Sunday, April 1, 2012

Back pain


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Back pain

Back pain is extremely common, and a person who has never had any back problems is fortunate indeed. Most back pain cases are short-term ones and will improve without specific treatment. On the other hand, a small minority of back pain cases is extremely cumbersome and may cause a decrease in level of functioning and long sick leaves.

The lumbar spine is an imperfect structure, technically speaking. Unfortunately we cannot return or exchange it, but must make do with the one we have. Its bones are called vertebra. They stack on top of one another and form a column with curves in the neck, chest and lower back area. The lower part consists of solid bones sacrum and coccyx.

Bony parts or vertebrae consist of the anterior or frontal parts and flexible shock-absorbing discs between them. The outer part or the wall of the disc consists of fibrous and elastic elements building a sort of protecting ring for the inner soft, elastic, gel-like part called nucleus pulposus. The posterior or back part of the vertebra forms a bony structure around the spinal canal with spinal cord in it and has articulations between neighboring vertebras directing movements of the spine. These are called facet joints. The muscles of the spine are also attached to the posterior part.

The innermost part of the disc is not sensitive to pain, but the outer part has nerve endings. The vertebral bodies and ligaments surrounding them can be the source of pain as also the nerve structures in the spinal canal and the openings or foramens of the nerve roots emerging from the spinal canal between the vertebras.

The degeneration of the elastic part of the spine, the intervertebral discs between the bony vertebral bodies is usually the principal reason for back pain. The risk factors of degeneration is smoking, heavy physical work and obesity. As the discs degenerate with age, they lose fluid and discs tears may arise in its outer part. In this case, a sour and irritating mass may burst into the tear from the softer part, nucleus pulposus in its middle. When the tear is inside the disc, symptoms resemble that of a local back pain. If the mass of the intervertebral disc spreads outside, it may press on the leg nerves and cause radiating pain in the leg.

With age, also other parts of the spine degenerate. As the disc´s degeneration increases it become less elastic and thinner. The space between the vertebrae diminishes, and there is less stability of the column. The body tries to stabilize the situation with additional bone growth by building bone spurs. These structures may make the spinal canal and the openings of the nerve roots narrower. If they grow large enough, they may also press the spinal cord or the roots.


Lumbago

The most common term used for general, temporary low back pain is lumbago. Typical symptoms of this entity include localized lower back pain without radiating pain in the legs. Exertion, poor posture or a chill may have preceded the pain. Usually the origin of the short term pain remains unknown. It may occur for example due to lumbar disc or facet joint problems or muscle strains. The symptoms usually disappear in a few days with rest and pain medication.

In this case, rest means avoiding harder tasks. Bed rest should be avoided if possible, but normal housework can be performed as much as is reasonably tolerated. Cold compresses in the beginning or alternatively heating pads may be tried if cold does not feel comfortable.


Sciatica

If intense back pain is accompanied by radiating pain in either leg, sciatica, or irritation of the nerve roots due to herniated intervertebral disc, may be the cause. If this situation accompanies symptoms of advancing paralysis in the leg or fecal incontinence, doctor should be contacted immediately, because emergency surgery may be required. This situation is very rare, however.

The most valuable thing in treating new sciatica pain is rest. A back brace may be used, and it may be helpful in situations where tasks have to be performed despite the pain. Treatment of sciatica may require particularly strong pain medication. In new sciatica cases, traction or auto-traction of the back may be considered. Normal back exercises and gymnastics contact should be avoided in the acute stage.

Most sciatica cases calm down within weeks or a few months. If irritation persists longer than two months, surgery may become necessary. It removes the element pressing on the nerve root, and this usually reduces the radiating pain.

When looking for hernia of the intervertebral disc or a blockage of the spinal cord vertebral canal MRI, computer tomography or myelography may be used. EMG is used in diagnosing pinched nerves. MRI or Magnetic Resonance Imaging shows degenerative changes of the intervertebral discs, intervertebral hernias, and possible pinched conditions in the spinal cord.



