Pain in the back or back ache is by far the commonest ailment presenting in orthopaedic clinics. 9 out of 10 patients suffer from back pain during their lifetime. It typically effects the lower back and may affect any age. Its cause is rarely serious and, in most cases, self-limiting. However, it can cause significant disability and loss of function.
The back or spinal column is made up of many vertebrae with discs in between. There are supporting ligaments and muscles as well as small joints called facet joints. The spinal nerves exit between the vertebrae.
Back pain may be acute, subacute, or chronic, the latter if it lasts more than 12 weeks. The pain may be burning, shooting, or piercing. It may be worse with prolonged sitting, bending, or walking. It may radiate down the legs and be associated with numbness and altered sensations or weakness.
90 percent of back pain is non-specific normally due to a muscle or ligament sprain, which the patient might not even remember. In the other cases, the pain is due to a disc problem. This is called discogenic pain and may be related to a prolapsed, collapsed, or desiccated disc. Pain may also arise from wear and tear (arthritis) in the low back. This may manifest itself as wear of the discs or facets joints and this may cause narrowing of the central spine canal (spinal stenosis) or impingement on the nerve roots (sciatica).
Pain due to infection (discitis or abscess), fractures or tumours is rare.
A thorough history and neurological examination usually identifies the likely cause. Further investigations including blood tests and MRI scans are required for confirmation of the diagnosis or if there is no response to treatment. These are also useful if there are neurological signs that raise the suspicion of other sinister problems such as infection, tumour, or vertebral collapse due to osteoporosis.
Most types of acute back pain settle spontaneously with some rest, analgesia, and gentle exercise
Chronic back pain is more challenging to treat and may be associated with psychological issues.
A positive attitude and motivation and daily stretching and exercises help. Loss of weight Is also important. Smoking is also associated with chronic back pain. Lifting, pushing, and pulling heavy objects is avoided. Attention to posture and lifting objects carefully is vital. Hot packs, sauna, jacuzzi, hot showers and baths are can provide great relief.
Medications include antispasmodics, neuroleptics, and anti-inflammatories. These are however not recommended on a long-term basis.
Physiotherapy is immensely helpful. There are different modalities that can be utilised including heat treatment, ultrasound, electrical, magnetic and hydrotherapy as well as acupuncture.
Injections remain a valid option. These are usually steroid injections and may include facet joint blocks, epidural injections, and ablation.
Very few patients require surgery. The vast majority can be treated non-operatively. However decompression of a trapped nerve root (by partial discectomy) or fusion of one or more levels of the spine or occasionally disc replacement remain valid options.
Mr Alistair Melvyn Pace
MD (Melit) MRCS (Eng) MRCS(Edinburgh) FRCS (Tr & Orth) MSc (UK) Dipl (Orthopaedics) CCT (UK)
Consultant Orthopaedic & Trauma Surgeon
Senior Lecturer University of Malta
DaVinci Hospital, Birkirkara