Spine Care

What are the common causes for lower back pain?

Back pain, in an overwhelming number of cases, is a result of muscle strain due to lifting a heavy weight or twisting; sudden impact in an accident; a herniated disc brought about by stress on tissues and bones of the spine; or osteoarthritis, a degenerative disease of the joints. Lower back pain is commonly caused by:

back pain, can be due to muscle strain associated with lifting a heavy object sudden twisting. It can also be the result of: sudden impact in an accident, herniated disc brought about by stress on tissues and bones of the spine, or osteoarthritis, a degenerative disease of the joints.

Other causes of low back pain are:

When to visit a doctor?

Back pain is as common as the common cold and not everyone needs to visit a doctor. One may try home therapy before visiting a doctor. However, one should be aware that back pain should not be neglected under certain conditions such as:

Back pain is as common as the common cold. However, back pain should not be neglected under certain conditions:

Back pain in children (<10 years) and the elderly (>70 yrs).
Back pain in patients with risk of osteoporosis like those on cancer medications, on prolonged bed rest, with hypothyroidism or diabetics, on anti-epileptics etc.
Back pain that radiates to the leg, with weakness of the leg or foot, loss of sensation in peri-anal area and difficutly with urination (either straining while urinating or urinary leakage. Back pain associated with features of infection like fever, loss of weight, loss of appetite.

Back pain in children (<10 years) and the elderly (>70 yrs).
Back pain in patients with risk of osteoporosis like those on cancer medications, on prolonged bed rest, with hypothyroidism or diabetics, on anti-epileptics etc.
Back pain with neurological signs like radiating pain along the leg / weakness of foot / difficulty in urination (either straining at urination or urinary leakage) and /or loss of sensation in the perianal region.
Back pain associated with features of infection like fever, loss of weight, loss of appetite.

Importance of accurate diagnosis

Your doctor will take a careful medical history and do a physical exam to decide if you need need an X-ray or other test such as an MRI (magnetic resonance imaging) or a CT (computerized tomographic scan) to confirm diagnosis. Most people with back pain may not require further studies.

The doctor will need to take a careful medical history and do a physical exam to look for certain red flags that indicate the need for an X-ray or other imaging test. In some patients, imaging such as X-ray, MRI (magnetic resonance imaging), or CT (computerized tomography) scan may be advised to confirm diagnosis.

I have a pain in my lower back that stretches down one leg. Should I be worried?

Treatment options for lower back pain

In most cases, the lower back pain is the result of muscle strain and spasm and does not entail surgery.

To treat the pain, the following options may be adopted:

Bed rest for severe back pain. This should not last longer than 2 to 3 days. Patients should get back to active life as soon as possible.

Medications for severe back pain
Exercise – effective in speeding up recovery and helping strengthen the muscles of the back and abdomen. It also helps reduce the risk of the back pain recurring.
Lumbar corsets – helpful only in the work setting. Regular use could weaken spinal and abdominal muscles and delay recovery.

In most cases, the lower back pain is caused due to muscle strain and spasm and does not entail surgery.
To treat the pain, the following options may be adopted:

Medications.
Bed rest – although not recommended beyond 2 to 3 days. Patients should get back to active life as soon as possible.
Exercise – effective in speeding up recovery and helping strengthen the muscles of the back and abdomen. It also helps reduce the risk of the back pain recurring.
Lumbar corsets – helpful only in the work setting. Regular use could weaken spinal and abdominal muscles and delay recovery.

Surgery for lower back pain

Surgery is rarely indicated for isolated back pain. For back pain associated with any structural problem of the spine, surgery may prove beneficial. The type of surgery would depend on the cause for the back

Sciatica/ Disc Herniation

The human spine is composed of multiple bones (vertebrae) which are interconnected by disco-ligamentous structure called intervertebral disc or simply called as “disc”.
There are 23 discs in a human spine, which help in smooth motion of the vertebrae, thereby giving the flexibility to your spine. Like gel cushion, they absorb pressure and impact.

When small tears occur in the outer layers of the disc, the gel-like central core of disc can protrude into fibrous layer (disc protrusion/bulge) or break through the fibrous layer (disc prolapse/extrusion/herniation). This extruded disc material, by chemical or physical properties, can irritate the nerves at that level innervating upper or lower limbs. Depending on the region of disc herniation it is called lumbar (lower back spine) or cervical (neck) disc herniation.

What are risk factors for developing disc herniation?

Often there is no definite cause for one to have disc herniation. However, it is due to an acute event in the presence of long-standing risk factors in a predisposed individual or a result of exaggerated normal wear and tear and degeneration.

