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Back Pain - Features and Treatment


Clinical Features

Men are more affected than women, probably because they are more exposed to trauma. The chief complaint is of pain, which in most cases is first felt in the back and later radiates down the leg. The onset may be abrupt; very often there are repeated attacks of lumbago without sciatic pain before the latter is finally felt.

Repeated attacks of sciatica with intervals of comparative freedom are common. About half the patients with sciatica will have had an injury shortly before the attack of pain. Subsequent attacks may start after a twist of the back (like taking a suitcase out of the boot of a car), or there may be no apparent reason. Pain is the most outstanding feature, the one thing that really matters to the patient. There may only be a dull ache, or there may be a stabbing, neuralgic pain that shoots the length of the limb with searing agony. At its least, the pain is a constant source of annoyance; at its worst, it is of almost intolerable severity. All ordinary movements are prevented, the victims changes position only slowly and deliberately, rest is impossible and even a cough is fearful. Rest generally relieves the pain somewhat although spontaneous movement during sleep may cause a spasm. It is generally eased by flexion of the knee and hip, and certain "trick" positions such as rotation of the back combined with extension of the hip on the bad side, or elevation of both arms occasionally gives relief.

Numbness, tingling and pins & needles, and weakness of the muscles of the buttock or calf are other accompanying symptoms.

Treatment

The cause of "root" pressure is treated wherever possible; the treatment of sciatica occurring as a result of disc protrusion is conveniently, divided into 3 categories:

  • Ambulation

    This may be tried when the pain is not so severe. A regime is instituted which combines as much rest as possible with sufficient controlled exercise to maintain the power of the spinal muscles. Heat and massage helps to relieve the muscle spasm and exercise should avoid movements that increase the pain. Painkillers and sedatives are used in conjunction.

    Manipulation under an anaesthetic is often helpful and sometimes dramatic. It is thought that hyperextension of the spine widens the intervertebral space allowing the protrusion to return, and therefore manipulation is more likely to be successful during the first attack than in subsequent episodes when there has been time for the protrusion to become fixed by fibrosis. Forced flexion must be avoided because it may increase the size of the protrusion.

    Epidural injections (injections into the spinal joints) of a large volume of fluid is sometimes helpful, probably because it displaces the nerve root from contact with the protrusion. Steroids are also used here to reduce local inflammation.

  • Bed Rest

    Rest in bed brings relief to a majority of sufferers from sciatica although a high proportion eventually relapses. Rest should be continued for at least three weeks during which the patient is not allowed out of bed at all. Analgesics and sedatives are given freely, and warmth is essential- electric heating, where available - or at least a hot water bottle, are most comforting.

  • Operations

    The percentage of really successful operative results is high and there are few complete failures. The operation is not severe and the operative mortality is negligible, the risk being hardly greater than that of the anaesthetic. The majority of patients are entirely relieved of root pain, and although a proportion has some backache for a time, they are able to return to their previous occupation unless it entails very heavy work. Some patients are left with mild pain and paraesthesiae, especially after exercise, but it tends to diminish gradually. Operation is performed primarily because of pain; the relief of pain is so dramatic, and most patients so grateful, that operation is being advised with increased frequency. The operation consists of removal of the protruding part of the disc; many surgeons, while approaching the disc remove at most a nibble of bone, but some consider it advisable to have a wider exposure. The patient should remain in bed after operation for three weeks; graduated exercises are commenced after a few days and continued until there is full recovery. Fusion of the lower lumbar vertebrae at the same time of the removal of the protrusion is desirable when there is misalignment or osteoarthritis of the intervertebral joints.

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