||Low Back Pain
Red Flag Conditions
Every patient with lower back pain / thoracic pain should be assessed by his doctor and undergo a diagnostic triage to ascertain which group he falls into:-
- Simple Backache OR
- Spinal Nerve Root Pain OR
- Red Flag conditions.
Red flag conditions are those types of problems which need an urgent specialist opinion, tests and investigation:-
- Age of onset less than 20 or greater than 55 years
- Violent trauma (e.g. fall from a height or road traffic accident)
- Constant progressive non-mechanical pain
- Thoracic pain
- Previous history of cancer
- Long term oral steroid use
- History of drug abuse or HIV
- Patient systemically unwell
- Recent unexplained weight loss
- Persisting severe restriction of forward trunk flexion
- Widespread neurological changes / suspected cauda equina syndrome
- Recent onset of incontinence of urine
- Loss of anal tone with incontinence of faeces
- Numbness affecting the anus, perineum and genitals
- Widespread (more than one nerve root) or progressive loss of strength in the legs or walking disturbance
- The appearance of a sensory level on pinprick testing.
- Structural deformity.
- Spinal Inflammatory Disease e.g. ankylosing spondylitis and related disorders
- Gradual onset before the age of 40 years
- Marked morning stiffness
- Persisting limitation of spinal movements in all directions
- Peripheral joint involvement
- Eye inflammation
- Urethral discharge
- Strong family history of similar problems.
- The Lumbar Spine extends from L1 (adjacent to the thoracic spine) down to L5 where it connects with the sacral bone .
- Simple Sprains usually occur when the low back is in a vulnerable position e.g. bending forwards and bent to one side whilst lifting shopping out of the boot of the car, or violent sneezing whilst bent forwards.
- The sprained part is usually in the superficial part of the spine (muscle, joint or ligament). The sprained tissue becomes inflamed, causing pain signals to be sent to the spinal cord.
- If the incoming pain signals are strong enough and go on for long enough, processing centres (dorsal horn) in the spinal cord become sensitised, sending out signals to the muscles in the vicinity of the sprain to contract to produce muscle spasm. This is initially a protective reflex which may prevent further injury to the sprained part.
- If the muscles in the area are contracting quite strongly, then the tension receptors in the local muscles and joints are activated. Strong signals from the tension receptors can be interpreted in the spinal cord as pain, adding to the pain signals from the inflamed tissue. These two kinds of signal combine together to keep the spinal cord dorsal horn in a sensitised state, and also keeping the spinal muscles in a contracted state through a feedback loop. The sequence of events can be therefore summarised in the diagram below:-
- Severe muscle spasm is a type of cramp, and like any other cramp in the body it hurts, causing restricted painful back movements. Over a variable period of time the initial back sprain heals, reducing the signals to the spinal cord, and also reducing the degree of spinal cord dorsal horn sensitisation. Once this sensitisation has declined, the outward signals to the muscles in the area of the sprain also lessen, allowing the pain and muscle spasm to resolve naturally.
- In about 10% of adults the back pain continues despite healing of the the initially sprained area. In this situation there is a perpetual loop as shown below, without there being any sprain or inflammatory process involved. This situation may leave individuals susceptible to further sprains due to the back muscles being in a contracted and shortened state, and also due to there being pre-existing dorsal horn sensitisation.
- In most of these cases the muscle spasm and restricted joint mobility can be treated successfully with Spinal Manipulation. This has the effect of resetting the abnormal tension receptors in the muscles and joints, reducing the spinal cord sensitisation, and allowing rapid resolution of the pain. Back Exercises are important after treatment to improve and maintain spinal strength and flexibility, helping to reduce the vulnerability to further injury.
- People with complex back pain can also be vulnerable to simple sprains. It is important to realise this fact, and not believe that the pain is due to the primary condition becoming worse.
- 5% of people with back pain also have symptoms radiating into one or other of their legs, associated with tingling, numbness, and weakness. The cause is due to a trapped / pinched nerve (sciatica) either due to a slipped disc (prolapse, herniation), foraminal stenosis (narrowed spinal exit hole), spondylolisthesis (slipped vertebra), or spinal stenosis (narrowed spinal canal diameter). These conditions need investigation with an MRI scan.
