Information About Back Pain
Introduction
Back pain is one of the leading causes of pain and disability in the developed world, and has an enormous impact on patients, their families and the healthcare system. If you suffer from back pain you are not alone and you have many options to help manage it. Most patients with back pain do not need surgery, however, there are some conditions where surgery can help.
Back pain can be acute or chronic. Acute back back pain generally comes on suddenly and resolves over few days. It is commonly due to muscle spasm or ligament strain. It is rare for acute flair ups of lower back pain to be due to a serious pathology. Most of us will experience acute episodes of back pain at times in our life which resolve and cause no long lasting problems. Simple pain analgesics, such as anti-inflammatory medications, and physiotherapy may help during an acute attache of lower back pain.
Chronic lower back pain can affect patients for weeks, months or even years. The most common cause of chronic lower back pain is lumbar intervertebral disc degeneration and lumbar spine degeneration. In simple terms this means age related changes, or "where and tear," in your lower back. When back pain becomes chronic it can significantly impact on a patients health, mobility, happiness and ability to work. It is in these patients that an opinion from a spine specialist may be of benefit.
Rarely low back pain can be caused by more serious health problems such as trauma, cancer or infection. These rare causes need to be managed in an urgent fashion by a neurosurgeon or spine surgeon. Basic medical assessment and radiological investigations can safely differentiate between the common degenerative types of back pain and the more serious causes. If you are worried you are not getting the appropriate management please contact us on 1800 DO SPINE (1800 367 746) or email [email protected] and we will try and help you as best we can.
Chronic lower back pain is commonly caused by lumbar intervertebral disc degeneration and related lumbar spine degeneration. This is where the intervertebral discs, or shock-absorbers in the spine, wear out over time. The wearing out of intervertebral discs is part of the normal ageing process. Like hip joints and knee joints can wear out, so to can the spine wear out.
In some patients disc degeneration happens more quickly, at a younger age, or to a more severe extent. When symptoms become chronic and unresponsive to treatments, permanent disability with reduced quality of life can follow. In addition, chronic pain and disability can also lead to psychological illness, such as depression or anxiety.
Lower back pain can be caused by the damaged disc itself, termed discogenic pain. Other parts of the spine can also wear out leading to pain. The exact pain generator may be difficult to identify in all patients and is often multifactorial, involving different structures in the spine. Identifying the pain generator is very important as it can help to direct treatment. Parts of the lower back that can cause back pain include:
75-80% of people will experience lower back pain at some stage, whilst severe disc degeneration is associated with a two-fold increase in chronic lower back pain. The prevalence of back pain increases with age, however, young people are also commonly affected by back pain.
Controversy exists regarding the concept of “discogenic” back pain, or pain that originates from the intervertebral disc. Not all patients with disc degeneration on MRI have back pain. Equally, all patients with symptomatic back pain do not necessarily have radiological evidence of disc degeneration. Having said this, large population based studies have demonstrated a significant correlation between back pain and the presence of disc degeneration on MRI. The degree of the radiological degeneration also correlates with the severity of pain and disability, particularly in younger patients.
For more information about lower back pain watch the video below. Keep reading for more information about the assessment and treatment of lower back pain.
Back pain is one of the leading causes of pain and disability in the developed world, and has an enormous impact on patients, their families and the healthcare system. If you suffer from back pain you are not alone and you have many options to help manage it. Most patients with back pain do not need surgery, however, there are some conditions where surgery can help.
Back pain can be acute or chronic. Acute back back pain generally comes on suddenly and resolves over few days. It is commonly due to muscle spasm or ligament strain. It is rare for acute flair ups of lower back pain to be due to a serious pathology. Most of us will experience acute episodes of back pain at times in our life which resolve and cause no long lasting problems. Simple pain analgesics, such as anti-inflammatory medications, and physiotherapy may help during an acute attache of lower back pain.
