Back pain

Back pain or backache is the pain felt in the back that may originate from muscles, nerves, bones, joints or other structures in the spine. Back pain is one of the most common medical problems experienced by most people at some time in their life. Back pain can be acute usually lasting from few days to few weeks, or chronic lasting for more than three months.
Back Pain can occur as a dull constant pain or a sudden sharp pain. Back pain may be confined to one area or may radiate to other areas such as the arm and hand, the upper back, or the low back, and might radiate into the leg or foot. Other than pain you may have weakness, numbness or tingling in your arms or legs caused from damage to the spinal cord.

Athletes participating in sports such as skiing, basketball, football, ice skating, soccer, running, golf, or tennis are at greater risk of developing back pain. During these sport activities, the spine need to bear more stress, take up more pressure, undergo twisting and turning, as well the bodily impact. This may cause strain on the back that can result in back pain. Athletes are at high risk of back pain both from trauma and from overuse injuries, especially in sports requiring hyperextension.

Common causes of back pain include:

• Musculoligamentous strain: It is the most common sports injury caused by injury to the soft tissues around the spine
• Spondylolysis: It is most commonly found in athletes who participate in sports such as gymnastics, pole-vaulting, and football. All these activities require frequent hyperextension of the lumbar spine
• Spondylolisthesis: It is a condition of the spine which occurs when one vertebra is displaced or slipped forward over the other below it
• Herniated nucleus pulposus: When injury occurs, the central core of the disc is pushed through a tear in the outer hard layer of the disc, causing a bulge and pressing on nearby nerves. If the herniated disc presses on a spinal nerve, it can cause back pain.

Other causes include growth-related problems such as scoliosis and Scheuermann’s kyphosis.

Your physician will diagnose back pain by asking appropriate questions or by taking a history of your problem and examining your spine. A complete examination includes examination of the signs of unusual curves of the spine, a rib hump, a tilted pelvis, and tilting of the shoulders and a test of your sensations. Other diagnostic tests may be needed to confirm the diagnosis.

Treatment for back pain is usually non-surgical and includes:

• Anti-inflammatory medications, or NSAIDs are recommended to provide relief from pain
• Cold packs, heat packs or both applied to the back to help ease much of the discomfort and relieve stiffness as well the pain
• Sleeping with the pillow between the knees while lying on one side or placing the pillow under your knees when lying on your back may help relieve back pain
• Exercises to strengthen your trunk and back muscles

These measures help relieve your back pain however in certain conditions the pain may not be resolved and may require surgical treatment. Your physician will decide on the appropriate surgery based on several factors.

Spina Bifida

Spina bifida is the most common birth defect which is known as neural tube defect that affects the central nervous system (brain and spinal cord). Most commonly it occurs in the first month of pregnancy because of incomplete development of the spinal cord or its coverings.

The 3 variants of spin bifida have been identified and they are:

• Spina bifida occulta:  It is the mildest and harmless form of spina bifida. The spinal cord and the nerves are normal but there may be a small defect or gap between the vertebra and does not cause any health problems.

• Meningocele: It occurs when the membranes of the spinal cord enlarge and protrude creating a cyst from the spinal opening. The defect is invisible through the skin and causes no problems.

• Myelomeningocele: This is the most severe form of spina bifida. It occurs when the spinal cord is exposed through the opening in the spine resulting in neurological problems. Children with this condition may have partial or complete paralysis of the parts of the body that are below the spinal opening. Most infants born with this condition also have hydrocephalus (accumulation of fluid in and around the brain), problems with bowel and bladder control, and other learning disabilities.

Children with spina bifida occulta exhibit no physical signs of the condition. In some cases, defects are recognized as a small dimple, birthmark, or a hairy patch at the site of the defect. In meningocele and myelomeningocele, fluid filled sac is visible on the spine. In most severe cases of myelomeningocele the nerves and the tissues from the spinal cord may get exposed.
Spina bifida affecting spinal cord may cause problems such as inability to control bowel movements, urinary incontinence, lack of sensation in the legs and feet, partial or complete paralysis of the legs, and less often, in the arms.

The exact cause for spina bifida remains unknown however certain factors may contribute to spina bifida and include genetic factors, environmental factors such as nutrition and radiation, and folic acid deficiency during early pregnancy.

