Around 4 in 5 adults (that’s a whopping 80 per cent) of adults experience low back pain at some point in their lifetimes. It is the most common cause of job-related disability and a leading contributor to missed work days. In a recent survey of thousands of people, more than a quarter of adults reported experiencing low back pain during the past 3 months.
You are not alone, but of course the severity and duration of pain varies immensely. Men and women are equally affected by low back pain, which can range in intensity from a dull, constant ache to a sudden, sharp sensation that leaves the person incapacitated. Pain can begin abruptly as a result of an accident or by lifting something heavy, or it can develop over time due to age-related changes of the spine.
Sedentary lifestyles can set the stage for low back pain, especially when a weekday routine of getting too little exercise is punctuated by strenuous weekend workout!
Most back pain is acute, or short term, and lasts a few days to a few weeks. It tends to resolve on its own with self-care and there is no residual loss of function. The majority of acute low back pain is mechanical in nature, meaning that there is a disruption in the way the components of the back (the spine, muscle, intervertebral discs, and nerves) fit together and move.
Subacute low back pain is defined as pain that lasts between 4 and 12 weeks. Though there is a long list of other back and spine pain which may be chronic and last a much longer time.
The human back is composed of a complex structure of muscles, ligaments, tendons, discs, and bones, which all work together to support the body and enable us to move around. When someone is suffering from back pain, they are often referring to the spine itself.
The spine runs from the base of the skull down the length of the back, going all the way down to the pelvis. It is composed of 33 spool shaped bones called vertebrae – each about an inch thick stacked upon one another.
The connection points between the vertebrae in the spine are referred to as facet joints which keep the spine aligned as it moves. These are lined with synovial which produces a viscous fluid to lubricate the joints.
Between the individual vertebrae, discs serve as cushions and act as shock absorbers between the bones. Running through the centre of the spinal column is the spinal cord which is a bundle of nerve cells and fibres that transmit electrical signals back and forth between the brain and the rest of the body. These signals are sent via 31 pairs of nerve bundles that branch off the spinal cord and exit the column between the vertebrae.
The ligaments which support the spine are the anterior longitudinal ligament and the posterior longitudinal ligament.
The spine itself – the body is the largest part of the vertebrae and the part of the spine which bears the most weight. The lamina is the lining of the spinal canal where the spinal cord runs.
The two main muscle groups in the back function are the extensors – which include the many muscles that attach to the spine and work together to hold the back straight and enable extension, and the flexors – which attach at the lumbar spine (lower back) and enable you to bend forwards. The flexors are located at the front of the body e.g abdominal and hip muscles. Although the spine is a continuous structure, it is described as 5 separate units:
1. The cervical spine – the neck and upper back and composed of the 7 vertebrae closest to the skull. It supports the weight and movement of the head and protects the nerves exiting the brain.
2. The lumbar spine – the lower back, composed of 5 vertebrae and provides support for the majority of the body’s weight.
3. The thoracic spine – the middle back, made up of the 12 vertebrae in between the cervical and lumbar spine.
4. The sacrum – the base of the spine that is composed of 5 vertebrae fused as one solid unit. The sacrum attaches to the ilium of the pelvis forming the sacroiliac joints.
5. The coccyx – the tailbone located below the sacrum composed of 4 fused vertebrae.
Underlying changes in the spine’s anatomy and mechanics are usually the cause of back pain. One of the most common issues in the lower back is a lumbar spinal disc. A spinal disc can cause pain from a herniated disc or from lumbar degenerative disc disease which is wear and tear on the spinal discs that causes chronic lower back pain.
Other common causes of chronic back pain stem from issues in the joints and vertebrae including Osteoarthritis. Spinal osteoarthritis consists of wear and tear on the facet joints which causes excess friction when twisting or bending the spine. This friction can lead to bone spurs which pinch the nerve root and produce sciatica pain. Other symptoms include stiffness and tenderness around the joint.
Sacroiliac joint dysfunction is another cause. This joint connects the hip bone to the sacrum. When the joint experiences too much or too little motion, it may cause pain in the hips, the pelvis and lower back.
