Mechanical Low back ache

This is the most common type of back pain. The majority of cases of sudden-onset (acute) low back pain are classed under this name. This is the type of back pain that most people will have at some point in their lives. It is called mechanical because it is usually not clear what is actually causing the pain. In other words, there is no specific problem or disease that can be identified as the cause of the pain. The severity of the pain can vary from mild to severe.

What is the cause of mechanical low back pain?

Mechanical low back pain means that the pain is not due to any specific or underlying disease that can be found. It is thought that in some cases the cause may be an over-stretch (sprain) of a ligament or muscle. In other cases the cause may be a minor problem with a disc between two spinal bones (vertebrae), or a minor problem with a small facet joint between two vertebrae. There may be other minor problems in the structures and tissues of the lower back that result in pain. However, these causes of the pain are impossible to prove by tests. Majority of pain is there in patients who are having sitting job, lack of exercises and improper diet.

To some people, not knowing the exact cause of the pain is unsettling. However, looked at another way, many people find it reassuring to know that the diagnosis is mechanical back pain which means there is no serious problem or disease of the back or spine.

Disc degeneration due to vitamin deficiency ( Vit B12, Vit D3 ) is also one of the cause for mechanical low back ache .

What are the symptoms of Mechanical low back pain?

Sometimes a pain may develop immediately after you lift something heavy, or after an awkward twisting movement. Sometimes it can develop for no apparent reason. Some people just wake up one day with low back pain.

Although mechanical back pain is sometimes called simple back pain, simple does not mean that the pain is mild. The severity of the pain can range from mild to severe. Typically, the pain is in one area of the lower back but sometimes it spreads to one or both buttocks or thighs. The pain is usually eased by lying down flat. It is often made worse if you move your back, cough, or sneeze. So, nonspecific low back pain is mechanical in the sense that it varies with posture or activity.

Most people with mechanical low back pain improve quickly, usually within a week or so, sometimes a bit longer. However, once the pain has eased or gone it is common to have further bouts (recurrences) of pain from time to time in the future. Also, it is common to have minor pains on and off for quite some time after an initial bad bout of pain. In a small number of cases the pain persists for several months or longer.

1.       Constant dull aching low back ache

2.       Usually not having radiation of pain in lower limbs

3.       Usually not associated with tingling and numbness

4.       Experience pain on sitting rather on standing and walking’

5.       Usually no pain on standing and walking

6.       Sometimes severity of pain increases

What is the treatment for mechanical low back pain?

Keeping active

Continue with normal activities as much as possible. This may not be possible at first if the pain is very bad. However, move around as soon as you are able, and get back into normal activities as soon as you can. As a rule, don't do anything that causes a lot of pain. However, you will have to accept some discomfort when you are trying to keep active. Setting a new goal each day may be a good idea. For example, walking around the house on one day, a walk to the shops the next, etc.

Also, sleep in the most naturally comfortable position on whatever is the most comfortable surface. Advice given in the past used to be to sleep on a firm mattress. However, there is no evidence to say that a firm mattress is better than any other type of mattress for people with low back pain. Some people find that a small firm pillow between the knees when sleeping on the side helps to ease symptoms at night.

If you have a job, aim to get back to work as soon as possible. There is no need to wait for complete freedom from pain before returning to work. Returning to work often helps to relieve pain by getting back to a normal pattern of activity and providing a distraction from the pain.

Medication

If you need painkillers, it is best to take them regularly for short time… This is better than taking them now and again just when the pain is very bad. If you take them regularly the pain is more likely to be eased for much of the time, enabling you to exercise and keep active.

Anti-inflammatory medicines

Muscle relaxant medicines

Physiotherapy

1.     Modalities

2.     Most important is exercises , one should do exercises as advised by physiotherapist , at least twice a day for 20 mins each.

Pain Block – Facet Blocks..

Cervical Spondylosis

Basic Anatomy

The back of the neck includes the cervical spine and the muscles and ligaments that surround and support it. The cervical spine is made up of seven bones called vertebrae. The first two are slightly different to the rest, as they attach the spine to the skull and allow the head to turn from side to side. The lower five cervical vertebrae are roughly cylindrical in shape - a bit like small tin cans - with bony projections.

The sides of the vertebrae are linked by small facet joints. Between each of the vertebrae is a 'disc'. The discs are made of a tough fibrous outer layer and a softer gel-like inner part. The discs act like 'shock absorbers' and allow the spine to be flexible.

Strong ligaments attach to adjacent vertebrae to give extra support and strength. Various muscles attached to the spine enable the spine to bend and move in various ways.