Chronic lower back pain can affect patients for weeks, months or even years. The most common cause of chronic lower back pain is lumbar intervertebral disc degeneration and lumbar spine degeneration. In simple terms this means age related changes, or "where and tear," in your lower back. When back pain becomes chronic it can significantly impact on a patients health, mobility, happiness and ability to work. It is in these patients that an opinion from a spine specialist may be of benefit.
Rarely low back pain can be caused by more serious health problems such as trauma, cancer or infection. These rare causes need to be managed in an urgent fashion by a neurosurgeon or spine surgeon. Basic medical assessment and radiological investigations can safely differentiate between the common degenerative types of back pain and the more serious causes. If you are worried you are not getting the appropriate management please contact us on 1800 DO SPINE (1800 367 746) or email [email protected] and we will try and help you as best we can.
Chronic lower back pain is commonly caused by lumbar intervertebral disc degeneration and related lumbar spine degeneration. This is where the intervertebral discs, or shock-absorbers in the spine, wear out over time. The wearing out of intervertebral discs is part of the normal ageing process. Like hip joints and knee joints can wear out, so to can the spine wear out.
In some patients disc degeneration happens more quickly, at a younger age, or to a more severe extent. When symptoms become chronic and unresponsive to treatments, permanent disability with reduced quality of life can follow. In addition, chronic pain and disability can also lead to psychological illness, such as depression or anxiety.
Lower back pain can be caused by the damaged disc itself, termed discogenic pain. Other parts of the spine can also wear out leading to pain. The exact pain generator may be difficult to identify in all patients and is often multifactorial, involving different structures in the spine. Identifying the pain generator is very important as it can help to direct treatment. Parts of the lower back that can cause back pain include:
- Intervertebral discs
- Facet joints
- Bone/periosteum
- Ligaments
- Paraspinal musculature and fascia
- Nerve roots
- Psychological causes
- Spinal instability
75-80% of people will experience lower back pain at some stage, whilst severe disc degeneration is associated with a two-fold increase in chronic lower back pain. The prevalence of back pain increases with age, however, young people are also commonly affected by back pain.
Controversy exists regarding the concept of “discogenic” back pain, or pain that originates from the intervertebral disc. Not all patients with disc degeneration on MRI have back pain. Equally, all patients with symptomatic back pain do not necessarily have radiological evidence of disc degeneration. Having said this, large population based studies have demonstrated a significant correlation between back pain and the presence of disc degeneration on MRI. The degree of the radiological degeneration also correlates with the severity of pain and disability, particularly in younger patients.
For more information about lower back pain watch the video below. Keep reading for more information about the assessment and treatment of lower back pain.
Video about back pain
Assessment of Low Back Pain
The initial workup for a patient with back pain involves ruling out the more serious causes such as cancer, infection or trauma. This is generally done by your general practitioner who will ask questions and perform a physical examination. Questions regarding unexplained weight loss, fevers and a history of traumatic injury may be asked in the initial assessment and are done so to work out if a more serious cause may be present.
If you back pain came on suddenly and then resolved over a few days it is unlikely to be due to a serious pathology. Such acute flare ups of back pain are common and not serious. If the episodes occur frequently or do not go away you should seek medical attention to rule out serious pathology.
In addition to the back pain itself, it is important to determine if the back pain is associated with symptoms of nerve compression which include:
These symptoms of nerve compression usually require more urgent investigation and treatment by a neurosurgeon or spine surgeon.
Following the initial assessment it is usual for some type of radiological investigation to be organised to look in more detail for the cause of the back pain. Investigations which will help in the assessment of back pain include:
Determining whether an intervertebral disc is painful or asymptomatic is challenging for surgeons. MRI provides a high level of anatomical detail but fails to accurately identify the pain generator in all patients. The “gold-standard” test for determining discogenic pain has previously been a positive provocative discogram. A discogram is where an intervertebral disc is injected in the hope of mimicking your back pain. If the injection re-produces your back pain then it is likely that this disc is causing your back pain. Discography has been demonstrated to cause accelerated disc degeneration, disc herniation, loss of disc height and the development of reactive endplate changes, so is not routinely practiced by Dr Oehme. A discogram may, however, be recommended in some patients prior to considering surgery for a degenerate disc.
