What to know about low back pain

Dr. Akinsulire

DR. AKINSULIRE ADEWOLE is a Consultant orthopaedic and trauma surgeon in the Spine/Oncology unit of the Department of Orthopaedics and Trauma at the Lagos University Teaching Hospital. In this interview with GERALDINE AKUTU, he sheds light on low back pain and how to deal with it.

What is low back pain and what causes it?
Simply put, pain occurring in the lower back is referred to as low back pain. It is not a specific diagnosis, but rather a complaint about a pain location that may be caused by a large number of underlying problems of varying levels of seriousness. Low back pain is a very common complaint everywhere in the world. It is estimated that four in every five adults will have low back pain at some point in their lifetime. Low back pain is also the leading cause of disability worldwide and a common reason for people being absent from work. Over half of my clinic patients have some form of low back pain, either as a primary complaint or in association with other complaints. The etiology of low back pain is varied. Pain can originate from all the structures that make up the lower back such as muscles, ligaments, intervertebral discs, nerves and joints. All of these structures can be injured and cause pain.

The commonest causes of low back pain are muscle strain and ligament sprain. Other causes can range from such trauma as fractures, dislocations, infective causes, degenerative causes and malignancy, which can be primary or secondary inflammatory disorders and vertebral spine deformities. Obesity, smoking, weight gain during pregnancy, stress, poor physical condition, poor posture and poor sleeping position may also contribute to low back pain. It can also be due to pathologies or problems in other parts of the body, such as unequal limb length or can also be a referred pain from problems in the abdomen or pelvis, which should be paid attention to. Not all back pains originate from the back.

What are the types of low back pain?
Back pain can be classified in many ways. It can be acute, sub-acute and chronic. Low back pain of four to six weeks or less is termed acute, while that which persists for more than three months is termed chronic. The fact that it is chronic does not mean it is life-threatening, but only an indication of the duration.

Back pain can also be grouped as non-specific low back pain or those of known etiology. Non-specific low back pain refers to back pain in the absence of a specific underlying condition that can be reliably identified. Usually, it is due to a muscle strain or ligament sprain. These muscle/ligament injuries can result from trauma, overuse, tears and abnormal postures. Most times this resolves in a few weeks. Back pain due to a specifically identified pathology could be as a result of infection, degeneration, trauma and malignancy to mention a few.

What can be done to prevent it from getting worse?
Aside from initial rest and adopting postures, which will help reduce pain, an individual with low back pain needs to be properly evaluated by a specialist to determine the cause and the type of low back pain. While many cases of low back pain are self-limiting and will resolve in weeks, it is important to identify the subset of low back pain, which will not improve and may even get worse if untreated. There are red flags, which if present will demand proper evaluation and treatment. This is where a review by qualified specialists is very important. Many times, I see patients who have a single episode of non-specific low back pain and have done radiographs, CT scans and MRIs. And I wonder what the indication for such test was. Clinical evaluation is usually the first step before a patient is asked to undergo several and unnecessary investigations. Lack of proper clinical evaluation results in waste of resources and sometimes unnecessary treatments, as imaging may detect harmless abnormalities. It is important to treat the patient and not the MRI scan.

What are those red flags you mentioned?
These are specific symptoms and signs, which suggest that back pain is not of a non-specific nature. They may indicate a significant and often sinister underlying cause, which may need specific treatment. These red flags include, unexplained weight loss, back pain following back trauma, fever, history of cancer, weakness in the lower limbs, loss of bladder or bowel control and abnormal sensation in the lower limbs. Any of these symptoms suggests there may be more to the back pain. The presence of these symptoms emphasise the need to see a specialist, who will appropriately identify, guide and make an accurate diagnosis before instituting treatment.

What are the treatment options?
In developing a treatment plan, the patient must be carried along 100 per cent, as full compliance will help in achieving treatment goals faster. Many things are taken into consideration, when determining the best treatment option. This includes the severity of symptoms, degree of disability, patient’s comorbidities and motivation.

There are general treatment options available to treat low back pain. They could be pharmacologic i.e. use of medication to help control the symptoms. This could range from analgesics, muscle relaxants or medication for neuropathic pain. These should be properly selected based on thorough clinical review and investigations. The pharmacologic medication does not address the underlying pathology; rather they are for symptomatic relief. Other measures include, physical therapy, which is specific exercise/treatment to the back and lower limbs to help improve muscle strength and function, joint mobility and ligament function. Lifestyle modification is also important, as such things as weight loss, increased physical exercise, use of ergonomic chair and support devices can also help.In patients with low back pain with a specific etiology, such as infection and malignancy, treatment will always be geared towards that specific cause.

What are the surgical options?
Most patients with back pain do not require surgery. However, a number of them might require invasive procedure to treat back pain. These range from minimally invasive procedures, which include injecting medications to specific areas of the spine/spinal canal, which also help in alleviating pain. These procedures can be conveniently done as a day case in which the patient comes the same day, has the procedure and goes home the same day. These injections help in symptomatic relief and many times do not treat the underlying pathology.

Surgery is also an option in treating patients with low back pain. Surgery could broadly be either a form of decompression, which is to remove anything that might be compressing the spinal cord or nerves. It could also be a lumbar fusion procedure, which is to remove a soft tissue between two adjacent bones and replace them with bone or metal, with the aim to fuse the bone together and eliminate motion at these spinal segments.

If surgery is recommended, is it necessary and what are the risks?
A vast majority of patients will not require surgery. Most patients will do well might non-invasive treatment options. Rather, surgery is indicated based on the symptoms patients present with, the failure of non-operative treatment and degree of functional impairment. Many times the decision to operate must be earned by the patient. Of course, sometimes the symptoms and presentation are so obvious that surgery is the first line of treatment. That is why it is imperative that patients with low back pain are evaluated by a specialist, as soon as possible. I have seen patients who are unable to move the lower limbs for several months and have just been taking medications without seeing a specialist. If surgery had been done much earlier for them, the symptoms would have dramatically improved.

Back surgery like any other surgery has its own complications, therefore a proper selection of patients is necessary as that would prevent failed back surgery syndrome. Patient might have comorbidities, which preclude immediate surgery. Proper preoperative planning is necessary and patient should be appropriately counselled about the goals of surgery and the surgeon should be aware of the patient’s expectations, which should be realistic, practical and achievable.

Surgery treatment has shown much advancement and there are minimally invasive keyhole surgeries to treat low back pain. Incisions as small as 2-3 cm are used to treat the problems and results are comparable and sometimes better than traditional open surgery. This ensures there is earlier recovery of function and minimal disruption in patient’s activities. These procedures are also being done in Nigeria with excellent results.

Are there home remedies for back pain?
I would say there are general measures one can put in place to reduce the occurrence and frequency of low back pain. This can range from regular exercises/aerobics, weight loss programme and adopting good postures while walking, sitting. A simple measure like brisk walking for about 30 minutes three times a week can help improve function. There are ways to lift object, which will protect the back and not add additional stress to it. In some situations, one might need to change jobs, as some jobs can predispose to back pain.

In this article:
AKINSULIRE ADEWOLEBack Pain
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