Back Pain
by Dr. Mo Lerner

drmo.gif - 6.86 K

Animals. That's what we are. And like our Simian relatives, the apes, we were meant to roam around, for the most part, on all fours. But once we stopped swinging in trees and came down to the ground we assumed a peculiar upright stance. This may bode well for standing room only at a major sporting event, but not for a lifetime of walking, lifting, and pulling. The spinal cord, a veritable extension of your brain, passes through a series of tiny holes in each vertebra until it reaches your lower back where tentacles of nerves carry messages to and from your limbs through yet tinier openings in the lower spine. Consider for a moment that the cord is the thickness of your thumb and the consistency of a scallop. It is easy to understand how even a little trauma or irritation to the spine that surrounds it can have painful and/or serious consequences.

The spinal column is like a stack of poker chips made of bone. Between each vertebra lies a rubber-like disc with a thick gelatinous center. These discs serve to both cushion the heavy load placed on the spine by body weight and gravity, and to prevent bone from rubbing directly on bone. Without disc cushions our bones would grind down to a powder. In fact, in many people-especially as they get older-the cushions weaken, the bones get closer together, and begin to crumble (Degenerative Osteoarthritis). It is also reasonable to expect that the more weight placed on the vertebral column, the greater the forces of gravity and the greater the potential for degeneration. This is why the medical profession places great emphasis on weight reduction for large patients with back problems.

But I often have to remind my well-meaning colleagues that being large can also paradoxically be beneficial since bones tend to remain denser and stronger if they carry more weight. This is why women and some men who are slight of build tend to suffer from Osteoporosis (osteo=bone, porosis=porous) which may lead to crumbling of the spine and the "hunched-over" posture one often sees in the elderly.

Back problems are second only to colds as a cause of absenteeism and runner up to headaches as a cause of pain. But they are second to none as the leading causes of work-related disability claims. Although back conditions are the primary cause for visits to my colleague Orthopedic Surgeons, many now refuse to see chronic back pain patients because of a generally poor permanent solution with any medical or surgical intervention.

80% of low back pain is mechanical which simply means that it is due to some stress or strain. This is a diagnosis which is commonly used when no anatomic or other overt defect is identifiable. Other more "tangible" causes of back pain include degeneration, tumors, inflammation, and infection.

STRAIN
People who notice the sensation of something pulling or giving way suddenly in their back after heavy lifting, twisting, pushing or bending often present with immediate onset of pain. This mechanical pain may be caused by a sudden stretching of the long elastic "bands" that actually hold the spine in place. People with back strain often have difficulty sitting still or finding any comfortable position for at least the first few hours after injury. It should also be noted that pain and stiffness may actually increase several hours later, as those of you who have been in minor auto accidents can attest to.

DEGENERATIVE DISC PROBLEMS
The disc cushions may get more brittle with time and the continued downward pounding of weight, work and gravity. With the vertebrae and cushions crumbling and weakening, the spaces between the bones narrows impinging on the delicate nerves which exit between them. Pinching of these nerves not only causes pain in the area but refers pain and even numbness and shooting or tingling pains to the areas of the leg supplied by these long nerves. Most people will notice an insidious progression of problems over several years although an exacerbation can seem sudden.

Sciatica (named for the Sciatic nerve which supplies most of the nervous function of the leg) is an often debilitating pain caused by disc encroachment. Pain is often noted all the way to the back of the foot and big toe. There might also be symptoms in the buttock, thigh, calf or ankle. Upright posture, standing and extremes of bending may cause pain. Many large people in their thirties and forties will notice this sort of discomfort and get relief only when they sit. Often a person tends to tilt to one side to avoid pressure on the nerve in question. Unfortunately, this can cause strain on a variety of muscles, ligaments and even feet. A vicious cycle of pain, spasm, and more pain ensues.

FACET JOINTS
If the vertebrae were just stacked one atop another they could tumble and collapse every time we bent over. Besides strong muscles and ligaments supporting the column, there are actually articulating joints between each pair of vertebrae to allow for flexibility of the trunk without total collapse. Time, wear, and tear can eat away at these Facet joints (from the French facette="face", referring to the small flat surface on a bone) which, unfortunately, lie adjacent to the gaps were nerves exit the column.

