What is causing your back pain?
Lower (or lumbar) back pain is a very common problem. The vast majority of adults will suffer from it at some stage during their lifetime. The majority of symptoms are due to simple or mechanical back pain that will resolve within a few weeks of onset with appropriate physical therapy and pain medications. The source of pain emanates from the muscles, joints, discs and ligaments of the spine. This is usually managed by the general practitioner and local physiotherapist, without requiring the advice of a spinal specialist.
In a minority of patients, the pain may not respond to these simple measures and this may benefit from further investigation and treatment.
Is your back pain serious?
Very occasionally, back pain can be related to serious underlying problem such as infection, tumours or fractures. Patients with these problems may exhibit features of ‘non mechanical’ back pain whereby the pain is constant and unrelated to increased activity. The so called, ‘Red Flag Signs’ are used to help identify people who may have one of these causes for their back pain. These RED Flag Signs include:
- Non mechanical back pain
- Age at first presentation under 20 years of age or over 50 years
- Thoracic Back pain
- Past medical history including: Carcinoma, Steroids, HIV infection and Intravenous drug abuse.
Do You need to see a spinal surgeon?
If the back pain becomes persistent or a patient has red flag signs then further assessment by a spinal specialist and investigation of the spine may be required. When indicated a referral to a Spinal Specialist can be arranged by the patient’s General Practitioner, within the NHS this usually will involve seeing a spinal physiotherapist initially and then review by the specialist when required.
Following appropriate assessment by the spinal specialist, further investigations may be required. MRI scans are commonly used to investigate the spine although other tests such as X-rays or CT scans may also be used. MRI scans of the lumbar spine are extremely sensitive. Scans may show changes that are due to natural aging of the spinal column, with almost everyone having such changes on their scan in middle age. These changes do not indicate disease and may not be the cause of the pain. Incorrectly attributing these symptoms to a normal age related change on the MRI scan could lead to inappropriate treatment. MRI scans are extremely sensitive at identifying or excluding serious causes of back pain.
What treatment do You need?
Treatment options then depend upon the severity and duration of the symptoms as well as the underlying cause. Changes seen include facet joint arthritis, degenerative disc disease and spondylolisthesis. Treatment options then fall into the following four main categories.
Many people get relief with over the counter medications such as paracetamol and nonsteroidal anti-inflammatory drugs (NSAIDs), such as ibuprofen or naproxen. NSAIDs can be very effective in reducing the inflammation of structures in the back and improve your symptoms. NSAIDs are not suitable for everyone , especially if you have a history of asthma, high blood pressure, kidney failure or stomach ulcers.
Muscle relaxant can be added for spasms.
If the pain is severe then narcotic pain killers can be considered but only for short periods of time as there is a risk of addiction and dependence if used incorrectly.
Physical or manual therapy
Performed by physiotherapists, chiropractors or osteopaths the vast majority of patients will improve with these treatments.
The source of the pain may be the degenerate discs or the facet joints. Under these circumstances the pain may be improved by and epidural injection or facet joint injections. See Injection Therapy.
The vast majority of patients with back pain will not require surgery. Some patients will experience persistent spinal pain despite these measures. Under these circumstances spinal surgery may be indicated. Surgery should only be undertaken following a period of conservative treatment and following discussion with the treating Spinal Surgical Specialist who will be able to discuss the benefits and risks of the different treatment options which include fusion surgery, disc replacements or other forms of dynamic stabilisation.
Do you need to see a pain specialist?
Unfortunately some patients may not gain benefit from non-invasive treatment, injection therapy or surgery. Following assessment by the spinal specialist these patients may be referred to the pain specialists, who are usually anaesthetists specialising in pain management techniques.