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BACK PAIN

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The human spine is very complex, so it can be difficult for a doctor to pinpoint the exact cause of low back pain or other symptoms. In addition, other factors like depression, anxiety, or stress can contribute to the onset of back pain.

 

Below are some common spinal conditions.

Degenerative Disc Disease (DDD)
Herniated Disc
Osteoporosis
Spondylolisthesis
Stenosis
Spinal Fractures

Any patient suffering from back pain or radiating leg pain should be examined by a doctor. The history of the pain and any activities that may have triggered your symptoms are important factors in diagnosis and treatment.

Degenerative Disc Disease (DDD)

Degenerative disc disease (DDD) is part of the natural process of growing older. Unfortunately, as we age, our intervertebral discs lose their flexibility, elasticity, and shock absorbing characteristics. The ligaments that surround the disc called the annulus fibrosis, become brittle and they are more easily torn. At the same time, the soft gel-like center of the disc, called the nucleus pulposus, starts to dry out and shrink. The combination of damage to the intervertebral discs, the development of bone spurs, and a gradual thickening of the ligaments that support the spine can all contribute to degenerative arthritis of the lumbar spine.

Learn about a clinical trial for back pain.

Degenerative disc disease is as certain as death and taxes, and to a certain degree this process happens to everyone. However, not everyone who has degenerative changes in their lumbar spine has pain. Many people who have "normal" backs have MRIs that show disc herniations, degenerative changes, and narrowed spinal canals. Every patient is different, and it is important to realize that not everyone develops symptoms as a result of degenerative disc disease.

 

 

 

When degenerative disc disease becomes painful or symptomatic, it can cause several different symptoms, including back pain, leg pain, and weakness that are due to compression of the nerve roots. These symptoms are caused by the fact that worn out discs are a source of pain because they do not function as well as they once did, and as they shrink, the space available for the nerve roots also shrinks. As the discs between the intervertebral bodies start to wear out, the entire lumbar spine becomes less flexible. As a result, people complain of back pain and stiffness, especially towards the end of the day.

Symptoms
The most common symptom of degenerative disc disease is back pain. When DDD causes compression of the nerve roots, the pain often radiates down the legs or into the feet, and may be associated with numbness and tingling. In severe cases of lumbar DDD, where there is evidence of nerve root compression, individuals may experience symptoms of sciatica and back pain, and sometimes even lower extremity weakness.

 

 

The physical therapist also works with the physician to determine if other types of treatments including ultrasound, heat, diathermy, transcutaneous electrical nerve stimulation (TENS), electrical stimulation, hydrotherapy, massage or spinal manipulation may be indicated.

Herniated Disc

Herniation describes an abnormality of the intervertebral disc that is also known as a "slipped," "ruptured," or "torn" disc. This process occurs when the inner core (nucleus pulposus) of the intervertebral disc bulges out through the outer layer of ligaments that surround the disc (annulus fibrosis). This tear in the annulus fibrosis causes pain in the back at the point of herniation. If the protruding disc presses on a spinal nerve, the pain may spread to the area of the body that is served by that nerve. Between each vertebra in the spine are a pair of spinal nerves, which branch off from the spinal cord to a specific area in the body. Any part of the skin that can experience hot and cold, pain or touch refers that sensation to the brain through one of these nerves. In turn, pressure on a spinal nerve from a herniated disc will cause pain in the part of the body that is served by that nerve.

Four Degrees of Disc Herniation:
Nuclear Herniation, Disc Protrusion, Nuclear Extrusion, and Sequestered Nucleus

 

Most disc ruptures will occur when a person is in their thirties or forties when the nucleus pulposus is still a gelatin-like substance. Oddly enough, most disc herniations will occur in the morning. The causes of this phenomenon are not entirely known, but are probably due to the physiology of the spine and the changes in the water content of the disc that occur throughout the day. The two most common locations for a herniated disc in the lower back are at the disc between fourth and fifth lumbar vertebra (L4-5) and at disc between the fifth lumbar vertebra and the first sacral vertebra (L5-S1). These two discs account for 98 percent of all painful disc herniations. A herniated disc can occur elsewhere along the spine, but low lumbar herniations are by far the most common.