Most cases of spina bifida can be diagnosed before birth with the help of prenatal tests such as alpha-fetoprotein (AFP) test, ultrasound, and amniocentesis. Postnatal tests include X- rays, CT scan of skull, and MRI and ultrasonography of the spinal area.
Treatment for spina bifida depends on clinical symptoms and most often includes physical therapy, antibiotics to prevent infection, and teaching the child bowel and bladder habits. Surgery is usually recommended after birth at an early age and they include spina bifida repair and ventriculoperitoneal shunting.

Spinal Injuries

Spinal injuries are the most common injuries that may occur while playing, performing normal activities, operating heavy machines, lifting heavy objects, driving automobiles, or when you suffer a fall.

Common spinal injuries you may suffer include:

• Fractures
• Dislocation of adjacent bones
• Partial misalignment (subluxation) of adjacent bones
• Disc compression (herniated disc)
• Hematoma (accumulation of blood)
• Partial or complete tears of ligaments

The most common symptom of spinal injuries is pain. Some injuries may damage spinal nerves that may cause inflammation, loss of muscle control and loss of sensation. Symptoms may proceed to paralysis, limited movement, and immobility. Workplace injuries are diagnosed using X-rays, computed tomography (CT) scans, and magnetic-resonance imaging (MRI) scans.

Depending on the type and severity of injury, you may be treated with pain medications, epidural injections (injecting into spine), physiotherapy, and surgery. Surgery is recommended when other treatments are a failure or inappropriate. Surgery for spinal condition depends on the type and severity of injury. Some of the common spinal surgeries include:

Coccygectomy
Coccygectomy is a surgical procedure which involves removal of part or entire portion of tailbone (coccyx) present at the end of your spine. It is performed in patients who have persistent tailbone pain due to injury, fall or contact sports and when all other conservative treatments are a failure.
During the surgery, an incision will be made on your lower back, a few inches above the anus following which the muscles will be retracted to find the damaged or broken coccyx. Then a part or the entire coccyx is removed.

Decompression
Spinal decompression is a procedure of relieving pressure on one or many “pinched nerves” of the backbone. It can be achieved either by surgical or non-surgical method. It is used to treat conditions that cause chronic backache like herniated disc, disc bulge, sciatica, spinal stenosis.
Non-surgical spinal decompression is performed using decompression machine, a safe and non-invasive method.
Surgical spinal decompression is performed by two procedures:

1. Microdiscectomy: A minimally invasive procedure which involves removal of a portion of a slipped disc by a surgical instrument or LASER.
2. Laminectomy: This is a procedure in which a small portion of the roof of the spinal bone is removed to relieve pressure on pinched nerve. This is performed as a last resort, when conservative treatment fails to provide relief from back pain.

Posterior and Anterior Spinal Fusions
Spinal fusion is a surgical procedure done for the treatment of upper and lower spine problems. It is mostly done in the lower back (lumbar region) joining two or more spinal bones to avoid the motion between them. This prevents the stretching of nerves and surrounding ligaments and muscles.
Anterior spinal fusion is a procedure where the surgeon makes an incision on the patient’s front part of the body; and posterior spinal fusion is a procedure where the incision is made on the patient’s back exposing the spine.

Laminectomy:
Laminectomy is a surgical procedure to remove the portion of the lamina (roof) of the spinal bone. It helps to relieve the pain associated with narrowing of spinal column. The procedure removes bones and damaged disks and makes space for spinal nerves and column.
In a traditional laminectomy the incision made is large and the overlying muscles must be cut.
In a minimal invasive technique very tiny incisions are made, the back muscles are moved aside and the lamina is removed.

Discectomy:
It is a surgical procedure performed on the spine for the removal of the fragment of slipped disc. Slipped disc is also known as bulging disc or herniated disc.
Slipped disc occurs when the inner core of the spinal disc bulges out through the outer layer of the disc. This fragment may press the spinal cord and the nerves that surround the spinal cord. This pressure causes the symptoms of slipped disc. Here the surgeon uses the small incision to look at the actual herniated disc, to remove the disc and relieve the pressure on the nerve. It is also called as open discectomy.

