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Lower back pain is one of the main reasons Singaporean visit their doctor. For adults over 40, it ranks third as a cause for doctor visits, after heart disease and arthritis. Eighty percent of people will have low back pain at some point in their lives. And nearly everyone who has low back pain once will have it again.
Very few people who feel pain in their lower back have a serious medical problem. Ninety percent of people who experience low back pain for the first time get better in two to six weeks. Only rarely do people with low back pain develop chronic back problems.
With these facts in mind, you can be assured that back pain is common, that it usually only causes problems for a short period of time, and that you can take steps to ease symptoms and prevent future problems.
Symptoms of Lower Back Pain:
- The pain may radiate down the front, side, or back of your leg, or it may be confined to the low back
- The pain may become worse with activity.
- Occasionally, the pain may be worse at night or with prolonged sitting such as on a long car trip.
- You may have numbness or weakness in the part of the leg that receives its nerve supply from a compressed nerve.
- An example of this would be an inability to plantar flex the foot. This means you would be unable to stand on your toes or bring your foot downward. This occurs when the first sacral nerve is compressed or injured.
- Another example would be the inability to raise your big toe upward. This results when the fifth lumbar nerve is compromised.
Causes of Low Back Pain
Why do I have low back pain?
There are many causes of low back pain. Doctors are not always able to pinpoint the source of a patient’s pain. But our doctor will make every effort to ensure that your symptoms are not from a serious medical cause, such as cancer or a spinal infection.
The vast majority of back problems are a result of wear and tear on the parts of the spine over many years. This process is called degeneration. Over time, the normal process of aging can result in degenerative changes in all parts of the spine.
Injuries to the spine, such as a fracture or injury to the disc, can make the changes happen even faster. There is strong evidence that cigarette smoking also speeds up degeneration of the spine. Scientists have found links among family members, showing that genetics plays a role in how fast these changes occur.
The intervertebral disc changes over time. At first, the disc is spongy and firm. The nucleus in the center of the disc contains a great deal of water. This gives the disc its ability to absorb shock and protect the spine from heavy and repeated forces.
The first change that occurs is that the annulus around the nucleus weakens and begins to develop small cracks and tears. The body tries to heal the cracks with scar tissue. But scar tissue is not as strong as the tissue it replaces. The torn annulus can be a source of pain for two reasons. First, there are pain sensors in the outer rim of the annulus. They signal a painful response when the tear reaches the outer edge of the annulus. Second, like injuries to other tissues in the body, a tear in the annulus can cause pain due to inflammation.
With time, the disc begins to lose water, causing it to lose some of its fullness and height. As a result, the vertebrae begin to move closer together.
As the disc continues to degenerate, the space between the vertebrae shrinks. This compresses the facet joints along the back of the spinal column. As these joints are forced together, extra pressure builds on the articular cartilage on the surface of the facet joints. This extra pressure can damage the facet joints. Over time, this may lead to arthritis in the facet joints.
These degenerative changes in the disc, facet joints, and ligaments cause the spinal segment to become loose and unstable. The extra movement causes even more wear and tear on the spine. As a result, more and larger tears occur in the annulus.
Mechanical and Neurogenic Pain
To best understand the cause of your pain, spine specialists sometimes divide low back pain into two categories:
- mechanical pain – caused by wear and tear in the parts of lumbar spine.
- neurogenic pain – occurs when spinal nerves are inflamed, squeezed or pinched.
The effects of spine degeneration or back injury can lead to specific spine conditions. These include
- annular tears
- internal disc disruption
- herniated disc
- facet joint arthritis
- segmental instability
- spinal stenosis
- foraminal stenosis
What are some of the symptoms of low back problems?
Symptoms from low back problems vary. They depend on a person’s condition and which structures are affected. Some of the more common symptoms of low back problems are
- low back pain
- pain spreading into the buttocks and thighs
- pain radiating from the buttock to the foot
- back stiffness and reduced range of motion
- muscle weakness in the hip, thigh, leg, or foot
- sensory changes (numbness, prickling, or tingling) in the leg, foot, or toes
Rarely, symptoms involve changes in bowel or bladder function. A large disc herniation that pushes straight back into the spinal canal can put pressure on the nerves that go to the bowels and bladder. The pressure may cause symptoms of low back pain, pain running down the back of both legs, and numbness or tingling between the legs in the area you would contact if you were seated on a saddle. The pressure on the nerves can cause a loss of control in the bowels or bladder.
If the pressure isn’t relieved, it can lead to permanent paralysis of the bowels and bladder. This condition is called cauda equina syndrome. Doctors recommend immediate surgery to remove pressure from the nerves.
How will my doctor find out what’s causing my problem?
The diagnosis of low back problems begins with a thorough history of your condition. You might be asked to fill out a questionnaire describing your back problems. Our doctor will ask you questions to find out when you first started having problems, what makes your symptoms worse or better, and how the symptoms affect your daily activity. Your answers will help guide the physical examination.
Our doctor will then physically examine the muscles and joints of your low back. It is important that our doctor see how your back is aligned, how it moves, and exactly where it hurts.