Symptoms
Usually a patient's main complaint is a sharp, cutting pain. In some cases there may be a previous history of episodes of localized low back pain, which is present in the back and continues down the leg that is served by the affected nerve. This pain is usually described as a deep and sharp pain, which gets worse as it moves down the affected leg. The onset of pain with a herniated disc may occur out of the blue or it may be announced by a tearing or snapping sensation in the spine that is thought to be the result of a sudden tear of part of the annulus fibrosis.

 

Abnormalities in the strength and sensation of particular parts of the body that are found with a neurological examination performed by a doctor provide the most objective evidence of nerve root compression. There are no laboratory tests that can detect the presence or absence of a herniated disc, but they may be helpful in the diagnosis of unusual causes of nerve root pain and irritation. An EMG or electromyographic test may help to determine which nerve root in particular is being pinched or is not working normally in the situation where several nerve roots may be involved. An MRI is the test of choice for diagnosis of a herniated disc, but a CT scan (CAT scan) may often be helpful because it provides better visualization of the bony anatomy of the spinal column, indicating where the source of pressure on the nerve root is located.

 

Treatment

Depends on stage of herniation. Very early stage Nucleoplasty. If more of herniation Percutaneous laser decompression if it is still more Microlumbar disectomy is advised.

Spondylolisthesis

 

 

 

Spondylolisthesis occurs when one vertebra slips forward on the adjacent vertebrae. This will produce both a gradual deformity of the lower spine but also a narrowing of the vertebral canal. It is often associated with pain.

Symptoms
The most common symptom of spondylolisthesis is low back pain. Many times a patient can develop the lesion (spondylolysis) between the ages of five and seven and not present symptoms until they are 35-years-old, when a sudden twisting or lifting motion will cause an acute episode of back and leg pain.

 

Usually the pain is relieved by extension of the spine and made worse when flexed. The degree of vertebral slippage does not directly correlate with the amount of pain a patient will experience. Fifty percent of patients with spondylolisthesis will associate an injury with the onset of their symptoms.

In addition to back pain, patients may complain of leg pain. In this situation, there can be associated narrowing of the area where the nerves leave the spinal canal that produces irritation of a nerve root.

Diagnosis
Many patients with spondylolisthesis will have vague symptoms and very little visible deformity. Often, the first physical sign of spondylolisthesis is tightness of the hamstring muscles in the legs. Only when the slip reaches more than 50 percent of the width of the vertebral body will there begin to be a visible deformity of the spine.

There may be a dimple at the site of the abnormality. Sometimes there are mild muscle spasms and usually some local tenderness can be felt in the area. Range of motion is often not affected, but some pain can be expected on hyperextension. Laboratory test results are normal in patients with one or both disorders.

Plain roentgenograms of the lumbar spine are best initial X-rays for diagnosing spondylolysis or spondylolisthesis. Spondylolisthesis is most easily seen on the lateral view of the spine, but in some cases specialized imaging studies such as a bone scan or CT scan (CAT scan) are needed to make the diagnosis. Patients with a dysplastic pars have an elongated interarticular region along with altered pedicles. This is usually best visualized by CT scan.

A spondylolisthesis is graded according to the amount that one vertebral body has slipped forward on another. A grade I slip means that the upper vertebra has slipped forward less than 25 percent of the total width of the vertebral body, a grade II slip is between 25 and 50 percent, a grade III slip between 50 and 75 percent, a grade IV slip is more than 75 percent, and in the case of a grade V slip, the upper vertebral body has slid all the way forward off the front of the lower vertebral body. This is a special situation that is called a spondyloptosis.

Differential Diagnosis
The diagnosis of spondylolysis is confirmed by the discovery of a pars defect on a lateral X ray and spondylolisthesis is confirmed by noting the forward position of one vertebral body on another.

Flexion and extension views of the lumbar spine may help to identify the presence of instability of the spine. This subtle movement may be an important part of the pain experienced and be essential to the planning for further treatment.

Treatment
The conservative non-surgical treatment for spondylolysis and spondylolisthesis is most commonly rest, followed by trunk and abdominal strengthening exercises. A physical therapist is often helpful in getting you back on your feet and can instruct you in the proper way to do these exercises without exacerbating your symptoms. If there is significant leg pain, patients can also take an anti-inflammatory medication. Braces are rarely indicated but may be helpful in reducing symptoms.

