Back pain is the most common cause of work-related disability, 80% of people experience back pain at some point in their lives. With increasing sedentary lifestyle and ever-expanding ageing population, back pain has become the most common reason to visit a primary physician and it does not refer to any specific disease, instead, it is a common symptom produced by the variety of underlying processes. For the purpose of patient education, back pain can be divided into three types: Acute back pain, chronic back pain and back pain with red flag signs. Acute back pain refers to sprains or strains of back muscles due to sudden movements or poor body mechanics while lifting heavy objects.
Acute back pain usually settles down within a few days to a week and may require a short course of rest, analgesic/pain medications and physiotherapy. Another category is chronic back pain, which refers to pain which lasts more than 3 months. This group of patients require an evaluation by the doctor, who may ask for some basic tests such as X-Ray or an MRI to identify the cause of back pain.
Mechanical/degenerative or inflammatory diseases are a common cause of chronic back pain and in most instances, they are treated by non-operative measures such as anti-inflammatory medications, physiotherapy and spinal injections and a small number of patients who are not improving with such measures may also require surgical intervention. The third category of back pain is associated with red flag signs which call attention for urgent evaluation by the doctor. Some red flags include:
Fracture: associated with significant trauma or senile osteoporosis or patient on chronic steroid therapy
Spinal infection: back pain associated with fever, urinary infection
Cancer: Patient with a history of cancer treatment or unexplained significant weight loss.
Back pain associated with radicular leg pain.
Cauda equina syndrome: Loss of bladder-bowel control or significant motor or sensory loss or loss of sensations in the buttock.
Back pain developing in children below the age of 15 years or sudden back pain in elderly patients.
Non- surgical: As mentioned earlier, acute back pain is self-limiting managed by a short course of pain medications, physiotherapy and chronic back pain requires evaluation by X rays and MRI if needed and managed accordingly. Majority of them are managed by non-surgical methods such as physiotherapy, spinal injections and adopting a more active lifestyle and habit of daily exercise, yoga or brisk walking. If pain is not settling down, patients may require surgical intervention.
Psychological evaluation: For stress and depression is often required for patients with chronic back pain if all radiological evaluations are negative, as it has been shown to manifest as back pain or at least modulate the chronicity of pain.
Spinal injections-pain management: Useful non-operative armamentarium to manage back pain arises due to Lumbar disc herniation (sciatica/disc prolapse), canal stenosis, sacroiliitis, facet arthropathy.
Surgery: A large number of surgical interventions options are available ranging from traditional open procedures of decompression and fusion to more minimally invasive procedures such as microdiscectomy, endoscopic discectomy, vertebroplasty/kyphoplasty, minimally invasive TLIF, OLIF, XLIF instrumented fusion techniques. More complex procedures such as scoliosis, kyphosis deformity correction or tumour excision depending upon the pathology.
Majority of patients with back pain as mentioned earlier do not require surgery, however, a small percentage of patients eventually require surgical intervention if their symptoms are not settling down with the non-operative measures or if patients found to have red flag signs(most of them). In the 21st century, with better technology and better-trained spine surgeons, the success rate of spine surgery has improved considerably with significantly reduced complication rate. The myth of every patient becoming paralysed or permanently disabled after spine surgery does not hold true in today’s world.
Smoking, obesity, stress, sedentary lifestyle, poor sitting posture are the important risk factors of chronic back pain. Inculcating a healthy and active lifestyle is essential to prevent back pain, which includes no smoking and a habit of daily walking, exercise or yoga to strengthen the back and core muscles.
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