Isthmian Spondylolisthesis is where one vertebral body slips forward over the vertebrae below it, straining the discs and joints at the spinal segment. Slippage is caused by a fracture in the back of the vertebrae and it causes lower back pain, stiffness, leg pain and numbness.
Spinal stenosis is the narrowing of the spinal canal due to a bone spur, herniated disc, or other irritant which causes back pain but also severe leg pain due to the nerve-root irritation.
Lower back pain is usually linked to the bony lumbar spine, but the upper back pain may be due to other disorders such as disorders of the aorta, tumours in the chest or spinal inflammation.
Back pain can also be due to problems elsewhere in the body such as kidney stones, endometriosis or obesity.
Back pain can be caused by injury such as sprains or spasms or structural issues including ruptured or bulging discs, by abnormal curvature of the spine due to conditions such as scoliosis, kidney problems, spinal infections, shingles, cancer, and cauda equine syndrome. Cauda equine syndrome causes pain and numbness in the lower back and buttocks from the spinal nerve roots.
Doctors can sometimes use injections or implanted devices to deliver immediate back pain relief. Injections can include epidural steroid injections. When inflammation within the spinal column causes nerve root irritation and swelling these injections help to reduce inflammation and ease pain. The injections relieve pain within the week and last from several days to months.
Other injections include a Selective Nerve Root Block, which numbs the area where the nerve root is compressed or inflamed, a Facet Joint Block where the joint is directly targeted, Facet Neurotomy where a heated needle is used to burn and disable the responsible nerve, a Sacroiliac Joint Block where the joint connected to the pelvis is injected, and Trigger Point injections where local anaesthetic is injected into painful trigger points.
Implantable devices are also sometimes used such as a Spinal Cord Stimulation which decreases the perception of pain by activating nerves in the lower back to block the pain signals to that area, and by using Implanted Drug Infusions, where a pump is implanted into the body to deliver regular doses of pain medication via a tube into the painful area of the spine.
Alternative therapies are also considered to help with pain such as acupuncture and spinal manipulation to either massage the soft tissue around the spine or to manipulate the ligaments or vertebrae. Manipulation is used for injury, damage or sprains to the muscles or ligaments.
Another non invasive treatment to consider as opposed to risking complicated surgeries is stem cell therapy. Back pain caused by bulging or herniated discs, degenerative conditions of the spine or injury can be treated with stem cell therapy – AMPP®, Activated Mesenchymal Pericyte Plasma using Lipogems® technology and Platelet Rich Plasma (PRP) therapy. Depending on the root of the back pain, these treatments can be injected into the discs (intradiscal), facet joints and paraspinal muscle.
PRP therapy is an effective and safe alternative to surgery. It takes advantage of the bloods natural healing properties to reduce pain and improve the joint function. The injections use a specially concentrated dose of platelets prepared from the patients own blood. Essentially, your own cells are used to encourage healing. With this procedure there is no chance of rejection, infection or contamination. It repairs damaged cartilage, tendons, ligaments, muscles, and bone. AMPP® – Activated Mesenchymal Pericyte Plasma using Lipogems® technology uses the body’s own stem cells to treat pain and inflammation. The minimally invasive procedure is an alternative to surgery and can help healing in post operative care. These injections harness the natural repair cells removed from body fat to alleviate pain in spinal discs, joints, ligament and muscles.
Surgery for back pain is only considered if all non surgical treatments including the above, have not proved to be effective. It is always a patient lead decision an only performed immediately very rarely.
Because back pain is always so varied, complex and difficult to pin point and describe the root cause, there are a number of differing procedures to alleviate and remedy back and spinal issues.
This is a common surgical procedure used to alleviate lower back pain caused by pinched nerves.
Lumbar Microdiscectomy is one of the most minimally invasive procedures that can be done to alleviate pain associated with nerve root irritation. In this surgery a relatively small incision is made in the lower back and the portion of the herniation that is in contact with the nerve root is pulled out. The goal is to relieve symptoms associated with pressure at the nerve root and has a 90-95% success rate in providing relief from buttock and leg pain.
Often the pain relief is instant but if neurological symptoms had also been experienced prior to surgery, it may take longer for the nerve to heal and the patient may still suffer from weakness and numbness for several months to a year. For some patients the symptoms may improve but never be fully resolved.