Prolonged Back Pain

The usual reason for prolonged and reoccurring back problems, which do not show pinched nerves requiring surgery, may be degenerative changes in the spinal column or the lower intervertebral discs and possibly reoccurring internal tears in them, spondylolysis or a stress fracture of the posterior part of a vertebrae, excess mobility between the discs or small bulges in the intervertebral discs.

A thorough evaluation is useful in cases of prolonged discomfort or pain that reoccurs often. The first step may be an x-ray. It shows the bones of the spinal column and the status of the intervertebral discs can be evaluated indirectly. Computer tomography, MRI and neural pathway examination and EMG may be used as an additional diagnosis tools.

Treating prolonged back pain may be difficult. Long-term goal is to maintain functioning via exercise so that the back stays flexible and the muscles strong. This may require a specifically designed back rehabilitation period in a specialized treatment facility.

Unfortunately no satisfactory treatment or prevention methods exist for degenerative changes. Prevention includes maintaining a healthy physical condition. Smoking cessation reduces the risk of back problems. Appropriate weight and work that is somewhat physical but not too hard for the back are helpful. Injuries of the back or excessive physical stress should be avoided as well as vibration.

Anti-inflammatory medicines relieve the pain. Heat or cold pads, electric therapy, and massage are useful for reducing pain, and they are often needed as a pre-treatment before the traction.

Some back pain responds to vertebral manipulation therapy. If the back pain accompanies pain that radiates to below the knee, this type of treatment is usually not recommended. Vertebral manipulation treatment works best for back pain that has lasted for 2-4 weeks. Acupuncture is also used to treat prolonged back pain, with pretty decent results.

Surgery is rarely used in other cases than sciatica and narrowing or stenosis of the spinal cord canal. Stabilizing surgery is considered in cases of painful degeneration of the lower back.

After flexibility and muscle strength reinstates, it would be beneficial to design for optimal conditions for the back. Any difference in leg length can be eliminated by using insoles or raising the heel of shoe of the shorter side.

Work requirements and functionality of the back should be in balance. Sometimes back problems make the sufferer to change professions. This may initially be a difficult thought for a lot of people, but it can also be an rare opportunity to create a new career.

If the change of the profession is required, it is essential that the new one is pleasing. Experience shows that those who have bad backs stay longer in jobs that are attractive vs. boring. Even if the job stays the same, attention should be paid to the work postures. Back pain increases in jobs that involve working in stooping positions, lifting heavy loads, or jobs that contain a lot of carrying or vibration.

Sedentary work with few breaks in the day is not the best for someone suffering from back pain. No one job probably offers ideal conditions, so compromises have to be made.

The back is one of the problem spots for the modern man. According to folklore, you can throw out your back while doing heavy forestry work or while lying on the couch listening to a program about forestry work. Medium-level exertion is advantageous. Too much or too little is harmful.

It is not sufficient to stay at home alone with the back pain. As one “listens” to the pain, it tends to increase, and if one does not allow the problem affect life too much, it is halfway conquered.

Self-treatment includes temporary use of over the counter anti-inflammatory medicine, and ointments if the pain feels like a superficial muscular pain. Cold compresses several times a day work sometimes well.

In the most severe pain phase one can relax the back by lying on the back and lifting the legs against a wall or bending the knees on top of pillows.

Sitting position strains the intervertebral discs the most, so prolonged sitting should be avoided. Leaning forward while working, heavy lifting and especially twisting the back while lifting are not recommended during the severe pain episode.

Bed rest should be avoided and various ordinary daily tasks continued. During the pain phase, a back brace may be used for pain relief and increased functioning. Temporary use does not weaken the back muscles. The back may be bended backwards, but any other back exercise should not be tried at the primary most painful period.

