Diagnosing that pain in your back

The lower back is a complex structure composed of bones, ligaments, joints, fascia, discs and muscles. Pain can arise from any of these structures and pinpointing the exact source can sometimes be difficult.

Lower back pain is a very common problem, with about 80 per cent of the population facing back pain at some point in their lives. In about 23 per cent of cases, it becomes a longstanding problem, while in 5 per cent, it becomes disabling.

Low back pain is the second largest cause of work absence, after the common cold. The majority of low back pain cases is due to non-specific causes, and most resolve spontaneously.

On the other end of the spectrum, it could indicate serious problems with the lower spine. These are known as red flags, and point to causes such as cancer, infection, fracture, severe spinal nerve compression and aortic aneurysm.

Not all back pain originates in the lower back. In about 65 per cent of cases, the pain does come from the lower back, but about 25 per cent originate from the hip and sacroiliac joint, while in about 10 per cent of cases, the cause is unknown, even after extensive investigation.

Pain is a very subjective experience. A tolerable degree of pain for one person may be intolerable for someone else. Our lifestyles are different in terms of physical demands and work responsibilities. All these considerations need to be taken into account when approaching this problem.

The lower back is a complex structure composed of bones, ligaments, joints, fascia, discs and muscles. Pain can arise from any of these structures, and pinpointing the exact source can sometimes be difficult.

The intervertebral disc is a common source of pain. The discs function to give cushioning and support to the spine. Genetic studies have found defects with collagen and vitamin D receptors in cases of disc degeneration.

Environmental risk factors include lifting heavy loads, torsional stress and motor vehicle driving.

There is probably an interplay between the two factors, resulting in wear and tear of the disc. Cigarette smoking blocks the body's ability to deliver nutrients to the discs, increasing the risk of osteoporosis and resulting in delayed healing. This results in prolonged pain for people who have had back injuries, back surgery or broken bones.

The roots of back pain

There are five main causes of low back pain. A pinched nerve, also known as sciatica, is usually caused by a herniated or slipped disc. Pain may be myofascial in origin due to poor posture, prolonged sitting at a computer, or other job-related tasks.

A narrowing of the nerve openings, either around the spinal cord or nerve roots, can cause back and leg pain. This reduces the distance a person can walk.

Localised pain can arise when an area is stretched or its muscles overused.

Back arthritis can affect the joints, and result in stiffness and pain.

Back pain can be isolated to the lower back or associated with pain that radiates from the back to the buttocks and down into the leg.

There are various grades of disc wear and tear. Once a disc is abnormal, it will always be abnormal. That does not necessarily mean that it will continue to be painful. Often, a torn and painful disc improves with time.

Many individuals with abnormal discs seen on MRI scans have never experienced back or leg pain. If you have an acute onset of lower back pain and are diagnosed with lumbar disc degeneration, there is a good chance most of your symptoms will improve within a year.

A herniated disc can compress on the nerve root, causing sciatica. Depending on the nerves that are compressed, pain can be experienced at different locations. This is known as the dermatomal distribution.

The cause of an episode of localised back pain, on the other hand, is more difficult to pinpoint.

Pressure in the disc increases with sitting and this can worsen back pain. Lying down puts the least amount of pressure on the disc, so you might find relief from your pain in that position. To compound the problem, work requirements and one's psychosocial environment can interact and worsen the back pain.

Psychological factors can affect our experience of back pain and lead to worry, anxiety, and depression. Activity promotes healing and decreases disability.

Chronic back pain is a psychosomatic ("mind-body") condition. Dependence, depression and frustration may make the pain worse, whereas a positive attitude and a sense of independence may lessen the pain.

Diagnosing the problem

The root cause of pain can be deduced from the history of the pain, examination by a doctor, imaging of the lower back, and even using diagnostic injections.

Warning signs that warrant urgent medical evaluation include the presence of fever, worsening pain, progressive movement of the pain from the back into the leg, numbness down the leg, bowel or bladder incontinence, and pain that is unrelieved at rest or disturbs sleep.