A Lumbar Laminectomy is most commonly performed to treat lumbar spine stenosis symptoms. During this procedure the lamina (bone in the back of the vertebra) at one or more segments is removed with the goal of alleviating pressure on the spinal cord and nerves. It is a surgery performed to enlarge the spinal column when spinal stenosis causes pressure on the nerve roots. It involves removing the backside of the spinal canal that forms a roof over the spinal cord. Along with the lamina, doctors often remove any bony protrusions or spurs which may have resulted due to osteoporosis of the spine.
The spinal fusion is a welding process by which two or more vertebrae are fused together to form a single immobile unit. It is used to stop the motion that normally occurs between the vertebrae and, in doing so, alleviates pain that is aggregated by movement, such as bending, twisting, or lifting. It can be performed to stabilise a spine that has been damaged by infections or tumours, or to stop the progression of a spinal deformity, such as scoliosis , or to treat injuries of the vertebrae and stabilise due to a defect in the facet joint.
Spinal fusion can sometimes be performed in addition to the Laminectomy in order to achieve adequate decompression off the nerve root, especially if the nerve root is compressed as it leaves the spine. This is known as foraminal stenosis.
Foraminal stenosis is difficult to decompress simply by removing bone as if the bone is fully removed in the location of the foramen, it is necessary to also remove the facet joint which leads to instability. Spinal fusion is needed to provide the stability.
Spinal fusion surgery is designed to stop the motion at these painful vertebral segments which decreases pain generated from the joint.
The procedure involves:
– Adding bone graft to a segment of the spine
– Setting up a biological response that causes bone graft to grow between the two vertebral elements to create bone fusion.
– The boney fusion results in one fixed bone replacing a mobile joint and stops the motion at that joint segment.
At each level in the spine there is a disc space in the front and paired facet joints in the back which work together to permit multiple degrees of motion. Two vertebral segments need to be fused together to stop the motion at one segment. The surgery involves using bone graft to cause two vertebral bodies to grow together into one long bone. Bone graft can be taken from the patients hip during the surgery, or harvested from cadaver bone, or manufactured from a synthetic bone graft substitute.
There are differing approaches such as Posterolateral gutter fusion – through the back, Posterior lumbar interbody fusion – through the back and includes removing the disc between two vertebrae and inserting bone, Anterior/ Posterior spinal fusion, Transforaminal lumbar interbody fusion, and Extreme lateral interbody fusion.
Fusion patients will often have a weak and unstable spine caused by infections, tumours, fractures, scoliosis, or deformity, and there will always be a risk of clinical failure, remaining pain, despite a successful fusion.
This is the removal of part of a disc that is herniated and causing pain. There are two kinds: Percutaneous – which involves removing a portion of the disc using a laser or suction device through a narrow probe placed through a small incision in the back.
Microsurgical – which requires a small incision where the surgeon, using a microscope, removes the damaged portion of the disc along with a small portion of the bone covering the spinal canal.
Vertebroplasy and Kyphoplasty
These two similar procedures are performed to relieve the pain and other problems associated with compression fractures of the vertebrae. Both involve bolstering fracture bone with a cement like material that is injected into the vertebrae through a needle. Although the two procedures are essentially the same, Kyphoplasty involves an additional step of inserting a small balloon like device into the compressed vertebrae and inflating. This step helps to restore height to the crumbled vertebrae and reduce the deformity.
Newer types of surgery include inserting a replacement disk for an alternative to fusion for degenerative disk disease or using a posterior motion device which can aid stenosis and mild degenerative spondylothesis. They provide similar results to fusion but with a smaller surgery and faster recovery times. These procedures, however, are still gathering the necessary long term data.
With surgery on the spine and spinal cord, the complications can be serious. There are risks such as bleeding, blood clots, infection and stroke, but also the risk of a herniated disc and significant further nerve damage involving subsequent pain and impairment and the need for additional surgery. It usually takes 3 – 12 months after spinal surgery for the patient to return to any normal daily activities, longer for the backbone to completely heal but the success in pain relief has proven to be successful in 70-90% of patients.