Posture and Lifting
- Postural Backache usually occurs when the spine is held in an abnormal posture for too long e.g. sitting for hours in an uncomfortable car/train/airplane seat, or sleeping on an uncomfortable mattress, or when the equilibrium of the spine is unbalanced e.g. by having one leg longer than the other.
- The muscles, joints and ligaments of the spinal column are packed full of position and stretch receptors, which are constantly monitoring and maintaining posture.
- People who suffer from postural low back pain usually have some ongoing problem with the Mechanical Balance of the spine, and quite frequently have areas where the spinal cord dorsal horn shows pre-existing sensitisation. When these sensitised areas are held in abnormal positions for prolonged periods, there is stimulation of the spinal stretch and position receptors, increasing the signals going to the spinal cord.
- As the spinal cord dorsal horn is already partly sensitised, it more readily becomes fully sensitised by the extra signals coming in. The result is that there is an increase in the out-going signals to the local spinal muscles, producing muscle spasm and pain.
- The situation can normally be resolved by moving and stretching the affected parts of the spine, so that the position and stretch receptors no longer respond by firing off excessively, allowing the dorsal horn to be less sensitised. This explains why people with postural back pain cannot maintain a single posture for very long, and why they are constantly shifting posture to cope with the situation.
- Correct posture is important for spinal equilibrium. When looking at the spine from the side, the sum of the inward curves (lordosis) equals the sum of the outwards curves (kyphosis) i.e. neck + lumbar lordosis = thoracic + pelvic kyphosis.
- If any one of these areas has an increase in curvature, then the other areas have to compensate. For example:-
- Slouching for prolonged periods (see picture above) tends to encourage a round shouldered posture (exaggerated thoracic kyphosis). Over time this leads to permanent increased curvature in the thoracic spine. As it would be impractical to walk around looking at the floor all the time, the neck and lower back compensate by increasing their degree of lordosis to allow us to be able to look straight ahead. Over time this extra lordosis can lead to neck and back pain, and also an increased risk of foraminal stenosis.
- High Heel Shoes - wearing excessively high heels causes shortening of the calf and hamstring muscles, and an increased forward tilting of the pelvis. Over time this causes compensatory changes in the shape of the rest of the spine, producing increased lumbar lordosis, thoracic kyphosis, and cervical lordosis.
- Lifting in the correct way is important to protect the spinal column from unnecessary loading, and to avoid sprains.
- The principles of correct lifting are:-
- Use lifting aids to carry heavy objects from A to B.
- Share the heavy load between 2 or more people.
- At all times keep the load close to your trunk. Holding objects held at arms length increases the load on the spine through leverage effects.
- When lifting up and dropping down, squat down with your knees bent and apart, keeping your back as straight as possible.
- Use your leg muscles rather than your back muscles to go down and straighten up.
- If you have to turn whilst holding a heavy load, turn using your feet, keeping the load close to you. Resist the temptation to rotate your trunk whilst keeping your feet still. Remember your spine is at it's most vulnerable when it is flexed forwards and/or rotated at the same time.
Mechanical Imbalance due to abnormalities of lower leg function can contribute to complex back pain. Lower Limb Length Inequality (short leg) on one side causes the pelvis to tilt towards that side. This produces a series of compensatory spinal curves from the low back up to the top of the neck, with associated muscle imbalance, back and neck pain. The leg length difference may need to be greater than 1/2" before it causes major problems, although lesser differences can still be symptomatic. The cause may be due to:-
Anatomical Shortening with a measurable difference between the two legs. This can be due to leg fractures, hip and knee problems in childhood OR simply being born that way.
- Correcting the shortening with a shoe heel raise of the appropriate height (start with half the difference).
- Spinal Manipulation can also be useful to re-set the dysfunctional areas of spinal muscle spasm that may occur in the compensatory curves in the lumbar, thoracic and cervical spine.
Functional Shortening is where there is no measurable difference in leg lengths, but with functional shortening of certain leg muscles groups, or due to a fallen inside arch of the foot.
