Back pain

Degenerative disc disease

Facet joint degeneration

 

 

Intervertebral disc herniation and sciatica

Spinal canal stenosis

Spondylolisthesis

BACK PAIN:

Back pain is a very common symptom. It affects more than 80% of people at some stage of their lives. Fortunately, most back pain resolves spontaneously without the need for surgical intervention.

The most common sort of back pain is what is known as “simple” or “mechanical” back pain. The exact source is often unidentifiable and is usually attributed to muscular pain. This usually resolves within days to weeks. Some useful adjuncts that can be helpful in the initial treatment of back pain is physiotherapy, back muscle strengthening, stretching exercises, core strengthening and life style modification (quitting smoking, avoid prolonged periods of sitting, awareness of one’s posture).

Chronic back pain tends to last for longer than three months and this might be due to an underlying spinal condition. These conditions are best investigated by an MRI scan. These conditions include:

  • Degenerative disc disease
  • Facet joint degeneration
  • Intervertebral disc herniation
  • Spinal canal stenosis
  • Spondylolisthesis
  • Spinal deformity
  • Inflammatory spondylitis
  • Spinal trauma, infections and tumours
  • Pathology outside the spine


Some of these conditions can be serious and warrant an urgent attention. Clinicians look for the “Red Flags” to help them determine whether this pain is due to a serious underlying condition.

Red Flags:

  • Age under 16 or over 50 with new onset pain
  • Feeling unwell, unexplained weight loss
  • Unexplained fevers
  • Past history of cancer or recent serious illness
  • Pain in the thoracic region of the spine
  • Widespread neurological deficit e.g. weakness in the limbs, bladder/bowel dysfunction
  • Pain that is non-mechanical (not related to movement, occurs at rest)
  • Pain that is worse at night
  • New onset spine deformity
  • History of significant trauma
  • Failure to improve with treatment


Red Flags necessitate urgent consultation with a spinal surgeon and an MRI scan on an urgent basis.

DEGENERATIVE DISC DISEASE:

Overview: As a person grows older, the soft disc between the vertebrae becomes stiffer. This is part of the normal aging process. By the age of 50, 90% of the population would show evidence of disc degeneration on an MRI scan. However, not all people with disc degeneration would complain of back pain. Research has suggested that the main factor leading to disc degeneration is genetic. Other factors include obesity, smoking, and prolonged periods of driving. Clinical Picture: Typically, degenerative disc pain is made worse by sitting and activities that involve forward bending. It can also be worsened by coughing, sneezing or straining. There is also a strong element of associated muscle spasms. The symptoms tend to resolve gradually and can recur periodically, often arising for no particular reason.  
Treatment: The mainstay treatment for degenerative disc disease is non-operative. Helpful modalities are physiotherapy, back muscle strengthening, core stability, stretching exercises and pain killers. Some people find osteopathy, chiropractic treatments and acupuncture also helpful. Surgery for back pain is not really recommended and its results are unpredictable.

FACET JOINT DEGENERATION:

Overview: Facet joints are the joints at the back of the spine connecting each vertebra with the vertebra above and below. These can develop arthritis similar to the hip and knee joints.

Clinical Picture: Facet joint pain is typically made worse by activities such as bending backwards, standing, reaching upwards or walking down stairs or hills. Unlike degenerative disc pain, bending forwards takes the pressure of the joints and improves the pain.

Treatment:
  • Non-operative measures: Always the first line of treatment. This includes physiotherapy, back muscle strengthening, core stability, stretching exercises and pain killers, osteopathy, chiropractic treatments, massage and acupuncture
  • Injections: Radiology-guided injections of local anaesthetic and steroids
  • Facet joint ablation: If the pain improves with injections but comes back, ablation of the nerve supply to these arthritic joints can provide longer pain relief.

INTERVERTEBRAL DISC HERNIATION AND SCIATICA:

Overview: Disc prolapse, frequently known as a slipped disc, is very common. A small tear in the outer tough layer of the disc can allow a portion of the central jelly-like disc material to escape out. This prolapsed disc can press on the spinal nerves causing inflammation and irritation to these nerves.

