Low back pain (LBP) is aching, burning, stabbing, tingling or sharp pain occurring in the lower back region. It is the commonest spinal problem affecting 80% of population at some stage in their life. It is good to note that 90% of these patients have degenerative causes and they get better with 6 weeks of conservative care. LBP that lasts for 6 weeks or less is called acute low back pain, muscle spasm or strain. Back pain that lasts longer than 3 months with no significant improvement is considered chronic.
Majority of the low back pain occurring without trauma is degenerative in origin.
Causes of low back pain are :
Degenerative disc disease (age related wear & tear)
Life-style related: Lifting heavy weight, prolonged sitting in inappropriate or awkward position, sedentary lifestyle, excess use of mobile phone or laptops
Injury: Fall, trauma, twisting of spine, sudden bending. In elderly patients with osteoporosis, spinal fracture and back pain can occur by just bending forward or coughing
Spinal diseases: Slip disc, stenosis, deformity, infection, tuberculosis & tumour
Obesity or overweight, osteoporosis, osteomalacia
Smoking or tobacco chewing
Arthritis: Rheumatoid arthritis, gout, osteoarthritis, ankylosing spondylitis, seronegative spondyloarthropathy and fibromyalgia
Non spinal causes such as malaria, viral fever, renal stone, gynaecological disorders or premenstrual syndrome
Many times the cause or the source of pain cannot be clearly identified and posture adopted during work or at home may play an important role.
Sciatica is a radiating leg pain that may start from back and radiate to one or both lower limbs. Nerve irritation or compression in lower back often causes sciatica. Sciatica due to slip disc increases on prolonged sitting, bending forward, coughing and sneezing. While radiating pain due to stenosis (nerve compression) increases on standing and walking. Other non-spinal causes of sciatica include peripheral vascular disease, sacroilitis, Pyriformis syndrome, etc.
Based on your history and clinical findings, doctor will discuss with you appropriate tests that need to be done. It is important to note that even at the end of evaluation; the exact cause may not be well defined. An evaluation is considered successful if it has ruled out those problems that could place you at major risk if not treated. However, lack of definite diagnosis does not necessarily mean more testing is mandatory. In fact, unnecessary testing is not only expensive, but it could expose you to unnecessary risks or radiation.
Investigations commonly done are:
X-rays of the affected region and CT (Computed Tomography) Scan provide useful information for the quality of bones, their alignment and shape.
Dynamic x-rays (Bending forward and backward X-rays) may be required to look for unstable bones.
MRI (Magnetic Resonance Imaging) gives better information of nerves, disc, facet joints and muscles in addition to bony anatomy and hence is an investigation of choice.
Other investigations such as blood tests, PET (Positron Emission Tomography) Scan, Nerve Conduction Studies, etc. are required at times.
Presence of any of the following symptoms or conditions may indicate serious spine problem and will require detailed investigations:
Failure to improve after 6 weeks of conservative care
Unexplained weight loss, night pain and fever
Traumatic spinal injuries
Urinary difficulties such as incontinence and retention
Leg weakness
The treatments can vary greatly depending on the type and source of the pain. If a treatable source of pain is found, then the underlying process should be treated. When the underlying cause is either not known or not treatable, then the symptoms are treated. Whatever said and done, the goal of treatment is to reduce pain, improve quality of life and increase functionality.
Our doctors usually decide the treatment plan after proper history taking, detailed clinical examination and necessary investigations. The patients who are candidates for conservative care are advised medications, brief period of rest, physical therapy and ergonomic precautions. In our practice, more than 90% of patients get better with conservative care and barely a few of them require surgery.
Medicines are generally used for a short duration to overcome painful episode. In a majority of cases, brief period of bed rest (< 5 days) is recommended to overcome the initial painful episode. After initial bed rest (not more than 5 days) light activities are usually encouraged. Physical therapy included patient education regarding ergonomics, specific strengthening and stretching (physiotherapy), manual therapies and modalities (Ice, heat-pack, short-wave diathermy, transcutaneous electric nerve stimulation, lasers ultrasound, acupuncture, etc). Exercise and strengthening need to continue for long as it will have the most permanent and long lasting effects. They are designed to increase stability and strength around the structures in the back that are being stressed. Exercises are tailored specifically to the abilities of the patient and the type of back pain being addressed.