The Bad Sprain
- Identifying, stretching and re-training the shortened muscle groups (ilio-psoas, quadriceps, hamstrings, gastrocnemius).
- Spinal Manipulation can be useful for the back pain in the short term. Shoe heel raises are not useful in this group as there is no true leg shortening. Arch supports may help.
Spinal Ligament Syndrome
- Mechanism - after a severe injury there is initial protective muscle spasm which usually settles in a few weeks (see Simple Sprain). Those who do not improve spontaneously may improve with Exercises and Spinal Manipulation techniques.
- Progression - a small percentage may go on to develop chronic LBP with extreme tenderness over the back of the hip bone (iliac crest - where the small dimples are in your back). It appears that this group have sustained a soft tissue sprain where the spinal ligaments and muscles attach to the iliac crest - a type of "pull-off" injury. These injuries can produce long standing chronic LBP, with an increased vulnerability to re-injury. It appears that most of the pain fibres are at the junction between the ligament/muscle and the lining of the bone (periosteum).
- Treatment in the pain clinic for this condition consists strengthening this junctional area by injecting a sclerosant solution around the area of the sprain on 2 - 3 occasions 3 - 4 weeks apart. The sclerosant solution initially causes local fibrosis at the point of injection, which then becomes converted into strong collagen tissue at about 2 months after the treatment. This can give back pain relief and increase the apparent strength of the spine (see Prolotherapy).
Facet Joint Syndrome
- Disc degeneration leading to loss of disc height causes increased tension in the lumbo-pelvic spinal ligaments at the base of the spine.
- Spondylolisthesis with forward shift of one vertebra in relation to another increases tension in the iliolumbar ligaments at the base of the spine.
- Symptoms - Chronic low back pain worse on standing and sitting for too long, worse on performing part bent forward jobs like washing up, hoovering etc. Pain may refer to the groin, buttock, hip and outside thigh. Common complaint in the over 40's.
- Treatment - Course of Prolotherapy.
Spinal Nerve Root Pain
- Mechanism - a small proportion of people have complex LBP due to inflammation of one or more of the small spinal joints (facet joints , ). X-rays may show arthritic changes in the joints, but there is a poor correlation between the degree of wear and the severity of the LBP. There is also a poor correlation between the part of the spine on the X-ray which shows the arthritic joints, and where the actual pain is when the back is examined clinically. An isotope bone scan may give a better correlation by showing up inflammation as increased joint blood flow .
- Groups at Risk - Facet joint syndrome is a common cause of chronic pain in the elderly where there may be associated loss of disc height at the level concerned. It is more common at the L4/5 and L5/S1 levels. It is also more common in those people with inflammatory spinal disease (ankylosing spondylitis, psoriasis, systemic lupus etc). People with long standing spinal imbalance may be more prone to developing facet joint inflammation due to differential wear on one side of the spine.
- Symptoms - back ache is often worse after sitting and standing still for long periods. It is usually better keeping on the move. More be provoked by spinal extension (bending backwards). May be a cause of referred pain to the legs (non-nerve root).
- Treatment initially consists of injecting the facet joint diagnostically with a solution containing local anaesthetic and steroid. These injections need to be performed under X-ray screening. If there is a positive outcome to this diagnostic test, then facet joint radio-frequency denervation (rhizolysis) should be considered next.
- See Spinal Nerve Root Pain for Sciatica (Lumbar Radiculopathy) caused by Annular Tears, Disc Prolapse, Spinal Stenosis, Foraminal Stenosis, Spondylolisthesis, Referred Pain, and the Sacroiliac Joint.
- Definition - progressive thinning of bone structure with loss of bone calcium, leading to an increased risk of fractures. Associated most commonly with immobility, the menopause, and old age.
- Normal Spinal Curves
- Early Osteoporosis
- Late Osteoporosis
- Types of Vertebral Wedge Fractures
- Symptoms - Spinal osteoporosis is usually asymptomatic between events. Minor injuries can produce a partial collapse or "wedge" fracture of a spinal vertebra. When viewed from the side on an X-ray the vertebra is shaped like a "dairy lee cheese" rather than the usual square shape. It commonly affects the thoracic and upper lumbar spine. There is sudden onset of severe pain in the back which lasts about 6 weeks and then resolves spontaneously.