Predisposed individuals (risk factors)

Acute events:

Are you suffering from this problem

The symptoms vary depending on the location and severity of the herniated disc.

Clinical examination will give a fair idea of what the problem could be, and to confirm the diagnosis you may asked to get an X-ray or MRI of the involved region. MRI can delineate exactly at what level disc is herniated and how much it compresses the nerve root involved. However, a study revealed that more than 50% of people with disc herniation don’t have any symptoms. Hence, we don’t recommend getting an MRI done unless you have specific symptoms and signs.

Suddenly both my legs feel numb. What is it due to?

Prognosis: 90% of patients will get relief from the symptoms by conservative management. Only 5-10 % may require surgical management.

Transforaminal Epidural Steroid Injections (TESI)

A few patients, who do not get relief with conservative therapy, may require TESI.

Microdiscectomy

This is the standard treatment for lumbar disc herniation and has highest success rate, besides being the least complicated.

Post-op concerns

Usually (90-95%), patients will be able to walk on the same day or the next day. They will be fit to go home in 24-48 hours and resume light activities within 15 days. In 5 -10 % of the patients, there may not be complete relief in symptoms. In 1-5 % of patients, there might be minor complications like CSF leak, in which case walking is delayed for 48 hours, and risk of local infection and recurrence.

CLAUDICATION / NUMBNESS OF BOTH LEGS (Lumbar Canal Stenosis)

Wear and tear with age can give rise to degenerative disc disease, a condition where there is progressive deterioration of spinal discs and arthritic changes in facet joints. It can also result in the narrowing of the spinal canal due to overgrowth of bone spurs, leading to spinal stenosis, which can cause pain, numbness and weakness in the legs due to compression of the neural elements.

Most of the cases can be asymptomatic.

When symptomatic, one may develop numbness / pain in both legs after walking for a while, which is relieved after sitting or lying down for some time. This is termed as neurological claudication. The time and distance after which this condition develops may vary from person to person, depending on the amount of compression over the nerve.

A few patients have also complained of back pain, along with bladder & bowel symptoms and weakness in the legs.

The evaluation for this condition will usually involve a review of the patient’s medical history and a physical examination, followed by X-rays. Your doctor may advise dynamic radiographs to evaluate if there is any instability.

MRI is usually done to know the level and severity of compression on the nerve and also to assess the surrounding tissue (facets hypertrophy, ligamentum flavum hypertrophy), and condition of the disc.

My low back feels stiff and there's a tingling in my legs. Should I see a doctor?

Prognosis: Most of the patients will get relief from the symptoms by conservative management. Only a few may require surgical management.

Conservative management

It is non-operative management through use of medications, physical therapy, lifestyle modification, posture care and occupational therapy.

Surgical management

Patients with failed conservative management or with severe neurological compromise (progressive weakness of legs / bladder and bowel symptoms), may be treated surgically.

Spondylolysis

Each vertebrae of the human spine is a complete ring-like structure, with central vertebral canal consisting of spinal cord and nerve fibers. For better understanding, the vertebrae can be divided into three portions, the front portion (anterior) is called “vertebral body” and the middle portion consists of pedicles on either side of the spinal cord and the posterior (rear) portion consists of facet joints(superior and inferior), pars interarticularis, and the spinous process. Any break or discontinuity in pars interarticularis is called Spondylolysis.

Spondylolysis (also referred to as “pars fracture”) is usually a fracture caused by repetitive stress rather than a break due to injury, and commonly occurs during childhood or adolescence. The crack may affect only one side, but there are quite a few cases with fractures on either side of the vertebra. When this happens, a vertebra could slide forward or backward onto another one; a condition that is known as spondylolisthesis.

Illustration of the Spinal Column and Location of a Pars Fracture (Spondylolysis)

Spondylolysis is a common condition in physically active children and teenagers. While some of them may experience symptoms, others may not develop symptoms until later in adulthood.

The symptoms include pain and stiffness in the lower back that gets aggravated with activity and gets better with rest. Hyperextension or abnormal stretching of the lower back will usually worsen the condition as it overloads the pars fracture.

At times, nerve symptoms such as “pins and needles” sensation in a leg, with or without numbness or weakness, may be experienced.

The evaluation for this condition will usually involve a review of the patient’s medical history and a physical examination, followed by X-rays to detect pars fractures.

The doctor may advise a bone scan for early detection of a stress fracture of the pars. In this procedure, chemical "tracers" are injected into the blood stream. The tracers converge in areas of increased metabolism or cell activity in bone tissue, indicating a stress fracture of the pars interarticularis, and then show up on special spine X-rays.