SPONDYLOLYSIS AND SPONDYLOLISTHESIS
Spondylo(Greek=vertebra/spine)-Lysis(Greek=dissolution), a gradual degeneration of the column usually as it joins with the pelvis, cannot just be blamed on continuous stress of obesity. In fact, many thin adolescent female athletes and young male football linemen suffer from this problem. It is possible that in some people minor fractures of the ring surrounding the delicate spinal cord and nerves in this area can eventually lead to a degenerative crumbling arthritis and minor slippage of the vertebra on top of each other.

If the slippage is more pronounced the defect is called Spondylolisthesis (from the Greek olisthanein= "to slip") in which case minor discomfort can become more constant. Often it begins with occasional pain and spasm in the back mostly due to stress on the muscles and tendons in the area which are trying to hold the joints in place.

In order to better understand the process of Spondylolisthesis try standing sideways in front of a mirror and look behind you at the area involved. It's in the "small" of the back, the fist-size valley in the center, just before the buttocks begin. Now imagine that valley suddenly enlarging and your abdomen lunging forward. Of course the process does not happen this quickly, however, if the forward slippage of one vertebra over another causes actual narrowing of the space that holds the spinal cord or nerves, or even if arthritis develops in the area after repeated spasm and bone degeneration, the pain will become relatively constant. Pain is usually worse when standing or walking and there is almost immediate relief when sitting or lying down. One may notice relief by leaning forward slightly in a sitting position.

INFECTION
Analogously, infections that might originate in the lungs, kidneys or any other bodily system, can spread to the spine. Osteomyelitis (from the Greek myeIo meaning marrow and itis=inflammation/infection) is often introduced locally from skin contagion especially near joints. Pain, redness, swelling and fever art often clues to infection of the spine. Of course, one of the most serious complications is spread of the infection to the spinal fluid which bates the brain causing Meningitis (from the Greek meningo referring to the membranes surrounding the brain).

SPONDYLOSIS AND SPONDYLITIS
Spondylosis (the suffix osis usually is a generic term meaning "condition" or "disease") is a non specific term describing the eventual crusty look and bending of the spine as seen on x-rays in older folks. Years of wear, tear, and arthritis take their toll. Older men are often seen limping in pain with this condition.

There are even problems with the back that may have a genetic or inherited component. Ankylosing (greek-"bent" or "crooked") Spondylitis (referring to inflammation of the spine) is a condition in which the spinal joints actually fuse as one ages. Young men are most often affected but in their early years, as the problem begins, they may only notice morning back stiffness. As the bones begin to fuse, all movements of the spine are difficult including taking a deep breath.

CANCER
A variety of tumors have a tendency to grow in the bone marrow of the spine. Benign tumors such as Hemangiomas( Heme= blood) associated with "strawberry-like" birth marks on the skin of the back can actually infiltrate underneath the surface to the bone and spinal cord producing pain.

Sometimes cancers of the bone, bone marrow, or blood start in the spinal area. This is understandable since essentially all blood products are manufactured in bone marrow.

Quite often cancer that originates in cryptic sites in the lungs (or virtually any other part of the body) makes its first appearance as back pain. This is because secondary tumors spread to the spine where pressure on the spinal cord or nerves cause patients to seek help.

BACK PAIN PROM OTHER SOURCES
Considering that nerves travel great distances in the body and that, embryologically, they often originate from areas a great distance from where they end up, the source of pain can often be confusing.

Abdominal and kidney problems are notorious for presenting as back ache. Kidney stones run a course from the kidney down a narrow tube in the back to the pelvis and ultimately out of the urethra. Most people assume at first that they must have "done something" to their backs.

When the major artery leading away from the heart-the aorta-is threatening to burst as a result of hardening of the arteries and/or high blood pressure, patients often feel a severe pain in the back.

A wide variety of abdominal and pelvic problems from constipation to serious bleeding can present as back ache.

DIAGNOSIS
Even with all the new technologies at our disposal, nothing replaces a thorough history and physical examination by a health care professional. Do not hesitate to describe anything new and unusual, no matter what part of the body you think it is coming from.

The diagnostician should examine you both lying and standing. You will be asked to touch your toes, stretch backward and slide your hand down both thighs. These maneuvers assess back motion. A good clinician will be feeling your back for evidence of spasm.

