By Dr.K.Karthik Kailash
80% of people have pain in the back at some point in time in their lives and 50% have recurrent symptoms pertaining to the back which affects their daily activities. A judicious choice of management is required in the management of these patients
Divided into
• Mechanical Disorders
• Developmental disorders
• Rheumatologic Disorders
• Infectious Disorders
• Neoplastic disorders
• Psychological Reactions
Mechanical Disorders:
These are usually
• Muscle strain
• Overuse syndrome
• Acute spine fractures
• Disc Herniation
• Often times history and physical examination indicates the problems
• Xrays AP and Lat in all patients with pain duration > than 3 weeks
• However, x rays may not reveal the problem as about 40% of the bone needs to be destroyed for the lesion to be seen on Xrays
• MRI as a definitive tool in the management of these problems as they are sensitive in picking up the problem very early
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Psyco somatic back pain
• Not an established entity in our country
• Major problem in the west
• Manifests as aggressive behaviour
• Counselling often solves the problem- Should be considered only after eliminating all other problems and the sufferer is often labelled.
The other causes of back pain in the adults due to wear and tear would be
• Facet arthropathy
• Spinal stenosis
Apart from the leading cause in the productive adult population which is disc prolapse or commonly called “Slipped Disc”
Disc Prolapse:
• 60-80% of the adult population have experienced back pain
• 2-5% affected on a yearly basis
• Leading causes of man days lost
• Poorly understood
What is this disc prolapse?
To understand this one must understand what this disc is all about. It is nothing but a circumferential tissue placed in between the vertebrae at all the levels in the spine from the neck down to the sacrum.
This tissue consists of the outer layer called the Annulus Fibrosus which envelops the soft inner layer called the Nucleus Pulposus. These two are anchored to the vertebrae by fibres which are strong and tautly held.
The main content of this tissue is water and protein material. In the younger adult the water content is large while with age the content decreases leading on to degenerative changes.
The main function of the disc is to provide height to the spinal column and mainly act as a shock absorber when the person is standing, sitting etc. It must be emphasized here that sitting puts the maximum strain on the back.
As one gets older water content is lost the height of the disc material is reduced and degenerative changes of the spine sets in.
How does this manifest?
The commonest complaint one comes across is that of low back pain which has come suddenly while lifting an object or sneezing etc. It is often occupied by sciatica or pain going down the legs. This pain is invariably worse with activity and relieved by rest. It is also found to be worse with sneezing or coughing as this increases the intraspinal pressure.
The Sciatica often disappears in 4 weeks with adequate rest and medication along with physiotherapy. If the pain were to be persistent then further investigations in the form of MRI is required. MRI only when doubt in diagnosis and when definitive management is planned
A conservative approach is the main modality of management which is successful in 90% of the times. This includes
• control of inflammation by means of anti inflammatories
• control of pain with appropriate analgesics
• Restore range of motion
• Improve muscle strength and endurance
• Improve coordination and retrain
• Maintenance of an exercise programme to sustain the above
If this conservative approach fails to relieve the pain then a surgical treatment is thought of. Surgical management consists of minimally invasive procedures like:
• Epidural injections
• Facet blocks
• Chemonucleolysis
• Percutaneous discectomy
• Endoscopic discectomy and fusions
However, the results of the above-mentioned procedures are not very certain and hence a definitive surgical management is thought of.
Surgery is indicated in:
• Impairment of bowel and bladder function namely difficulty in controlling urine and motion and this is an absolute emergency as the results are better when operated at the earliest
• Gross motor weakness means weakness of toes and legs
• Sciatic pain persisting for more than 4 weeks after conservative management
• Recurrent episodes of pain
• Worsening of neuro status on treatment
Surgery is often done as a Microdiscectomy wherein here the offending discal material is taken out and the pressure on the nerves relieved. This procedure is a relatively simple surgery but it also has certain complications namely infection or neurological deficit namely weakness of the leg muscles. However, the risk of neurological problems in present-day circumstances is less than 0.1%
The benefits of pain-free living far outweigh the problems of surgery. However, one can be rest assured that 90% of the patients would not require operation.