Back Ache
Back Ache: Brief introduction, causes and principle of treatment
Back Ache generally refers to pain on dorsum, lumbar region and up to the tail bone. It’s one of the commonest Orthopaedic Problems in adults. Various reasons might cause back ache. It hampers activities of daily living as well as job performance. Some factors that contribute to this situations are poor posture, depression, obesity, age and height, smoking, stress, exercise etc. Life time risk for this problem is 60-70 % in developed nations.
The problems may lie on skin, muscle, bone or deeper organs of urogenital system, intestine, stomach or Aorta. Whenever someone comes to a physician, generally he may be asked about duration of illness, any event preceding back ache, pain radiation to other sites on body, stool and urine incontinence, associated fever, weight loss, night pain and any relevant medical or surgical diseases in the past and few other relevant questions. After that, he will be thoroughly examined after exposure of back and the lower extremities. Then the patient might be ordered for Complete Blood count (CBC), Erythrocyte Sedimentation rate (ESR), Urine routine examination, X-ray of Lumbosacral Spine (L-S Spine).
Doctors try to categorize the Back ache into Mechanical cause, Trauma, Infection, and Tumour in the same sequence as above to discern problem of skin, muscle, vertebral bone or pelvic bone. If doctor can’t pinpoint the diagnosis or think there is more serious ongoing pathology then the patient will be ordered for CT-scan or MRI.
Any patient who has fever, weight loss, night pain or any significant deformity must be screened thoroughly for underlying tumor infection or any other possible serious illness
Treatment is decided according to the cause of back ache. Some common causes of back ache and their treatment is described as below
Common Causes of Back Ache
1. Poor posture during activities of daily life, Muscle sprain
2. Disc Herniation
3. Lumbar Stenosis
4. Spondylolisthesis
5. Spondylitis
6. Tuberculosis of Spine
7. Osteoporosis and fragility fractures
8. Tumor of Spine
9. Skin Problem- Shingles
10. Other Non-spinal causes
1. Urogenital problems like stones, tumor or infection in kidney, bladder or Urethra
2 Gynaecologic problems in females
3 Duodenal Ulcers, Appendicitis, Aneurysm of Aorta (uncommon causes)
Sometimes, back ache is a surgical emergency when it leads to stool and urine incontinence. In such cases it’s urgent to decompress the compressed nerve roots to prevent long term incontinence.
Some common causes of back ache and their treatment in Orthopaedic OPD
1. Back Ache due to Poor Posture or Muscle Sprain
Its treated with pain killers (e.g. Tab Aceclofenac ) and taught about care for body posture in daily living.Muscles strengthening exercises are taught.
Its treated with pain killers (e.g. Tab Aceclofenac ) and taught about care for body posture in daily living.Muscles strengthening exercises are taught.
2. Disc Herniation or Protrusion of Intervertebral Disc
Between each two vertebrae lies a cartilaginous disc which might dislodge and compress the nerve root. To understand here, Blue structure is a disc. Green structures are nerve roots. Blue disc slips posteriorly and compresses the green nerve roots.
The treatment of this condition is largely physiotherapy. Patients are advised not to bend forward, lift weight and do back muscles strengthening exercises.
Pain is controlled with painkiller tablets. If there is any nerve root compression such as pain on thigh or calf, numbness in any part then neurotropic medicines are given.
For example, Pregabalin and Vitamin B 12.
If there is no improvement then one or two shot of Epidural cortisone like injection are given.
Last option of Disc herniation treatment is Dissectomy – surgical removal of the disc. There can be a chance of disc herniation even after surgery.
3. Lumbar Canal Stenosis
The canal where nerves pass is occluded to some extent.
Pain is managed first with medication. If it does not improve, epidural injection is given. Laminectomy is done, part of bone that encircles the spinal cord is removed.
4. Spondylolisthesis
One vertebrae slips over other. It is treated conservatively with NSAIDs and physical therapy like for other causes of back ache. If its more than 50 %, it may lead to instability and neural symptoms. Surgery alleviates pain by relieving tension on nerve and providing stability of spine by fusion of vertebrae.
X-ray of the lateral lumbar spine with a grade III anterolisthesis at the L5-S1 level.
5. Spondylosis of Lumbar Vertebrae
It’s a broad term for degeneration of disc or vertebrae. No gold standard treatment is yet found. Largely its managed conservatively with NSAIDs (e.g. Aceclofenac). It’s treated with surgical fusion of adjacent verteabrae with degenerative changes and decompression of nerve for neural compression symptoms for those who fail to improve conservatively.
6. Tuberculosis of Spine
This is a problem of developing nations. It may affect individuals of any age group. After confirming with biopsy, medical treatment is done with Anti-Tubercular medicine for a course up to 18 months. If diagnosed and started pharmacologic treatment earlier, then complications can be prevented. Surgery might be needed for biopsy, pus drainage, to stabilise the unstable spine, correct and arrest progression of kyphosis.
7. Osteoporosis and Osteoporotic Fracture
Osteoporosis is demineralization of bone leading to loss of strength of bone that leads to fracture of the vertebral bone with low energy trauma like coughing, sneezing or minor falls on ground level. Usually post-menopausal women and elderly patients suffer from this condition.
When there are Osteoporotic fractures then management is simply done with analgesics. Kyphoplasty is a surgical procedure to inject bone cement into the compressed vertebrae that can alleviate pain but it’s not widely available. Such patients need treatment with Calcium supplement, Bisphophonates to prevent further resporption and fracture of bone guided by bone densitometry.
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