Back Pain

Back pain is an extremely common symptom in adults and is considered a normal part of life. 90% of people will experience back pain at some time in their lives but fortunately for the vast majority of people, this is a self limiting rather than a concerning feature.

Back and neck pain is itself a symptom rather than a true diagnosis of what is the cause of the symptoms and in patients that are experiencing troublesome symptoms, it is the role of the spinal surgeon to assess and diagnose what may be the cause of these symptoms. It is during this assessment that the surgeon will assess the likely cause and consider the likely progression of symptoms and then suggest an appropriate approach to managing those symptoms. As each person is different it is important to assess each persons symptoms considering the best management plan and it is not uncommon for this to be different depending on an individuals circumstances.

Causes of back pain

It is important to stress that most people will not have a concerning cause for their symptoms and so a full assessment with special investigations such as scans may not be necessary in everyone. In fact many people will have full resolution to their symptoms before presenting to a spinal surgeon and it is very unlikely that the is a serious condition underlying if symptoms resolve fully without intervention. With that in mind, the following conditions often present with back or neck pain with or without associated leg or arm pain.

Degenerative pain.

The normal aging process of the spine includes “wear and tear” changes to the mobile elements (discs and joints) of the spine and this when associated with pain is often referred to as degenerative neck or back pain. This tends to be self limiting but may recur or progress and tends to respond well to interventions such as osteopathy, chiropractic treatment and physiotherapy. The aims of these therapies is to manage the acute flare up of pain using manipulative or manual therapy and then reduce the likelihood of recurrence by starting a program of self performing exercises to strengthen the spinal musculature to support the spine and maintain as much movement in the spinal joints. No one program of exercises fits all but often protocols overlap and it is suggested always to tailor a program to best suite each patient. Pilates has become popular as a generic safe way of exercising the spine and a number of other programs are also useful.

Occasionally the pain does not settle despite this approach and a spinal surgeon will investigate things further and ascertain if there is an alternative cause as well as if simple injection therapy can aid the rehabilitation process ( see facet joint injections, nerve root blocks and rhizolysis) There are surgical options to consider which as specifically tailored to each condition.

Deformity as a cause of pain

Spinal deformity as a term covers a number of conditions including scoliosis, spondylolisthesis and buy far the most common, degenerative scoliosis. Not all of these conditions will present with any pain and often as they are asymptomatic may not need treatment at all. But some patients do have progression of their symptoms and relapses of pain and surgery may be considered if their pain persists.

Very often simple injections of steroid will control the symptoms, but surgery can be aimed at correcting the deformity, relieving and nerve compression and preventing progression of the deformity. The surgery may be performed at a single level or may involve multiple levels and is always considered a major form of surgery. There are a number of minimally invasive surgical options to be considered which can be helpful in aiding recovery and reducing the time spent in hospital but Mr Orpen will be able to advise you if any or these procedures are suitable for your specific condition.

Facet joint pain

This common condition responds well to physiotherapy/ osteopathy and chiropractic management. If these options fail, a set of facet joint injections of steroid may be performed as an outpatient or day case procedure under local anaesthetic. Denervation of the facet joints can be performed in a similar fashion for those that fail to have sustained benefit from facet joint injections

Discogenic back pain

This term refers to pain origination from the spinal discs and is a common source of both back pain and also associated leg pain/ radiculopathy. The pain from the disc commonly is worse on flexion and relieved by extension of the back and may be brought on by long periods of walking, standing or repeated lifting. Often it is relived by lying flat when all the stress is removed form the spine.

There are few injections that will improve these symptoms although nerve root blocks and epidural steroid injections are designed to place an anti-inflammatory around the disc and if there is an element of acute inflammation, these this will often improve symptoms. If symptoms are resistant to conservative options, surgery can be considered and this may involve a discectomy alone, and discectomy and stabilisation with a DIAM devise, fusion in the form of posterolateral fusion and interbody fusion, an anterior fusion ( ALIF) and Mr Orpen will also discuss if a disc replacement is an option to be considered.

The condition and cause of pain in these situations is very complex and surgery is seldom considered unless all other options have failed and symptoms are very disabling or severe.

Rare but concerning causes of back pain.