The spinal cord, which contains nervous tissue carrying messages to and from the brain, is protected by the spine. Nerves from the spinal cord come out from between the vertebrae in the neck to take and receive messages to the neck and arms. A major blood vessel called the vertebral artery also runs alongside the vertebrae to carry blood to the rear (posterior) part of the brain.

What is cervical spondylosis?

Cervical spondylosis is an age-related degeneration ('wear and tear') of the bones (vertebrae) and discs in the neck. To an extent, we all develop some degeneration in the vertebrae and discs as we become older. It tends to start sometime after the age of about 30.

One feature of the degeneration is that the edges of the vertebrae often develop small, rough areas of bone called osteophytes. Also, over many years, the discs become thinner. This degeneration is a normal ageing process which can be likened to having 'wrinkles in the spine'. In many people, the degeneration does not cause any symptoms. For example, routine X-rays of the neck will show these features (osteophytes and disc thinning) in many people who do not have any symptoms.

However, in some people, the nearby muscles, ligaments, or nerves may become irritated or 'pressed on' by the degenerative changes. So, cervical spondylosis often causes no problems but can be a cause of neck pain, particularly in older people

What are the symptoms of cervical spondylosis?

If symptoms develop, they can range from mild to severe. Symptoms may include:

·       Pain in the neck:

·       This may spread to the shoulders and base of the skull. Movement of the neck may make the pain worse.

·       The pain sometimes spreads down an arm to a hand or fingers. This is caused by irritation of a nerve which goes to the arm from the spinal cord in the neck.

·       The pain tends to come and go with flare-ups from time to time. You may have a flare-up of pain after unaccustomed use of your neck, or if you sprain a neck muscle or ligament.

·       However, a flare-up often develops for no apparent reason. Some people develop chronic (persistent) pain.

·       Some neck stiffness, particularly after a night's rest.

·       Headaches may occur. The headaches often start at the back of the head just above the neck and travel over the top to the forehead.

·       You may develop 'pins and needles' in part of an arm or hand. This symptom is caused by irritation of a spinal nerve as it leaves the bony (vertebral) area. However, do tell a doctor if loss of feeling (numbness) or weakness develops in a part of a hand or arm. These symptoms suggest more pressure on a nerve. This is called a 'cervical radiculopathy'.

·       sometimes, clumsiness of a hand, problems with walking, or problems with bladder function occur when pressure from a worn bone (vertebra) or disc damages the spinal cord. This is called 'cervical myelopathy'. Again, it is important to report these symptoms to a doctor.

What are the treatments for cervical spondylosis ????

Medicines

Painkillers are often helpful. Should not be used for long time…..

Physiotherapy

1.     Cervical Traction

2.     IFT to neck

3.     Hot packs

4.     TENS to upper limb

5.     Manual therapy

Other treatments

Some other treatments which may be advised include:

·       A good posture may help. Check that your sitting position at work or at the computer is not poor (that is, not with your head flexed forward with a stooped back). Sit upright. Yoga, Pilates and the Alexander Technique all improve neck posture; however, their value in treating neck pain is uncertain.

·       A firm supporting pillow seems to help some people when sleeping. Try not to use more than one pillow.

Pain Block – can be used intermediate pathway for pain relief before surgery if pain doesn’t relives with the help of medicines…

Indications for surgery-  ( Red Flags )

1.       Rarely required

2.       Failed conservative trial for longer duration

3.       Was better for some time after pain block and symptoms again recurred

4.       Weakness in upper limbs

5.       Sever tingling and numbness upper limbs with large disc prolapse in MRI

6.       Difficulty in walking , loss of balance while walking

7.       Difficulty in passing urine and motion

Surgical Options available….

Cervical Fusion Surgery

Cervical Disc replacement surgery

             

Disc replacement surgery

Cervical myelopathy

This occurs when there is pressure on or damage to the spinal cord itself. Again, cervical spondylosis is a common cause of this condition, as the degenerative changes to the vertebra can narrow the canal through which the spinal cord passes. A prolapse of a cervical disc can also cause myelopathy if the prolapse is into the central canal of the vertebra. This may happen suddenly or develop over a period of time. There are various other rare causes of cervical myelopathy. For example, a tumour or infection that affects this part of the spinal cord.

As the spinal cord is made up of groups of nerve fibres carrying messages to the brain from the rest of the body, pressure on these nerves in the neck region can produce symptoms from several parts of the body.

The symptoms of a cervical myelopathy may include:

·       Difficulties with walking. For example, the legs may feel stiff and clumsy.