For patients with spondylolysis, surgery to repair the defect in the pars intra-articularis is indicated only after non-operative measures such as physical therapy and exercises have failed to relieve symptoms. In younger patients, surgery may be used to directly repair the pars defect; in older patients or in those with some degree of instability, a fusion may be required.

If you have spondylolisthesis with the slippage greater than 50 percent of the width of the adjacent vertebral body, then a fusion is required to stop further slippage and provide relief from the associated symptoms of instability and nerve root irritation. Surgeons using a technique called a "fusion in-situ" can do this. What this means is that the surgeon will fuse the two abnormal vertebra together to prevent further slippage, but no attempt will be made to bring the vertebrae back into their original alignment.

Back Pain Treatment Self-Care at Home

General recommendations are to resume normal, or near normal, activity as soon as possible. However, stretching or activities that place additional strain on the back are discouraged.

Sleeping with a pillow between the knees while one side may increase comfort. Some doctors recommend lying on your back with a pillow under your knees.

No specific back exercises were found that improved pain or increased functional ability in people with acute back pain. Exercise, however, may be useful for people with chronic back pain to help them return to normal activities and work.

Stenosis

 

 

Lumbar spinal stenosis is a disease that is caused by a gradual narrowing of the spinal canal. This narrowing happens as a result of the degeneration of both the facet joints and the intervertebral discs. In this condition, bone spurs, called osteophytes, which develop because of the excessive load on the intervertebral disc, grow into the spinal canal. The facet joints also enlarge as they become arthritic, which contributes to a decrease in the space available for the nerve roots. The ligaments of the spinal column, especially the ligamentum flavum, become stiff, less flexible, and thicker with age, which also contributes to spinal stenosis. These processes narrow the spinal canal and may begin to impinge and put pressure on the nerves roots and spinal cord, creating the symptoms of spinal stenosis.

Stenosis may occur in the central spinal canal (central stenosis) where the spinal cord or cauda equina are located, in the tract where the nerve root exits the central canal (lateral recess stenosis) or in the lateral foramen (foraminal stenosis) where the individual nerve roots exit out to the body.

Some distortion of the spinal canal will occur in virtually every person as they age, but the severity of the symptoms will depend on the size of a person's spinal canal and the encroachment on the neural elements. The rate of deterioration varies greatly from person to person, and not everyone will feel symptoms.

Spinal stenosis may be caused by a number of processes that decrease the amount of space in the spinal canal available for the neural elements. Degenerative causes are the most common, but there are a few unusual causes of stenosis. These include calcium pyrophosphate crystal deposition, amyloid deposition, and intradural spinal tumors. The reason why stenosis causes weakness and pain is the subject of a significant amount of debate and medical research. Pain in the buttocks or leg, which is a common symptom of lumbar spinal stenosis, may be associated with the compression of the micro-vascular structures carrying blood flow to the nerve roots. At the same time, the symptoms of spinal stenosis may be the direct result of physical compression of the nerve roots. Each of these processes may interfere with the normal function of the nerve roots and decrease the effectiveness and endurance of the spinal nerves.

 

Symptoms
Some people with degenerative disease of the lumbosacral spine may be totally asymptomatic, some may complain of mild discomfort in the low back, and others may not even be able to walk. In patients who have significant spinal stenosis, they will begin to notice pain in the buttocks, thigh or leg that develops with standing or walking, and improves with rest. In some cases, a patient will complain of leg pain and weakness without having any back pain. More severe symptoms of the disorder include numbness, paresthesias and weakness in the lower extremities. Certain positions can alleviate the symptoms of spinal stenosis by increasing the amount of space available for the nerves. These positions usually involve flexion of the lumbar spine and bending forward. "Any positions that flex the lumbar spine are associated with resolution of symptoms." * For instance, patients with spinal stenosis can ride a bike and walk up an incline or flight of stairs without any pain. They can often walk for extended distances if they have something to lean on, like a shopping cart. However, if they are walking down an incline or flight of stairs, or if they have to give up the shopping cart, their symptoms will often reappear.

