Indian Journal for the Practising Doctor

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Low Backache
Author(s): FarooqFazilli, MD* Vol. 2, No. 2 (2005-05 - 2005-06) In olden days, it was very easy for a practitioner to diagnose acute lumbago, fibrositis or a sprain of the ligament of the spine, etc. The patients could be convinced and were happy about the diagnosis. Modern research work has shown that many of these patients are cases of lumbar disc disease. If the doctor pronounces 'disc' disease in every case, the patient's symptoms can multiply two to three fold. This is because of the fear that the layman attaches to a 'disc disease'. To make things more complicated, in majority of the normal persons above the age of 30 years, X-rays will show some evidence of 'disc disease'. It has also been shown in some studies that the exacerbation of the pain is not due to increased prolapse of the disc, but lowering of the pain threshold by depression, anxiety and other psychological factors. Many practitioners have tendency to treat the X-rays of the lumbar spine and not the patients. They fail to realize that these X-ray changes will not disappear. In 80% of the cases seen in private practice, the X-rays do not represent the disease. X-rays only exclude rare diseases like tuberculosis, ankylosing spondylitis, spondylolisthesis, mechanical instability, osteoporosis or secondary deposits. It is also a wellknown fact, that in the disc disease the X-rays of the spine can be absolutely normal. Only a CT or MRI Scan, which is a 'major' investigation, may show a prolapsed disc. Therefore, the practitioner becomes dependent on the patient's explanation of the severity of the pain. It has been seen that a patient may be absolutely free from pain after a "manipulation" done by a quack. This has happened on a number of occasions. Many modern allopathic specialists have also tried manipulation as a treatment with success. Unfortunately, there is difference of opinion amongst orthopedic surgeons regarding manipulation treatment. Usually such patients of backache and disc disease, with or without sciatica, are getting large doses of various analgesics along with vitamins. It should be remembered that vitamins have no role to play in this disease. The most common causes of backacke are: 1. 2. 3. 4. 5. 6. Sprain of the spinous ligament or fibrositis. Mechanical instability of L5 and S1 vertebrae or lumbo-sacral strain. Postural backache. Anxiety and depression. Backache in females - due to Gynae causes or Osteomalacia. Disc syndrome.

In a young patient, TB spine and ankylosing spondylitis must be excluded. TB spine is curable condition. If suspected, additional investigations for tuberculosis must be done in order to classify the disease properly and treat them as well. MRI may clinch the diagnosis.

Ankylosing Spondylitis.
Also commonly known as Spondylo-arthropathy, can ruin the future of a bright , enthusiastic student and young achiever. There is no cure for this disease, although it is not lethal but it leads to severe deformity of the spine. The whole back becomes curved forward permanently. The life history of this disease is like frozen shoulder. As the severity of the pain goes on reducing, the stiffness and the deformity of the spine go on increasing. The stiffness will cause reduction in the pain and the patient does not complain of severe pain any more. The diagnosis can be made easily by taking the X-rays of both the sacroiliac joints, which show the earliest changes. 'Isotope Bone Scan', if available, is more useful here. ESR is markedly raised. Thus a young man, complaining of chronic low sacral backache, inability to bend down to touch the toes, early morning back stiffness lasting for an hour or more and having a markedly raised ESR is possibly suffering from ankylosing spondylitis. A young man, complaining of chronic low sacral backache, inability to bend down to touch the toes, early morning back stiffness lasting for an hour or more and having a markedly raised ESR is possibly suffering from ankylosing spondylitis. In old people, osteoporosis and secondary deposits should be excluded. Fortunately most of the times (though not always), X-rays can exclude secondary deposits. But osteoporosis is very difficult to diagnose on X-rays unless compression fractures are also present. Osteomalacia, which is now known to be quite common in old age, can also look like osteoporosis on the Xrays of the spine. Few injections of vitamin D and calcium must be given to all old patients while continuing to treat their backache as due to 'disc' disease, which is the most common 'disease' at that age. Majority of menopausal females have some degree of osteoporosis.

Common Causes of Low Backache

1. In young and middle-aged men with low backache, there are often tender spots in the midline in the lower spine. These tender areas are due to strain of posterior spinal ligaments. Fibrosis, which is more common in females, also produces tender spots in low back, but these are usually not in midline. All above patients respond well to local heat, liniments, application of belladonna plaster( which should not be removed for 4-5 days) and mild analgesics 2. Mechanical instability between L 5 and S 1 (best diagnosed by X rays taken in extreme flexion and extension), spondylolisthesis and lumbosacral sprain are also similar illnesses. These patients are young, and in addition to low backache, may complain of deep pain referred to both the thighs (bilateral "sciatica" is rare). Their pains are not increased by coughing and sneezing. The straight leg raising sign is absent. These

patients need assurance that they have no 'slipped disc'. Most of the patients respond to rest and spinal support given by lumbo sacral belt. A course of short wave diathermy or local heat and analgesics is also useful. Later on, back exercises can be taught to the patient. 3. Postural backache is extremely common in school and college children where the writing desks are not made with good angles. Also people sitting on the chair, where the backs are not straight often develop this pain. People with backs bent and obese people with protruding tummies also develop postural backache. Some people have a faulty posture while standing and walking (Fig. 1). Correct posture should be practiced in the office and schools. Chairs with straight backs should be used with proper angle for the table and desk to avoid excessive bending (Fig: 2).

