You should be able to deal with most episodes of back pain yourself, but there are times when you should seek help.
Most people will try some gentle physiotherapy or chiropractic treatment, and in many cases this will enable symptoms to settle. If pain is aggravated by this treatment, provides only transient relief or there is no significant improvement over 4 to 6 weeks there is little point continuing with it and medical review may then be indicated.
Your local medical practitioner will be able to diagnose and commence treatment for the majority of cases of back or neck pain. They will also identify conditions that require referral to a spinal surgeon.
There are, however, no magic cures for back pain so be realistic about what your doctor can do for you, and be prepared to invest some time and effort in making yourself better.
If you have severe pain that gets worse over several weeks instead of better, or if you are generally unwell with back pain you should see your local doctor.
Your local doctor will usually reassure you that there is nothing serious going on, and can try a variety of medical treatments to help control your pain which should help you get on with your life as quickly and easily as possible.
Even where investigations indicate the presence of a disc bulge or protrusion and you have symptoms of “sciatica” (pain in the buttock and leg extending below the knee) or “brachalgia” (pain in the neck shoulder and arm) due to nerve irritation in your back or neck symptoms will usually settle by themselves within six to twelve weeks.
There are also a few rare but serious symptoms which can occur in conjunction with back pain that indicate the need or urgent medical review and assessment.
- Difficulty passing or controlling your passage of urine
- Numbness around your bottom or genitals
- Numbness, pins and needles or weakness in both legs
- Unsteadiness on your feet
- loss of dexterity, inability to do up buttons etc.
These symptoms suggest the presence of significant spinal cord or nerve compression that may require urgent surgical intervention in order to prevent permanent damage.
When is review by a specialist is indicated?
Neck and shoulder pain, which is also often associated with occipital headaches is a common complaint of the middle aged and elderly. Symptoms are usually related to degenerative changes, or what we call “Cervical Spondylosis”. This is a similar process to the arthritis that affects other joints in the body.
Changes of cervical spondylosis may be evident on x-rays of people as young as 20 to 30 years of age and this process will continue as you get older. There is nothing we can do at this stage to stop the process and surgery is not indicated unless these symptoms are associated with features of nerve root or spinal cord compromise.
Your local doctor may perform investigations to exclude rare but serious conditions and can advise you about the use of analgesics or anti-inflammatory medication. Gentle physiotherapy or chiropractic treatment that involves the active mobilisation and stabilisation of the cervical region may help. Passive manipulation, this is when the therapist performs forceful and often extreme movements of the cervical spine, should be avoided.
Injection procedures such as facet joint injections can sometimes assist in identifying the origin of pain but rarely results in sustained benefit. Surgery to treat a symptomatic degenerative condition does not stop the process and will often result in increased stress and wear in adjacent joints that subsequently become symptomatic. For these reasons assessment by a spinal surgeon is usually not indicated.
Brachialgia: (Neck and arm pain due to nerve root irritation or compression)
This can develop as result of a disc protrusion in the cervical spine, or narrowing of the spinal canal or the opening between adjacent cervical vertebrae due to arthritis. In this situation pain will extend from the neck into the shoulder and arm and will follow the distribution of the affected nerve.
This type of pain can be quite severe, and is often worse during the night. Despite this, and regardless of the cause of the pain, symptoms will usually settle spontaneously over four to eight weeks.
Quite strong pain killers may be needed to control the pain during this period, and the short term use (1 to 2 weeks at the most) of a cervical collar may be of benefit. Your local doctor should be able to assist you with these treatments. The prolonged use of a collar will result in loss of muscle tone and is likely to prolong the recovery process. The use of analgesics and a collar should therefore be coupled with gentle muscle toning exercises and you are encouraged to maintain activities as much as possible.
Your doctor is likely to request an x-ray or a CT scan to help diagnose the origin of the pain, but both investigations may fail to identify the cause of the trouble as they do not display the anatomy of the region well in all cases. An MRI (Magnetic Resonance Imaging) is a better investigation, but a rebate will only be paid for this investigation by the government in certain situations.
Assessment by a specialist is indicated if there is evidence of neurological compromise, (i.e. weakness, numbness or reflex changes) or if symptoms persist beyond four to six weeks and the pain is bad enough to consider surgical intervention. The specialist may then request an MRI if the investigations undertaken to that point have failed to demonstrate the cause of the pain.
Sciatica is a term that describes pain extending from the buttock into the leg and which radiates below the knee.
Sciatica may result from a variety of conditions but is usually due to the compression or irritation of one of the lower lumbar nerve roots. Pain usually results from a disc protrusion or rupture, where disc material reduces the capacity of the spinal canal and results in the compression or irritation of a lumbar nerve root.
In the majority of cases (90%), symptoms will settle spontaneously within six to twelve weeks, and treatment is initially directed towards reducing discomfort so that you can remain active both at work and at home.
Your local doctor may perform investigations to exclude rare but serious conditions, and can advise you about the use of analgesics or anti-inflammatory medication. Gentle physiotherapy or chiropractic treatment, and the provision of advice about ways to both modify your activities and improve the tone and support of the muscles around the lumbar spine may also help.
As with brachialgia, assessment by a specialist is indicated if there is evidence of neurological compromise, (i.e. weakness, numbness or reflex changes) or if symptoms persist beyond four to six weeks and the pain is bad enough to consider surgical intervention. The specialist may then suggest you consider having an epidural injection or request an MRI if the investigations undertaken, to that point, have failed to demonstrate the cause of the pain clearly before proceeding to surgical intervention.
“Mechanical back pain” is a term used to describe back, buttock and leg pain that results from degeneration of intervertebral discs and/or facet joints. This sort of back pain is usually episodic and symptoms may be aggravated by a particular incident or event, but may also develop or deteriorate gradually over time.
It is important to remember the degeneration evident on an X-ray, MRI or CT scan is the result of the wear and tear, the stresses and strains or injuries your body has endured through your entire life and that specific events may have done nothing more than aggravated these changes or initiated symptoms relating to them. Wherever possible non-operative treatment is recommended and surgery is considered the last resort. In most cases your local doctor will be able to advise you about the use of pain killers and anti-inflammatory medication, as well as direct you to a therapist that can advise you about appropriate exercise.
Assessment by a specialist is really only indicated if symptoms persist and remain disabling despite involvement in an adequate exercise program and modification of activities over a period of at least six months. If pain has not improved with this type of treatment in this period of time it is unlikely to do so from that point. This does not mean that these activities should be stopped, as ongoing muscle toning activities will help you maintain your level of activity.
If at this stage you feel your pain is bad enough to consider surgery specialist review and assessment may be appropriate. This is not to say that surgery will be offered or even considered appropriate, but unless you feel you have reached the point of wanting to consider this option, there is little point asking the surgeon what can be offered.
Injections into the facet joints or disc (discography) may be requested to assist in identifying the origin of your pain.
Facet injections may provide relief of symptoms due to facet joint disease and help us identify the origin of your pain. In the case of long standing or chronic low back pain facet injections may provide only a short term solution to a long term problem. Percutaneous facet denervation (rhizolysis) is a minmally invasive and low risk procedure that can help to reduce pain if a short term relief to facet injections was achieved.
In general, if you can manage your symptoms and cope with your limitations, doing so is a better alternative than having a spinal fusion.
The surgical treatment of this “mechanical” low back pain at present is limited to a spinal fusion, and this should be considered as the last resort.