Back Talk

Other than headache, low back pain sends more people to the doctor than any other painful ailment. Around 80% of us will spend some time flat on our back because of back pain--making it one of America's major health problems. It is also a problem that is generally misunderstood.

The misunderstanding starts with the pain itself. Back pain is deceiving. What might feel like a strained muscle may actually be a ruptured disc or a mechanical joint problem. The fact is, you can't tell what's wrong with your back by the pain. That's why so many people get into trouble. They think they're treating one problem when they might be aggravating what is actually wrong. The result--they end up with a much more serious problem than they started out with.

When someone's back starts hurting, it is usually assumed that there is a disc problem. Contrary to popular belief, most back problems are not directly related to the disc alone. And, for the record, THERE'S NO SUCH THING AS A SLIPPED DISC. Discs can be injured and insulted. They can rupture and herniate. But, they never, never slip!

This section briefly answers some of the more commonly-asked questions about low back ailment; explains how problems are identified and treated, and suggests ways to prevent low back problems.

Causes Of Low Back Pain

Why Do I Get Low Back Pain?
The lumbosacral area of the lower spine bears much of the body weight and is a key stress point in body movements, especially bending, lifting and twisting. Most aches and pains in the low back can be attributed to injury, aging, or abnormalities in bone or joint formation of the lower back.

What Are The Common Causes of Low Back Pain?
The most common causes of low back pain are:

• Muscle and ligament problems such as strains, imbalance, dysfunctions, or injuries which may lead to pain and spasm
• Problems associated with the discs themselves such as poor genomics as well as accumulated insult and injury
• Degenerative discs becoming a disease process
• Problems associated with the small alignment joints of the spine called the facets

What Are Muscle Spasms Of The Low Back?
Low back muscle spasms are continuous or interrupted cramps caused by undue stress or injury of muscles and ligaments of the back; their purpose is often to splint or protect a nearby painful nerve, joint, or ligament.

Normally, as the body moves, muscles contract and relax in quick succession. However, when a muscle is overworked or injured it can go into a continuous contraction or spasm as a means of attempting to tell the body to put it to rest and let it recover. The blood vessels that bring it nutrients and carry off waste may constrict. Soon cells in the stricken muscle becomes oxygen-starved and the body calls to the nervous system for help by the production of painful sensations. Often there is a vicious cycle: pain--spasm--more pain--more spasm.

Because spasms often occur in non-muscular (joint, ligament, disc space) injuries, people frequently mistake a mechanical low back or disc problems for a muscle injury.

What Is Mechanical Low Back Pain?
Mechanical low back pain is pain related to certain motions and postures of the back. Often there are abnormal changes, such as weakening of some of the supporting structures of the low back, most especially the pairs of little facet joints or the outer fibers of the disc structure. These changes allow abnormal motion in the joints or disc space and can cause an irritation of the nerves that give feeling to these joints. This may produce severe, usually recurrent, local and radiating buttock/leg pain and reflex spasm in nearby muscles.

What Are Lumbar Discs?
Lumbar discs are the structures which serve as cushions between vertebrae of the spinal column. The center of the disc is normally a clump of soft, slippery, stringy tissue, which is sealed in what seems to be a fibrous, elastic outer rind built rather like the casing of an automobile tire.

What Happens When The Discs Disintegrate?
With age or injury, the inner core of these cushions starts to dry up, causing the tough outer rind to bulge, buckle, separate, or split into layers. Edges of the casing start to pull away from the vertebral bones, and the vertebrae move closer together. There may be a loss in disc height and flexibility. Although this is, to some extent, a natural process of aging and body repair, it can cause serious symptomatic problems.

Disc degeneration often produces growth of new bone along the edges of the vertebrae and the facet joints and is sometimes called "arthritis." These bone "spurs" can cause a narrowing of the space available for the spinal nerves and compression of nearby spinal nerves, possibly resulting in pain, numbness, and loss of strength of certain muscles.

What Is A Herniated Disc?
Herniated discs are commonly misnamed "slipped" discs and can occur from injury, low back loading, or spontaneously when the outer rind of the disc ruptures or herniates and the inside tissue breaks through its boundaries and puts pressure against the very sensitive spinal nerves. The slightest movement--even a laugh, a sneeze, or a cough--can cause excruciating pain that runs into or shocks the leg and foot.

