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Health Sense: The causes and treatments of lower back pain
Sacralization of the fifth lumbar vertebra
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Sacralization of the fifth lumbar vertebra. Courtesy of Patrick 87
Lower back pain is the most common musculoskeletal disorder and the most common reason for patients to seek medical attention after the common cold. It is the number-two cause of missed work and the number-one cause of disability in patients younger than 45.
Four out of five people will experience back pain in their lives.
There are many risk factors, including smoking, bad posture, genetics, body habitus and work conditions.
Previously, surgical decompression and the fusion of the spine were the default treatments. In recent years, however, we have the option of minimally invasive percutaneous spinal procedures likened to angioplasty of heart vessels, done as day surgery with reduced risk of side effects and complications.
Ironically, the severity of the pain is often unrelated to the extent of physical damage. Muscle spasms from a simple back strain can cause excruciating back pain that can make it difficult to walk or even stand, whereas a large herniated disc or completely degenerated disc can be completely painless. Muscle sprains may often mimic nerve impingement symptoms, resulting in back pain and 'nerve root' leg pain.
The causes of lower back pain can be very complex, and there are many structures in the low back that can cause pain.
The following are possible sites and mechanisms of lower back pain.
First there is non-mechanical back pain, which accounts for 60 percent to 70 percent of cases of acute back pain. As the term implies, it is not a structural problem requiring surgery.
Acute muscle sprain or injury can be secondary to either acute loading or repetitive strain. Poorly conditioned muscles undergoing a particular action that they are not used to, like lifting heavy luggage on a holiday, can result in acute pain.
Fortunately, most of these injuries are self-limiting and 90 percent will recover by themselves within two weeks. Medications and increased exercise tolerance form the cornerstone of treatment. Studies have shown that on the contrary, excessive bed rest and avoidance of movement may be counter-productive for back pain.
Other chronic disorders of the muscle, fascia, ligaments, and supporting structures include Myofascial pain syndrome and Fibromyalgia. These ailments often manifest as muscle stiffness with localized or radiating pain in the legs or arms. Numbness may also be a predominant symptom.
These types of pain can be extremely disabling. Significant risk factors include female gender, stress, hormonal disorders and deconditioned muscle. A local injection of botox or steroids into the trigger points can provide effective pain relief.
Second is mechanical back pain, which may be treated with interventional pain procedures. These structural problems may even require open surgery to correct the mechanical problems, of which there are several.
A patient might have an intervertebral disc, a disc herniation or a discal tear, resulting in the protrusion of disc material into the spinal canal.
Treatments using interventional pain procedures include nucleoplasty and intradiscal radiofrequency lesioning. These procedures will use a spinal laser wand to enter the disc and vaporize 1ml of the disc, generating 1cc of vacuum. This vacuum will shrink and draw the bulging disc inward, relieving the pressure effect on the impinged nerve.
There may also be impingement of spinal nerve roots due to protruding discs or enlarging facet joints, encroaching into the spinal canal and resulting in narrowing of the space (spinal stenosis) and nerve entrapment.
For patients who are afraid of surgery or not a candidate for open surgical decompression, we can offer canal adhesiolysis and ballooning of the spine using percutaneous neuroplasty. This will dilate and open up space for the surrounding impinged nerves.
There are also disorders of spine alignment (scoliosis, spondyloslisthesis). Severe scoliosis can cause a lot of strain on the surrounding supporting structures such as facet joints, muscles and ligaments.
Radiofrequency ablation of these structures can be a simple procedure to relieve the pain of scoliosis.
Facet arthropathies/spondylosis may also be a concern. Facetal pain can be secondary to acute inflammation or degeneration. Additional physical stress may be exerted on the facet joints if it is compounded with scoliosis or kyphosis of the spine. Again, radiofrequency ablation of the painful nerves can give relief to patients who do not want fusion of their spine.
Finally, there might be pathological conditions of the vertebral body. Compression fractures of the vertebral body can result in loss of height and additional stress on the surrounding facet joints.
In this case, vertebroplasty is a useful means of stopping the fracture ends of the vertebra from rubbing against one another and to increase the height of those compressed spinal bodies.
It is important to note that some types of lower back pain have no known anatomical cause, but the pain is still real and needs to be treated. However, usually lower back pain can be linked to a general cause (such as muscle strain) or a specific and diagnosable condition (such as degenerative disc disease or a herniated lumbar disc).
There are a few symptoms that are possible indications of a serious medical condition requiring surgery and patients with these symptoms should seek medical attention immediately. These symptoms include sudden bowel and/or bladder incontinence (cauda equina syndrome), progressive weakness in the legs (cauda equina syndrome) and severe, continuous abdominal and lower back pain (possible abdominal aortic aneurysm).
People with fever and chills, a history of cancer with recent weight loss, or who have just suffered severe trauma should also seek immediate medical attention.
The author is a physician, the founder of Singapore Pain Care Center and the director and consultant of the Women's Pain Center at KK Women's and Children's Hospital. For more information, visit paincarecenter.sg.