Fig (1)

Fig (2) A): Normal Posture B): Abnormal Posture 1. Anxiety and depression are some of the most common causes of low backache seen in practice. Unfortunately the routine X-rays show some changes and these patients are branded as cases of osteoarthritis or spondylosis. Low backache is also commonly complained of by male patients with history of frequent masturbation, nocturnal emissions, and impotence. In females, low backache is due to the worry of leucorrhoea and not due to true gynaecologic causes. Similarly, patients of depression often complain of low backache in addition to other symptoms which must be spotted in order to avoid diagnosing such a case as chronic disc disease. Such patients of chronic backache do not respond to analgesics. Sedatives and anti-depressant drugs give better response. Fear of disc disease should be removed from the minds of these patients. 2. Backache in females: Most of the time gynaecologic causes have been over emphasized. Backache due to 'Gynae' causes is rare, although endocervicitis and leucorrhoea can cause low backache. All 'Gynae backaches' are sacral and are felt below the region of L5 vertebra (below the level of the iliac crest). Rarely, retroverted uterus or some pelvic tumors may also cause backache. Osteomalacia is also one of the causes of backache in females; these backaches are felt in the lumbar spine, the pelvis and both the thighs. They are so common that all female patients during the childbearing age should receive vitamin D and ca1cium 3. Disc disease of the lumbar spine: For practical purposes, slipped disc, intervertebral prolapsed disc, osteoarthritis of the lumber spine, lumber spondylosis, osteoarthrosis, and degenerative diseases of lumber spine are all different stages in the life cycle of same disease The price that the man has to pay for the erect posture is the wear and tear of the disc - specially of the lumbar spine. This usually starts after the age of 20 or 30 years. Sitting in the chair that has no straight back, bending down for gardening, cooking while standing, bending down by flexing the spine and not the knees, are all factors which

hasten this disease. People who have a good tone of the abdominal muscles, who swim or do the exercise of "push ups" are less likely to develop this disease at an early age. (Fig. 3)

Fig (3) Symptoms: The main symptom is low backache which increases on bending down. Often it increases on coughing and sneezing. Sometimes there is an acute attack of sudden, severe, backache, after lifting a heavy weight. By the time the complication of sciatica (with the pain radiating to one leg) occurs, it is a "spot diagnosis". (Radiation to both legs is rare). Signs: On examination, the lower back is held stiff, the normal lumbar curve has disappeared and the lumbar spine appears flat. Scoliosis may also be present at this area. The patient cannot bend down to touch his toes. Tenderness may be elicited at the site of affected disc. The diagnosis is made from the above history, symptoms and signs. X-rays are not necessary unless one want to exclude other diseases. Treatment: It is doubtful whether pain-relieving tablets should even be given to these patients! This is because their spine needs rest. If you remove the symptom of pain, the patient bends and damages the spine further. Possibly the symptom of pain warns the patient and reminds him not to bend more! Rest is the most important treatment. In very acute cases, complete rest in the supine position, on a hard bed or a hard mattress put on the wooden boards, must be advised. It is wrong to continue to sleep on a Dunlop or soft mattress, often with a few pillows under the spine and feet, under the soothing effect of strong analgesics and sedatives given by the doctor. More severe the pain, more 'strict' should be the bed rest. For severe pain, pelvic traction can be tried at home (Fig. 4). This traction can be given for a few hours everyday. Unless strict bed rest with pelvic traction is tried for two weeks, operations are the last resort and can be postponed especially if there is no complication of sciatica.

Fig (4) The concept of bed rest in patients with acute backache is being doubted. According to modern trends, bed rest is advised upto 1-2 days, unless they have sciatica. Since it is only the back, which needs rest, it can be achieved by using a lumbo-sacral belt and the patient is allowed to resume his normal activities as early as possible. Even the concept of pelvic traction for backache has few followers. Instead, with the help of an interventional specialist, an epidural injection can be given. Back exercises should start after the pain disappears.

In a chronic case, change over to hard bed permanently (or putting wooden boards under a firm mattress) is the first advice. In order to bend, the patient must flex the knees and not the spine. (Fig. 5) Local heat or a course of short-wave diathermy is often useful. Wearing a lumbosacral belt would prevent the patient from bending without his knowledge. These belts should not be worn for more than two or three months, for fear of loss of the tone of the back muscles. These patients must be advised to continue 'back exercises' permanently, in order to avoid future relapses. An assistant can explain the photographs showing the exercises to the patient (Figs. 67). In the office and the house, the patient only should use all chairs with a straight back. He should avoid sitting on armchairs, sofas or couches.

Fig. (5)

Fig. (6): Patients being taught simple back exercises.

Fig. (7): Other back and trunk exercises, which may also be performed, if possible. Local liniments and belladonna plaster are very helpful. Massage by a good masseur may be helpful. Manipulation by an expert may be tried in stubborn cases. Gardening, driving a car or working in a factory should be done with a lumbo-sacral support. Lifting heavy handbags should be avoided. Obese patients must be made to lose weight. This is a good opportunity for fat people to diet. Otherwise, in the long run, suffering becomes more as the lumbar spine ultimately has to bear all the weight in the upright position: If possible, swimming should be made as a permanent hobby. Finally, drugs are least important in the treatment. Analgesics and tranquillizers may be prescribed depending on the severity. Vitamins or calcium have no role to play in this disease. FarooqFazilli, MD Faculty Member, Regional Institute of Health, Kashmir, India .