Back Pain

‘My back hurts’ or ‘a severe backache’ are common versions used for describing back pain. Back pain can occur around your spine or in the region of the neck, thoracic region, or lower back. An injury to the backbone (vertebral bodies) or to the muscles supporting the backbone gives rise to pain and stiffness in the back. Since low back pain is most prevalent, back pain is commonly referred to as low back pain, which is the cause of concern in the majority of the people.

Back pain is quite common with almost everyone complaining of symptoms of back pain at some point in their lives Acute back pain generally improves after treatment; however, many people complain of pain within 1 to 2 years. In India, 6% of the population leading a moderate activity to a sedentary lifestyle suffer from low back pain, and 92% people involved in high physical effort activities suffer from severe and recurrent back pain with a prolonged recovery time. The occurrence of pain increases with age and women tend to suffer more than men. With such a high prevalence of back pain in the general population, it is important to understand the condition in detail.

The type of pain can be roughly categorized on basis of its nature, duration, and onset.

This helps in choosing appropriate treatment measures to relieve the back pain. The type of pain also helps the doctor to advise suitable tests and investigations to determine the cause of the back pain.

Duration of Pain

• Acute back pain
  In general, the acute pain refers to pain that lasts for a short period of a few days to few weeks and improves with minimal treatment. Lifting heavy weights, suffering a fall, sudden muscle spasm, and pregnancy (labor pain) are some of the common causes of acute back pain.
   
• Chronic back pain
  Chronic pain lasts for 3 months or more and the requires various treatment modalities for effective management. Finding out the exact cause of the pain is difficult in chronic back pain. Changes in lifestyle, improving posture while sitting and standing, physiotherapy and use of medications help in managing chronic back pain effectively. 

Nature of Pain

• Sharp shooting pain spreading along the path that the affected nerve follows is a result of compression of the nerve or nerve root near the spinal cord. This is generally due to problems with the vertebral disc (example: sciatica or sciatic nerve pain). This pain is usually accompanied by a tingling sensation and/or numbness.
• Dull aching pain may occur due to muscle or ligament injury.
• Pain can sometimes be continuous in nature.

Onset of Pain
There may be: 

• Sudden onset
• Gradual onset
• Gradual worsening of pain

Low back pain is frequently accompanied by some other symptoms. These symptoms also help the doctor to understand the cause of pain. The symptoms include:

• Pain getting worse on sitting, lying down, lifting weights, or bending.
• Pain in the back spreading to the legs, buttocks.
• Pain with tingling and numbness in the legs or groins.
• Pain with loss of bladder and bowel control.
• Pain with severe stiffness causing discomfort while sitting, standing, or moving.
• Pain spreading from the back to the bladder with frequent urge to pass urine.
• Pain in the back with severe abdominal pain associated with fever and vomiting.
• Bloating of the abdomen sometimes causes pain in the back.
• Tumors cause low back pain that increases when lying on the abdomen and is associated with fatigue and weight loss.

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CAUSES

There are a number of causes that can lead to back pain. The common ones include:

• Disc problems such as rupture, degeneration, or herniation of the intervertebral disc.
• Muscle sprain from injury, fall, lifting heavy weights, and prolonged sitting.
• Degeneration of vertebral bodies (bones) due to aging (arthritis), osteoporosis, autoimmune diseases (ankylosing spondylitis), spine deformity, and spinal stenosis.
• Tumors (Malignancy) of the spine.
• Infection in the spine.
• Spine Fracture.
• Back pain could also be a result of various underlying medical problems involving other parts of the body. These include pancreatitis, gastritis, peptic ulcer, gallbladder diseases, kidney stone and infections, endometriosis, fibroid, and prostatitis.

RISK FACTORS 

There are certain risk factors that make a person more prone to back pain. These include: 

• Age
  The chances of back pain increase with age. You may experience back pain for the first time at around 30 to 40 years of age.
• Obesity
   Excessive body weight strains the back muscles.
• Lack of exercise
  Lack of exercise leads to weakness in the back muscles.
• Psychological conditions 
  Conditions such as depression, stress, and anxiety, increase the risk of low back pain.
• Smoking
  Smoking decreases the blood supply to the spine and slows down the healing process.
• Incorrect posture
  Wrong posture and faulty positions while sitting and sleeping make you prone to back pain. Also, having a habit of using wrong methods of lifting a weight from the ground using back muscles instead of legs increases the risk of low back pain.
• Deficiency
  Deficiency of nutrients, such as calcium, vitamin D, and phosphorus, increases the risk of back pain.
• Diseases
  Diseases such as arthritis, cancer, and hereditary diseases of the spine, put you in a high risk of developing back pain.

