We've got your back

Above photo: MRI scans showing a large sequestered disc (‘slipped disc’ in common parlance) causing back pain radiating down the lower limbs, numbness and difficulty in urinating.

Throughout history, humans have projected the spine as an allegory of strength and moral righteousness. Thus, we have expressions such as:

"A man can't ride your back unless it's bent." - Martin Luther King Jr

"Vocation is the spine of life." - Friedrich Nietzsche

"Spineless, savage, harpooning fish-eaters, incapable of any feeling of..." - King Triton, before being interrupted by Princess Ariel in the movie The Little Mermaid (1989)

The anatomic reality is that the human spine is truly a wondrous structure, displaying both strength, as well as flexibility. Made up of 33 individual building blocks of bone articulated with each other via intervening discs, the spinal column is a sinuously long column of mobile segments, distantly reminiscent of a millipede's body.

This bony column contains a hollow canal, which houses within it, the spinal cord - a leash of nerves that transmit signals between the brain and the rest of the body. These signals control movement, enable perception of senses like touch, pressure, pain and temperature, and regulate the internal environment of body organs like the heart, lungs and intestines.

It is no wonder then, that ancient man attributed much to the backbone.

In Greek mythology, the deity of medicine, Asclepius, wielded a serpent-entwined wooden staff, which represented the spine as the nerve centre of all psychic forces believed responsible for bodily functions.

The primordial Greek Titan, Atlas, who held the human world on his shoulders, lends his name to the topmost spinal bone segment holding up the human head.

For ages, yoga practitioners in India have paid emphasis to maintaining proper back posture for health purposes. In recent times, chiropractors believe that spinal instability, termed "subluxation", was responsible for a whole cartful of diseases, ranging from arthritis to diabetes and cancer.

Realisation of the importance of the spine in enabling motion and sensation was followed by the devising of techniques to treat back disease and injury.

Over 4,000 years ago, spine injuries were documented by Egyptian healers, who dutifully recorded such cases on illustrative papyri. Unfortunately, therapy methods were mostly of dubious value, what with attempting to treat spine injuries by wrapping the neck with slabs of meat, and pouring honey on the skin at intervals.

In 400BC, Hippocrates - widely considered to be the "Father of Medicine" - advocated splints and traction to treat spinal injury and deformity. Limited to the technology and anatomic knowledge of his time, some of his devices resembled medieval torture machines.

By AD1000, a breath of fresh air came in the form of Ibn Sina, the great Muslim physician, who described the functional neuroanatomy of the spine and the body in accurate detail. This enabled the development of practical devices to stabilise the backbone after injury or deforming diseases.

However, truly meaningful spine treatment had to sit it out until the discovery of antiseptics, radiological imaging and safe delivery of anaesthesia in the 19th and 20th centuries.

Prevalence of back pain

In 2010, the United States National Institutes of Health estimated that up to 85 per cent of all adults suffered from back pain at some time in their lives.

In Britain that same year, health authorities pointed at back pain as the major cause of absenteeism from work among British workers. Such symptoms have cost the United Kingdom an estimated 12 million lost hours annually.

An alarming trend was reported in the US where the national burden for complex spinal surgery rose 15-fold between 2002 and 2007, and tallied US$85bil (S$107.5bil), compared to the cost of combating cancer at US$89bil during the same period.

This rise is expected to continue (outpacing that of cancer treatment), and is caused by both the sheer number of patients suffering from spine disorders, as well as the high cost of spinal surgery.

The ubiquity of back-related symptoms can be backed by the observation that it affects the man who delivers your LPG cylinder tank and lugs 50-plus kilogramme weights everywhere, as much as the person having a sedentary occupation, brandishing only a pencil or a computer mouse for a living.

While we can understand why a hunched-up 80-year-old wheezing frailty with every breath may have back pain, we cannot comprehend why a 20-year-old strapping young man has excruciating pain when he is the epitome of physical fitness.

Occasionally, such symptoms take on a little more gravity when a spinal nerve is "pinched" by a "slipped disc", and treatment becomes more than just taking pills and going for therapy. No one, it seems, is immune to back pain and back-related diseases.

Frighteningly, there are other conditions where back pain is a harbinger of more ill things to come. Of late, spinal infections have increased in prevalence in the country. These infections sometimes carry on for months before breaking out into fever and general body malaise.

Nerves may get damaged by destroyed bone and collections of pus. Sometimes, tumours arising from other parts of the body may seed the spine with multiple colonies of tumour cells, all ready to devour bone and cause not only pain, but also instability and nerve compression, leading to paralysis.

Uncommonly, spinal deformities may worsen rapidly in the growing child, and may necessitate corrective surgery to prevent worsening of the condition.

The very term "back pain" itself may be misleading. Many spine-related conditions eventually end up with the sequel of a spinal nerve getting compressed, but the symptoms are wholly in the lower part of the body - the regions the harassed nerve is responsible for.

These symptoms could be pain and numbness in the thigh, heel or calf, or meander down the entire lower limb. The absence of any back pain makes it very difficult for the patient to accept the doctor's opinion that the spine is the culprit at all.

To back the diagnosis up, doctors often resort to imaging techniques like simple radiographs, or more costly modes like the magnetic resonance imaging (MRI) scan that renders the spine in exquisite detail. Bones, cerebrospinal fluid, discs and nerves can all be seen in fine detail in these scans.

Dr Oh Kim Soon is an orthopaedic spine surgeon in private practice, who is also associate professor and faculty advisor to two private medical colleges.

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