It is helpful, but not mandatory, to have had investigations prior to seeing Dr Oehme for an opinion about your back pain. Often we will organise scans prior to your review if we think they will be required. Otherwise, we will organise them at your appointment and then arrange a follow up visit after all of the investigations have been performed.
Treatment of Lower Back Pain
Unless patients have significant nerve compression or neurological deficits, such as lower limb weakness, or bowel or bladder dysfunction, the initial treatments for most degenerative lumbar spinal conditions are conservative non-operative therapies. The majority of exacerbations or acute low back pain will resolve without the requirement for surgical intervention. Non operative treatments represent the mainstay of conservative therapies for lower back pain and include :
Unfortunately there is often not a quick fix, or " magic wand" solution, for back pain. It is unrealistic to visit a spine surgeon and expect them to instantly cure your chronic back pain. Back pain requires motivation and effort by patients over considerable time to see improvements. This usually involves trying several of the above treatments and committing to a programme for a period of time. If one doesn't work you may need to try another.
There is good evidence that both exercise and behavioural therapies are effective treatments for patients with chronic low back pain. In patients with chronic low back pain without previous surgery, it has been demonstrated that cognitive interventions and physical exercises aimed at improving function are equal to lumbar fusion at relieving symptoms at four years. As such, only patients who have failed intensive pain management strategies will be considered for surgery to treat low back pain.
Surgery for Lower Back Pain
In some circumstances surgery may be an option for your lower back pain. Dr Oehme will only offer surgery for back pain to motivated patients who have actively tried non-operative interventions over a period of time. Surgery for back pain is a partnership between patient and surgeon. Patients must be realistic and motivated to improve. The improvements from surgery may take many months to become evident.
Most current surgical treatment strategies to treat back pain are based around the concept of a painful "black disc", or abnormal motion segment. Once the pain generator has been identified surgery may be an option. The exact treatment recommended will depend on the underlying cause of your back pain. Back pain due to spondylolisthesis will be treated differently to back pain due to degenerative disc disease. Treatments generally aim to stabilise a symptomatic lumbar motion segment, core to which is a degenerate lumbar disc. When this disc is removed, it is generally replaced with a fusion device or an artificial disc. Dr Oehme typically performs spinal fusion for back pain. Spinal fusion can be achieved by utilising a variety of different approaches.
See our spinal fusion page for more information about surgery for back pain. Dr Oehme is an expert in lumbar spinal fusion surgery to treat back pain and is happy to discuss options with you.
Feel free to contact our staff to arrange an appointment with Dr David Oehme who will provide expert assessment of you back pain.
The initial workup for a patient with back pain involves ruling out the more serious causes such as cancer, infection or trauma. This is generally done by your general practitioner who will ask questions and perform a physical examination. Questions regarding unexplained weight loss, fevers and a history of traumatic injury may be asked in the initial assessment and are done so to work out if a more serious cause may be present.
If you back pain came on suddenly and then resolved over a few days it is unlikely to be due to a serious pathology. Such acute flare ups of back pain are common and not serious. If the episodes occur frequently or do not go away you should seek medical attention to rule out serious pathology.
In addition to the back pain itself, it is important to determine if the back pain is associated with symptoms of nerve compression which include:
- Leg pain - termed sciatica
- Loss of feeling, numbness or tingling in the legs or feet
- Leg or foot weakness
- Problems with walking
- Troubles with bladder and bowel function.
These symptoms of nerve compression usually require more urgent investigation and treatment by a neurosurgeon or spine surgeon.