If the back hurts more in the morning, sleeping arrangement should be considered. The position of the back might be checked during sleep. Goal is not to distort the back during sleep. There are many choices of mattresses to accomplish this task in an optimal way. Some patients have liked waterbeds. They are not so fashionable any more. The key point here apparently is heat, which relaxes the back muscles. Some back pain patients may experience worse pain when using a waterbed. There are other bed solutions that satisfy a proper back position during sleep. Sometimes mattresses adjusted to the weight and the body structure may be a suitable alternative. Mattresses can be made to order based on a computer analysis.

The lower back should be supported adequately while working and driving. Armrests should be at the right height that eliminates twisting to the sides. Tipping the chair backwards reduces the stress on the intervertebral discs. Lifting legs on the table every once in a while relaxes back even further, and likely also mind. This page may be shown to the supervisor if there is any suspicion of laziness due to the relaxed posture.

After the most acute pain subsides, the back can be used more. Normal pelvic motion can be exaggerated when walking—this massages the lowest discs gently. Swimming may be started as soon as you are able to do it.

Back exercises can be started during the recuperation period. A physiotherapist´s advice is valuable additional support if available. The best way to strengthen the back, abdominal and leg muscles is to make regular instructed exercises several times a week with an increasing intensity.

General physical condition should also be taken care of. Aerobic exercises should be done at least three times a week, 20 minutes at a time, so that pulse rate elevates. This helps to keep the blood circulation in the pelvic-level back area. Smoking should be stopped. It is a risk factor for back pain, apparently because it reduces circulation in the back.


Spinal Stenosis

A displaced vertebra, congenital abnormalities of the back or degenerative changes may cause a stricture in the spinal cord canal. This so-called spinal stenosis may cause leg pain while walking as well as weakness. Leaning forward may help.

X-rays will point to the diagnosis, and computer tomography or MRI can confirm the diagnosis. Neural pathway examination or EMG is sometimes also used in diagnosing this problem.

Stenosis is typically a problem of the elderly. Treatment includes moving about as much as the condition allows. Calcitonin treatment may help to alleviate the leg pains of patients. There is actually no other medication available. When walks get shorter and pain gets unbearable, surgery may be used to relieve the neural structures and thus stabilize the situation. Normally even after this, the back will not support tougher labour.


Spondylolysis

Spondylolysis is a stress fracture of the arch in the posterior part of the vertebra. . It is considered to be an overuse injury or a stress fracture. When both sided it often leads to spondylolisthesis or forward slipping of a vertebra. If too much displacement of the bones occurs, there may be pressure on the nerve roots.

Hereditary may play a role in spondylolysis. Sports with excessive stress and overstretching of the lower back may be one of the causes of this problem. The slippage may be born easier in periods of rapid growth.

Spondylolysis may be asymptomatic for a long time. Symptoms generally appear during the teen-age. There may be intermittent or constant slight pain in the lower back and tightening of the posterior thigh muscles. If the slippage compresses the nerves and narrows the spinal canal there may be symptoms of pain from lower back down into legs.

Diagnosis can be confirmed with an x-ray. A CT or MRI scan may be needed to rule out other possible conditions. The treatment consists of rest, medication and exercise to build up a muscle corset to improve the stability and functioning of the lower spine. It is often successful especially when started early. Sometimes surgery is needed to stabilize the spine and to prevent further slipping and compression of the nerve roots.


Ankylosing Spondylitis

Ankylosing spondylitis is also called Bekhterev's disease. It belongs to the group of inflammatory arthritis and autoimmune diseases with a connection to the genetic markers for example to HLA-B27. It gives inflammation in the spine and the sacroiliac joint. The end result can be the union of the entire spine called bamboo spine.

Ankylosing spondylitis may cause prolonged back pain in a young person. Earlier it was thought to affect only men, but that does not seem to be the case. If a moderate back pain continues for over three months in a person younger than 40 and if morning stiffness in the back lasts over an hour and remaining still makes the pain worse, an examination is in order to eliminate the possibility of this disease.