·       Changes to the sensation of the hands. For example, it may be difficult to feel and recognise objects in the usual way and you may have a tendency to drop things.

·       Problems with your bladder. For example, you may experience problems with emptying your bladder, or incontinence.

·       Needs support while walking like a stick or walker

·       Eventually not able to walk and patient requires either wheelchair or stature..

Prolapsed Intervertebral Disc

Understanding the back

The spine is made up of many bones called vertebrae. These are roughly circular and between each vertebra is a disc. The discs are made of strong rubber-like tissue which allows the spine to be fairly flexible. A disc has a stronger fibrous outer part called annulus fibrosis and a softer jelly-like middle part called the nucleus pulposus.

The spinal cord, which contains the nerves that come from the brain, is protected by the spine/vertebral column. Nerves from the spinal cord come out from between the vertebrae to relay messages to and from various parts of the body.

Strong ligaments attach to the vertebrae. These give extra support and strength to the spine. Various muscles also surround, and are attached to, various parts of the spine.

What is a prolapsed disc?

                        

              When you have a 'slipped' (prolapsed) disc, a disc does not actually slip. What happens is that part of the inner softer part of the disc (the nucleus pulposus) bulges out (herniates) through a weakness in the outer part ( annulus fibrosis )of the disc. A prolapsed disc is sometimes called a herniated disc. The bulging disc may press on nearby structures such as a nerve coming from the spinal cord. Some inflammation also develops around the prolapsed part of the disc.

Any disc in the spine can prolapse. However, most prolapsed discs occur in the lower back (the lumbar spine). The size of the prolapse can vary. As a rule, the larger the prolapse, the more severe the symptoms are likely to be.

Stages of Disc herniation

Causes for slip disc

1)     Heavy weight lift

2)     Sudden bending downwards

3)     Any jerk to back or fall

4)     A job involving lots of lifting.

5)     A job involving lots of sitting (especially driving).

6)     Weight-bearing sports (weightlifting, etc).

7)     Smoking.

8)     Being overweight (obesity).

9)     Increasing age (a disc is more likely to develop a weakness with increasing age)

What are the symptoms of a prolapsed disc?

Back pain

The pain is often severe and usually comes on suddenly. The pain is usually eased by lying down flat and is often made worse if you move your back, cough or sneeze.

Nerve root pain (usually sciatica)

                         

Nerve root pain is pain that occurs because a nerve coming from the spinal cord is pressed on (trapped) by a 'slipped' (prolapsed) disc, or is irritated by the inflammation caused by the prolapsed disc. Although the problem is in the back, you feel pain along the course of the nerve in addition to back pain. Therefore, you may feel pain down a leg to the calf or foot. Nerve root pain can range from mild to severe but it is often worse than the back pain. With a prolapsed disc, the sciatic nerve is the most commonly affected nerve. (The term sciatica means nerve root pain of the sciatic nerve.) The sciatic nerve is a large nerve that is made up from several smaller nerves that come out from the spinal cord in the lower back. It travels deep inside the buttock and down the back of the leg. There is a sciatic nerve for each leg.

Other nerve root symptoms

The irritation or pressure on the nerve next to the spine may also cause pins and needles, numbness or weakness in part of a buttock, leg or foot. The exact site and type of symptoms depend on which nerve is affected.

Cauda equina syndrome - rare, but an emergency

Cauda equina syndrome is a particularly serious type of nerve root problem that can be caused by a prolapsed disc. Commonly caused due to disc prolapse at the last segment of lumbar spine L5-S1. There is central disc protrusion with large base and compressing on cord and nerve roots ( Cauda equine ) .This is a rare disorder where the nerves at the very bottom of the spinal cord are pressed on. This syndrome can cause low back pain plus:

·       Problems with bowel and bladder function (usually inability to pass urine and motion ).

·       Numbness in the saddle area ( Private parts )  around the back passage (anus).

·       Weakness in one or both legs.

                                                           

This syndrome needs urgent treatment to preserve the nerves to the bladder and bowel from becoming permanently damaged. See a doctor immediately if you develop these symptoms.

Treatment

Medications in the form of painkillers and muscle relaxants

Should be used on short term basis , should not be the definitive management.

Physiotherapy in the form of modalities and exercises ….

IFT

TENS

Hot packs

Pain Block

Surgery in the form of Microscopic Discectomy ….

Indications for surgery ….

1)     Failed conservative management

2)     Severity of symptoms

3)     Weakness in lower limbs

4)     Numbness in private parts

5)     Difficulty in standing and walking

6)     Difficulty in urine and motion