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Back pain is one of the most common complaint of many patients. The annual incidence of back pain is estimated to be 15% to 20% with a prevalence rate of up to 60%. Pain is a complex problem and is very subjective. Back pain is currently the fifth most common cause of patient visits to the physicians with associated costs approximating up to 50 billion dollars a year.
Only 1% of patients suffering from pain have nerve root symptoms due to pinching of the exiting nerve root from the lumbosacral spine. The vast majority of patients with back pain will experience resolution of the pain symptoms without any treatment, more than 95% will have resolution of symptoms by 4 weeks.
Sometimes, back pain may not originate from the spine but may be referred from other structures like hip joints or abdominal viscera (I,e abdominal malignancy, aortic aneurysm). This is the reason, to be very cautious in excluding extra- spinal causes in atypical presentation of the back pain.
Symptoms
Thorough history taking is very important during the initial evaluation of the patient.
Patient might experience dull constant pain in the low back without spreading anywhere else (Musculoskeletal Origin).
Sharp shooting pain going down one or both legs along with numbness and tingling going down the leg, which is indicative of nerve root irritation/damage in the spine.
Patients may describe low back pain with feelings of weakness or numbness in the legs after walking a certain distance and relieved with sitting or bending forwards may have lumbar stenosis leading to neurogenic claudication.
Back pain with radiation down the legs with loss of bladder or bowel control is an emergency and may be due to cauda equina compression which requires immediate medical attention and emergent MRI imaging of lumbosacral spine.
Back Pain Causes
Trauma to the muscles, ligaments and spinal vertebra – leading to acute pain after an injury.
Torn muscles and ligaments will cause acute back pain.
Disc degeneration may cause symptomatic back pain with nerve root symptoms leading to pain and numbness going down one or both legs
Ruptured disc can cause back pain, sharp shooting pain and numbness going down the leg with weakness of specific muscles of the leg depending upon the level of pinched nerve.
Arthritis of the lumbar spine may narrow nerve root foramen as well as the canal itself, causing spinal stenosis leading to radicular or myelopathic symptoms.
Torn muscles and ligaments will often cause acute back pain that resolves. Disc degeneration may cause symptomatic back pain with nerve root symptoms.
Different etiologies in groups are as below;
Degenerative disease
– Disc degenerative disease
– Hypertrophy of ligamentum flavum
– Annular tears in the annulus fibrosus
– Facet hypertrophy
– Sacroiliac disease
– Fractures (pathologic or trauma)
Infectious causes
• Soft tissue abscess over the spine, epidural abscess
Neoplastic Causes
– Metastatic (breast, lung, prostate, and thyroid)
– Lymphoma
– Multiple Myeloma
– Sarcoma (bone or soft tissue; 3% to 4%)
– Aneurysmal bone cyst
– Giant cell tumor (osteoclastoma)
– Ewing sarcoma
Intradural, extramedullary (40%)
Meningioma, Schwannoma. Neurofibroma, Lipoma
Intradural, intramedullary (5%)
Astrocytoma, Ependymoma, Hemangioblatoma, Dermoid cyst
Auto-immune causes
Rheumatoid arthritis, Ankylosing Spondylitis
Vascular causes;
AVM, AV Fistula
Traumatic Causes
Torn muscles and ligaments, compressed vertebra, fractured vertebra, subluxation, spondylolisthesis
Investigations
Lumbosacral spine x rays- to r/o fractures, dislocation.
MRI Scan of Lumbosacral spine- is the ideal test to r/o ruptured disc, extradural compressive pathology, abscess, intra or extra- medullary tumor or metastasis to the spine.
CT Myelography – is sometimes indicated if a far lateral herniated disc is suspected and it is not visible on MRI scan of the spine. In such case, CT Myelography can provide more information than MRI Scans.
Bone Scan – to r/o Metastasis to the spine or infectious disease process
Nerve Conduction and EMG Study – to determine if there is a lumbosacral radiculopathy and at what level ( pinched nerve in spine) and to rule out plexopathy, Inflammatory muscle disease or peripheral neuropathy
Back Pain Treatment
Conservative Treatment
Bed Rest
Prolonged bed rest was routinely used in the past, but studies showed that it did more harm than good so now-a days it is advisable to recommend bed rest for 2-3 days but not to exceed 4 days. Early ambulation and participation in non-pain provoking activities is encouraged.
Physical Therapy
Physical therapy 3 times a week for 4-6 weeks in recommended, during the sessions, traction, massage, ultrasound, range of motion exercises and strengthening exercises are done, which patient can continue at home after discharge from therapy. Patient or physical therapist must be careful not to overdo the therapy in the beginning.
Medications
Muscle Relaxants
Zanaflex, Soma, Robaxin, Flexeril, Skelaxin can help to relax back muscles
Anti-inflammatory Drugs
Mobic, Ibuprofen, Naprosyn can be helpful for the pain
To help with pain;
Cymbalta 30 to 60 mg daily
Gabapentin 300 mg at night, may increase slowly to 3-4 times a day
Topical ointments/Gels
These have been helpful for temporary relief of pain
Narcotics– should be avoided or used for a short time to avoid habituation.
Epidural Steroid Injections
If there is disc herniation leading to radicular pain, epidural steroid injections can sometimes help to relieve the pain for weeks to months, they can be given every few months up to 3 times in a year.
Surgical treatment
It is urgently required if there is cauda equine compression leading to weakness, numbness in the legs and bladder/bowel control problems, this condition is usually due to a large midline disc herniation compressing the cauda equina.
In other cases, surgery is the last option if conservative treatment ( physical therapy, medications, epidural steroid injections) fails and patient continues to have unremitting radicular pain or there is weakness of muscles of the leg like foot drop.
Type of the surgery depends upon the nature of the problem and varies from microdiscectomy to spinal fusion.
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Source by Javaid Iqbal M.D