For most people except those who are very old and those with certain genetic factors, back pain can be prevented by making some lifestyle changes. Here are ways that can help in preventing back pain: 

• Improve your posture
   Avoid improper posture and faulty techniques of weightlifting.
• Opt for back strengthening exercises
  Strengthen your back muscles by following an exercise regimen which includes regular stretching, strength training, and aerobic exercises. If you are overweight, shed those extra kilos to get the excess weight off your body.
• Quit smoking and follow nutrient-rich dietary habits.
• Stay active throughout the day
  Interrupt your prolonged sitting hours at work by taking small walk breaks and by taking your phone calls standing or walking around.

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A diagnosis is established by the doctor om the basis of symptoms, a history of pain, physical examination and investigations. A detailed history regarding the onset, severity, duration, and other symptoms present with the back pain helps the doctor recognize the seriousness and critical need for investigations. Investigations help in confirming the diagnosis made from clinical examinations. Investigations include imaging studies, such as:

X-ray of the Spine
This helps in detecting any fracture in the vertebral bodies, a deformity in the spine, and any structural abnormality in the vertebral column

Magnetic Resonance Imaging (MRI)
MRI is used to look for any problems in the soft tissues, such as muscles, ligament, and blood vessels. Magnetic radiations used in MRI help in the diagnosis of a tumor, an infection, a slipped disc or disc rupture and nerve entrapment. 

Computerised Tomography (CT) 
There is more visible clarity of an underlying problem such as disc rupture, spinal stenosis, and tumors with a CT scan as compared to an X-ray. A CT scan is commonly performed to visualize the three-dimensional view of any underlying problem in the spine that could  be causing the back pain.

Discography 
Discography is used to identify the spinal cause of the back pain by injecting a dye in the intervertebral disc. It is commonly performed in people in whom standard treatment for back pain does not help in improving symptoms

Myelogram
Myelogram increases the visibility of ruptured disc or nerve compression on an X-ray and CT scan after the injection of a dye in the spinal canal.

Bone Scan
A bone scan helps in identifying any abnormality in the bone. It also helps in identifying any abnormality in the blood flow in the bone and severity of the joint disease.

Nerve Study
This includes electromyography to measure the condition of nerve in the muscles, nerve conduction studies, and evoked potential studies. These studies analyse the transmission of electrical impulses in the nerve and are used to diagnose nerve entrapment, which leads to tingling and numbness associated with back pain.

Urine Analysis 
This helps in detecting infection and other kidney problems that cause back pain.

Blood Tests
Blood tests such as complete blood count, C-reactive protein, erythrocyte sedimentation rate, are done to rule out infection, inflammatory disease, or cancer.
The HLA-B27 blood test is a marker assay for diagnosing ankylosing spondylitis, which is commonly seen in young adults.

Not all people with back pain require all these investigations. The doctor advises investigations when back pain is associated with  fever, failure of recovery beyond 6 weeks, loss of sensation, loss of bladder and bowel control, severe stiffness along with pain, drug abuse, and a history of cancer and other diseases.

The treatment of back pain is usually divided into three groups. The doctor decides the treatment on basis of the nature of pain and symptoms which are present along with back pain.

Non-medical treatment

Acute and non-specific back pain generally gets better with rest and self-care. Some of the back pain self-care methods include the following:

• Hot fomentation and massage
  This increases the blood flow and relaxes muscle stiffness.
   
• Physiotherapy exercises and traction
  These should be done under the supervision of physiotherapists. These help in decreasing the pain significantly.
   
• Alternative therapies
  These include:
  • Yoga, which involves different stretching exercises and positions that relax the stiffness in muscles.
  • Acupuncture comprises the use of needle pricks at specific points on the body to relieve pain.
  • Chiropractic involves spinal manipulation with controlled force on the vertebral bodies to release stiffness and bring flexibility in the intervertebral joints.
  • Mind relaxation techniques, such as meditation, biofeedback, and behavior modification techniques, also help in relieving pain.

Medical Treatment
Medicines play a key role in the management of chronic back pain and are essential when non-medical treatment measures fail to relieve the pain. Commonly prescribed medicines include:

• Paracetamol or Acetaminophen
  This medicine is generally the first medicine prescribed for back pain. It also has fewer side-effects.
   
• Non-steroidal anti-inflammatory drugs (NSAIDS) These are painkillers and include ibuprofen and naproxen. These are prescribed when paracetamol does not relieve the pain.
  Painkillers are also available as topical creams, ointments and sprays help in decreasing the intensity of pain.
   
• Muscle relaxants
  Doctors advise muscle relaxants, such as cyclobenzaprine and methocarbamol, along with NSAIDs for reducing the stiffness of muscles.
   
• Narcotic-like drugs 
  Tramadol and morphine are used to give relief from severe pain. They are prescribed for a short period of time (2-3 weeks). These are not advised for long periods due to the side effects, such as drowsiness, constipation, dryness of mouth, slow breathing, and itching of the skin.
   
