Back pain

Back pain in general

Because of the complexity of the spine, with its numerous joints, muscles, ligaments, and intervertebral discs which can become injured or can degenerate with age, there is a lot of potential for pain in the spine or back.

Backache is a common cause for distress in any population. It causes pain and is a major cause for physical disability and psychological distress. It thus cannot be looked upon in isolation but must be viewed in terms of how the condition affects the individual; how it affects his or her family; and how it affects society as a whole.

The individual – Pain in the back can be extremely uncomfortable. It often leads to a period physical incapacity, leaving the affected individual feeling helpless and extremely anxious about his (or her) condition.

The family – It is distressing for the family to see one of its members suffering from backache and, in many ways, sharing his suffering. There is also an economic element to this as the affected individual is often unable to work and, if unsupported by his employer, will suffer significant loss of income.

The society – Back pain, on an accumulative basis, can be extremely costly to society. It is calculated that the cost to the United Kingdom in 1998, as a result of this condition, was in the region of £1600 million.

 

Common Causes of Orthopedic Back Pain

Most Orthopedic back pain arises as a result of an acquired condition and may be categorised as either ‘mechanical’ (directly as a result of anatomical changes in the spine) or as non-mechanical (when any changes in the spine may be associated with the pain rather than causing it).

As Outlined on a ‘Surgical Sieve’

• Mechanical backache (The most common form of back pain)
• Traumatic:  includes sprains, tears and fractures
• Degenerative: wear and tear, and aging changes
• Non-Mechanical backache: A large number of Metabolic, Vascular, Inflammatory, and Infectious conditions masquerade as spinal disease, particularly when they affect the spinal cord or nerves, but the most common conditions included in this group which pertain to directly to Orthopaedic Surgery are summarised below:
• Infective: Bacterial and other infections  –  Tuberculosis. Perispinal abcesses
• Metabolic: Osteoporosis
• Vascular:  Epidural haematoma. Vascular malformations e.g enlarged intraspinal veins
• Auto-immune:  Rheumatoid arthritis, Ankylosing spondylosis, Psoriasis, DISH
• Endocrine: Cushings disease
• Neoplastic:  Primary tumours uncommon. Secondary tumours more frequent. Malignant myeloma
• Ideopathic:  Diffuse idiopathic spinal hyperostosis  (DISH). Generalised ligamentous laxity. Scoliosis. Sheuermann’s disease
• Neurological:  paraplegia
• Mind/body:  Myofascial pain syndrome,  Fibromyalgia

 

The Microbiome

The Microbiome is the collective name for the approximately 100 trillion micro-organisms within the gastrointestinal tract.

There has been increasing interest and research into the Microbiome over the last few years as it has been found that it has a marked effect, beneficial or detrimental, on the individual’s health, affecting the immune, metabolic and neurobehavioral traits of the body.

The effect on these various systems appears to be related to the diversity of the Microbiome, which is a measure of how many different species contained in the gut. Although the definition of what constitutes a normal Microbiome has not been resolved it is felt that when a great number of different types of organisms present the Microbiome is considered to be ‘diverse’ and healthy. Conversely when the Microbiome is constituted by only a relatively small number of different types of organisms it is said to be ‘dysfunctional’ and the term Dysbiosos is used.

It has been found that there is a link between a dysfunctional Microbiome and inflammatory bowel disease, as well as a group of diseases termed the spondyloarthritides; which affects both the spine and the joints of the body. These include ankylosing spondylitis, psoriatic arthritis, juvenile spondyloarthritides, reactive arthritis and inflammatory bowel disease related arthritis. The typical clinical features include inflammatory backpain, sacroiliitis, synovitis and and enthesitis.

The gut Microbiome is markedly affected by diet (prebiotic). A single bacterial species in the bowel can upset the homeostatic balance of the immune system. Attempts are being made to therapeutically manage the intestinal Microbiome using both prebiotics and probiotics but there remains, at present, a dearth of scientific information to support specific dietary interventions.

 

Backpain

Nature of the Pain – Referred or Radicular

Painful conditions in and around the spine and the tissues of the back often cause pain to radiate down the adjacent arm or leg, which can commonly be associated by weakness and numbness in the affected limb. Depending upon its nature, this pain is termed ‘referred’ or ‘radicular’.

