Low Back Pain and Sciatica

Structure of the lumbar spine

The spinal column is made of bones, intervertebral discs (cushions in the spine), facet joints (much like joints of the hips and knees) and ligaments. These structures protect the spinal cord and nerves situated within the spinal canal (space behind the vertebral body). There are a number muscle attachments to the spinal column. These muscles provide support to the spinal column as well as aid in movement of the spine.

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Figure: The spinal column comprising of bones, discs and ligaments

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Figure: Spinal canal is the space inside the spinal column in which lies the spinal cord and nerves

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Figure: Some of the muscle attachments of the spinal column

Causes of low back pain

Low back pain is a very common symptom. It can affect both the young and old. It can be caused by problems in the structures that make up the spinal column.

Low back muscle strain is a common cause of acute low back pain. It can occur from activities like heavy lifting or incorrect posture in performing certain activities. This can be associated with muscle spasm limiting the movement of the spine. Anti-inflammatory medications, muscle relaxants and physical therapy give good short-term relief. In the long term though, one must adopt good lifting techniques and posture and be particularly careful during heavy lifting, to prevent a recurrence of back pain and muscle spasm.

Acute low back pain can be caused by problems in the bones of the spine eg. vertebral body (front part of the spine). Most commonly this is due to a fracture (when the bone is broken). A fracture of the spine can occur when there is a large amount of energy transferred (high impact injury) such as a road traffic accident or a fall from height. In some cases, the bones may be weakened and a low energy injury may produce a spine fracture. This can occur in patients with osteoporosis (osteoporotic fracture) or where there is infiltration of the bone by an infection or tumour (pathological fracture). A fracture of the bone in the cervical spine (neck) can cause acute neck pain while a fracture of the bone in the lumbar spine (low back) can cause acute low back pain. If a fracture fragment enters the spinal canal (space behind the body of the vertebra), the spinal cord or nerve roots can get impinged causing pain, numbness, tingling sensation to go down to the arms or legs. There can also be weakness of the arms or legs. It is best to seek a medical consultation when a fracture is suspected.

The intervertebral disc (disc between the bones of the spine) can be a cause of back pain. Disc degeneration is a process where the disc essentially loses fluid and tears may appear in the outer lining (annulus) of the disc termed annular fissures. A tear in the outer ring can also be called an annular tear. An slipped disc is the term given when the disc material has come out of its usual confines. Other terms for a slipped disc are herniated disc or herniated nucleus pulposus (HNP). A slipped disc can cause low back pain and muscle spasm. A herniated disc can sometimes press on the nerve roots that are inside the spinal canal.

The bones of the spine move at the joints which are at the back of the spine. These joints are called facet joints. Arthritis in these areas are called facet joint arthritis. Facet joint arthritis is a cause of neck pain or low back pain. They are often associated with degenerative discs.

There are some inflammatory conditions such as ankylosing spondylitis and rheumatoid arthritis which can affect the spine. Both ankylosing spondylitis and rheumatoid arthritis involve other joints in the body. In rheumatoid arthritis, hands, hips and knees can be involved whereas in ankylosing spondylitis, the sacroiliac joint and the hips are involved.

What is Sciatica?

Sciatica refers to pain radiating/shooting down the leg. This is typically at the back of the leg, which is where the distribution of a nerve called the sciatic nerve, thus the term sciatica. This occurs most commonly when nerve roots in the spinal canal are compressed.

Radiculopathy is a term which is used to describe pain, numbness, tingling down the arms or legs. This occurs when there is compression of the nerve roots in the spinal canal. It can also occur from compression of the spinal cord itself. Spinal cord or nerve roots compression can occur from a herniated disc (slipped disc or herniated nucleus pulposus), tumours, fractures or infections. It can even occur when there is abnormal movement of the vertebral body (spinal bone) called spondylolisthesis. Long term compression of a nerve can cause damage to the nerve and result in atrophy (wasting) of the muscles that are supplied by it. This can result in weakness of the arms or leg. In some cases, nerves to the bladder are also compressed (cauda equina syndrome) and this can result in numbness around the buttock and difficulty in passing urine. This is a medical emergency and patients should go to the emergency department for treatment when this occurs.

Spinal stenosis is a term that is used to describe encroachment of the spinal canal and thus compression of the nerve roots. This can cause pain down the legs and often to the calves which occur when walking or standing for prolong periods. A proper evaluation by the doctor needs to be done to distinguish spinal stenosis from other causes with similar symptoms.

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Figure: Slipped disc in the lumbar spine (low back)

Surgical and Non-surgical treatment of the spine

Prior to recommending treatment options for low back pain or nerve symptoms, a proper clinical evaluation is done by the doctor. Imaging modalities such as X-rays and/or MRI may subsequently be done depending on the clinical history and examination by the doctor. Once a diagnosis is established, treatment options can then be suggested.

Treatment of low back pain from a muscle strain, degeneration of the spine or annular tear/annular fissure is often successfully done with medications and physical therapy. Anti-inflammatory medications and muscle relaxants are often used in combination to give good pain relief. Physical therapy can be started early and continued to help with recovery. In severe cases, a short period of bed rest is sometimes instituted. Bed rest is often instituted as a short-term treatment option with a focus to mobilise the patient as early as possible. This will prevent long term complications of prolonged bed rest and immobilisation.

Treatment of sciatica or radiculopathy depends on the severity and cause of the symptoms. One of the commonest pathologies that cause nerve compression symptoms are slipped discs (herniated discs) or herniated nucleus pulposus (HNP). Treatment of slipped disc can often be successfully done with non-surgical treatment using anti-inflammatory medications and physiotherapy. A short period of bed rest may sometimes be utilised. In some cases, a spinal injection may be given to give good pain relief.

Surgical treatment for slipped discs may be required in cases where the symptoms are very severe and the nerves are not working properly. If there is evidence such as muscle wasting and weakness from prolonged compression of nerve roots, surgical treatment may be offered to prevent further injury to the nerves. Surgical treatment for slipped disc can be done through a keyhole surgery to remove the portion of the disc that has “slipped out” using a microscope. This will create the space the nerves require to recover. Most patients recover quickly from this procedure and may go back the same or next day.

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