Pain is generally marked in rest, but may be weaker in motion. In younger patients swelling of some joints of the lower extremities may be seen. Also insertions of the tendons to the bones often show signs of inflammation. In this condition the so-called SI or sacroiliac joints may show signs of inflammation. These changes take place gradually over several years. They can be observed in x-rays, computer topographies or MRIs.

For the diagnosis it is sometimes needed to run the usual laboratory tests. In the case of ankylosing spondylitis, sedimentation rate and CRP may be high. They may also be perfectly normal. The diagnosis is made with the clinical picture and history of the problem, also imaging and laboratory tests are usually needed.

There is no known cure for this disease. Symptoms may be alleviated with medication and physical therapy. Physiotherapy and physical exercises may be able to improve functioning in the everyday life.



Disc Inflammation

The intervertebral disc may inflame. This is usually caused by bacteria. In adults, the inflammation commonly begins after surgery or some other invasive procedure relating to the disc.

Symptoms include common symptoms of inflammation such as temperature, pain, and weakening of the physical condition. The back pain is not always unusually strong and in children the clinical picture may be ambiguous.

Diagnosis is confirmed with laboratory tests and MRIs. Treatment is antibiotics.



Metastases

Cancers sometimes send metastases to the lumbar spine or elsewhere in the spine. The most common cancer types that do this are prostate and breast cancers. Symptoms consist of localized pain.

An x-ray or MRI will help diagnose this problem. If one has been treated for a malignant tumor, pain in the spine should be checked more quickly.


Osteoporosis

Deficient calcium levels usually cause no symptoms until the spine is so weak that vertebrae break with the least injury or even without an injury. In this case, the back is mighty sore and posture problems may arise.

The risk group for osteoporosis includes those women who get their menopause early and who have not started hormone replacement treatments, persons whose relatives have had fractures due to osteoporosis, those who are underweight or overuse tobacco and alcohol, those who do not consume dairy products, and those who have rheumatism or receive cortisone treatment.

Fracture is diagnosed with an x-ray or MRI. The fracture usually ossifies by itself. It is recommended to move as much as pain allows. Before fractures arise, insufficient calcium levels can be verified by measuring bone density. Osteoporosis should be treated with appropriate medication before fractures appear.


Piriformis Syndrome

Piriformis syndrome is quite rare but it is possible that a nerve gets pinched between the two parts of the piriformis muscle in the buttocks, in which case the symptoms mirror those of sciatica. Neural pathway examination helps in diagnosing whether the problem is pinched nerves in the lumbar spine or the gluteal muscles.

Physical therapy relaxes the muscle. Cortisone injections may work and in some cases surgery is used to help free the nerve.


Muscle Weakness

Weak back and abdominal muscles may contribute to pain, more so in tall persons. Physical therapists can check muscle strength levels if this might be the problem.

Treatment consists of strengthening the muscles. Testing the strength level and range of motion helps in creating a program aimed at improving the performance of the weakest part. If one begins exercise without testing, it may end up exercising the weakest part the least because it is the most difficult part to handle and train.



Tailbone Pain

Sometimes the tailbone gets sore due to a minor injury; for some reason this is more prevalent in women. When the area is examined and x-rayed, usually nothing out of the ordinary is found in addition to the pain.

This condition can be a nuisance, because it can take a long time. There is no effective treatment. Thermotherapy may be useful, also anti-inflammatory medication or cortisone injections can be tried.



X-Ray Changes

Back x-rays or MRIs often show degenerative changes of different levels as well as various structural abnormalities. A person may have four or six lumbar vertebrae instead of five, or the lowest vertebra may have attached itself to the pelvis, the back arch of the vertebrae may be open etc.

These phenomena usually do not cause back problems; in fact, changes such as these are found in people who have never had back pain. Loosening or shifting of the arch of the vertebra or spondylolysis is a significant change in view of back pain, but the importance of the other phenomena is unclear.

