Mechanical Back Pain
Mechanical back pain is the general term that refers to any type of back pain caused by placing abnormal stress and strain on muscles of the vertebral column. Typically, mechanical pain results from bad habits, such as poor posture, poorly-designed seating, and incorrect bending and lifting motions.
Mechanical back pain affects men and women equally. The onset most frequently occurs in people aged 30-50 years. Low back pain is the most common and most expensive of work related disabilities in the United States.
Mechanical Back Pain should be self-limiting with treatment but radiological films are appropriate if the conservative care does not help in approximately 6 weeks.
Low back Sprain-Strain
A strain is an injury to either a muscle or tendon. Tendons are the tough, fibrous bands of tissue that connect muscle to bone. With a back strain, the muscles and tendons that support the spine are twisted, pulled, or torn.
A sprain is the stretching or tearing of a ligament. Ligaments are the fibrous bands of tissue that connect two or more bones at a joint and prevent excessive movement of the joint.
Symptoms of a strain and/or sprain include: pain that increases with movement, muscle cramping or spasms, decreased range of motion in the spine. The patient may feel a “popping or tearing” at the time of injury.
Twisting or pulling a muscle or tendon can result in a strain. It can also be caused by a single instance of improper lifting or by overstressing the back muscles. A chronic strain usually results from overuse involving prolonged, repetitive movement of the muscles and tendons.
A sprain often results from a fall or sudden twist, or a blow to the body that forces a joint out of its normal position. All of these conditions stretch one or more ligaments beyond their normal range of movement, causing injury.
Poor posture, weak abdominal muscles, repetitive heavy work, and obesity all also lead to an increase in sprain/stains of the lumbar spine.
Treatment is usually rest/ medications/ ice/ heat for the first 24 hours and then exercise.
In general, most low back sprains-strains are expected to heal without the need for any future restrictions.
Cauda Equina Syndrome
At the bottom of the spine, near where the lumbar vertebrae start, is the cauda equina. This is a bundle of nerves shaped like a horse’s tail that provide nerve function to the legs, feet and pelvic organs. In Cauda Equina Syndrome, these nerves are completely or partially blocked from sending proper messages to these areas.
Symptoms include low back pain, numbness or weakness in one or both legs and a decreased sensation in the pelvic area. Loss of control over bladder or bowel function (retention or incontinence) is part of this decreased sensation and the patient may often report sexual dysfunction.
Causes of Cauda Equina Syndrome include, a large lumbar disc herniation (most common), severe spinal stenosis, tumor, infection, hemorrhage or fracture. Any severe injury to the back, such as a fall, can also cause this.
Surgery is discussed immediately on diagnosis as the longer there is pressure on the nerves, the less likely it is for the patient to recover all function.
Treatment to be considered:
- Posterior Lumbar decompression (laminectomy)
- Posterior Lumbar discectomy
- Lumbar fusion
Spondylolisthesis is a condition of the spine whereby one of the vertebra slips forward or backward in relation to the next vertebra. Forward slippage of an upper vertebra on a lower vertebra is referred to as anterolisthesis, while backward slippage is referred to as retrolisthesis. Spondylolisthesis can lead to a deformity of the spine as well as a narrowing of the spinal canal (central spinal stenosis) or compression of the exiting nerve roots (foraminal stenosis). Spondylolisthesis is most common in the low back but can also occur in the mid to upper back and neck.
Patients typically have complaints of pain in the back with intermittent pain, numbness and tingling, weakness or muscle spasm to the legs. The diagnosis of spondylolisthesis is easily made using a lateral X-ray (from the side) will show if one of the vertebra has slipped forward compared to the adjacent vertebrae. Often flexion/ extension x-rays are used. Spondylolisthesis is graded according the percentage of slip of the vertebra compared to the neighboring vertebra.
- Grade I is a slip of up to 25%.
- Grade II is between 26%-50%.
- Grade III is between 51%-75%.
- Grade IV is between 76%-100%.
- Grade V, or spondyloptosis, occurs when the vertebra has completely fallen off the next
Treatment will depend on the grade of the “slip” and the symptoms of the patient.
Lumbar Degenerative Disc Disease
Degenerative disc disease is not really disease but a term used to describe the normal changes in the spine due to age. It happens throughout the whole spine but mostly in the lumbar discs as they have the most pressure on them throughout life.
This is caused by the loss of fluid in the disc over time, which makes it less useful as a shock absorber and narrows the distance between the vertebrae. This also lessens the space nerves have to exit the spinal column. Time, and wear and tear on the disc can also cause cracks or breaks in the annulus (the outer covering of the disc). Often the disc material inside leaks out causing a disc herniation and increases acceleration in degeneration.
