The Painful Back
(Related conditions considered in other chapters: Osteoarthrosis Ankylosing Spondylitis
7.2 Introduction
7.2.1 Low back pain with or without pain extending down the lower limb (sciatica) is a very common symptom. The known causes include disease of the intervertebral discs, inflammation or degeneration of the muscles and ligaments in the back (musculo-skeletal lesions), strain of ligaments or muscles and osteoarthritis (spondylosis) of the vertebral bones in the lower back [See also Chapter 6]. Non-specific strain of the muscles and ligaments in the lower back is the commonest cause of back pain. Terms like "lumbago", "fibrositis", or "rheumatism" are frequently used, but lack clear definition.
7.3 Acute Back Pain
7.3.1 An intervertebral disc (a flexible "shock-absorber" which separates the bones making up the spine) may burst causing pressure on adjacent nerves giving rise to acute back pain which may spread down the leg as far as the foot. The commonly used term "slipped disc" is a misnomer (ie: the disc does not slip but prolapses with pressure exerted on the ligaments of the spine or on adjacent nerves). In such circumstances the pain is often severe, rendering the person temporarily immobile. With appropriate measures the acute (sudden) pain and associated limitations in mobility normally settles within a week or two.
7.3.2 The majority of persons with acute back pain make a spontaneous recovery with no significant ensuing problems. A less fortunate minority continue to experience pain and disability. These persons usually require treatment in hospital. This may include physiotherapy, injections in the back or surgery. Persons affected in this way may go on to have persistent back pain which is usually made worse by strains due to lifting or bending.
7.3.3 Acute back pain may recur, rendering the affected person temporarily immobile each time; but each attack of pain is unlikely to last longer than a few days or weeks at a time.
7.4 Chronic Back Pain
7.4.1 When the low back pain with or without pain extending elsewhere (ie to the lower limbs) is due to disc prolapse or longstanding degenerative or inflammatory disease of the lumbar vertebrae there may be a persistent limitation of spinal movement. The person may not be able to bend the lower spine through the normal ranges of movement, ie. there may be difficulty in bending forward or sideways or in rotating the lower spine.
7.4.2 In addition, if a nerve root is pressed upon there may be an area of tingling, numbness or, rarely lower limb weakness such as foot-drop. Pain is made worse by movement, coughing and straining. Rarely the spinal cord may become compressed by the prolapsed disc or by bony outgrowths of the vertebrae, leading to paralysis and/or impairment of sensation in the lower limbs and an inability to control bladder and bowels [See Chapter 5 ].
7.5 Care Needs
7.5.1 Acute back pain or recurrent episodes of back pain may be so severe that the person is unable to do anything except lie still in bed because any movement of the spine makes the pain much worse. Fortunately such severely disabling back pain lasts only a few days in the great majority of cases.
7.5.2 As a general rule the needs of persons with chronic (longstanding and persistent) back pain are usually minimal and there are periods when the back pain is minimal and of a low grade. Such pain is rarely avoided by receiving assistance, indeed it may well be inadvertently exacerbated by inappropriate assistance.
7.5.3 A person with low back pain may well have difficulty in bending but this can usually be overcome by flexing the hips and knees. Inability to bend would not usually prevent a person from dressing (except perhaps for shoes and socks - for which technical aids may be available) or from attending to toilet needs.
7.5.4 In acute episodes of back pain or in those with persistent back pain movement may increase the pain. Turning in bed, getting in and out of bed, rising from a chair, walking and turning will need to be performed carefully by the affected person to minimise this pain, but assistance from another person is rarely required except in the acute episodes or when a persistent back pain has been temporarily aggravated. Indeed, in the absence of any muscle paralysis, the movements can normally be performed unaided and are best done so if inadvertent exacerbation or unnecessary dependence on others is to be avoided.
7.6 Mobility Considerations
7.6.1 Pain in the lower back or down one or both legs may occur on walking. However, this can usually be controlled by pain-killers (analgesics). A surgical corset may also be helpful in reducing the occurrence and/or level of pain. Apart from acute or recurrent acute episodes of severe back pain which usually do not last for more than a few weeks, it is unlikely that someone with chronic back pain, in the absence of any paralysis, would have any substantial difficulty in walking
7.6.2 In the rare cases when a nerve root is involved leading to weakness such as foot-drop, this can be controlled by a calliper and need not interfere with movement, or impair walking ability.
7.7 Duration of Needs
7.7.1 Acute or recurrent episodes of back pain are most commonly of short duration, measured in days or weeks rather than months. Care needs would be confined to these periods. Recovery, either spontaneous or as a result of successful surgical treatment (laminectomy or discectomy) usually results in complete relief of symptoms and associated disability.
7.7.2 A person with chronic back pain may experience periods of worsening superimposed on persistent low-grade pain. However, in the absence of complications, care and mobility needs are likely to be minimal. There is however a minority of people with chronic back pain in whom psychological factors such as depression or somatisation, tend to perpetuate symptoms and disability. [See also Chapter 19].
7.8 Further Evidence
7.8.1 Further evidence is most appropriate in cases where the nature and intensity of back pain (with or without pain in the lower limbs) is reported to severely inhibit walking ability or to give rise to substantial care needs by night or day. Either a factual report from the hospital or GP or a comprehensive report and examination by an examining medical practitioner (EMP) can be most helpful.