Our doctor may do some simple tests to check the function of the nerves. These tests are used to measure the strength in your lower limbs, check your reflexes, and determine whether you have numbness in your legs or feet.
The information from your medical history and physical examination will help our doctor decide which further tests to run. The tests give different types of information.
Radiological imaging tests help your doctor see the anatomy of your spine. There are several kinds of imaging tests that are commonly used.
X-rays show problems with bones, such as infection, bone tumors, or fractures. X-rays of the spine also can give your doctor information about how much degeneration has occurred in the spine, such as the amount of space in the neural foramina and between the discs. X-rays are usually the first test ordered before any of the more specialized tests.
The magnetic resonance imaging (MRI) scan uses magnetic waves to create pictures of the lumbar spine in slices. The MRI scan shows the lumbar spine bones as well as the soft tissue structures such as the discs, joints, and nerves. MRI scans are painless and don’t require needles or dye. The MRI scan has become the most common test to look at the lumbar spine after X-rays have been taken.
What can be done to relieve my symptoms?
Ninety percent of people who experience low back pain for the first time get better in two to six weeks without any treatment at all. Patients often do best when encouraged to stay active and to get back to normal activities as soon as possible, even if there is still some pain. The pain may not go away completely. One goal of treatment is to help you find ways to control the pain and allow you to continue to do your normal activities.
Whenever possible, doctors prefer to use treatments other than surgery. The first goal of these nonsurgical treatments is to ease your pain and other symptoms.
In cases of severe pain, doctors may suggest a short period of bed rest, usually no more than two days. Lying on your back can take pressure off sore discs and nerves. Most doctors advise against strict bed rest and prefer that patients do ordinary activities using pain to gauge how much is too much.
A back support belt is sometimes recommended when back pain first strikes. It can help provide support and lower the pressure inside a problem disc. Patients are encouraged to gradually discontinue wearing the support belt over a period of two to four days. Otherwise, back muscles begin to rely on the belt and start to shrink (atrophy).
Many different types of medications are typically prescribed to help gain control of the symptoms of low back pain. There is no medication that will cure low back pain. Medications are prescribed to help with sleep disturbances and to help control pain, inflammation, and muscle spasm.
Physical Therapy and Exercise
In addition to other nonsurgical treatments, doctors often ask their patients to work with a physical therapist. Therapy treatments focus on relieving pain, improving back movement, and fostering healthy posture. A therapist can design a rehabilitation program to address a particular condition and to help the patient prevent future problems. There is a great deal of scientific proof that exercise and increased overall fitness reduce the risk of developing back pain and can improve the symptoms of back pain once it begins.
Spinal injections are used for both treatment and diagnostic purposes. There are several different types of spinal injections that your doctor may suggest.
Some injections are more difficult to perform and require the use of a fluoroscope. A fluoroscope is a special type of X-ray that allows the doctor to see an X-ray picture continuously on a TV screen. The fluoroscope is used to guide the needle into the correct place before the injection is given.
Only rarely is lumbar spine surgery scheduled right away. Our doctor may suggest immediate surgery if you are losing control of your bowels and bladder or if your muscles are becoming weaker very rapidly.
For other conditions, doctors prefer to try nonsurgical treatments for a minimum of three months before considering surgery. Most people with back pain tend to get better, not worse. Even people who have degenerative spine changes tend to gradually improve with time. Only one to three percent of patients with degenerative lumbar conditions typically require surgery. Surgery may be suggested when severe pain is not improving.
There are many different operations for back pain. The goal of nearly all spine operations is to remove pressure from the nerves of the spine, stop excessive motion between two or more vertebrae, or both. The type of surgery that is best depends on that patient’s conditions and symptoms.
The lamina is the covering layer of the bony ring of the spinal canal. It forms a roof-like structure over the back of the spinal column. When the nerves in the spinal canal are being squeezed by a herniated disc or from bone spurs pushing into the canal, a laminectomy removes part or all of the lamina to release pressure on the spinal nerves.
When the intervertebral disc has ruptured, the portion that has ruptured into the spinal canal may put pressure on the nerve roots. This may cause pain, weakness, and numbness that radiates into one or both legs. The operation to remove the portion of the disc that is pressing on the nerve roots is called a discectomy. This operation is performed through an incision in the low back immediately over the disc that has ruptured.
Many spine surgeons now perform discectomy procedures that require only small incisions in the low back (minimally invasive). The advantage of these minimally invasive procedures is less damage to the muscles of the back and a quicker recovery. Many surgeons are now performing minimally invasive discectomy as an outpatient procedure.
Read more about Microdiscectomy or Microdecompression Surgery
What should I expect after treatment?
For acute back pain, you may be prescribed two to four weeks of physical therapy. You might need to continue therapy for two to four months for chronic back problems. Treatments are designed to ease pain and to improve your mobility, strength, posture, and function. You’ll also learn how to control your symptoms and how to protect your spine for the years ahead.
Read more about Prevention of Lower Back Pain
Read more about Back Problems
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