‘Referred pain’ arises from an area of inflammation or some other painful lesion, such as fibromyalgia, present somewhere about the shoulders or in the lower back or buttocks. The pain, however, appears to be present in the limb rather than in the back. This occurs as a result of the brain misinterpreting the site of origin of the pain because the nerves which supply the area of inflammation in the trunk also have branches which pass down the adjacent limb. With ‘referred pain’ the discomfort in the limb is present in association with the pain in the trunk. It is generally not of a sharp, shooting nature. It may, however, be associated with mild ‘pins and needles’ in the fingers or toes as well as sometimes associated with weakness in the arm or the leg. Treatment of the originating lesion will usually alleviate the referred pain and other symptoms.

‘Radicular pain’ arises when a nerve itself is directly irritated, usually by pressure from prolapsed intervertebral disc, a thickened ligament or an enlarged osteoarthritic joint in the spine. This irritation causes pain which seems to be originating in the limb, in the area of distribution of the affected nerve and often goes right down the limb. When in the leg this pain is known as ‘sciatica’. The pain in the arm or leg may, or may not, be associated with pain in the back or neck. The pain in the limb, in this instance, has a sharp, ‘shooting’ nature. It is more likely to be associated with definite ‘pins and needles’ in the hands or feet. It is also likely to be associated with weakness and/or loss of sensation in the limb. Radicular pain will not subside until the pressure on the nerve is reduced. This may occur spontaneously. If not, surgical decompression may need to be considered.

It is important to differentiate between ‘referred’ and ‘radicular’ types of pain but, in addition to these causes, there are many conditions, as mentioned above, which cause an inflammation or degeneration of the nerve itself. These too can also cause pain and/or altered sensations in the limbs but are usually not within the province of an Orthopaedic Surgeon.

 

Mechanical Backache

Non-specific Back Pain

Generally, if one is fit, the back can take a lot of strain and rarely gives a problem. However, the muscles around the spine give it much of its support and if these get ‘out of condition’ due to age or inactivity a sudden exertion can ‘sprain’ the back which will result in some discomfort. Similarly, emotionally or physically stressful working or social conditions cause an increase in muscle tension which can lead to diffuse aches and pains, especially around the neck and shoulders, and sometimes the lower back. These pains are far and away the most common cause of backache. Fortunately most of the pain arising from these causes will settle relatively quickly but there are some measures which you can undertake which may be of some assistance.

Prevention of backache is the best measure.

• Keep fit. Regular exercise strengthens the body and keeps the spine supple.
• Be careful how you lift items, especially if they are heavy.
• A large abdomen pulls on the spine. Keep your weight down.
• Reduce stress. This can be difficult but, if necessary, consult a Psychological Counsellor.

If such pain is present in the back

• It is generally felt that it is better to keep moving, if possible, although it is usually necessary to modify ones activities to accommodate to the pain. Physiotherapy can help but some might wish to maintain their present exercise regimes.
• If at all possible, lose excess weight.
• Correct any spinal imbalances or deformities if present.
• Spinal manipulation of the lower back from an Osteopath, Chiropractor or Physiotherapist is sometimes helpful.
• The use of effective ‘pain killers’ as a temporary measure is often invaluable. If necessary your doctor can prescribe these if you find that the simple analgesics, available ‘over the counter’, do not help.
• A spinal support (corset or neck brace) is sometimes of assistance
• Electrical Interferential treatment can help. A transcutaneous, electrical nerve stimulation (TENS) machine can sometimes reduce much of the discomfort.
• In some instances Acupuncture can be very effective.
• Fibro-muscular pain often responds to local massage.
• Muscle relaxants such as Valium, if given for a short time, can help although they have side effects of dependence and drowsiness and can contribute to the risk of a fall, particularly in the elderly

 

Degenerative Spinal Pain

For various reasons, sometimes from prolonged strains or sometimes from an inherited predisposition, the structures in and around the spine begin to degenerate. In doing so the back can become subject to more severe and prolonged episodes of backache. The structure which usually takes the brunt of this degeneration in the spine is the intervertebral disc. Degeneration of this structure can cause a localized pain in the back. The process, if it continues, sets up, in turn, a series of events which lead to further degeneration of the disc and increasing pain . These events include prolapse of the intervertebral disc, collapse of the ligaments between the vertebrae of the spine and, in the later stages, arthritis of the facet joints.

The person who is suffering this degree of degeneration of the spine may well find that he (or she) is experiencing two different types of pain. There may be discomfort, localized in the back or neck, which arises from the damaged structures within the spine itself; and there may be pain, which passes down the legs or arms, caused by pressure on a nerve.

