Low Back Pain

Low back pain, both acute and chronic, has been the subject of many research papers, books and reports.

This is because it is extremely common and most importantly extremely costly in terms of both lost work hours and medical treatment. The cost of treating back pain is approximately 1% of the total UK NHS budget.

Back pain is assessed in the pain clinic to exclude serious and life-threatening causes such as infection, tumours and aortic aneurysms. Back pain may also be felt secondary to a more significant pain in another area. The pain clinic will refer you to the appropriate doctor/surgeon if such a condition is found.

When the pain is primarily from the low back or lumbar spine then it may be either confined to that area or associated with pain in the legs, groin or abdomen or even further up the back even as far as the neck, shoulders and head. This latter pain is called referred pain.

Simple or mechanical low back pain is pain felt in the back alone. It is important to treat this early and effectively and exclude sinister causes as mentioned above. Bed rest and immobility are not recommended for more than 2 to 3 days. Continuation of a normal life style using regular over-the-counter painkillers and careful goal-targeted exercises suffice for the majority. If this is insufficient then your G.P. can refer you to a physiotherapist and prescribe stronger painkillers such as codeine-containing drugs.

Patients with low back pain with referred symptoms may have prolapsed discs compressing nerves, inflammation in the joints between the bones of the vertebral bodies (facet joints), arthritis or degeneration in the same bones with resulting nerve compression and referred pain. This nerve compression results in sciatica, that is shooting pains in the legs and this is referred pain.

The Sacro-iliac joints are also a common origin of low back pain. These are relatively immobile joints and can become inflamed and cause pain with sitting or walking. They are often involved with Rheumatoid-like illnesses.

The majority of patients with low back pain who come to the pain clinic are many weeks down the road from its onset. Sinister causes still have to be ruled out. Often they will have seen other Consultants and have had investigations such as MRI scans and X-rays. Treatment in all cases follows the lines as mentioned above i.e. pharmacological, physical and psychological.

Facet Joint Injections

Your symptoms and signs may suggest that the facet joints (the joints between the vertebral bodies) are the source of your pain.

Sitting, stretching backwards and turning to the side are often painful here. These joints can be injected with very small doses of steroid and a positive response (pain relief for weeks/months) can be followed up with an injection therapy known as rhizolysis where the nerves that supply the joints are destroyed with radiofrequency waves which cause local heating hopefully giving a long period of pain relief. These nerves can regenerate so causing a return of the pain some months/years later but the procedure can be repeated if necessary. SPECT CT scanning is a very sensitive indicator of active facet joint inflammation.

Slipped discs will often give rise to both local and referred symptoms. Most commonly it occurs in the lumbar spine and gives rise to aching or shooting pains in one or both legs.

Slipped discs also occur less commonly in the neck with associated arm pain and even less commonly in the thoracic vertebral area with associated chest or groin pains. Similar symptoms may arise if a spondylolisthesis occurs.

This grand sounding term describes the slippage of one vertebra on another. This can lead to narrowing of the space available for the spinal cord and the nerve roots. Narrowing of the spinal space is called spinal stenosis. MRI scans are excellent diagnostic tools in this area.

If spinal stenosis leads to excessive interference with peripheral sensation or power or interferes with bowel or bladder function, then an operation is necessary.

Where spinal stenosis is causing symptoms but no operation is deemed necessary then performing an epidural with depot steroid can help the peripheral symptoms. The depot steroid can reduce the symptoms due to inflammation and nerve compression.

As a rule of thumb, with slipped discs, the shorter the time of symptoms then the greater the chance of prolonged pain relief. Steroids are not licenced to go in the epidural space but the procedure has been performed for many years with the benefits outweighing the risks for most people. The main risks are infection, blood clot formation with nerve compression and inadvertent spinal tap. I perform epidurals using an x-ray machine to make sure the needle is in the right place and to minimise the risk of spinal tap.

Other aspects to management of back pain

There are many other ways of managing back pain using physical, pharmacological and psychological methods as injections are certainly not suitable for everyone and in those deemed suitable sometimes they do not work sufficiently.

These other methods can be discussed in the pain clinic itself but include the use of TENS machines, analgesic drugs including topical painkillers, physiotherapy, psychotherapy and pain management programmes. There is an outpatient-based pain management programme in Shrewsbury; your GP can refer you for assessment for your suitability for this.