• Antidepressants 
  These are used chiefly in chronic back pain and those who are depressed from long-standing pain. These include amitriptyline, duloxetine, and imipramine. Since side effects (e.g., blurred vision, weight gain, and drowsiness) are very common, these drugs should be taken under strict medical supervision.
   
• Steroids 
  Corticosteroids, such as prednisolone, help in relieving radiating pain down the legs. They also reduce the inflammation and swelling at the injury site, which causes back pain.
   
• Anti-convulsants
  Recent studies have shown that the use of anti-epileptic medicines along with painkillers is effective in relieving nerve-pain, especially in chronic back pain. Carbamazepine, gabapentin, and valproic acid are commonly used anti-seizure medicines. Confusion, gastric disturbance, and headache are common side effects caused by anti-convulsant medicines.

Surgery

Doctors advise surgery when non-surgical treatment does not decrease the pain. Radiating nerve pain, increasing weakness in muscles, deformity in the spine (spinal stenosis), and rupture of an intervertebral disc, which are not successfully treated with medicines or non-medical treatment require surgery. Surgery is also performed in case of emergency conditions, such as fracture and cauda equine syndrome, which can cause paralysis along with back pain.

• Spinal fusion is a procedure in which the vertebral bodies are fused or joined with each other, thereby ensuring no movement in them. This procedure is helpful in the case of arthritis in the vertebral bodies and makes the body movement less painful and free.
   
• Laminectomy is a surgical procedure in which the surgeon removes the part of vertebral bone or ligament that is causing pressure on the nerve. This procedure is commonly done in the case of spinal stenosis wherein there is a narrowing of the spinal canal, which causes back pain.
   
• Foraminotomy involves widening the spinal canal to increase the space at the exit of the nerves from the spinal cord.
   
• In a discectomy, the surgeon removes the entire or part of the disc that is herniated or slipped from its original position. This relieves the pressure on the nerves exerted by the herniated disc.

Although there are risks involved in every procedure, the overall effect is pain relief, freedom of movement, less need for medicines, and an increase in work productivity. The choice of surgery should be made after discussing the pros and cons with the surgeon.

Lifestyle Management in Back Pain

• Avoid Triggers of Back Pain
  Back pain can be a very distressing condition. Living with back pain could be a challenging component of back pain management. Routine activities of day-to-day life at home and workplace can sometimes trigger back pain and increase the existing pain. Movements and postures that involve repetitive actions of the spine while at work or at home could trigger or worsen back pain. It is, therefore, necessary to identify and avoid such triggers at home and at the workplace so as to prevent back pain. 
   
• Stay active throughout the day 
  Having a sedentary lifestyle an also make a person more prone to back pain. Inactivity is also the cause of obesity, which adds to the back pain. Stay active throughout the day. Also opt for regular moderate physical activity, such as 45 minutes of walking, swimming, or aerobic exercise along with different stretching exercises. This will not only help in strengthening the back muscles but also help in weight loss.
   
• Have a Healthy and Nutritious Diet
  Following nutritious healthy dietary habits by consuming foods rich in minerals and vitamins help in maintaining a healthy spine. Include foods rich in Vitamin D and calcium. These nutrients help in keeping your bones healthy, prevent osteoporosis and decrease the risk of bone fractures.
   
• Quit Smoking
  Smoking reduces blood flow to the spine. It also triggers a cough which could aggravate back pain.
   
• Improve your posture
  Balance your body weight with an even distribution of weight on the feet. The correct posture is that in which the normal curves in the spine are maintained while sitting and standing. An incorrect or faulty posture places stress on the back muscles and results in chronic back pain.
  Maintaining a correct posture is also important while lifting and carrying heavy weights to avoid strain on the back muscles.

Prognosis of Back Pain

Acute low back pain has an excellent outcome with a return to normalcy within 1 month. Recurrence is common in chronic back pain that can give rise to anxiety, fear of pain, and avoidance of work. Outcome chiefly depends on the psychological attitude towards the pain. Depression and other behavioral problems slow down the recovery of low back pain. Prognosis also decreases with age and in the case of back pain due to genetic diseases. Research studies have observed that psychological factors (depression, fear, etc.), history of back pain in past, level of job satisfaction, and workplace environment are the chief factors that predict the prognosis of low back pain.

Complications of Back Pain

Psychological problems are common complications seen with chronic back pain. Fear, avoidance of work, anxiety, poor concentration, memory loss, and depression accompany any chronic pain in the body. Mental stress can cause a headache, loss of sleep, and gastric disturbances.
A mild form of back pain rarely causes disability. A severe form of recurrent back pain, however, can restrict the body movements to a significant extent and influence the work productivity of an individual.