In a very small group of patients pain may be caused by fractures, infections and as a result of cancers. Each of these will be considered separately but as they are not common should not be the first thing to come to mind when evaluating back and neck pain. Doctors are trained to consider these conditons when evaluating back pian and so will usually have asked probing questions about the pain to evaluate whether the symptoms may suggest any of these conditions may be present.

Some of these questions are directed at so called red flag signs which are designed to remind practitioners and patients that don’t often treat spinal problems to be thinking about the possible underlying condition and even in themselves are not a clear indication that there is a problem. What they do suggest is that a second careful look is taken and appropriate investigations are performed to exclude more serious conditions.

These symptoms relating to back pain include:

• New onset back pain in children needs investigation as children seldom experience back pain and most of the conditions we commonly see occur exclusively in adults

• New onset pain in older patients particularly when occurring for the first time, after a stumble or fall, or that gives pain at night should be investigated further.

• Any patient that has a known history of a malignancy that develops back pain, should have this investigated

• If one feels unwell or has lost weight with the development of back pain, this should be investigated further

• Back pain that is associated with worsening neurology, should be investigated.

Most patients are better off initially seeing their family practitioner if any of these symptoms are present but if they feel further investigation is required should ask for a referral to a spinal surgeon. In the presence of these symptoms, Mr Orpen will ensure you are seen straight away.

Investigations in back pain evaluation

The most common investigation usually performed is an x-ray of the spine or neck taken in the position that brings on the most symptoms, this is usually therefore performed standing upright. X-rays are a useful way of assessing the spine as they can be performed in different positions such as standing, sitting, flexing forward or extending the neck or back. The are particularly aimed at looking at the bony elements of the spine and help to assess structure and mechanics which is useful as many of the causes of back pain are related to abnormalities of structure and how the bony elements relate to one another.

MRI scanning is an extremely useful investigation performed on the spine and is specifically aimed at looking at the neural elements and discs. It is typically performed lying flat and so does not give the best assessment of the spinal structure but can give some useful clues. MRI scanners are long tubes and therefore for scans of some parts of the body, the whole body enters the tube which may cause difficulty with patients that suffer from claustrophobia but this experience is typically less in an open scanner.

The Ridgeway Hospital has an open scanner which may be useful in these instances but image quality is not as good as a closed scanner and some scans cannot be performed in the open scanner. Mr Orpen will let you know if you scan can be performed in the open scanner or if a closed scan is recommended. If claustrophobia is a real difficulty, then we can prescribe sedative medication that some patients find very useful in making the scan more tolerable.

CT scans are sophisticated x-rays which involve computers to generate 3 dimensional views of the spine in great detail. They are also performed lying flat but also are useful in some conditions where very fine detailing is required. They are not requested in all patients but are used in some specific situations and in specific conditions.

Bone scans or bone scintograms are a nuclear imaging study often used to assess for malignancy and infection in the spine. SPECT CT scans are a combination bone scan and CT scan which can be used when trying to isolate a specific cause or source of pain when a number of potential causes exist. This is often useful when trying to plan very limited surgery in the presence of a number of degenerative findings on MRI scans and x-rays. These scans are seldom a first line option in working up back pain and Mr Orpen will specifically advise if this si the case.

Diagnostic injection procedures:

When trying to identify a pain source, a very useful technique is to inject local anaesthetic around the pain source to temporarily block the pain signals from that area. Often the injection itself may also cause some pain due to stimulation of the painful area. This local anaesthetic may be short working ( lignocaine- 30 min – 1 hour ) or long working ( marcaine 8-12 hours). Often this is mixed with a steroid which has a potentially long working therapeutic action as a long working anti-inflammatory agent. Nerve root blocks, facet joint injections and discograms are used in similar circumstances to aid the diagnosis in evaluating pain.

Summary

Evaluation of the many causes of back pain is typically performed using a combination of the above mentioned. This therefore involves taking a clear history to guide the examination which is then supported by a group of key investigations which may then be supported by some further diagnostic procedures to ensure the best judgement may be made in choosing a particular treatment. There are some conditions where this process will be short as early on in the process, the diagnosis will be very clear and also in other situations, a complex diagnosis may need a number of investigations before a clear plan may be formulated.