 

The presentation and severity of the symptoms of spinal stenosis depends on the several factors, including the original width of the spinal canal, the susceptibility of the nerves involved, and the unique functional demands of the patient and the pain tolerance of each individual patient.

Diagnosis
The diagnosis of spinal stenosis begins with a complete history and physical examination. The doctor will determine what symptoms are present, what makes them better or worse, and how long they have been present for. A physical examination is essential for determining how severe the condition is, and whether or not it is causing weakness or numbness in certain parts of the body. Abnormalities in the strength and sensation of particular parts of the body that are found with a neurological examination provide the most objective evidence of chronic nerve root compression caused by spinal stenosis. There are no laboratory tests that can detect the presence or absence of a stenosis, but they may be helpful in the diagnosis of unusual causes of nerve root and spinal cord dysfunction. Routine radiographs of the lumbar spine are very helpful in determining the amount of degeneration that is present in the spine, which gives an indirect indication of whether or not spinal stenosis is present. These x-rays are also used to determine if certain parts of the spine are unstable, which may be contributing to the symptoms of stenosis.

A CT scan (CAT scan) provides excellent visualization of the bony anatomy of the spinal column and is an indispensable tool for determining where the stenosis is located. This test is often performed in conjunction with a myelogram, which involves injecting dye into the space occupied by the spinal cord and nerve roots, in order to determine how well the cerebrospinal fluid is able to travel along the nerve roots. An EMG or electromyographic test may help to determine which nerve root in particular is not working normally in the situation where several nerve roots may be involved.

More than 1.3 million osteoporosis-related fractures are reported in the United States each year. Click here to read tips on maintaining a healthy bone mass.

Osteoporosis is a condition in which the skeleton contains a smaller total quantity of bone tissue than normal for the age, sex and culture of the patient. Skeletal growth usually peaks at about age 20 and by age 65, most people have lost 30 percent of the bony tissue they had at their peak of skeletal maturity. Because of this, osteoporosis is described medically as a phenomenon rather than a disease or pathologic condition.

A person with osteoporosis has a less than normal amount of bone tissue for their age, sex and culture in addition to a clinical disability, often in the form of consequent vertebral compression fractures, which occur spontaneously or as a result minor incidents that would not harm the average person.

Therefore, if a person has an osteoporotic skeleton without having the associated clinical disabilities, the patient may have some other medical problem. "The significance is that the medical disease, not the skeleton, needs treatment."

 

 

Diagnosis
Ordinary X-ray views of the spine can reveal the osteoporosis. In addition, a patient may reveal a history of fractures following minor trauma and may complain of disability because of skeletal pain.

Fractures

Compression Fractures
The most common types of fractures affecting the low back are compression fractures which usually result from a fall. They can be diagnosed with an x-ray. With most compression fractures, bed rest, physical therapy and conservative medical care is effective. However, there is a small chance that the compression fracture could be caused by a secondary medical condition. Usually your physician will give you a thorough neurological and physical exam in order to rule out osteoporosis or malignancy.

 

Burst Fractures
Burst fractures usually occur through a violent compressive load resulting in failure of both the anterior and middle columns of the vertebrae. In this case vertebral height is significantly decreased. This fracture is considered unstable and requires immediate stabilization of the body and medical attention.

 

Flexion/Compression Fracture
Flexion and compression fractures frequently occur at the T1 and L1 levels. The amount of anterior column failure depends on the amount of compressive force. Usually there is some loss of vertebral height with this injury, but as long as the middle and posterior columns are intact, this fracture is considered stable.

 

Flexion/Distraction Fracture
This type of fracture is also known as a chance fracture, and is often caused by seat belts in cars. In this fracture, all three columns of the vertebral body can fail and there may be injury to bone, ligaments and discs. An interior subluxation is often encountered. This fracture is considered unstable and required immediate stabilization of the body and medical attention.

 

 

Compression/Torsion/Translational Fractures
Usually coupled together with or without flexion. Compression effects can occur on the lateral margins of the vertebral body while torsional and translational forces may affect the body or disc and ligament structures.

 

Surgical treatment

Vertebroplasty may be a boon in these cases.

 

 

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