it is no substitute for a lifelong program of back care following the surgery.

TYPES 

Minimally invasive laminotomy/ discectomy

This type of surgery creates a small tunnel through the muscles in the back down to the area where the herniated disc is located. In comparison, an open discectomy involves a much larger incision and also involves stripping the muscles away from the spinal column so that the surgeon can see the area where the herniated disc is located.

TYPES

Anterior Lumbar Interbody Fusion (ALIF)
Patients who are suffering from back and/or leg pain are potential candidates for the ALIF procedure. This pain is generally caused by the natural degeneration of the disc space.

TYPES

Transforaminal Lumbar Interbody Fusion (TLIF)
Patients who are suffering from back and/or leg pain are potential candidates for the TLIF procedure. The causes of the pain may range from a natural degeneration of the disc space to some type of traumatic event.

 

Minimally Invasive Techniques in Spinal Surgery:

Artificial Lumbar Disc Replacement