Last week, in my column I discussed lower back pain due to problems in the vertebral body in addition to muscular and ligamental causes.
To summarise the causes of pain due to problems in the vertebral body:
1. Osteoporosis
2. Fractures
3. Malignancy
4. Infections
Osteoporosis and Fractures were discussed in detail in my last week’s column.
Malignancies such as multiple myeloma and secondary deposits due to malignancies in the body can cause severe lower back pain. LBP is associated with weight loss and all other features of the corresponding malignancy.
Infections such as Tuberculosis in the spine (especially in the vertebral body) can cause back pain. Back pain can be the only presenting symptom of the disease. Weight loss and fever may be associated with the back pain. X-rays, MRI and CT scans together with blood investigations will confirm the diagnosis.
Pain caused by disc problems
The commonest causes are disc degeneration, disc bulges and rarely disc fractures.
Disc bulges can take place over a period of time (chronic) and also suddenly (acute).
Acute disc bulges usually occur due to abrupt sudden movements of the spine and also pressure exerted by e.g. lifting heavy items. Awkward positioning of the spine during activities can also be a reason. Disc bulges can take place at any stage of life. The younger age group involved in sports can develop back pain due to disc bulges. Examples are, rugby players, cricketers, football players or for that matter any outdoor sportsmen are at risk. Most cricketers, especially, the fast bowlers have a tendency to develop back pain due to disc bulges. This is due to abrupt, forceful movement of the spine. I can think of a few world famous fast bowlers such as Imran Khan and Dennis Lillee developing major back problems during their career. These are well documented. They had to change their actions or slower the pace to avoid further damage to the spine. Sri Lankan players are not an exception. Due to confidentiality issues I would not discuss the issues about our cricketers as they have not been discussed openly.
Two famous sportsmen had problems with the back due to disc issues, Tiger Woods and Andy Murray. They both ended up with spinal surgery and their careers were never the same.
When discs are prolapsed it can press on the nerve roots forming the sciatic nerve. This symptom is commonly termed as sciatica. Pain shooting down the leg (one or both) is called radicular pain or sciatica in layman’s terms.
As I said before around 40 per cent of back pain can be due to disc bulges.
Treatment and management is challenging.
The most important thing is correct diagnosis. Symptoms will give a clue to the diagnosis and MRI scans will confirm the diagnosis.
Once the condition is diagnosed treatment is by:
A-Medication
Simple analgesics and opiates. Anti neuropathic medication if the disc prolapse is old leading to sensory issues.
B-Complimentary therapy
Physiotherapy
Hydrotherapy
Acupuncture
Reflexology
Exercise
C-Interventions under X ray guidance
Epidurals with an epidurogram.
Root blocks
Dorsal root ganglion blocks
Spinal cord stimulators
D-Surgery
Surgery should be the last resort but there is no guarantee that it will relieve back pain. Surgery can help leg pain.
As pain consultants we refer patients to the spinal surgeons for a surgical review.
E-Psychology
In chronic conditions psychological help may be necessary to help the patients cope with the pain Ex-CBT.
I refer patients to psychologists who are trained in pain management.
Spinal Cord Stimulator
A spinal cord stimulator is an implanted device that sends low levels of electricity directly into the spinal cord to relieve pain.
This article is written from Dr Namal Senasinghe’s personal experiences and nothing is copied other than some photos. Dr Senasinghe MBBS Dip in Pain Med FFARCS FFPMCA is a consultant in pain medicine with international experience. He lived and worked in U.K. for 25 years and opened the London Pain Management Centre at No. 31, Horton Place, Colombo 7, Sri Lanka on September 2, 2020. The occasion was graced by Prime Minister Mahinda Rajapaksa.