Second most common physical problem after headache
The importance of our back can be gauged from the commonly used adage about a particular person being the backbone of that organisation or society. The backbone plays an important role in maintaining and functioning of our body.
The human spine is a complex structure spanning from the head to the tail bone. The spinal column protects the spinal cord and the nerve roots. It allows the body movements in three dimensions and also maintains the balance of the head, the trunk and the pelvis through the various inter-vertebral discs, facet joints, muscles and adjacent ligaments.
Backache is the second most common problem a person experiences after headache. It is estimated that everyone will have back pain at least once in his or her life time. The mountainous terrain exerts more forces on the back and makes the people in the mountains more prone to back pain.
Back pain could be due to fall from a height, carrying too much of heavy loads, lack of exercise, wrong posture while driving, while sitting or while carrying loads. The people having sedentary lifestyle are more prone to develop back pain due to weakness in the surrounding muscles.
Among the florid symptoms of back pain, slipped inter-vertebral disc is a common cause. The inter-vertebral disc material slips from its place and compresses the spinal cord or the exiting nerve root. Prolapsed inter-vertebral disc is becoming a common problem in young age because of wrong workouts in the gymnasium.
Slipped disc gives rise to pain in the region supplied by the compressed nerve or the typical radiating pain in legs (sciatica). The disc pain is characterised as radicular pain which has a nature described as shooting, burning or an electric current like pain in one or both legs. Continuous disc pressure on the nerve root causes progressive decrease in the efficiency of the muscles and long standing compression may even present with variable degree of paralysis.
Treatment modalities of slipped disc depend upon the degree of compression of nerve. These vary from medications, physiotherapy, injection epidural steroid to surgical removal of the slipped disc. It is worth mentioning here that not all cases of slipped disc, can be treated with only exercise or medications and neither do all such cases need surgery. A moderately or a grossly slipped disc can never revert back to its place and it has to be removed surgically.
Elderly patient usually presents with spine canal stenosis (narrowing of spinal canal) due to over growth of the surrounding structures which is characterised by neurological claudication in lower extremities, numbness and occasionally with urinary retention, dribbling and/or constipation.
Just like a slipped disc, a vertebra can also slip either due to fracture of the parts of the vertebra or due to degeneration of the facet joints. If the bony spinal canal is unstable at any level then it may require surgery.
Other common cause of back pain is facet joint arthritis. As other joints of the body degenerate with advance in the age so do the facet joints. The back becomes stiff in morning on while getting up and pain is relieved after increase in the movements as the day progresses. Facet joint arthritis is treated with NSAIDS, physiotherapy, exercises, local steroid injections and rarely with surgery.
Spinal cord tumors are a rare presentation among the causes of back pain. Spinal tumours can occur in any age group and are usually associated with back pain at night and neurological symptoms of numbness or paralysis. Spinal tumours are usually treated with surgery. Though spinal cord tumour surgery is technically difficult comparing to the other spine surgeries but the results are gratifying in properly selected cases.
As minimally invasive surgery has became popular among surgical specialties, it has followed even so in spine surgery. Minimal invasive spine surgery has reduced the co-morbidities associated with open surgery like incidence of infection, prolonged hospital stay and post-operative pain after surgery.
Injection therapy has been found to be quite effective in treating various back pain pathologies. Steroid injections, anesthetic drugs and other agents are used for treating various causes of back pain. The rationale for using steroid injection is that it works as an anti-inflammatory around the injected area, hence, reduces the pain. Epidural steroid injections are usually given for radicular pain caused due to slipped disc.
Steroid injections are also given for the pain due to facet joint arthritis and fibro fasciitis pain at the lumbo sacral junction. This fibro fasciitis pain is quite common in young ladies. Local steroid therapy is also quite affective therapy in such cases.
Tuberculosis infection of spine is quite common in our country. However with the current TB drugs available, TB infection can be controlled in 90 per cent of the cases with anti tuberculosis drugs. Only 10 per cent of the patients require surgery, if infection is not controlled with drugs or if patient develops paralysis during or before treatment.
Spinal needle biopsy is a simple, effective and cheap procedure to diagnose the pathology of spine. It can easily differentiate between infection and tumour of the spine. The author believes that if the culprit is to be punished or killed, then first he should be properly identified before commencing the punishment. It is a terrible mistake if an innocent person is killed in the place of a culprit. In the same way if a patient of infection is being treated for cancer or vice versa then it is a grave mistake. The same principle is to be applied in case of disease as in case of culprit, first the disease has to be identified and then treated accordingly. One can appreciate the outcome of such a mistake which can be made on empirical treatment started on the basis of clinical judgement only.
Lack of awareness, neglect of pain, poverty, lack of trained doctors and shortage of good hospitals accentuates these simple problems to a serious problem in about 20 per cent of back pain patients. Spine surgeries are difficult and risky but its success completely depends on the skill of surgeon and standard of medical facilities available in the hospital. Spine surgery, like any surgery has very good results if done on time and before landing up in the complications due to neglect of treatment. After the surgery, the patient has to follow a definite protocol for a certain time to get the ideal result. The author himself has done more than a thousand surgeries, varying from simple to most complicated high risk spine surgeries in the past 20 years and none of them have resulted into paralysis after surgery. In fact the author’s name was recorded in the Limca book of records for spine surgery.
(The author is an orthopaedic and spine surgeon, and the founding president of State Chapter of Indian Orthopaedic Association)