Transforaminal Lumbar Interbody Fusions
Transforaminal lumbar interbody fusion is a surgical procedure of the lower back where the damaged disc which is located between the two spinal bones (vertebrae) is removed and the vertebrae are fused together.
In transforaminal procedure, the damaged disc is removed from the side and is replaced with artificial device (prosthesis) made of bone, plastic or ceramic. Space around the prosthesis is filled with milled bone and then stabilized with titanium screws and rods. The prosthesis and the milled bone will fuse with other vertebrae over the time and provide more stability to the spinal column.
This surgery is performed for various conditions such as degenerative disc disease, low grade Spondylolisthesis, spinal instability and others.

Anterior Cervical Decompression Fusions
Decompression fusion is a surgical procedure to remove the pressure from the spinal cord and/or nerve roots by reconstructing the upper part of the spinal cord. This procedure is performed to reduce deformity and stabilization, minimizing neurological injury and early rehabilitation of the spine.
Cervical decompression is performed by making a small incision in front part of the neck. The fusion can be done by replacing the damaged part with new bone where the bone is collected either from different body part of the same patient, from a donor or an artificial bone.  Spine surgeons prefer anterior procedure because it provides a better access to site of injury.

Your spine surgeon may recommend for rehabilitation that includes both physiotherapy and occupational therapy to promote complete and faster healing.

Spinal stenosis is the compression of spinal nerves caused by narrowing of spinal canal and it is one of the common causes of low back pain. The symptoms include back pain, burning or aching type of pain in buttocks that radiates to the legs (sciatica), weakness in the legs or "foot drop”. One of the causes for spinal stenosis is the ageing and other causes include Paget’s disease, achondroplasia, spinal tumors and spinal injuries. As age advances the chances of developing osteoarthritis, disc degeneration and thickening of ligaments may increase and these conditions cause spinal stenosis.

Spinal stenosis may be treated with conservative treatment approaches such as use of pain medications, physical therapy, steroid injections, or acupuncture. In chronic cases, surgery may be required to treat the condition.

Nonsurgical Treatment

• Physical therapy: Physical Therapy involves stretching exercises, massage, and lumbar and abdominal strengthening.
• Anti-inflammatory medications: Non-steroidal anti-inflammatory drugs (NSAIDs) initially provide pain relief and also reduce swelling.
• Steroid injections: Cortisone steroid injections are given around the nerves or in the "epidural space” to decrease swelling and pain.
• Acupuncture: Acupuncture can be helpful in cases where the pain is less severe.
• Chiropractic manipulation: Chiropractic manipulation can be done in some cases but not when there is co-existing osteoporosis or herniated disc because these cases increase the symptoms or cause injuries.

Surgical Treatment
Surgery is considered for patients in whom the pain and weakness is causing debilitation such as inability to walk for a long time. The two main surgical procedures to treat lumbar spinal stenosis are laminectomy and spinal fusion.

• Laminectomy: This procedure involves removal of the bone, bone spurs, and ligaments that compress the nerves.
• Spinal fusion: In this procedure, two or more vertebrae are permanently fused together.

Spine Tumors

Spine tumor is the abnormal growths of uncontrolled tissues or cells in and around the spinal cord. Tumors can either be cancerous (malignant) or non-cancerous (benign). Some of the commonly occurring benign spinal tumors are osteoma, osteoblastoma, hemangioma, and osteochondroma. Most commonly occurring malignant spinal tumors are chondrosarcoma, Ewing’s sarcoma, lymphoma, osteosarcoma, and multiple myeloma. Tumors that begin in the spine are called as primary spinal tumors. Tumors that spread to the spine from other parts such as the breast, prostate, lung, and other areas are called secondary spinal tumors.
The cause of primary spinal tumors is not known, but may occur with genetic defects.
Secondary spinal tumors occur when the cancer cells arise from kidneys, lungs, breasts, and spreads to the spine. Other causes include

• Rapid division of cancer cells in the nerves, bones, or cartilage of the spine
• Exposure to radiations and chemicals
• Hereditary – Neurofibromatosis is a tumor of the spinal nerves

People with spine tumor experience persistent and chronic back pain, numbness, burning and tingling sensation, loss of sensation in legs, arms, ankle, knee, and difficulty in balancing, and also experience bladder or bowel control problems.
Spine cancer can be diagnosed by neurological examination which identifies the exact location of the tumor. Other imaging tests done to confirm the spinal tumor may include cerebrospinal fluid (CSF) examination, myelogram, and spine computed tomography scan, spine magnetic resonance imaging scan, and spine X-ray. In addition to these tests, bone scan and positron emission tomography (PET) scan are also done. After the tumor is found, biopsy is done to identify the type of tumor and provide necessary treatment.
Medications such as corticosteroids and anti-inflammatory drugs are prescribed to reduce inflammation and swelling around the spinal cord. External braces are also used which provide support and control pain.
Other treatments include chemotherapy, radiation therapy, surgery, and physical therapy which may provide permanent relief.

