Backache- its causes and management
The prevalence of back ache is so common that most of us have suffered from it at least once in a life time. With variable estimates, about 80% of people get backache in their life. About 70% of the people, who suffer from it, seek medical help and incidentally more women do so, indicating that its incidence may be more in women. Unfortunately, back ache is one of the most expensive health problems.
Spinal strain and injury- This is caused by a stretch injury to the ligaments, tendons and muscles of the back, which results in tears of varying degrees in these tissues. This is the most common cause of back injury. This injury can take place at any age after a mechanical stress to the back and is characterized by localized discomfort and pain. The severity of the injury can vary from mild to severe. If it persists longer than three months, it is referred to as chronic.
Pressure on nerve roots- An impingement by bone, any other issue or any local inflammation can cause irritation of the nerves emerging from the spine, resulting in pain. If the impingement presses on the sciatic nerve, the pain may run from the buttock down one leg. This is called sciatica.
An impingement can be caused by the following-
- Herniated disc- The spinal disc, which is a rubbery cushion between vertebrae, can gradually develop age-related changes. It looses its elasticity and may crack due to mechanical stress. The nucleus may then bulge out and press on nerves leading to herniated disc.
- Osteoarthritis- This is a degenerative disease of the spinal vertebrae. This is the most common form of arthritis leading to the degenerative changes in the discs which may crack and put pressure on the nerves.
- Spondylolisthesis- This a condition where one of the vertebra slips forward or backward compared to the next. This causes pain due to impingement on the nerves.
- Spinal stenosis- This is caused by the narrowing of the space around the spinal cord which can put pressure on the spinal nerves.
- Fractures of vertebra- This can exert pressure on the spinal nerves, causing pain. Osteoporosis is an important cause of fractures in old persons.
- Spinal deformities- Deformities like scoliosis, in which spine is curved from side to side and kyphosis, in which there is a bowing or rounding of the back leading to hunchback, can cause pain.
- Ankylosing spondylitis- This is a chronic inflammation of the spine and the sacro-iliac joints. The chronic inflammation causes pain and stiffness in and around the joints, leading to the restricted movements in the affected joints.
- Bacterial infections- Some common infections like bacterial, fungus or tuberculosis may initially present as spinal pain before assuming seriousness. Infections of the cartilage and bone of the spine can lead to backache. Shingle is also one of the causes of backache. Brucellosis can also cause it by involving sacro-iliac joints, which is transmitted by the goat’s milk.
- Spinal tumors- A spinal tumor or a growth of any kind can cause back ache.
- Uncommon causes- Paget’s disease (a chronic disorder that can result in enlarged and deformed bones), bleeding and infection in the pelvis or aneurysm of the aorta can also cause backache.
Each individual having backache needs its evaluation by a clinician. The management of the disease depends upon its underlying cause. However, the commonest cause of backache is spinal strain and injury. It has been found that 9 out of 10 cases of backache improve without surgical intervention. But 50% of all patients, who had backache, will have another episode of backache within a year.
The patient should be confined to the bed only for 2 to3 day since prolonged confinement to the bed will produce muscle atrophy and weakness resulting in a delay in healing. Initially, cold compresses should be applied for 24 hours to reduce pain and tenderness and then afterwards hot compresses to reduce the swelling.
- Medications- Pain relievers like acetaminophen, or non-steroidal anti-inflammatory drugs like ibuprofen or naproxen are prescribed. A muscle relaxant may also be prescribed to relieve the spasm in the affected area. Narcotics like codeine or hydrocodone may be used too for a short period. Certain types of anti-depressants can be prescribed particularly tricyclic ant-depressants like amytriptyline to relieve chronic backache independent of their effect on depression. The patients, who have a pinched nerve causing leg pain, may improve with steroids medications which can either be used orally or injected around the spine in the affected area.
- Exercises- The strengthening exercises for the posterior spinal muscle are important after a period of rest. When the patient is free of pain, mobilizing exercises should be started though in case of sciatica it is wise to postpone forward flexion of the spine for some weeks. The patients must learn and perform regularly exercises of the core muscles in their proper form in order to retain and build muscle strength. Strong core muscles will reduce the recurrence of the episodes of backache and will help in performing day to day physical movements effortlessly. Their doctor or clinician will guide them in this matter.
- Spinal supports- A corset is often a reasonable substitute for bed rest if chronic back pain or chronic sciatica is not particularly severe. It may be recommended in more severe cases if economic conditions prohibit complete bed rest. The object of the support is not to immobilize the lumber spine but to provide the support for the lumber curve and to limit the forward flexion. The support is useful in the later stages of treatment of acute sciatica after a severe and prolonged attack, in lumber osteoarthritis and in intractable postural backache. A corset is hardly necessary for recurring backache of short duration or where there are intervals of long durations between attacks.
Severe disabilities require manipulations and operations.
- Manipulation- It can do three things i.e. correct displacements break down adhesions and stretch the contracted capsules of injured or arthritic joints. Chronic backache due to trauma or postural strain can be treated by manipulations if mobilizing exercises don’t produce definite relief in three weeks.
- Operations- Operation for the removal of protruding inter-vertebral disc may be carried out because of neurological symptoms of the compression on the nerve. This must be performed by a neuro-surgeon. Lumber or lumbo-sacral fusion is sometimes indicated in osteoarthritis with disc degeneration. This is termed arthodesis and is performed either by removing the disc and packing the space with cancellous bone (body to body fusion) or by bone grafts (posterior fusion). The goal of the surgical procedure is to provide pain relief and improve alignment of the vertebrae. This procedure had its own limitations regarding its outcome.
Neither disc degeneration nor osteoarthritis can be cured by treatment. There will be a problem of management of recurrent acute attacks or of chronic pain. Other causes as mentioned above that are responsible for backache must be evaluated, investigated thoroughly and treated accordingly by the expert.