Back Pain

 

 

Why is back pain important?

Back pain is recognized as one of the main causes of functional incapacity and disability in developed societies. It has been found that 70 to 90% of the world's population experience back pain at some point in their lives. Back pain occurs in all age groups with a frequency of 20-30%, and it is most common in the age group of 40-50. In developed societies, this syndrome ranks second in terms of treatment for chronic diseases, following heart diseases, and is fifth in terms of surgical treatments.

The significance of back pain is particularly apparent in the industrial sector and the working community. The total cost of lost workdays and productivity, diagnosis, treatment, and compensation in countries like the USA can reach 16-20 billion dollars annually.

Despite all these significant figures, especially mechanical back pain, if not due to causes like tumors, infections, or rheumatic diseases, is essentially a benign syndrome. 70-85% of those with back pain recover without any treatment after the first acute attack.

However, 38% of those with an acute back pain episode have a second episode within a year, and 81% of those with chronic back pain experience an acute episode in the same year. The key is to prevent the first acute episode of back pain, and equally important is for those who have experienced the first episode to learn to prevent the second. Because with repetitions, pain becomes chronic, and the patient becomes a victim of chronic pain symptoms.

What is back pain? How does it develop?

 

A General Look at the Spine

• Your spine consists of 33 bones called vertebrae. It extends from the base of the skull to the coccyx. It evolves in a cylindrical shape to support the head and body. It's surrounded by muscles, ligaments, and other tissues.
• Each vertebra has a hole in it. These holes combine to form a cylinder,a canal  and the spinal cord passes through this cylinder called spinal canal.
• Between each vertebra, there are soft cushions  called as discs to prevent friction and allow mobility.
• Lumbar or cervical hernias occur due to displacement or tearing in these cushions. There are 7 vertebrae in the neck region, balancing between the chest and the head.
• The chest region has 12 vertebrae, balancing between the waist and the head. Ribs and muscles attach to these vertebrae to form the rib cage.
• There are 5 vertebrae in the lumbar region. The most robust and firm vertebrae are in this region. Muscles of the lumbar region and intervertebral ligaments connect to the lumbar vertebrae. Below the lumbar vertebrae are the pelvic bone and coccyx.
• Back pain usually results from the stretching of a ligament or muscle holding a vertebra in its normal position. When these muscles and ligaments weaken, the spine loses its integrity, resulting in pain. As nerves spread from the spinal cord to every part of the body, lumbar problems can cause pain and weakness almost everywhere in the body.
• Back pain may arise due to lifting and carrying heavy objects, standing for long periods, leaning forward, or sitting. It can be due to falls or unusual heavy exercises. Tension and stress causing headaches in some people can also lead to back pain.
• Severe coughing and sneezing can even cause back pain. Overweight people may experience back pain due to the increased load on the back. Back pain can result from infections or immune system problems damaging the muscles, joints, bones, and connective tissues in the back. Joint diseases can cause back pain.
• Loss of bladder or bowel control, difficulty moving the legs, or numbness and tingling in the legs, along with back pain, could indicate damage to the spinal cord and nerves and require urgent treatment.

Common Causes of Back Pain

Back pain can be classified as follows:

1. Lumbar hernia - disc herniation
2. Disc degeneration, degenerative disc disease
3. Narrowing of the spinal canal - narrow canal, spinal stenosis
4. Sciatica - the piriformis muscle compressing the sciatic nerve
5. Calcification of the joints formed by vertebrae - facet disease
6. Failed back surgery syndrome
7. Sacroiliac joint disease
8. Pain originating from the lumbar muscles
9. Spinal cord injuries
10. Disc inflammation - discitis

 

Disc Herniation – Lumbar Hernia

 

How does a lumbar hernia form?

There are cushions called discs between the vertebrae. These cushions, filled with a gel-like substance, act similar to a car's shock absorber, balancing the burden  on the back. The disc has an aqueous part called the nucleus and a ring around it. The ring can get damaged due to excessive loading. This damage evolves in three forms.

1. Bulging: Similar to  a burn on your finger, edema (swelling) occurs in the ring. This edema presses on the nerve, causing pain.

2. Protrusion: As seen in old-fashioned car tires, a bubble forms in this ring and presses on the nerve. It is a more serious situation than the first.

3. Extrusion: The ring tears, and the gelatinous substance inside the disc spreads toward where the nerves are. The risk of these changes occurring in the ring increases depending on factors such as weight, age, height, heavy lifting, and intense sports. All three of these formations cause pain. Common symptoms are:

1. Pain in the lower back or neck area, corresponding to the affected nerve distribution.
2. Pain that increases with movement, coughing, or leaning forward.
3. Numbness in the affected arm or leg depending on the severity of the compression.
4. Loss of strength.
5. Loss of reflex.

Nerves spread according to where they exit from the spinal cord. Therefore, in both lumbar and cervical hernias, pain and numbness vary depending on the compressed nerve.

How is a disc herniation diagnosed?

The most crucial element in diagnosing lumbar or cervical herniation is the patient's clinical examination. Imaging methods are then utilized. Unfortunately, the advance of technology and imaging methods has also led to many inappropriate  treatment approaches. Deciding on a diagnosis and treatment based solely on imaging, MRIs, or CT scans is very wrong. Ultimately, it's the patient, not the MRI image, that needs to be treated.

Methods used in diagnosing disc herniation include:

• Radiological image of the spine: Shows if the pain is due to a disorder in the bone tissue, a fracture, or another cause.
• MRI: Magnetic resonance imaging is the best method to show if the event is a lumbar herniation or originates from the joints. Soft tissues appear clearer.
• CT scan: Can be used if MRI is not available. It might show bone tissue better than MRI.
• EMG: Used to measure the damage in the nerves.
• Myelography: It was used more when there was no MRI or CT. It involves taking an X-ray after injecting a dye into the cerebrospinal fluid.
• Discography: Used to view changes in the disc by injecting dye into it.

Treatment:

Treatment for lumbar herniation is not only based on the intensity of pain but is conducted considering other symptoms. If the patient has only pain, initial treatments include bed rest and applying ice to the painful area. Initially, only simple drugs are used. If they're insufficient, muscle relaxants are added. Acute bed rest of up to two weeks might be necessary. More extended bed rest is not right. Many patients' acute pain regresses within these two weeks. If not, the solution isn't immediately surgery. If a patient has:

1. Loss of strength.
2. Numbness.
3. Reduced or lost reflexes, surgery isn't the immediate go-to.

At this stage, physical therapy or interventional procedures performed   by algology are implemented. If pain is primary, interventional procedures are first used to reduce or eliminate the pain, followed by physical therapy and rehabilitation. Interventional procedures  used in the treatment of lumbar and cervical herniation are:

1. Steroid injection under imaging to the area where the nerve root is compressed.
2. Intradiscal electrothermal treatment.

If a patient has permanent numbness, loss of strength, and loss of reflex, then surgery may be necessary. After recovery, the patient should continue with back exercises and preventative care.