As the space between the vertebrae get smaller and the discs get worn, the spine becomes less stable. The body reacts to this by constructing bony growths called bone spurs (osteophytes). Bone spurs can put pressure on the nerve root and cause pain numbness and tingling in the extremities.
People who smoke and those who do heavy physical labor, such as repeated heavy lifting, are more likely to have accelerated disc degeneration. People who are obese are also more likely to be symptomatic. Exercise, weight loss, and quitting smoking are ways to slow down disc degeneration. Surgical intervention would only be considered after extensive conservative care.
Spondylosis, also known as spinal osteoarthritis, can affect the lumbar, thoracic, and/or the cervical regions of the spine. It is most frequently found in the lumbar spine since the lumbar spine carries most of the patient’s weight.
Lumbar spondylosis is principally a disease of mid and later life. As the lumbar discs and associated ligaments undergo aging, the disc spaces frequently narrow. Thickening of the ligaments that surround the disc and those that surround the facet joints develops. This ligamentous thickening may eventually become calcified. Narrowing of the spinal canal or of the openings through which the spinal nerves leave the spinal canal can occur.
Compression of the nerves within the spinal canal or the nerves exiting the spinal canal can lead to pain, numbness or weakness in the legs, buttock or bowel and bladder. Abnormalities of gait can occur. Occasionally, these degenerative changes can produce instability of the spine.
Sitting for prolonged periods of time may cause pain and other symptoms due to pressure on the lumbar vertebrae. Repetitive movements such as lifting and bending (e.g., manual labor) may increase pain.
Lumbar Radiculopathy (Sciatica)
Lumbar radiculopathy refers to disease involving any of the lumbar spinal nerve roots. This can manifest as pain, numbness, or weakness of the buttock and leg. Sciatica is the term often used by lay people. Lumbar radiculopathy is typically caused by a compression of the spinal nerve root. This causes pain in the leg rather than in the lumbar spine, which is called “referred pain.”
The spinal nerve roots are irritated or compressed by one of many conditions, including lumbar disc herniation, spinal stenosis, osteophyte formation, spondylolisthesis, foraminal stenosis, or other degenerative disorders.
Lumbar radiculopathy symptoms may include pain, tingling, numbness, weakness, and reflex loss. Lumbar radiculopathy symptoms may present in the leg and foot. Where the pain, numbness and tingling occur will lead the spine specialist to which nerve is being affected.
Conservative treatment is almost always recommended for Sciatica/ Lumbar radiculopathy before surgery is considered.
Lumbar spinal stenosis is a condition where either the spinal canal (central stenosis) or one or more of the nerve openings between the vertebrae becomes narrowed (foraminal stenosis). If the narrowing is substantial, it causes compression of the spinal cord or spinal nerves, which causes the painful symptoms of lumbar spinal stenosis, which includes low back pain, buttock pain and lower extremity pain, numbness and tingling. This can either be bilateral (central) or on one side (foraminal stenosis). This is usually made worse by exercise and relieved by resting. Bending forward opens up the spinal canal so this a position of comfort for the patient. Bending backward will increase the pain.
Lumbar Stenosis is usually caused by degenerative arthritis of the spine, but can be made symptomatic following injury or tumor. Diabetic neuropathy and peripheral vascular disease are often mistaken for Lumbar stenosis and should be ruled out before a final diagnosis is made.
Lumbar stenosis is a progressive situation, and will increase as you age.
Lumbar Stenosis is generally treated conservatively. Conditions such as Cauda Equina Syndrome (new onset paralysis, bowel or bladder incontinence), needs rapid surgical evaluation to weigh the benefits of immediate surgery.
For patients with progressive spinal stenosis symptoms, there are elective surgical options that may provide improvement.
Lumbar Disc Herniation
A lumbar herniated disc is when the inner core of a disc in the back herniates, or leaks out of the disc, and presses on an adjacent nerve root. A lumbar herniated disc may occur due to trauma or be spontaneous. Something as simple as a sneeze can herniate a disc.
Because there is limited space in the spinal canal, even a small lumbar disc herniation may impinge on one of the nerves and cause significant pain. While back pain may be present, the most common pain is in the buttock, with radiation to the feet of the affected side. This will follow the normal distribution of the nerve affected. Numbness and tingling may also be reported. This is called lumbar radiculopathy.
Most herniated discs tend to shrink back into the disc space or dissolve over time. Conservative care is recommended first unless the patient has signs of paralysis. Once a disc has been herniated, disc degeneration is expected due to the loss of the integrity of the disc.
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