Most spinal pain is related to degenerative or ‘wear and tear’ changes affecting the discs and facet joints. Degeneration in the facet joints may be referred to as arthritis identical to that seen in hip and knee joints. These ‘wear and tear’ changes are normal, to a degree and are part of the normal process of ageing, such as ‘hair going grey’. Some individuals develop degeneration sooner and this is more related to the genetic inheritance from their parents than their lifestyle, occupation or injury. These factors are more important in predicting whether an individual will recover or develop chronic (more than one year) symptoms.
What are the symptoms?
Back and neck pain can come on slowly or suddenly. Pain may last days or weeks before resolving, or it can persist for months or longer. There may or may not be a clear precipitating event such as twisting or lifting.
Symptoms may be worse with movement, with difficulty bending to put shoes and socks on.
The pattern of your back symptoms should help a specialist determine where the back pain is arising.
If there are associated symptoms, “RED FLAGS”, such as feeling unwell (sweats, fever, weight loss), unexplained thoracic pain, persistent night pain, first presentation of back pain in a child or after 55 years, bladder and bowel problems or recent history of cancer, then an urgent referral is advised.
What is the prognosis and treatment options?
A simple episode of back or neck pain, without “RED FLAGS”, should be managed simply. Regular analgesia such as co-codamol and an anti-inflammatory such as ibuprofen, taken maximally and continuously, if tolerated, over 1-2 weeks.
Generally the best advice is to try and keep moving secure in the knowledge that, although back pain may be severe ,this is not doing damage or causing harm. Gentle stretching exercises, perhaps directed by a physiotherapist, can be beneficial. Lifestyle modification such as avoiding prolonged periods of sitting in a car, and heavy lifting is recommended.
Chiropractic and Osteopathic treatment is frequently sought by individuals with back pain. Gentle manipulation of the spine may produce relief in some individuals, but forceful manipulative treatments have the potential to do harm and should be avoided. It is not recommended that these treatments are repeated over weeks or months unless there is clear benefit seen in the first few treatments.
Most episodes of back pain will improve or fully resolve within a few weeks. If symptoms persist then it is worth seeing a specialist. A specialist will take a history of your symptoms and examine you. Appropriate imaging may include x-ray and MRI. The specialist should then be able to exclude serious spinal problems, reach a clear diagnosis and explain to the individual what the problem is. This should lead to appropriately directed treatment and an indication of prognosis in the future. We understand that an individual who understands what is and what is not going on with their back does better.
Different types of Spinal injections may be offered by the specialist to target the site of your pain. These include facet joint injections, selective nerve root blocks and caudal epidural. These are similar in using a powerful steroid (cortisone) to effectively reduce swelling, redness, pain and heat (inflammation). Injections are simple and safe to perform with a low risk and may help facilitate exercise and rehabilitation. Injections do not work for everyone and may not last, but in some are highly effective, work indefinitely and may avoid the need for surgery.
Injections may also help the specialist to work out where your back pain is arising. This may lead to other treatments such as Rhizolysis, which is simple way of cauterizing the small nerves which supply the facet joints and can produce a more sustained relief of facet related back pain.
Surgery for mechanical back pain is generally less reliable than surgery to treat a trapped nerve and sciatic(leg) symptoms. Surgery should always be the last resort and only considered if symptoms remain severe, despite a rigorous period of conservative treatment.
The most frequently performed operation for back pain is a lumbar fusion. This can be performed through the back (posterior), side, or front (anterior) of the patient depending on the experience of the surgeon and the level of the spine being fused.
There are many forms of motion preserving surgery, such as disc replacement. This has the advantage of avoiding fusion, which reduces the chance of developing problems at other levels but may be less reliable overall in relieving symptoms. Surgeons will have varied preferences for the choice of implant they use.