To evaluate a pars defect and visualize healing bone, a CT scan may be used, while to assess the surrounding tissue and condition of the disc an MRI may be recommended.

I love playing sports but had to stop due to severe back and leg pain. Can you help?

Spondylolysis treatment is initially nonsurgical and includes rest and bracing, which can last up to 3-4 months. The fracture is assessed with a series of X-rays/ bone scan/ CT scan every few months to see if it has healed.

Physical therapy can also be used to help maintain and strengthen the muscles of the abdomen and back with specific directed exercises.

Surgery

If pain persists after non-surgical treatment, surgery may be required. There are two operations that may be performed:

Pars repair: This is a minor surgery, wherein the pars fracture is fixed with screws and bone graft, with the principle of bony fusion like any other fracture.
Interbody fusion: If the procedure is delayed, there can be degeneration of the disc and increased pressure on the nerve roots, wherein pars repair is contra-indicated, then Transforaminal Lumbar Interbody Fusion is performed.

Slipped vertebrae/ Spondylolysthesis

Spondylolisthesis is when a spinal vertebra slip forward over another vertebra caudal to it. There are different types of the condition, depending on the anatomical changes.

Spondylolytic lysthesis: It is caused when the crack in a pars fracture affects both sides of connection (between the lamina and pedicles). The condition can be a direct result of spondylolysis.

Degenerative spondylolisthesis: Usually seen in elderly age group, this condition is caused by the deterioration of the facet joints and discs of the spine.

Congenital spondylolisthesis: Usually seen in the younger age group, this condition is caused due to birth defects in the bony structure of vertebrae (predominantly pars).

The evaluation for this condition will usually involve a review of the patient’s medical history and a physical examination, followed by standing X-rays, which can grade lysthesis. Your doctor may advice dynamic radiographs to evaluate if the lysthesis is stable or unstable.

A CT scan may be used to evaluate a pars defect or any bony problems, while an MRI may be useful to assess the surrounding tissue, nerves and condition of the disc.

Could my neck pain be a sign of something serious?

Treatment depends on the clinical symptoms.

Conservative treatment: If the person is asymptomatic or has only back pain / stiffness, then surgery is NOT the first choice. Bracing / exercises and physiotherapy may be tried, which can give satisfactory results.

Surgical treatment: Surgery is recommended if conservative treatment doesn't give good results and / or if the patient has neurological symptoms like leg pain / numbness / bladder symptoms.

Surgery involves decompressing the nerve roots and fixing the bone with or without reducing the lysthesis by using screws and bone graft.

Slipped vertebrae/ Spondylolysthesis

A common problem, neck pain affects most adults at some point of time in their life. It can involve just the neck and shoulders, or may stretch down an arm, with the pain being either a dull ache or like an electric shock in your arm. Other symptoms like a feeling of numbness or muscle weakness in an arm, help in pinpointing the cause of the neck pain.

Some causes of neck pain include:

There's a pain in my neck which also affects my arm. Is it because of my posture?

Most of the time, neck pain goes away by itself in a couple of days. If at all, only a little conservative treatment may be required. Neck pain that persists over several weeks usually responds to exercise, stretching, physical therapy, massage and watchful waiting. Only in very few cases are steroid injections or surgery indicated.

Try these self-care tips to help relieve the discomfort:

Cervical disc herniation

Cervical disc herniation is a clinical condition wherein the intervertebral disc between the two vertebral bodies in the neck can herniate back, pressing on the spinal cord or the nerves that connect the arms and hand.

Most people (almost 90%) may have disc herniation, yet they would not have any complaints. The remaining 10% may present symptoms like:
i. Neck pain
ii. Shooting pain along the arm up to hand, together with decreased sensation or weakness of the hand.
iii. In rare cases, multiple disc herniations or a single large disc herniation can compress the spinal cord, causing symptoms in both upper limbs and lower limbs. [Cervical myelopathy].

Physical examination by a doctor has a key role in the diagnosis and decision-making on management of this condition. As more than 90% are asymptomatic, unnecessary investigations can cause panic and a sense of nervousness in the patients.
After a clinical diagnosis is made, your doctor may advise an X-ray or MRI of cervical spine to confirm the diagnosis and aid in deciding the treatment.

My father wobbles when walking and complains of weakness in the arms. Is it just age?

Almost 80% of symptomatic disc herniation patients can get better with conservative management, in the form of medications, posture care, neck exercises and physiotherapy.

