Lower Back Pain

Lower back pain is one of the most common health problem. At least 75-80% people suffer from significant back pain requiring some sort of treatment in their lifetime. Low back pain or Lumbago is not a disease. It is a symptom of various disorders of vertebral bones, back muscles, spinal disc, spinal ligaments, spinal cord or occasionally, abdominal organs. Lower back pain can also get referred to hip area.

Reason of back pain:

• Spinal causes: Any disorder affecting tissues of spinal column can cause back pain.
  • Slip disc (Lumbar disc herniation)
  • Spinal stenosis
  • Lumbar spondylosis (disc degeneration, facet arthritis)
  • Spondylolysis
  • Spinal cord anomalies (tethered cord, diastematomyelia)
  • Spine deformity (scoliosis, kyphosis)
  • Vertebral pathologies: Fracture, infection, tuberculosis, tumors.
  • Osteoporosis
• Muscle spasm: Muscle spasm is most common cause of back pain. When there is a primary pathology in spine or nearby structures, muscles tighten to create an internal brace to support spine. Most of the time, acute pain of the primary pathology subsides with time; however, muscle spasm continues. This becomes a chronic source of pain.
• Patients with poor sitting posture, especially those who work in sitting position for long time are prone to muscle spasm.
• Spinal deformities cause uneven loading of muscles and may lead to back pain from overloading of one side of muscles.
• Heavy weight lifting or sports activities can cause muscle or ligament strain and pain the back.
• Abdominal pathologies: Various abdominal organs are located in the back side of abdomen (near spine), e.g. kidney, pancreas, uterus, ureter and urinary bladder etc. Any pathology involving these organs can lead to lower back pain.

Risk factor for lower back pain:

• Age: Older individuals are more affected by back pain due to spondylosis.
• Obesity: Overweight individual are prone to have back pain due to increased stress on muscles. These people also have more spinal degeneration which can also cause back pain.
• Lack of activity: Muscles get weaker when not used. They become painful with minimal stress.
• Heavy activities: People involved in heavy labor and sports activities have increased degeneration of spinal joints and ligament strain.
• Psychological stress: People with depression and anxiety suffer from back pain more often.
• Smoking: Smoking leads to osteoporosis. Smoking also reduces blood supply to disc and slows healing process.

Prevention of back pain:

All of us are going to have spinal degeneration with aging. Mild back pain is experienced by everyone at some or the other point in time. There are certain Dos and Don’ts which can help us in preventing back pain and to reduce it’s severity if we are already suffering.

• Regular exercises: Regular exercises will keep back muscles healthy. It will also increase blood flow to different spinal structures, especially disc, keeping them healthy. Exercises will also make vertebrae stronger. Exercise also help in maintaining correct posture and reducing muscle spasm. Yoga activities strengthen core muscles and stretch ligaments, making them less prone to damage.
• Weight reduction: Maintaining a healthy weight will not only reduce load on spine and back muscles, it will also reduce chances of developing many other illnesses, e.g. diabetes, hypertension.
• Quit smoking: If necessary, take doctor’s help.

Healthy Activities:

• Healthy sitting: We should not sit in same position for long time. A 5-10 minutes break should be taken after every 1.5-2.0 hours of sitting. A short walk and stretching is recommended for people involved in desk job. While sitting, back should be straight. Sitting on sofa will slouch your back. This puts excessive stress on lumbar discs. A hard/ firm surface is better to sit. While driving long distances, special care need to be taken. A pillow or folded towel behind the back will maintain normal lumbar spine curvature.
• Healthy standing: Do not slouch while standing. If you have to stand for long time, keeping one foot on stool will reduce muscle pull on lower back and pelvic muscles. Taking some support with hands will reduce load on lower back.
• Lifting: Lifting a heavy weight in forward bent position (e.g. taking luggage off conveyor belt at airport) is one of the worst activity for the back. It puts immense amount of pressure on spine and lumbar discs. We should bend our knees to lower the body to lift anything heavy. Keep the weight near your body to reduce lever arm effect. It will be better if heavy weight can be divided in multiple lighter weights for easy lifting.
• Healthy sleep: It is very important to have a sufficient and relaxing sleep for a healthy back. A firm mattress is recommended.
• Other activities: Do not get involved in very heavy weight lifting exercises. Driving requires it’s own set of precautions.

Treatment of back pain:

In majority of the patients, back pain is a self-limiting symptom. Following treatment can be taken at home for recent onset mild back-pain.

• Local application of heat/ cold
• Local application of analgesic gel
• Gentle massage can help
• Lumbar belt (if available) while sitting, standing, traveling
• Paracetamol or locally available pain killer
• Avoid heavy activities for few days

In 1-2 weeks, patients usually get significant relief. However, it is recommended to consult a spine specialist in following situations:

• Back pain not subsiding with above treatment (significant pathology)
• Back pain associated with sciatica (spinal nerve pressure)
• Back pain with loss of sensation/ weakness in legs/ urinary problems (spinal cord damage)
• Back pain with fever (infection)
• History of fall (suspected fracture)
• History of cancer (could be spine metastasis)

Spine specialist will examine the patient and will decide if further course of medicine and physiotherapy should be tried or patient need further investigations. Usually following medical treatment is given:

• Powerful pain medicines to reduce pain
• Muscle relaxant to reduce muscle spasm
• Nerve medicines (Pregabalin, Gabapantene etc.) if there is associated nerve related symptoms
• A physiotherapy is usually added to reduce muscle spasm and strengthen back muscles

If patient does not recover in a reasonable period of time, further investigations are required. Usually following tests are done.

• X-ray: It’s a baseline study to detect any bone abnormality.
• MRI Scan: MRI will assess internal structures of spine (disc, nerve, joints, ligaments etc.)
• CT Scan: A CT is required if detailed bone assessment is required.
• EMG NCV: These tests will assess functioning of the nerves.
• Blood tests: Various blood tests to detect infection, tumors, osteoporosis etc. are required based on suspected pathology.
• Other tests: DEXA scan (Osteoporosis), abdominal ultrasound (abdominal pathology), x-ray of knee/ hip joints.

If a significant pathology is detected in investigation, further treatment with spinal injection or surgery (decompression with/ without fusion) might be required based on the severity of the symptoms and patient’s recovery with non-surgical treatment.

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