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Back Pain

Back Pain

Back pain is one of the commonest ailments of our modern society. 2 out of every 3 people report back pain at some time in life and nearly half of us have had backpain in the last month. Everyone's discs degenerate as we get older and disc degeneration can be seen as early as the late teens as a result of trauma or surgery but it is often due to bad genetics. 70 % of people who suffer an attack of LBP will suffer 3 or more recurrences.

Whilst the majority of people with back pain can manage their ongoing pain, as well as more painful flare episodes, with non-surgical care, a small percentage of patients may require surgery. People with ongoing severe, disabling pain and associated symptoms (e.g., numbness, tingling, and difficulty sitting) may find it difficult to function and go to work in spite of an extensive functional rehabilitation. It is in this small group of patients that surgery may be indicated.

Management

The first step in the management of the painful back is identifying the pain source. Given the complexity of the spinal column as well as the fact that in certain conditions back pain may be coming from other structures such as the pelvis, or blood vessels, this may not be easy. Features in the pain pattern and findings on examination of the spine can help in identifying the 'pain source' but often an MRI is required and sometimes diagnostic spinal injections may be indicated.

The majority of back pain is due to either disc degeneration ,facet joint (small joints at back of spine) wear and tear and irritation of the nerve roots within the spinal canal. Involvement of nerve roots gives rise to leg pain.

Treatment

Treatments for back pain are multiple and varied as is reflected by the endless variety of commercially available options At times back education and counselling about the problem to ease a person's anxiety is enough to make it tolerable until the episode resolves. Prolonged bed rest is no longer recommended. Medications such as non steroidal anti inflammatory drugs (NSAIDS) can be helpful. Occasionally stronger medications such as muscle relaxants and narcotics can be used for a short period.

The first line of treatment in patients with no "red flags" should be physiotherapy. Treatments can be generalised treatments like core stability, pelvic and aerobic exercises (walking, jogging, swimming, cycling) or local treatments. This may include heat, cold, massage, ultrasound, electrical stimulation, traction and acupuncture. All of these measures can help some people with back pain. How long the benefit will be or what the chances are of receiving benefit from any of these treatments isn't completely known. Spinal manipulation may be helpful in the some acute situations but must be done by practioners familiar with such techniques.

Injections such as epidurals, facet joint injections and nerve root blocks are often helpful. The help is twofold - to relief pain and also to help identify the pain source. These injections contain local anaesthetic and steroids Injections are occasionally placed into the disc, but this is done far less frequently.

Surgery

Surgery for low back pain should only be performed when non-surgical treatment options have been tried and have failed. The most commonly performed operation for back pain has been spinal fusion. There are a variety of ways this is done but the basic idea is to take the painful segment of the spine and stop movement, hence stopping pain. This can be done through the back (posterior) or through the tummy (anterior), or sometimes both ways. Spinal fixation often involves metalwork such as screws and rods and some form of bone graft or bone substitute. A good result is a decrease in pain and this is achieved in around 80% of patients. It is very rare for someone to be completely out of pain after a spine fusion. Full recovery can take more than a year.

Newer techniques focus on removing the pain sorce but maintaining movement. Disc replacement involves removing the disc and replacing it with artificial components, similar to what is done in the hip or the knee. Doing this lets the segment of the spine keep some flexibility and hopefully maintain more normal motion. This has been used in Kings Oak Hospital for a number of years now and early results are very promising. Here are a number of other "non fusion" options but the patient must meet a number of strict criteria to be suitable for such treatments.