Only few patients who don’t get good relief with conservative treatment may need surgery in the form of either Anterior Cervical Discectomy and Fusion (ACDF) or Anterior Cervical Disc Replacement (ACDR). The surgery is performed on the front of the neck where a small cut is made and the affected disc removed, thereby relieving pressure on the nerve root and spinal cord. Stabilizing is done either by fusion with bone graft (ACDF) or artificial disc replacement (ACDR).

Cervical myelopathy

Cervical myelopathy is a clinical condition that involves compression of the spinal cord in the cervical spine (neck). The cervical spine comprises 7 vertebrae, with 6 intervertebral discs and 8 nerve roots. The spinal cord travels inside the vertebral column that is constructed with vertebrae in the front, cushioned by intervertebral discs, and facet joints and lamina at the back. The branched nerve roots primarily control the function of the shoulders, arms and hands. Any excessive pressure on the spinal cord can cause a decrease in its functioning.

The symptoms of cervical myelopathy may appear in the neck or may be felt elsewhere in the body

Neck symptoms include:

With the progression of the condition, you may experience a shooting pain that originates in the neck and travels down the spine.

Other symptoms include:

Early detection of cervical myelopathy helps in effective treatment. To diagnose the condition, your doctor may:

my child’s shoulders and hips don’t seem to be even. Can this be caused by a crooked back and can it be corrected?

To treat cervical myelopathy, while there are non-surgical options such as physical therapy and cervical collar brace, surgery is often necessary to eliminate the compression of the spinal cord and prevent deterioration of the condition.

The surgical procedures include widening of the spinal canal (laminoplasty) and spine decompression surgery with spinal fusion, which helps stabilize the spine after herniated discs, bone spurs or ossified ligaments are fully or partially removed.

Based on your condition, your doctor may recommend the surgery to be performed from the back of the neck (posteriorly) or from the front of the neck (anteriorly).

Scoliosis

Scoliosis is abnormal side-to-side curvature of the spine. Normally a human spine is straight when seen from back, any deviation to the side by more than 10 degrees is considered scoliosis.

There are many reasons for abnormal curvature of the spine. Based on the reason behind the abnormal, there are classified.

i. Idiopathic scoliosis -This is the most common variant, in which there is no reason that could be identified.
ii. Congenital scoliosis – This is due to abnormal development of vertebra during early development.
iii. Muscular/ Paralytic scoliosis – This variant is seen in children with muscle weakness like cerebral palsy, muscular dystrophy.
iv. Degenerative scoliosis – This is seen in elderly due to normal wear and tear (degeneration) of spine joints / ligaments and disc.

Since early diagnosis and treatment initiation plays an important role in the disease progression and decision making, consult a doctor on observing any symptoms of scoliosis in your child.

Scoliosis can usually be diagnosed by physical examination. However, your doctor may advise you to get full radiographs of spine to classify what type it is, check curve magnitude, and level of involvement. You may be asked to get further radiographs, to know the correctability or flexibility of the curve by getting side bending/ traction views.

An MRI may be required if you have any neurological symptoms, along with scoliosis. A CT scan may be required to plan for surgery, especially in the presence of bony anomalies like in congenital scoliosis.

After an accident, my brother finds walking painful. Could it be a spinal fracture?

Most children with mild scoliosis may not require treatment with a brace or surgery, but need regular check-ups to see if there have been changes in the curvature of their spines as they grow.

Before beginning treatment, a few factors are taken into consideration:

Braces

If your child has moderate scoliosis, your doctor may recommend wearing a brace to prevent further progression of the curve.

The most common type of brace is made of plastic and is contoured to the body so as to fit perfectly under the arms and around the rib cage, lower back and hips, making it practically invisible under the clothes.

Since a brace’s effectiveness increases with the number of hours it is worn, it is advised to have one on 24 hours a day. Braces do not hinder children’s participation in sports or other physical activities, and can even be taken off if, for instance, they want to go swimming.

Once bones stop growing, the braces are discontinued. This typically occurs:

Surgery

As severe scoliosis progresses with time, your doctor may suggest surgery to reduce the severity of the spinal curve and to prevent it from worsening.

Spinal fusion is the most common type of scoliosis surgery. In this procedure, two or more of the bones in the spine are connected together so that they can’t move independently. Pieces of bone or a bone-like material are placed between the vertebrae. Metal rods, hooks, screws or wires typically hold that part of the spine straight and still while the old and new bone material fuses together.

In case the scoliosis is progressing rapidly in a young patient, doctors can install a length adjustable rod that keeps pace with the child’s growth. The rod, attached to the top and bottom sections of the spinal curvature, is usually lengthened every six months.