Clinical Picture:

  • Back pain
  • Leg pain, usually referred to as sciatica. This pain starts at the back of the hip area and radiates down the leg. Patients usually describe this pain as sharp shooting electric-like pain or burning pain down the leg
  • Leg numbness
  • Weakness
  • Cauda equine syndrome. This is a rare but serious condition.
Treatment:
  • Non-operative measures: pain killers, physiotherapy, chiropractic treatments, osteopathy and massage therapy usually help. By three months, around 85% of patients would have improved. Studies have shown that the prolapsed disc reduces in size over time spontaneously.
  • Nerve root injections: This is a mixture of steroids and local anaesthetic, injected around the compressed nerve root in the back. This settles the inflammation and reduces the pain. This is a simple procedure with minimal risks. However, the duration of pain relief is unpredictable.
  • Surgery: This is to excise and remove the bulging part of the disc. This is 80-90% successful in providing significant improvement in the leg pain. However, like with any surgery, there are risks associated. This can be discussed in details during the consultation.

SPINAL CANAL STENOSIS:

Overview: This is a condition in which the diameter of the spinal canal reduces over time, leading to reduction in the space available for the nerves. This is usually due to progressive degeneration in the spine. The nerves in the spinal canal are surrounded by the disc at the front, the facet joints on the sides and a ligament called ligamentum flavum from behind. As the spine degenerates, the disc itself starts to wear out and bulges toward the nerves, the facet joints overgrow into the spinal canal and the ligament becomes thickened and buckles inwards. All these changes cause narrowing of the spinal canal, hence strangling the nerves.

Clinical Picture: Spinal stenosis typically gives patients back pain as well as leg symptoms.

  • Back pain is usually because of the underlying wear and tear in the spine
  • Leg symptoms as a result of spinal canal stenosis are referred to as neurogenic claudications. These symptoms are usually described by patients as:
    • Progressive leg heaviness, cramps or pain when walking or standing.
    • Pain usually starts in the buttocks then moves down to the thighs, calves and feet.
    • Pain forces them to stop or sit down for a bit before they can start walking again.
    • Waking distance reduces gradually after each time they stop.
    • Pain improves a bit by leaning forward (on shopping trolleys for example)
  • While bladder and bowel dysfunction can occur, luckily this is uncommon.
Treatment: The natural history of spinal stenosis symptoms is that 1/3 of patients improve, 1/3 remains static and 1/3 gradually deteriorates over time.
  • Non-operative measures: should always be tried first. Pain killers and physiotherapy can help controlling the symptoms.
  • Nerve root injections: This is a mixture of steroids and local anaesthetic, injected around the compressed nerve root in the back. This settles the inflammation and reduces the pain. This is a simple procedure with minimal risks. However, the duration of pain relief is unpredictable.
  • Surgery: This is to remove any structure compressing the nerves and to widen the spinal canal. This is 80% successful in providing significant improvement in the leg pain. However, like with any surgery, there are risks associated. This can be discussed in details during the consultation.

SPONDYLOLISTHESIS:

Overview: This is a term to describe the forward slippage of one vertebra on another. The normal alignment of the vertebrae in relation to one another is maintained normally by the integrity of the intervertebral discs and joints, as well as the bony structures that form the back of the spine. Hence, two common types of spondylolisthesis exist; degenerative and lytic. In the degenerative type, as the disc and facet joints degenerate, they lose their ability to support the spine. In the lytic type, there is a defect in part of the bone at the back of the spine, which affects its stability.

Clinical Picture:

  • Back pain. This is because of the degeneration as well as the abnormal movement / position of the spine. Pain is worse in certain positions.
  • Leg pain and sciatica. This is because of pinching the nerves in the spinal canal or as they exit the spine in the neural foramens.
  • Sensory deficit and / or motor weakness are usually indicative of a progressive pathology.


Treatment: Treatment is aimed at relieving the symptoms.

  • Non-operative measures: should always be tried first. Pain killers and physiotherapy can help controlling the symptoms.
  • Nerve root injections: This is a mixture of steroids and local anaesthetic, injected around the compressed nerve root in the back. This settles the inflammation and reduces the pain. This is a simple procedure with minimal risks. However, the duration of pain relief is unpredictable.
  • Surgery: Surgery is only indicated in progressive conditions, or cases of persistent symptoms despite non-surgical treatments. Nerve decompression surgery is successful. However, decompression alone might risk worsening of the slippage of the vertebra. Hence, surgeons tend to add a fusion procedure to restore the alignment and reduce the risk of worsening the slippage. Fusion is done by using metal screws, rods and a spacer to replace the worn out disc. But in turn, this increases the risk of surgical complications. This can be discussed in details during the consultation.