LOW BACK PAIN – II

     Last week’s column dealt with muscle strain which is the most common cause of back pain.  Treatment of this problem is always conservative with rest, pain relievers and warm packs.  But there are other more serious problems with some people who have low back pain.

     The lady came to the clinic because of worsening back pain when she tried to walk.  She indicated that she used to be able to walk through the mall without difficulty.  Now she described having to stop and rest after walking by 3-4 stores in the mall.  When she sat down to rest, the pain would go away in a matter of minutes and then she could walk a little further before the problem recurred.  She said that if she tried to keep walking, her pain problem would become intolerable.  She had tried over the counter Ibuprofen, Naprosyn and Aspirin but they had not really corrected her problem.  She came to the doctor because now, in addition to the problem of the back pain, her legs were becoming weak and she felt that she wasn’t walking in a normal manner.  There was no event that seemed to cause the problem, it just simply seemed to fade in.

     After a number of tests and x-rays were done, it turned out that she had a condition called “spinal stenosis”.  This means that the canal that carries the spinal cord from the brain down the back has become too narrow and is pinching the spinal cord itself.  I explained this to the lady and she wanted to know what could be done.  She was told that the problem comes basically from arthritis on the spinal canal.  If you can imagine how some people have little nubbins grow on their fingers near the joints, these same kind of outgrowths of bones can grow on the inside of the spinal canal and pinch the spinal cord.  When this occurs initially, the person will have pain in her back. Then as the problem gets worse the motor tracks of the spine that carry nerves controlling the muscles of the legs also are affected.  When this occurs, the person’s walk begins to change becoming weak and unsteady.  She was told that this condition could be treated with pain meds and rest, perhaps, but the real treatment unfortunately was surgical.  She was referred to the neurosurgeon who carried out a procedure called a decompression laminectomy which completed relieved her pain and restored her gait to normal. This is a predictable result in 80% of the people who are treated surgically for this condition.

     The next group of people with low back pain are exemplified by a 54 yr old gentleman who went out to shovel snow.  He no sooner got the driveway cleared and the city snowplow came by and filled his driveway back in with 3 feet of slushy, wet snow.  He then shoveled that heavier, slushy wet snow out of the driveway.  He did finish the job but recalls having severe back pain near the end of the endeavor.  On this occasion the pain was located in the low back and radiated down his left leg on the outside of the leg past the knee.  When pain radiates into the leg like that it is called “radicular pain”.  This means that the pain is coming from a “ruptured disk”.  Between each vertebra is a vertebral disk that is very much like a jelly donut.  It is a cushion that protects one vertebra from the next one.  Normally these disks are alternatively squashed and stretched as a person bends over or stands up and extends their back.  The weakest point of the jelly donut is on the part next to the spinal canal.  If one squashes this jelly donut too tightly, it will pop and the jelly will squirt out onto the nerves coming out of the back.  The irritation of the nerve right there in the back makes it feel like something is wrong with the person’s leg even though the person’s leg is completely normal.  This type of injury occurs in situations such as the gentleman above or in the example of somebody bending over to pull a large weed out of the ground or a tent peg out of the ground.  As they pull very hard, all of a sudden they will have excruciating, disabling pain in their back that shoots down one leg.  That is right when they rupture the disk.  This type of back pain can be treated conservatively without surgery.  If the person avoids the activity that caused the problem often the disc will be resorbed and the pain resolve without any surgery.  If the problem does not clear spontaneously over the course of several weeks and the pain is persistent with associated weakness in the leg, then surgery might be an indicated step.  With today’s microsurgical techniques the neurosurgeons are remarkably slick in getting the jelly disk-like material out of the back and alleviating the pain and disability.

     So far we have talked about muscle strain, spinal stenosis, and ruptured disks.  Another form of low back pain is called “facet joint arthritis”.  The vertebral bones in the spine are held together by a pair of hinges on each side. These let the person bend over and twist from side to side as normally can be done.  In older individuals, arthritis can develop in these joints very much as it develops in the knees, hips, or shoulders.  Facet joint arthritis can be very frustrating but is treated like any other type of arthritis.  The use of Ibuprofen or Aleve or the more recently released arthritis medicines is some help.  Rest and avoidance of aggravating activity are also important.

     The last form of low back pain is that which occurs when one of the bones is broken.  One of the most common problems we see in the elderly is called a “compression fracture”.  A compression fracture is what happens when the load on one of the vertebral bones becomes so big that the bone will no longer hold it up and it virtually gets squashed. Almost always this is due to osteoporosis that occurs with age and demineralization of bone.  The best treatment for this is prevention by getting adequate calcium and something to slow bone erosion.  In today’s world there is a new treatment by which a plastic material is injected into the collapsed bone area to rebuild the bone and re-establish an erect posture.  In my experience this has been highly successful with several people that have had this more recent type of treatment done.

     Rarely, cancer metastases into the bones of the spine occur and is the cause of low back pain and compression fractures.  This is a very difficult problem and needs to be treated in the context of the whole person and their tumor.

     The healthcare providers at your local clinics are well versed in both the diagnosis and treatment of low back pain problems.  This is one of the most common complaints presented at the clinic.  Those problems that can be dealt with conservatively using rest and medication and local application of heat do not require surgical intervention.  Those problems that require a disk removal or relief of spinal stenosis or re-expansion of a compression fracture require referral on to a specialist after diagnosis.  Chiropractic treatment is often helpful unless there is a significant organic lesion such as spinal stenosis, ruptured disk, or cancer metastasis, or compression fracture.