- Investigation - DEXA scanning (Densitometry) can examine bone density in the spine (L4) and hip (neck of femur). Those who are found to be osteoporotic or osteopaenic should consult their doctor for prophylaxis advice (see treatment below)
- Analgesia - initially pain can be severe enough to warrant the use of morphine. See Analgesic Flow Chart for medication suggestions.
- Prophylaxis - all those at risk of developing further osteoporotic fractures should ensure a normal dietary intake of calcium and vitamin D. In addition treatment with biphosphonate medications like alendronate or editronate can help to strengthen weakened bones, reducing the risk of fractures in the future. Please see your doctor for further advice.
- Vertebroplasty is relatively new technique, and involves using a needle to inject a type of cement into the vertebral body. This helps to resolve the pain and give the affected vertebra more strength. This treatment is not widely available in the UK (see Vertebroplasty).
- Persisting pain may occur in some patients after the wedge fracture has healed. Examination often reveals continuing spinal muscle spasm in the area of the wedge fracture. Treatment with Trigger Point Injections and gentle Spinal Manipulation may help.
Referred pain from the lumbar spine
- Any structure in the lumbar spine (discs, nerves, muscles, facet joints, spinal ligaments) can refer pain to other areas of the body.
- This occurs because the affected part of the spine shares the same nerve supply as the area that the pain is referred to, making the brain believe the source of the pain is somewhere else.
- Spinal structures with a nerve supply originating from L1 to S1 refer pain to the legs, whilst those with a nerve supply originating from C4 to T1 refer pain to the arms.
Referred pain to the lumbar spine
Failed Spinal Surgery
- Spinal Causes
- Lower thoracic spine muscle spasm can often refer pain downwards to the lumbar region. This is typical of muscle pain where the cause of the pain is found at its origin (where it starts), and where the brain seems to think that it's coming from its insertion (where it ends). If practitioners concentrate on where the pain is referred to i.e. the lumbar region, they will miss the cause of the problem, which is often much higher up.
- Visceral Causes
- Problems with the internal organs of the abdomen and pelvis can often cause referred pain to the lower lumbar region. In women this can be due to abnormalities of the kidneys, uterus, ovaries, bladder and lower bowel. In men this can be due to abnormalities of the kidneys, lower bowel, prostate, bladder and testicles. See your doctor for further advice.
- Rare Causes include a rupture of an aortic aneurysm (main artery from the heart), and tumours of the spine and surrounding areas.
- Those with chronic spinal and nerve root pain who did not obtain relief from surgical intervention (discectomy, spinal decompression, fusion), are often labelled as "Failed Spinal Surgery". This group also includes those who feel that surgery may have worsened their condition.
- Where conservative treatments (Acupuncture, TENS, Exercises, Manipulation, Facet Joint Injections, Prolotherapy, Epidural Injections, Nerve Root Blocks, Epiduroscopy), and maximal oral drug therapy (see Analgesic Flow Chart) have failed to improve the pain, two further options include Spinal Cord Stimulation or an implanted Intrathecal Morphine Pump.
- Definition - Ankylosing spondylitis is a form of chronic inflammation of the spine and the sacroiliac joints causing pain and stiffness. Over time this can lead to a complete cementing together (fusion) of the vertebrae, a process referred to as ankylosis , leading to marked loss of mobility.
- Ankylosing spondylitis is also a systemic rheumatic disease, affecting other organs in the body. It also shares many features with other inflammatory conditions like Psoriasis, Reactive Arthritis, Crohns Disease, and Ulcerative Colitis. These conditions are collectively called "spondyloarthropathies".
- It is 2-3 times more common in males than in females. In women it affects joints away from the spine more frequently. It affects all age groups, including children. The most common age of onset of symptoms is in the second and third decades of life.
- Cause - It appears to be a genetically inherited condition associated with the gene marker HLA-B27 in 90% of sufferers. There may also be some additional environmental trigger that begins the inflammatory process. The gene can be detected with a simple blood test. The numbers of people who carry the gene varies by country. Only a small proportion of gene carriers develop the condition.