Few patients may not benefit from conservative care and require intervention. The procedures that are recommended include pain injections, minimally invasive (key-hole) surgeries or open surgeries. During pain procedures, we usually inject a high concentration of local anaesthetic agents and locally acting steroids. These medicines reduce the pain generators and inflammation at the local site thereby giving pain relief. In some cases the relief may be long lasting while in some cases pain may recur once the effect of medicines wears off. Hence patients that need a more definitive solution are advised surgery. The aim of surgery is to free the neural structures, correct the misalignment and to remove the abnormal disc, bone, tumours or infectious materials. Some patients who have instability or are at risk of developing instability will require implants (titanium/PEEK materials commonly used). Due to advances in the surgical techniques majority of surgeries have good/excellent outcome and post-surgical paralysis is an extremely rare event. The risks and benefits of the surgery need to be discussed before going for an operation.
Rest: For majority of degenerative conditions, complete bed rest is prescribed only for a few days (2-5 days). During this period getting out of bed is allowed only for toiletry activities. Only in cases of spinal fracture, instability, infection or excruciating pain total bed rest (no getting up at all) is advised. The ideal sleeping positions are 1) Sleeping on your back with pillow under your knees; 2) Sleeping on sides (right/left whichever is comfortable) with pillow between the two legs. Prolonged bed rest (>5 days) comes at a cost. If bed rest is continued for more than 5 days, weakness develops in the paraspinal muscles which may cause more harm than good. Hence bed rest more than 5 days is not encouraged except in cases of infection, trauma or instability. The ideal bed for resting is standard cotton mattresses! One should not fall prey to expensive so called “Spine Friendly Mattresses” and also should avoid sitting on floor or hard surfaces.
Light physical activities: Once the patient is out of bed – light physical activities are recommended. However patient should totally avoid the following during the recovery period 1) Bending forward; 2) Lifting weight; 3) Sitting on floor and 4) using Indian style toilets. All these positions will increase the pressure on the lumbar discs and may aggravate your condition. It is also recommended to do therapeutic exercises recommended by your doctor based on your conditions. Simple rule during this period is any activity that aggravates your pain should be totally avoided. Pain is basically a protective reflex of the body and basically it tells you to avoid that position for better recovery.
Hot fomentation: Simplest home remedy to reduce pain is the “Grandmother’s hot water bag”. It can be applied to the painful regions twice a day for a period of 30 minutes. Diabetic patients need to be careful of the skin burns if the temperature is very hot and applied for long duration. Very rarely a patients may benefit from ice pack rather than hot fomentation. Basically hot or ice both are pain relieving methods and does not influence the primary spine pathology. Hence once can follow whatever is beneficial for them.
Ergonomics: Stay active and stay mobile once the pain subsides. Avoid prolonged sitting (>1 hour). Take hourly breaks of 5 minutes and do some stretching and strengthening and then you can continue sitting for an hour more. Sit on a chair with comfortable backrest to supports your back and neck and it should have comfortable arm rests too. A pillow can be used to anatomically contour the hollow in your back if you have a straight chair. Avoid leaning forward (slouch) or reclining positions while sitting. While getting up from bed turn to one side and get up – don’t crunch your back while you get up.
Physiotherapy: Spine is made up of multiple bones and discs like a pile of bricks! Hence the spine is a very unstable structure. The stability to spine is mainly provided by muscles and ligaments. Not only the muscles have to be strong but they should move in a coordinated way to allow spinal movements. Here comes the role of physiotherapy and exercises. The experts in this field do a detailed evaluation of your condition and they know exactly which muscles need to be strengthened and which one to be coordinated properly. It is very much important to do these exercises under observation of the experts and later on it needs to be continued at home. During the course of recovery the exercises keeps on changing from limited exercises (due to pain) to full-strengthening exercises and finally exercises to increase flexibility. Hence continuous physiotherapy is recommended. Many times during the initial painful episode, it may not be possible to do physiotherapy due to pain. Moreover, it is also not recommended to travel daily to physiotherapy centres during pain. Hence daily physiotherapy should start soon after the acute episode and it should be continued to prevent recurrences of low back pain.
Weight loss: A bid protuberant tummy or excess body weight can shift the weight bearing axis in front of your spine and cause low back pain. So watch out for your paunch! With a spinal problem it is very difficult to lose weight and the only exercise possible would be daily brisk walking. Patients who are fit can go for swimming as it will strengthen your back muscles and also it will help to lose weight. Dietary modifications should go hand in hand with exercises.