Spine Fracture - Traumatic

Fall from height and road traffic accidents are the two most frequent causes of a spine fracture. The spine is a highly stable structure by the virtue of disco-ligamentous structures, protecting the spinal cord in the spinal canal. In trauma, bone or disco-ligamentous structural failure can put the spinal cord at risk of compression and thereby cause neurological deficit (paralysis).

Back or neck pain depending on the site of injury, immediately after the fall / accident.
Some may develop weakness of hands or legs, and then this is called acute traumatic spinal cord injury.

Onsite management

Principle: DO NO HARM
Patient should be shifted on a flat sheet, preferably a stretcher/ spine board. Trying to lift the patient or shifting to a wheelchair can worsen the situation and also cause permanent injury to spinal cord

You doctor may advise to get X-ray (Radiographs), CT scan/ MRI, depending on the clinical situation.

Does a spinal cord injury always mean permanent disability?

Most spine fractures, apart from a few, don’t require surgery.

Conservative management

Non-operative management includes medications, physical therapy and occupational therapy.

Surgery

Depending on the severity of the fracture, it can be treated by a brace or surgery (pedicle screw fixation).

Acute Spinal Cord Injury

A spinal cord injury (SCI) — is damage to the spinal cord resulting in a change, either temporary or permanent, in its normal motor, sensory, or autonomic function.

Prognosis or scope of improvement in weakness/ function depends on various factors like severity of injury/ time since injury/level of injury etc.

If the SCI is complete, the chances of neurological improvement are very bleak.

We have great hope that ongoing research will make the repair of spinal cord injuries possible in the near future. Presently, effective treatments and rehabilitation programs enable a number of people with spinal cord injuries to lead productive, independent lives.

The ability to control your limbs after a spinal cord injury depends on two factors: the place of the injury along your spinal cord and the severity of injury to the spinal cord.

The severity of the injury is often classified as either of the following:

Paralysis as a result of a spinal cord injury may be referred to as:

Emergency symptoms

When to see a docto

A serious injury to the head and neck calls for immediate medical evaluation for the possibility of a spinal injury. It should be assumed that the victim has a spinal injury unless proved otherwise since:

A traumatic spinal cord injury may stem from a sudden blow to the spine that fractures, dislocates, crushes or compresses one or more of the vertebrae. It may also be caused by a gunshot or knife wound that penetrates and cuts the spinal cord.

The most common causes of spinal cord injuries include:

Complications

The areas most often affected include:

Bladder control. While the bladder continues to store urine from the kidneys, the brain may not be able to exercise control because the message carrier (the spinal cord) is injured. This increases risk of urinary tract infections, kidney infections and kidney or bladder stones.
Bowel control. Even though the stomach and intestines work as they did earlier, control of bowel movements is often altered.
Skin sensation. Loss of all or part of skin sensation, means it cannot send a message to the brain when it is affected by things such as prolonged pressure, heat or cold.
Circulatory control. Problems ranging from low blood pressure to swelling of your extremities, may arise. Changes in circulation may also increase risk of developing blood clots, such as deep vein thrombosis or a pulmonary embolus.
Respiratory system. If the abdominal and chest muscles are affected, it may make breathing and coughing difficult.
Muscle tone. Patients may experience one of two types of problems: uncontrolled tightening or motion in the muscles (spasticity) or soft and limp muscles lacking muscle tone (flaccidity).
Fitness and wellness. Patients commonly experience weight loss and muscle atrophy, but restricted mobility may also lead to a more sedentary lifestyle, place you at risk of obesity, cardiovascular disease and diabetes.
Sexual health. Sexuality, fertility and sexual function may be affected. While men may notice changes in erection and ejaculation; women may experience changes in lubrication.
Pain. Muscle or joint pain may be experienced due to overuse of particular muscle groups. Nerve pain can occur in those with an incomplete injury.
Depression. The mental strain of coping with all the changes and living with the pain, may causes some to slip into depression.

On-site care

Slipped vertebrae/ Spondylolysthesis

Spondylolisthesis is when a spinal vertebra slip forward over another vertebra caudal to it. There are different types of the condition, depending on the anatomical changes.

Spondylolytic lysthesis: It is caused when the crack in a pars fracture affects both sides of connection (between the lamina and pedicles). The condition can be a direct result of spondylolysis.

Degenerative spondylolisthesis: Usually seen in elderly age group, this condition is caused by the deterioration of the facet joints and discs of the spine.

Congenital spondylolisthesis: Usually seen in the younger age group, this condition is caused due to birth defects in the bony structure of vertebrae (predominantly pars).

A CT scan may be used to evaluate a pars defect or any bony problems, while an MRI may be useful to assess the surrounding tissue, nerves and condition of the disc.