Degenerative changes visible in spine x-rays or MRIs are an age-related fact that may affect just about everyone as we age. They may necessarily not have anything to do with current pain symptoms. A high level of degeneration tends to stiffen the spine as the aging process continues.



Hemorrhoids

The most common reason for anal pain is hemorrhoids. Anal fissures, infections, prolapsed colon and tumors may also cause pain in this region. Diagnosis bases on a doctor’s inspection and sigmoidoscopy and, if necessary, contrast medium x-rays.

Sit baths several times a day are useful. If sitting hurts,to sit on, a partially filled children’s swimming ring may be used. OTC hemorrhoid creams and suppositories can be used for short periods of time only.

If one suffers from hemorrhoids, stools should be kept soft and wiping should be done gently. The paper may be moistened before wiping and the softest possible paper used. If necessary, toilet paper that has moisturizer in it can be used. The painful area must not be scratched.

Emergencies

Back pain accompanied by advancing paralysis of a leg or difficulty in urine or stool continence.
Post-surgery back pain that is worse, accompanied by fever.

See a Doctor

Back pain accompanied by pain radiating down the leg.
Prolonged back pain accompanied with problems with walking.
Prolonged back pain in a young person.
Severe back pain after a fall.
Back pain accompanied with fever.
Back pain, if person has had malignant tumors.

Back pain, more information:

Low back exercise videos Tv-gym.com.
American Academy of Orthopedic Surgeons on low back pain.
Netdoctor.co.uk page about lumbago.
American Family Physician on acute low back pain.
Mayoclinic.com pages on sciatica.
Medicinet.com slideshow: myths and facts about back pain.
American Academy of Orthopedic Surgeons on herniated disc.
webMD about herniated disc.
American Academy of Orthopedic Surgeons on spinal stenosis.
webMD about exercises to reduce low back pain.
Spinalsurgeon.com chronic low back pain.
About.com pages about types of spine surgery.
Understandspinesurgery.com pages with 3D animations about spine problems and operations.
Emedicine on piriformis syndrome.
Mayoclinic.com pages on ankylosing spondylitis.
Spineuniverse.com article about disc space infection.
Mayoclinic.com pages on osteoporosis.
HealthDesk.com about compression fractures.
Back.com article about degeneration.
Cure-back-pain.org article about back muscle weakness.
Emedicine article on spinal metastases.
Emedicine article on tailbone pain.
Wikipedia on hemorrhoids.
Ezinearticles.com about early pregnancy back pain.
Spineuniverse.com article about back pain during pregnancy.
Which sleep position Is best.
Anatomy of the spine and of spondylosis.
Spine degeneration.

NEW!

You can make the most of your doctor's appointment if you are well prepared. It may be helpful to bring along a list of your symptoms and complaints. We made forms for neck, shoulder, low back and knee pain you can fill in advance, send to your email and print as a reminder, or forward to your doctor if she/he accepts email.

This may help you to remember better all the relevant information. Your doctor may get a clearer picture and have more time to examine and to think about your problems. The security of the form is on the level of an email, so please do not send any sensitive information. We do not use, store or give this information to anyone or use your email address for any other purposes. It is used only to send the form to you. You may also print an empty form and fill it by hand.

The service does not cost anything. It is in the testing phase. If it is a useful, we will create similar forms for other areas of pain. Tell us what you think. What is missing, or there is too much of something? Can this be beneficial?

The form or any other material on this site is not intended to substitute professional medical advice, diagnosis, or treatment. You should never disregard professional medical advice or delay in seeking it because of something you have read on this site.

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3 comments:

  1. I have so much appreciated explanations and advises given herein,they are so helpful in ones understanding of a specific illness.

    ReplyDelete
  2. Thank you. It's always nice to get positive feedback.

    ReplyDelete
  3. The computerized table cycles through distraction and relaxation phases to isolate the spinal disc under negative pressure. chiropractor near me

    ReplyDelete