BACK PAIN - Full extract 

Marika was taking a box of groceries from the boot of her car. Carefully leaning forward, she lifted the box in her outstretched arms. Suddenly she felt something go in the low part of her back. She grimaced in pain, barely able to stand.

Fortunately a neighbour saw her in difficulty. Somehow they hobbled inside and Marika slumped on to a bed. She was still in pain when her husband arrived home from work several hours later. He rang for a home-visit and I saw her after surgery.

Marika's pain and tenderness were localized to her low back, just to the right of her spine. She had an acute muscular back strain, sometimes still referred to as acute lumbago. With simple analgesics her back pain gradually improved over a few days. She was referred to a physiotherapist for exercises and further advice about proper back care.

Back pain is one of the most common symptoms that people see their doctor about. Usually it is a minor problem such as muscular back strain. However, each case has to be carefully assessed. 

A thumbnail anatomy sketch can help us understand how back pain may occur. The vertebral column or spine is like a stack of cotton reels, each one separated by elastic shock-absorbing material called discs. The side pieces of the vertebrae are joined above and below by small facet joints. Running down the back of the vertebrae in a bony canal is the spinal cord which carries nerves to the limbs and other structures. The vertebral column is further stabilized by sheets of muscle. Evolution has not been kind to our backs. Walking on two legs instead of four causes a lot of wear and tear on the spine. 

In front of the upper part of the spine is the thorax which contains the heart, lungs, and major blood vessels. In front of the lower spine is the abdomen, containing organs such as the kidneys, liver, gallbladder, gut and blood vessels. Below this are all the pelvic structures. Disorders in any of these organs can cause severe back pain. When anyone complains of back pain, a careful history and examination is important. 

It is very unusual to see a child with back pain. From adolescence onwards, back symptoms tend to be caused by a combination of poor posture and incorrect lifting. It is so important to keep the back straight and lift with the knees. Lifting while leaning forwards can put enormous strain on the lower back and may cause serious back injuries. 

Acute back pain due to muscle strain or facet joint problems usually settles fully with a brief period of rest and simple analgesics. Physiotherapy may help to settle the symptoms more quickly.  As soon as possible a return to normal activity is encouraged. We now know that early mobilization is the best form of treatment for most back injuries. With severe back pain, a course of anti-inflammatory medication may also be suggested. 

There are many different approaches to the management of back pain, and some people prefer to try other methods such as chiropractic or acupuncture. However, any back pain that persists should always be checked with your doctor. 

Some episodes of severe back pain are due to a disc protrusion. The pressure on the back may be so great that a portion of a lower disc bulges through and pushes on nerves as they leave the spine. It usually produces a searing pain in the low back or buttock and may radiate down the back of the leg towards the foot. This pain is called sciatica . There may also be associated numbness in the lower leg or foot, as well as loss of leg reflexes when they are tested. 

The presence of sciatica means that further investigation and treatment may be required. Plain X-rays of the back may be quite normal. However, a CT scan will usually show a significant disc protrusion if one is present. When sciatic symptoms are very severe or persistent, referral to a specialist may be necessary. If several weeks of rest, anti-inflammatory medication, physiotherapy and other forms of treatment have not been successful, other approaches might have to be considered. This may include spinal epidural injections, or surgery to relieve the pressure on the nerve. 

Another important consideration is the age of the patient. Some conditions such as arthritis and chronic degenerative disc problems are more common in older people. Osteoporosis, with thinning of the bones, may cause a collapsed vertebra and severe back pain. Elderly patients may also have back pain caused by secondary cancer deposits in the spine, for instance in older men with cancer of the prostate. There are features of back pain which suggest there could be a more serious cause; back pain that persists for weeks, or keeps the person awake at night, should always be checked in case further investigation is required. 

With chronic or recurrent back pain, a program of exercises can help to improve posture and take pressure off the lower intervertebral discs. The main emphasis these days is to get the person with the back problem very involved in the treatment plan. Activities such as high-impact aerobics and jogging may cause further back symptoms and should be avoided in people with back problems. In contrast, a swimming program may be very beneficial. 

Health Tip:
* Although there are effective treatments for both acute and chronic back pain, prevention is a much better approach. Many back problems can be avoided altogether.

Dr. Andrew Pattison: Common Consultations
North East Valley Division General Practice, Melbourne, Australia.   Disclaimer
  - Last modified: August 18, 2001