In this situation the pain may well still respond to the conservative measures outlined above but should the discomfort become too disabling it may be necessary to consider some form of surgery as discussed in the Spinal Degeneration and/or Spinal Fractures sections of this website.

 

Spinal Fractures

Pain and deformity can arise as the result of a fracture of the spine, arising as the result of a major accident (in the young) or osteoporosis of the bone (in the elderly). As a result of the fracture the spine may become deformed and/or the pain may be prolonged if fracture healing is delayed. Urgent consultation with a surgeon should be sought for all injuries to the neck or back, particularly if there are neurological deficits such as pain, weakness or numbness in either the arms or the legs.

 

Chronic Backpain

If the pain in the back or in the neck becomes severe and is prolonged i.e. longer than 3 months, it is termed ‘chronic’. In this situation the affected individual can consider the various options – to continue with the conservative measures, to consider any surgical option, or to attend a Pain Clinic which specialises in treating back pain using non-operative methods.

 

Pathological Backache

Rarely tumours or infection may affect the vertebrae (less than 1% of cases of severe back pain). The pain, in these instances, is generally a deep, constant ache, worse at rest, which may be accompanied by systemic conditions such as a raised body temperature or marked loss of weight. While the pain could be due to a degenerative condition, you should consult your Physician or General Practitioner immediately if any of the following ‘Red Flags’ are present:

• The backache is prolonged i.e. present longer than 3 weeks.
• The pain is severe.
• The pain radiates down one or more limbs.
• There is loss of sensation in the back or limb.
• There is paralysis of one, or part of a limb.
• There is an associated problem with bowel or bladder function.
• It is a child or adolescent who is experiencing the backache.

 

In these instances it is important to know exactly what is causing the pain and treat it accordingly. The physical examination will usually suggest the diagnosis but, to accurately localise the cause and site of the pain it may be necessary to assess the back using some of the specialized radiological investigations such as an MRI or CAT scan, or a bone scan. Occasionally more invasive procedures such as discography may be necessary.

 

Non-Mechanical Backache

Myositic Trigger Spots

Not all pain in the back is ‘surgical’ in nature. In many instances the discomfort which an individual experiences will be be found to be originating from a small localised thickening within the muscles and soft tissues of the back and other areas of the body. These masses are termed ‘myofascial trigger points’ and are generally found in the Myofascial Pain Syndrome and Fibromyalgia.

Benign Hyperlaxity Syndrome

The Benign Joint Hyperlaxity Syndrome is a condition in which the ligaments of the body have a degree of stretch within them which leads to a degree of instability of the joints of the body. Initially though to be relatively benign it is becoming recognized that it can have some serious consequences. The condition makes the joint more susceptible to strains and dislocations which, in turn, can cause it to be painful. Many joints of the body may be affected, not least of all those of the spine and pelvis, as well as the feet.

Other conditions causing non-mechanical back pain

There is a group of conditions which, when present, have generalised effects throughout the body.  As part of their symptomatology they can give rise to backache. Sufferers from the Irritable Bowel syndrome quite often experience pain in the back for no apparent cause. However, in others of this group the spinal manifestations are very specific. This applies particularly to Rheumatoid arthritis, Psoriasis and Ankylosing spondylitis. A relatively uncommon, often unrecognized, but benign condition also giving rise to pain in the back is Forestier’s disease (DISH); manifesting with small, hyperostotic outgrowths of bone between the thoracic vertebrae. Although Forestier’s Disease is often asymptomatic, if it affects the cervical spine it can also cause difficulty swallowing, difficulty eating, sleep apnoea and other otorhinolaryngological symptoms.

 

Non-Skeletal Causes of Back Pain

Pathological conditions of the upper abdominal organs and viscera can cause referred pain in the back. These include the liver, gall bladder, kidneys, pancreas and abdominal arteries. Consult your Physician or General Practitioner urgently if there is pain in the abdomen as well as in the back.

Surgical treatment of back pain

Although most cases of backache settle down within a relatively short period, particularly with ‘conservative treatments’ there are a few common conditions of the spine for which surgery may possibly be the best treatment option. These include: many of the degenerative disc conditions, the spinal fractures, spondylolysis, spondylolisthesis, severe deformities and tumours. These conditions and their surgical procedures are considered in the other sections of this website.