Low back pain is one of the most common musculoskeletal ailments that afflict the population. Are you affected by back pain? In Februrary 2000, the Back Society of Singapore conducted a survey of 1,001 adults aged 15 years and above who were randomly selected and interviewed over the telephone.

The Back Survey showed that over the previous six months prior to the survey, 18% or one in five adults had suffered an episode of neck or back pain. Up to 50% of back pain sufferers had experienced an attack at least once a month or more frequently. Of those afflicted, 10% deemed it serious enough to have taken medical leave, 16% had sought help from a doctor and a further 4% had seen a specialist. Only 4% seeks specialist’s advise and that is a serious problem.

The magnitude of the problem is similar to that in other developed nations. In the United States, United Kingdom and Scandinavia, it is known that back and neck pain constitute one of the major causes of physical disability and is responsible for more visits to the doctor than any other medical condition except common cold.

Common conditions that present as backache

Musculo-ligament strain

Simple back strain is probably the most common cause of low back pain. The pain is usually mild and of limited duration, often improving with very little treatment or spontaneously within several hours or a day. Back strain is commonly seen in office workers who sit for many hours of the day and then develop a sore back after a long day.

Prolapsed intervertebral disc (PID)

Prolapsed intervertebral disc is one of the most common causes of recurrent back pain in adults between the ages of 20 to 50 years. The history is usually long standing. The pain is typically episodic and mechanical in nature, with long pain-free periods in between attacks. In the early stages, the pain may be localised to the back, but as the prolapse becomes progressively more severe, radicular symptoms may arise. Upper lumbar disc prolapses may present as groin discomfort or pain down the anterior thigh. Lower lumbar prolapses are sometimes associated with the typical sciatica in full-blown cases of root impingement, but in mild cases of root irritation, may present as just vague aching discomfort around the lower leg.

Lumbar spondylosis

Lumbar spondylosis describes the syndrome of disc degeneration coupled with loss of disc height, facet osteoarthritis, and osteophyte formation. The pain associated with lumbar spondylosis is typically facetal in nature, which is worsened on extension of the spine. Spondylotic pain tends to be chronic and may occur even on daily basis. The pain is typically worse in the mornings, and after prolonged standing or walking.

Spinal canal stenosis

Spinal canal stenosis is a condition in which part or all of the entire spinal canal stenosed. Symptomatic stenosis typically occurs in patients in the fifth to seventh decades of life. Degenerative spondylolisthesis has been found to be four times more common in women. Most patients report a long history of intermittent back pain with progressively leg symptoms, which are typically worsened by walking or standing and relieved by sitting or squatting. This is referred to as neurogenic claudication.

Isthmic spondylolisthesis

Isthimic spondylolisthesis occurs in approximately 5% of the population. Patients typically present with a long history of musculo-ligamentous strain, which eventually develops in many cases to eventual sciatica or neurogenic claudication as a result of progression of the spondylolisthesis.

Miscellaneous

There are of course many other causes of back pain, including ankylosing sponylitis, metastatic spine disease from cancers such as colon, breast and lung; primary tumours both benign and malignant; and spine infections such as tuberculosis. In such cases, the back pain tends to be more constant and progressive, and may be associated with other systemic symptoms.

Red flags

Certain symptoms are “red flags” and when present, early medical attention is advised.

  • Back pain that is constant rather than episodic, with no significant relief even at rest
  • Back pain that is aggravated by bending in all directions, rather than worsen in mainly one direction of movement
  • Severe pain localisable to a single spot or focus on the back
  • Pain that is progressively severe over days or weeks
  • Back pain associated with persistent “nerve pains”, ie, pains or sensations of numbness, pins and needles, aching in one or both legs, that do not go away even with rest or treatment
  • Symptoms of weakness of the legs, difficulty in walking, unsteady walking
  • Symptoms of bladder or bowel problems that are associated with the back pain, such as difficulty in passing urine, or incontinence
  • Whenever back pain is associated with general symptoms of poor health, eg, loss of appetite and weight, lethargy, fever and chills
  • Whenever there is a history of previous cancer

Management of low back pain

There are certainly many causes of low back pain, and even more treatments. Because most disorders of the spine – no matter severe or minor, ranging from cancer to a strained muscle – often present in the initial stage in the same manner, much confusion has arisen regarding the optimum treatment of back pain. Many patient drift from doctor to “sinseh” to friends, all looking for the ultimate cure, and the “cure” they often apprently find or are promised, are temporary at least, because many episodes of low back pain are self-remitting, sometimes without any intervention whatsoever from well-meaning friends or doctors, not unlike the common cold or “flu”. Unfortunately for many, these “cures” are all too transient, the pain returns to haunt them and faith is lost in the initial practitioner who claimed success for the cure.

Treatments available

Simple treatments such as bed rest (not more than 24 to 48 hours), application of heat or cold to the affected area, and application of local liniments should be effective in relieving most minor discomforts.

If pain persists beyond 24 to 48 hours, advice from the family physician or therapist should be sought.

For more severe or persistent pains, many effective treatments are available. We may prescribe various medication which are highly effective in reducing inflammation and pain or for muscle relaxation. Physiotherapy encompassing massage, mobilisation of the joints and manipulation is often very helpful in relieving pain.

Other physical therapy techniques such as traction are helpful in acute stage as well. Pain management techniques, including trigger point injections, facet blocks, nerve root injections and epidurals may often be valuable in relieving acute pain as well. In the recovery phase, attention has to be paid to increasing spinal flexibility and strength through stretching and conditioning exercises, and overall fitness may also have to be improved. This is important in reducing risk of recurrence of pain,which is especially frequent in the first six months following an acute episode.

When should spine surgery be considered?

In general, spine surgery is indicated for the following reasons:

  • When there is significant nerve injury present as a result of nerve compression, with the pressure of weakness, numbness, or impaired coordination in one or both limbs, such as walking with an unsteady gait
  • When there is severe or persisting pain as a result of nerve compression, that has not improved with conservative care, and that interferes with the patient’s activities to a significant degree.
  • When there is severe nerve compression and/or spine instability that may possibly lead to progressive neural injury in the future
  • When significant back pain is a result of nerve compression, or spinal instability such as spondylolisthesis, has not responded to conservative measures, and interferes with physical activities to a large degree.

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