- The initial inflammation may be a result of an activation of body's immune system by a bacterial infection. Chronic inflammation resulting from the continued activation of the immune system in the absence of active infection is the hallmark of an inflammatory autoimmune disease.
- Symptoms - gradual and progressive pain and stiffness in the low back, upper buttock area, neck, often worse in the early morning or after prolonged rest, and often improved by exercise. Small joints may be affected and tendinitis is common (inflammation of the tendon attachment points to bone).
- Bony ankylosis (fusion) is associated with complete pain relief but complete loss of spinal mobility. Fuseed bones are brittle and more likely to fracture. Sudden onset pain of pain often means a fracture has occurred - more common in the lower neck.
- Ankylosis of the rib joints together with lung inflammation can lead to severe breathing difficulties.
- Other organs can be involved in the inflammatory process e.g. eyes (iritis), heart (rhythm disturbances), and kidneys (failure due to amyloidosis).
- Diagnosis - May be missed in the early years due to vague mild symptoms and signs. Usually based on
- History (see symptoms above)
- Examination - positive sacroiliac spring test, limited range of movement in spine and joints
- Blood tests - raised ESR, positive HLA-B27
- X-rays - spinal syndesmophytes and pelvic sacroiliitis
- Limited measured chest expansion
- Eye signs (iritis)
- Signs of related conditions like ulcerative colitis, crohns disease, psoriasis, and reactive arthritis (chlamydia).
- Treatment - the mainstay of pain treatment involves the use of medications to reduce inflammation or suppress immunity, physical therapy, and exercise. Medications decrease inflammation in the spine, and other joints and organs. Physical therapy and exercise help improve posture, spine mobility and lung capacity.
- Asprin and other NSAIDs (indomethacin is popular) - see analgesic flowchart
- Immunosupressive drugs - sulphsalazine and methotrexate
- TNF (Tumour Necrosis Factor) blocking drugs such as etanercept, infliximab and adalimumab.
- Oral or injectable steroids.
- Physical therapy to maintain proper posture, deep breathing and spinal movements.
- Pacemakers for heart rhythm disturbances, and drugs to treat heart failure.
- Definition - Alkaptonuria is a rare hereditary disease that results from a deficiency of the enzyme homogentisic acid oxidase. This enzyme deficiency leads to a build up of homogentisic acid in tissues of the body. Alkaptonuria is known to be especially frequent in Slovakia and the Dominican Republic.
- Inheritance - Autosomal recessive condition . Both parents are asymptomless carriers of the gene - 25% of their children will not carry the gene, 50% will be asymptomless carriers, and 25% will develop alkaptonuria (also known as Ochronosis).
- Ochronosis - Accumulation of homogentisic acid causes darkening of the tissues of the body e.g. cartilage of the joints and ears, skin , and whites (sclerae) of the eyes . Bluish discoloration of the nails is also characteristic.
- Symptoms - Alkaptonuria leads to premature progressive degeneration of the cartilage of the joints due to the accumulation of homogentisic acid in the cartilage. This results in osteoarthritis of joints throughout the body at an unusually early age. Typical joints affected include the spine, knees, hips, and shoulders. Joint symptoms include stiffness, pain, swelling, and limited motion.
- Homogentisic acid accumulated in the urine will cause it to turn black when it is left to stand. Alkaptonuria was easily diagnosed among the nomadic Bedouin peoples because people with the disease left a characteristic dark spot in the sand marking the spot where they had urinated.
- Bluish discoloration of the eyes, ears, or nose
- Premature widespread osteoarthritis symptoms / X-rays
- X-rays show calcification of cartilage, prostate gland (in males), and heart valves
- Urine turns black when left to stand
- Blood and urine tests show elevated levels of homogentisic acid
- Treatment - There is no effective treatment for the underlying enzyme deficiency of alkaptonuria. Ascorbic acid (vitamin C) has been found to prevent pigment deposits.
- Degenerative joint symptoms are treated as for degenerative arthritis (osteoarthritis) of any cause. Sometimes joint surgery can be helpful, including arthroscopy and joint replacement.
- Future treatments for alkaptonuria might involve gene alteration therapies.