Are There Other Causes Of Disc Problems?
Anything that upsets the structural balance of the back and spine, including abnormal curvature (scoliosis), and poor posture, can lead to disc-related problems. Having one leg that is shorter than the other can cause a tilt in the spine resulting in unequal weight bearing, and may lead to damage of the discs. Any injury or imbalance of the ligaments and muscles which help support the spine can cause abnormal pressure on the disc casing.

What Causes Instability In The Spine?
Sometimes the tough but elastic fibers that make up the outer rind of the disc start to break down from injury, aging, or an inherited tendency. When this happens, the disc and attached bones may start to shift around or wobble. This creates instability in the spine and may be so painful as to require a bone-to-bone fusion. Deterioration of the little alignment joints of the spine may produce painful instability; it can also occur as a result of a fracture of the bony connection of the facets to the supporting vertebral body.

Does Extra Weight Cause Back Pain?
If you are overweight, it is almost certain that there is excess loading on your lumbar spine. It is extremely important for overweight individuals with low back pain to undergo weight loss as the first part of a treatment program. Excess weight also leads to a thinning of the abdominal muscles which are so important in maintaining strength of the body trunk.

How important is Exercise?
Exercise is one of the most important things a person can do to maintain good health as well as good spine health. At the very basic level walking and swimming (particularly aquatic aerobic exercise programs) as well as stabilization exercises, stretching and spine distraction (daily) are the keys to a healthy back. The next most important thing is to be a non-smoker.

What Is Failed Back Surgery Syndrome?
Failed Back Surgery Syndrome exists when multiple back operations have produced no improvement in back or leg pain and no recovery of function. Often there can be progressive incapacitation and even further loss of function.

DIAGNOSING THE PROBLEM
How Is The Problem Diagnosed And Confirmed?
The patient's clinical history (the story about what has happened) is invaluable in determining the general or specific nature of the problem and what has produced it. A careful assessment of the patient's complaints provides important clues to differentiate soft tissue, muscle, or ligament problems from spinal nerve compression, or from mechanical or joint syndrome.

Next to the clinical history, the physical and neurological/orthopedic examination is of key importance in determining the actual nature and extent of the problem. The use of a patient questionnaire is also of significant value.

What Other Diagnostic Techniques Are Used?
The patient's clinical history (the story about what has happened) is invaluable in determining the general or specific nature of the problem and what has produced it. A careful assessment of the patient's complaints provides important clues to differentiate soft tissue, muscle, or ligament problems from spinal nerve compression, or from mechanical or joint syndrome.

Next to the clinical history, the physical and neurological/orthopedic examination is of key importance in determining the actual nature and extent of the problem. The use of a patient questionnaire is also of significant value.

What Other Diagnostic Techniques Are Used?
There are several techniques used today to evaluate back problems, including selective injections, discography, myelography, electromyography, regular x-rays, CT scans, and magnetic resonance imaging.

Sometimes a combination of these is used, such as a CT scan following the injection of a small amount of myelogram dye into the spine. An example of the diagnostic methods used to determine if a problem is being caused by instability might include a trial period using a brace, special x-rays made while the patient bends forward or backward (flexion/extension), the CT scan, and discography.

What Is A Myelogram?
A myelogram is a diagnostic test in which a special substance that has an opaque appearance on x-ray film is injected into the spinal fluid, after which x-ray films are taken. This test shows irregularities or defects of the spinal canal or spinal nerves and is helpful in diagnosing herniated discs and spinal tumors, as well as differentiating scar tissue inside and outside the canal from other problems. To avoid future problems, the dye used should be water soluble as opposed to oil based.

What Is A Regular X-ray Of The Spine?
This is the simplest of diagnostic tests; it requires no special preparation or injections. An x-ray is taken in projection front to back, from the side and/or an angle. Information obtained is limited, but it does help to reveal bony structures, congenital anomalies, fractures, degenerative changes, destructive lesions, loss of disc height, malalignments, etc.

What Is A Discogram?
This procedure involves injection of the disc space with saline (salt water) and an x-ray dye to determine the structural integrity of and the presence or absence of painful changes in the disc.

What Is A CT Scan?
The computerized tomographic (CT) scanner and its attached computer interpret x-ray shadows and print cross-sectional pictures of the spine. The final result looks like a tree trunk cut in slices to show its rings and scars. The CT scan provides a much more detailed picture of the spine than does the regular x-ray or myelogram, and has dramatically increased the physician's ability to make a more accurate diagnosis, provide appropriate treatment, and assess treatment results. Newer scans even have the ability to image the spine in three dimensions!