Leg and foot pulses, sensation ("tickling" and "needle poking") and motion tests are very important in assessing for nerve damage. One does not even have to suffer from arthritis, disc or bone damage-simple muscle spasm can squeeze the nerves causing pain and tingling

SPECIAL TESTS
Often, with mechanical stress pain, no special tests are required. X-rays of the back may reveal degenerative crumbling, fusion and/or narrowing of disc spaces of the spine. Even if the bones look normal individually, the spine may assume a stiff upright position from spasm. Normally the spine assumes a gentle curve. Muscle spasm and pain are the body's splinting system; a way of assuring that as little movement as possible takes place that might create more damage.

Computerized Tomography (CAT) Scans are simply a rapid sequence of x-rays pieced together by computer to give somewhat of a clearer view of tough-to-get-at spots in the spine.

Magnetic Resonance Imaging (MRI) Scans take advantage of minute differences in electrical activity of various tissues in the body and can be especially useful in creating "virtual reality" three dimensional pictures of many problems with the spine.

Electromyography measures the conduction of nerves in muscles and may be useful in detecting nerve and muscle damage in weakened areas.

Myelography involves injecting dye into the spinal fluid which outlines all the related structures on x-ray. Trapped nerves or impingement points in the spinal canal can be accurately pin-pointed this way.

WHAT CAN BE DONE
Most back problems are treated in the same fashion. If there is pain, stiffness and spasm, one does what the body is telling it to do. Initial rest in a comfortable position for a day or two is fine.

In the past, patients were almost universally advised to lie for extensive periods in a firm bed. We now know that early mobility is usually best. This is because movement increases blood flow which, in turn, speeds healing.

Heat over the affected areas also increases blood flow and provides soothing relief. A hot tub is ideal because it also decreases the stresses of gravity on the involved structures. A warm water bottle (notice I did not say hot water bottle) is effective but avoid use of electric heating pads. All too often people fall asleep with these devices on and we commonly treat people for serious burns.

Hot or cold liniments are helpful. Many contain forms of Aspirin which can be absorbed thought the skin. There are several products made from hot peppers (Capsaicin) that when applied to the skin produce a burning sensation. It is believed that local pain sensors art deactivated temporarily giving relief.

Anti-inflammatory analgesic agents have been a mainstay of therapy since Aspirin was introduced over a century ago (and likely in its primitive form centuries earlier).

The colloquial term NSAIDs, which stands for Non-Steroidal Anti-inflammatory Drugs, applies to a wide variety of modern agents that decrease pain associated with inflammation of joints and muscles. The major problem with most of these drugs including Salicylates (such as Aspirin) is that they also tend to break down the buffer system that protects the stomach. Ulcers and gastrointestinal bleeding are a serious and common complication, although there are new drug combinations that hold the promise of preventing such damage.

Acetaminophen, Opiates (such as Codeine) and Muscle Relaxants don't necessarily cause bleeding and do offer some relief. Even these agents, however, are not without there own potentially serious side effects, especially when used long term.

ALTERNATIVE THERAPIES
There is increasing support scientifically for "alternative" treatments including Massage Therapy, Acupuncture, Hypnosis, Psychotherapy, Antidepressants, Meditation, etc., for certain conditions. One must be open to a variety of culturally specific practices, many of which are time honored. Spinal Manipulation should only be attempted by a suitably trained and licensed health care professional and only in selected situations.

LIMITATIONS
Malignancies, congenital disorders, and crippling back problems obviously require special procedures.

Removal of degenerating discs and opening tight bony spaces were once commonplace procedures. Injecting herniated disc cushions with a kind of meat tenderizer is still occasionally practiced.

Although there are certain circumstances where surgery is an option, the end result is often disappointing. Nature and time still seem to have the upper hand in degenerative back and spine disorders.

Although cures for back pain are often not possible, physiotherapy, controlled exercise programs, ultrasound, TENS (Electrode nerve desensitization) and, of course, properly controlled and supervised exercise programs often make back ailments less debilitating.

Most importantly, let me reiterate in closing the most obvious caveat of all: Seek professional help and get as many opinions as you can before embarking on any treatment for your aching back. ß



Heretic Physician