The good news is that 90 per cent of people with acute low back pain recover within four to six weeks. The symptoms of pain can be addressed using painkillers, muscle relaxants, acupuncture, transcutaneous electrical stimulation, and heat or cold therapy.

Heat is comforting, and can help to relieve joint stiffness and muscle spasms. Cold is good for helping to reduce pain and swelling in sprains and strains.

Pain is merely a signal that something is wrong. Getting rid of the pain does not get rid of the source of the problem.

A regular exercise programme will help strengthen and keep your back flexible. This consists of flexion, extension, aerobic and stretching exercises.

Avoid exercises that require twisting or vigorous forward flexion, such as aerobic dancing and rowing, because these actions may raise pressure in the discs and actually do more harm than good. In addition, avoid high-impact activities if you have disc disease.

Keep in mind that stronger muscles will help reduce the risk of back injury. Proper lifting techniques and ergonomics at the workplace also play an important role in preventive measures.

In acute cases of low back pain, keep active and avoid prolonged bed rest and strenuous activity for six weeks.

Dealing with back pain

The aims in treating persistent and chronic back pain would be to ensure medical compliance, stress reduction and physical conditioning.

It is important (for self-esteem) to maintain some work role if possible, establish a clear role in the family, take on regular interpersonal duties, and maintain hobbies or personal interests.

Psychological approaches such as yoga, biofeedback and self-hypnosis are helpful in reducing chronic pain.

What is the outlook of back pain? Most non-specific back pains ease and go away quickly, usually within six weeks. However, once the pain has eased, it is common to have further bouts of pain (recurrences) from time to time in the future.

Also, it is common to have minor pains on and off for quite some time after an initial bad bout of pain. In a small number of cases, the pain persists for several months or longer.

A very small number of people will require back surgery. On average, only two in 100 will require surgery. Surgical candidates will include patients with:

● Progressive or severe neuromotor deficit (decrease in function of muscle motion), for example, foot drop or functional muscle weakness such as hip flexion weakness or quadriceps weakness.

● Persistent neuromotor deficit after six weeks of conservative treatment.

● Chronic sciatica with positive SLR (straight leg raise; an evaluation procedure in back pain to assess disc disease) for longer than four to six weeks.

● Uncontrolled and severe persistent pain.

● Cauda equina syndrome (disease of the nerve roots near the tail bone).

Finally, a note of advice is to stay active and return to normal activities as soon as possible, avoid worrying, and take steps to avoid strain and future back injuries. Take charge of your mindset, your condition and your own healing and recovery, and this will maximise your chances for reclaiming a healthy back as quickly as possible.

● Dr Eugene Wong is adjunct associate professor at the Perdana University Graduate School of Medicine. This article is contributed by The Star Health & Ageing Panel, which comprises a group of panellists who are not just opinion leaders in their respective fields of medical expertise, but have wide experience in medical health education for the public. The members of the panel include: Datuk Prof Dr Tan Hui Meng, consultant urologist; Dr Yap Piang Kian, consultant endocrinologist; Datuk Dr Azhari Rosman, consultant cardiologist; A/Prof Dr Philip Poi, consultant geriatrician; Dr Hew Fen Lee, consultant endocrinologist; Prof Dr Low Wah Yun, psychologist; Datuk Dr Nor Ashikin Mokhtar, consultant obstetrician and gynaecologist; Dr Lee Moon Keen, consultant neurologist; Dr Ting Hoon Chin, consultant dermatologist; Prof Khoo Ee Ming, primary care physician; Dr Ng Soo Chin, consultant haematologist. For more information, e-mail starhealth@thestar.com.my. The Star Health & Ageing Advisory Panel provides this information for educational and communication purposes only and it should not be construed as personal medical advice. Information published in this article is not intended to replace, supplant or augment a consultation with a health professional regarding the reader's own medical care. The Star Health & Ageing Advisory Panel disclaims any and all liability for injury or other damages that could result from use of the information obtained from this article.

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