Following the initial assessment it is usual for some type of radiological investigation to be organised to look in more detail for the cause of the back pain. Investigations which will help in the assessment of back pain include:
- X-ray - including full length EOS scan to local at global spinal alignment
- Dynamic x-ray - flexion/extension views to look for segmental spinal instability
- Bone scan including SPECT CT - to look for active disc degeneration and active facet joint arthritis
- CT Scan
- MRI Scan (Note if you are able to have an MRI, this is the best test to assess causes of low back pain)
Determining whether an intervertebral disc is painful or asymptomatic is challenging for surgeons. MRI provides a high level of anatomical detail but fails to accurately identify the pain generator in all patients. The “gold-standard” test for determining discogenic pain has previously been a positive provocative discogram. A discogram is where an intervertebral disc is injected in the hope of mimicking your back pain. If the injection re-produces your back pain then it is likely that this disc is causing your back pain. Discography has been demonstrated to cause accelerated disc degeneration, disc herniation, loss of disc height and the development of reactive endplate changes, so is not routinely practiced by Dr Oehme. A discogram may, however, be recommended in some patients prior to considering surgery for a degenerate disc.
It is helpful, but not mandatory, to have had investigations prior to seeing Dr Oehme for an opinion about your back pain. Often we will organise scans prior to your review if we think they will be required. Otherwise, we will organise them at your appointment and then arrange a follow up visit after all of the investigations have been performed.
Treatment of Lower Back Pain
Unless patients have significant nerve compression or neurological deficits, such as lower limb weakness, or bowel or bladder dysfunction, the initial treatments for most degenerative lumbar spinal conditions are conservative non-operative therapies. The majority of exacerbations or acute low back pain will resolve without the requirement for surgical intervention. Non operative treatments represent the mainstay of conservative therapies for lower back pain and include :
- Analgesia (pain medications)
- Non-steroidal anti-inflammatory medications (NSAIDs)
- Physiotherapy
- Steroid pain injection therapies - such as epidural injections and facet joint injections
- Behaviour modification - e.g. avoiding heavy lifting
- Bracing
- Weight loss - this is important as extra weight places more stress on the spine contributing to back pain.
- Strengthening exercises - to strengthen core and paraspinal muscles to provide extra stability to the spine thereby reducing pain.
- Clinical Pilates
- Clinical Osteopathy
- Massage and myotherapy
- Hydrotherapy and swimming
- Treatment of depression, anxiety and other mental health problems
- Formal pain management programmes
Unfortunately there is often not a quick fix, or " magic wand" solution, for back pain. It is unrealistic to visit a spine surgeon and expect them to instantly cure your chronic back pain. Back pain requires motivation and effort by patients over considerable time to see improvements. This usually involves trying several of the above treatments and committing to a programme for a period of time. If one doesn't work you may need to try another.
There is good evidence that both exercise and behavioural therapies are effective treatments for patients with chronic low back pain. In patients with chronic low back pain without previous surgery, it has been demonstrated that cognitive interventions and physical exercises aimed at improving function are equal to lumbar fusion at relieving symptoms at four years. As such, only patients who have failed intensive pain management strategies will be considered for surgery to treat low back pain.
Surgery for Lower Back Pain
In some circumstances surgery may be an option for your lower back pain. Dr Oehme will only offer surgery for back pain to motivated patients who have actively tried non-operative interventions over a period of time. Surgery for back pain is a partnership between patient and surgeon. Patients must be realistic and motivated to improve. The improvements from surgery may take many months to become evident.
Most current surgical treatment strategies to treat back pain are based around the concept of a painful "black disc", or abnormal motion segment. Once the pain generator has been identified surgery may be an option. The exact treatment recommended will depend on the underlying cause of your back pain. Back pain due to spondylolisthesis will be treated differently to back pain due to degenerative disc disease. Treatments generally aim to stabilise a symptomatic lumbar motion segment, core to which is a degenerate lumbar disc. When this disc is removed, it is generally replaced with a fusion device or an artificial disc. Dr Oehme typically performs spinal fusion for back pain. Spinal fusion can be achieved by utilising a variety of different approaches.
See our spinal fusion page for more information about surgery for back pain. Dr Oehme is an expert in lumbar spinal fusion surgery to treat back pain and is happy to discuss options with you.
Feel free to contact our staff to arrange an appointment with Dr David Oehme who will provide expert assessment of you back pain.
Related Articles
References
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