MRI of a patient showing
disc prolapse between L5 and S1 vertebra
Low backache is extremely prevalent, and is the second most common reason for the people to seek medical attention. Low back pain accounts for approximately 15% of the sick leave, and is the most common cause of disability in persons less than 45 years of age. The annual incidence is 5%. The prognosis for most cases of low backache is good, and improvement usually occurs with little or no medical intervention. Low backache is termed chronic, if it lasts longer than 12 weeks.
What are the causes of low backache?
Mechanical low backache or the "musculoskeletal" backache is the most common form of back pain. This may result from strain of the muscles or the ligaments in the back. It excludes structural causes like disc prolapse and tumours. Only 1-3% of the patients with low back ache will have lumbar disc herniation (slipping of the intervertebral disc situated between the vertebral bodies causing compression of the nerve root).Sciatica is the pain due to the irritation of sciatic nerve (the nerve which supplies the lower limb) due to lumbar disc prolapse. Sciatic pain is usually present in the low back and buttock and goes down the thigh up to the foot. Several studies have shown that smokers are more prone to get back pain, sciatica and spinal degenerative changes. Smoking also delays the bone healing and increases the chances of surgical failure after spine surgery.
What are the points to be noted in the patient with backache?
What are the 'Red flags' or warning signals in a patient with backache?
- Age of the patient.
- Any history of cancer (like prostate or breast carcinoma).
- Unexplained weight loss.
- Long term use any steroidal drugs or drugs for AIDS.
- Duration of back pain.
- Any pain or worsening of pain at rest.
- Drug abuse
- Numbness or weakness of legs
- History of injury to the back.
- Urinary disturbance(difficulty in passing urine)
- Work status.
- Educational level of the patient.
- Any pending cases in court against the patient.
- Worker's compensation issues.
- Previous failed treatment for backache.
These conditions tell that patient is not having a simple back pain, but has a serious underlying back problem.
What are the investigations to do for low backache?
- Age of the patient if greater than 50 or less than 20 years.
- If the patient suffers from cancer.
- Unexplained weight loss.
- Drug abuse.
- History of significant trauma to the back.
- Prolonged intake of steroids.
- Acute difficulty in passing urine.
- Numbness over the buttocks and groin.
- Weakness of the legs.
For over 90% of the patients with back pain, no further testing is necessary except for the physician consultation, if the pain subsides in first 4 weeks. Otherwise one must proceed with investigations like X-rays, CT scan and MRI scan for the back (lumbosacral region). It will reveal bony abnormalities, lumbar disc prolapse or spinal tumour, if present.
What are the treatments available?
Initially all cases of backache can be managed conservatively (non-surgical) except under special situations, where patient should be taken up for emergency surgery. If there is lumbar disc prolapse, patient can be taken up for surgery after a trial of conservative management. Spinal tumours should be operated immediately.
Non-surgical treatment includes:
- Bed rest: This will reduce the intra discal pressure and pressure on the nerve roots. Bed rest up to 4 days is allowed. Prolonged bed rest does more harm to the patient, producing weakness, stiffness and pain.
- Activity modification: For some period of time, patients are advised not to lift heavy objects, not to sit in the chair for a long time and not to bend or twist the back.
- Exercise: Low stress aerobic exercise is advised. Walking, cycling and swimming are allowed in the first two weeks. Physiotherapist should be included in the programme for the benefit of patient.
- Analgesics: For acute pain, paracetamol, or other drugs like diclofenac sodium can be used.
- Patient education: Patient should be educated how to modify the daily activities, how to lift weight etc., by charts and diagrams.
- Steroids: In some cases, epidural steroid injections may be helpful.
- Physical treatment: Lumbar traction is of no use. Spa therapy has proven effective in some studies. Relaxing techniques and ultrasound therapy to the back may be helpful to some extent.