• Surgery: It is done to remove the tumor confined only to one portion of the spine. To minimize nerve damage, electrodes are used to test different nerves of the spine. In some cases sound waves are used to break tumors and the remaining tissues are removed.
• Radiation therapy: This method uses high beam of radiations to destroy the cancer cells. It is used after surgery to destroy the remaining cancer cells. An advanced device called cyberknife, painless and non-invasive treatment that passes high doses of radiations to the targeted areas of the spinal cord is used in radiotherapy.
• Chemotherapy: Combination of anti-cancer drugs is used to destroy the cancer cells. Chemotherapy is used to shrink the cancer cells, to stop the division of cancer cells, and prevent them from spreading to surrounding tissues. The drugs enter the bloodstream and reach the cancer cells to destroy them. Some of the commonly used drugs are methotrexate, doxorubicin, cyclophosphamide, carboplatin, and ifosfamide.

Some of the complications observed after surgery are temporary loss of sensation, nerve tissue damage, and bleeding
Physical therapy: Exercises may be needed to improve muscle strength and the ability to function independently.

Transverse Myelitis

Transverse myelitis is an inflammatory condition of the spinal cord, which occurs in a transverse manner across the width of the spinal cord. It affects the myelin, which is the protective outer layer of nerve cells, disrupting the transmission of nerve impulses and the communication between the spinal cord and the rest of the body. The inflammation may be caused by viral infections, abnormal immune reactions, reaction to certain vaccines or may be associated with certain conditions such as Sjogren’s syndrome, multiple sclerosis or neuromyelitis optica.

Signs and symptoms depend on the segment of the spinal cord affected, but usually there is an onset of sudden pain in the neck or back, which may radiate to the arms, legs or around the abdomen. Other symptoms may include numbness, tingling, burning or cold sensations, weakness of the arms or legs, paralysis, and loss of bowel and bladder control. The symptoms may develop over a few hours and progressively worsen in a few days. Symptoms may recover or cause permanent impairment.

Your doctor diagnoses transverse myelitis by reviewing your medical history and performing a thorough neurological examination. Additional tests such as MRI or CT scan, and blood tests may be ordered. Spinal tap may be performed, where a sample of the spinal fluid that encases the spinal cord is removed and analyzed for abnormal amounts of protein or the presence of disease markers.

Transverse myelitis cannot be cured but most patients have partial recovery.  Treatment is targeted at relieving symptoms. Your doctor may prescribe corticosteroid anti-inflammatories, antivirals, painkillers and medication to treat other conditions, and advise bed rest. Plasma exchange therapy may be performed, where blood plasma is replaced with special fluids. Rehabilitative processes such as physical therapy, occupational therapy and psychotherapy are recommended for long-term recovery and functioning.

Whiplash

Whiplash is a soft tissue injury to the neck, usually caused by sudden forceful jerk commonly occurring as a result of an automobile accident, sports injuries, or an accidental fall. Sometimes whiplash may also be referred to as neck strain, neck sprain or hyperextension injury.

Neck pain, stiffness in the neck and headache are the most common symptoms of whiplash. Headache may develop immediately after the injury or after a short period of time. Other symptoms include dizziness, tingling or pricking sensation in the upper extremities, shoulder pain and stiffness, and psychological conditions such as memory loss, anxiety, depression, and sleep disturbances.

Diagnosis depends on the history of the injury and the symptoms. X-ray of the neck may be taken to make sure there are no fractures or dislocation of the cervical spine.

Pain medications, muscle relaxants, bed rest, cervical collar, neck exercises, ice therapy, heat therapy, and physical therapy have been used in the management of symptoms.

Bed rest and use of a soft cervical collar to immobilize the neck, usually results in minimal benefit, and hence early initiation of simple exercises is advised to restore flexibility.

Physical therapy can be useful to help strengthen muscles and reduce pain.

To avoid this injury always wear your seat belt and adjust your headrest to a proper height while driving.