What Is Magnetic Resonance Imaging?
MRI is an advanced form of imaging which uses magnetic rather than x-ray energy to create the image. High-resolution MRI has proven itself to be powerful non-invasive tool in helping to diagnose disc, muscle, and nerve tissue problems of the spine. MRI has now essentially replaced most other invasive diagnostic means.

TREATMENT FOR LOW BACK PAIN
What Are Some Non-Surgical Treatment Methods?
For many patients, management of their back problems is achieved through a low back education program, weight control, therapeutic swimming, and specialized physical therapy including custom exercise programs and proper body mechanics and dynamics. Bed rest, short-term use of back supports, and limited amounts of non-narcotic medications are often helpful.

What Is Spinal Distraction?
Safe and controlled spinal distraction, performed on a daily basis has shown itself to be a very effective means of treating patients with disc herniations who are not immediate surgical candidates. Distraction can serve as effective therapy but it is also an important means of maintaining good spine health and in preventing future disability in those identified (at an early age) as having genomic problems.

When Is Surgery Indicated?
SA surgical procedure is considered only after conservative treatment measures have failed or been decided against due to the presence of significant nerve deficit such as numbness, loss of strength, loss of bowel or bladder function or reflexes used in sexual function.

What Are Some Of The More Commonly Performed Minimally Invasive and Surgical Procedures?

• Injections and Blocks
• Discectomy ("laminectomy")
• Laminectomy is a surgical procedure in which the portion of the vertebra called the lamina is either partially or completely removed. Discectomy is the surgical removal of displaced tissue from the center of a herniated and degenerated disc. The entire annulus, the outer ring, is not removed. In laminectomy and discectomy, tissue is removed through an open incision by the use of surgical instruments. The object of a discectomy is to remove the displaced disc tissue which is pressing against the spinal nerves.
• Lumbar Decompression
• This is the surgical procedure for removal of portions of bone from the affected lumbar vertebra(e) and excision of degenerated disc. The object of a lumbar decompression is to free the spinal cord and nerve roots from the overgrown bony structures of the spine.
• Stabilization (fusions)
• Lumbar fusion is a surgical procedure which involves the placement of bone between unhealthy segment(s) in the low back to reduce abnormal motion, thereby addressing certain symptoms of low back/leg pain. The objective of surgically joining two or more vertebrae is to provide stability.

PREVENTING LOW BACK PAIN

What Exercises Are Best?
Therapeutic swimming (aquatic aerobic exercises), which differs from recreational (laps) swimming, is one of the best-all-around exercises for your back. Other good exercises include hiking, brisk walking (not jogging), stretching, and gentle sit-ups with the knees bent. Some people need to work on flexibility of the spine and legs, whereas other people need to work on strengthening, and still others need to work on a combination of stretching and strengthening, so it is difficult to prescribe an exercise program without knowing your specific needs.

The following is a list of Do's and Don'ts in exercising the back for the general population.

DO'S
• Stretch and warm up before exercising.
• Stretch again after exercising.
• Do those exercises that are specific for your type of activity and back problem and your pattern of pain.
• Maintain good posture.

• Don't do standing toe touches (standing and reaching down to touch your toes or to touch your toes and to touch the floor).
• Don't do straight leg raising exercises (lying on your back and raising both legs up off the floor). Generally, this increases the arch in the lower back and, for some people, can cause considerable discomfort.
• Don't do straight-legged sit-ups, as the abdominal muscles are not worked maximally.
• Don't do alternate standing toe touching (reaching and touching the opposite toe and thus forward bending and rotating the body at the same time).
• Don't bounce when stretching.
• Don't do rotation and twisting type exercises.
• Don't hold your breath while exercising.

W"Get Back To An Active Life"
Institute for Low Back and Neck Care is one of the world's leading full-service low back care centers, specializing in "problem" backs and innovative conservative care programs.

Comprehensive services range from evaluation and treatment of first-time acute low back problems to the rehabilitation of persons who have undergone unsuccessful surgery.

Through our strong commitment to conservative care programs, we offer new approaches for the management of low back problems. Our continuing research is geared toward the prevention of back problems through patient education and individualized back wellness programs.

If you wish more information on low back problems, see your physician or contact the Institute.