How you CAN beat BACK PAIN FREE PULLOUT

PAIN is the most common reason for a GP appointment — not surprisingly, given that an estimated third to a half of all Britons live with daily pain. Today, our expert pain series looks at back pain, which blights the lives of more than eight million Brito

UNDERSTANDING your back pain begins with understanding your spine, a stack of 24 individual and nine fused bones, the vertebrae, supported by muscles and ligaments that help you stand, twist and bend.

In between each of the top 24 vertebrae is a cushioning disc. Its outer layer, the annulus fibrosus, is a tough ring, ‘not unlike a car tyre’, says Lee Breakwell, a consultant spinal surgeon at Sheffield NHS Foundation Trust. ‘It’s tough and semi-rigid but allows some movement.’

The inner part, the nucleus pulposus, ‘is like a jellybean full of rubbery protein’, he adds. Down the back of the spine and behind these discs, running through space at the rear of each vertebrae, is the spinal cord, the bundle of nerves from which smaller branches of nerves connect all parts of the body to the brain.

The lowest five vertebrae of the spine, the lumbar vertebrae, is where the back is most flexible. But it is also where the most common form of back pain — lower back pain — occurs.

The cause can be anything from a simple muscle sprain to a series of abnormalities in the spine putting pressure on nerves. Just how and where that pain manifests depends on which nerve is being pinched or trapped, and by what. In most cases, however, the cause will remain a mystery. WHAT TYPE OF PAIN DO YOU HAVE? MYSTERY LOWER BACK ACHE THE vast majority of lower back pain is ‘ non- specific’ — the cause is unknown. This is because with so many muscles, ligaments, nerves and moving parts, the spine is an ‘immensely complex structure that frequently keeps its secrets’, says Laura Finucane, a consultant physiotherapist at NHS Sussex Musculoskeletal Partnership.

There could be a minor mechanical problem with one of the back bones or one of the cushioning discs that has put sudden pressure on a nerve. More likely, the pain has been triggered by lifting something heavy or otherwise sustaining an injury to one of the muscles in the back.

Or it could just be down to bad posture, says Tim Allardyce, a physiotherapist and osteopath at the Surrey Physio clinic in Croydon. ‘If you sit in a chair all day your back gets very stiff. Getting up and moving every half an hour might be enough to correct symptoms.’

Fortunately lower back pain can disappear as quickly as it arrives. The NHS says 90 per cent of cases settle within six weeks.

The key to a speedy recovery, says Laura Finucane, is to keep active and get a good night’s sleep. Anti-inflammatory painkillers, like ibuprofen, can help.

Only if a patient has the telltale symptoms of sciatica lower back pain accompanied by pain, tingling or numbness in the bottom, backs of the legs and feet, is it time for an MRI scan, says Mr Breakwell (see box on next page for scans and X-rays).

Dealing with back pain is a question of far more than massage or any other form of physical manipulation. ‘This has to be done in combination with other measures, taking into account all aspects of a patient’s life,’ says Laura Finucane.

A physiotherapist will also talk to the patient about their exercise, lifestyle, posture and sleep habits. ‘ Not sleeping well definitely ramps up your pain levels,’ says Laura Finucane. Key risk factors associated with back pain are depression, being overweight and smoking. Posture is important, and patients are taught to sit correctly — avoiding hunching up.

Losing weight can also help: a review of international studies published in the American Journal of Epidemiology in 2010 found that being overweight significantly increased the risk of back pain. Extra weight increases the load on the spine, while chronic inflammation associated with obesity may also trigger pain.

Although many people with back pain are afraid to be active for fear of further damage, countless studies have shown exercise to be key to getting better.

Colin Natali, a consultant orthopaedic surgeon with 16 years of NHS experience, who

now works privately at the Schoen Clinic in Chelsea, london, has put a series of free videos of suitable exercises on Youtube (search ‘uFixu’).

Surgery is possible, although rarely advised. the procedure is called a fusion, in which two vertebrae are joined with a bone graft. Screws or rods are used to hold the vertebrae together while they are fusing. this prevents the bones moving and causing pain by impinging on nearby nerves or muscles.

‘this is about the only surgical intervention for back pain,’ says consultant spinal surgeon lee Breakwell. ‘Unfortunately it works only about 50 per cent of the time and there is a high rate of reoperation, so we advise against it.’

National Institute for Health and Care Excellence (NICE) guidance recommends the operation is done only as part of a research trial. However, a study published in the journal BMJ Open last year found 4,500 spinal fusion operations are performed on the NHS every year.

ARTHRITIC BONES

Facet joint degeneration, normally caused by arthritis, is thought to be responsible for anything between 15 and 45 per cent of cases of lower back pain.

Each vertebra has a pair of bony wings protruding at the rear that meet those of the vertebra below. these facet joints, and the cartilage that cushions them, can suffer wear and tear, leading to stiffness, localised pain and, if nerves are trapped, sciatica (pain running from the back, through the buttocks and down one or both legs).

the treatment is an injection of a combination of anaesthetic and steroids. Injected directly into the joint, this can reduce or stop the pain for weeks or even months — long enough to allow the patient to follow an exercise programme that will bring longer-term relief.

alternatively, the injection may be given directly into the nerves supplying the joint. this too will relieve pain temporarily. However, the main purpose of these so-called ‘medial branch blocks’ is to see if the patient is a suitable case for radiofrequency denervation, in which an electric current is used to heat up and desensitise the nerves.

Studies show this works for only about 60 per cent of people, who experience a reduction in their pain of between 50 and 80 per cent. the effect can last for anything from a few weeks to a couple of years.

SLIPPED DISC

IN MEdICal parlance this is a prolapsed or herniated disc, but it adds up to the same thing — pressure on a nerve that can cause anything from mild pain to excruciating sciatica, which radiates down into the buttocks and legs.

as we grow older, the outer shell of the discs that separate our vertebrae ages too and starts to stiffen and crack. Eventually, the gel-like inner tissue may be squeezed out.

In itself, this isn’t necessarily a problem, says Mr Breakwell. ‘It’s like your hair going grey as you age.’ a degenerated disc may not cause pain — though common, ‘slipped’ discs account for only 5 per cent of lower back problems. What’s more, a prolapsed disc will frequently repair itself.

Sciatica, which can be agonising, is one of the more obvious manifestations of a slipped disc.

the good news, says the Cochrane research group, is that 90 per cent of sciatica cases resolve with conservative management — including pain relief and lifestyle changes.

Surgery is a last resort, says Mr Breakwell: ‘Only if the pain is disabling, is surgery an option.’

the operation is called a discectomy, in which the part of the disc that has bulged out is cut away. Studies have shown that this can give ‘considerable’ relief of pain in up to 90 per cent of patients.

SQUEEZED NERVES

a condition called stenosis may be responsible for lower back pain or sciatica.

Stenosis refers to any restriction of the spaces in the spine through which the nerves run, which can be caused by age-related bony growth

or a thickening of the ligaments and other tissues to the point where they impinge on the nerves.

Again, exercise and physiotherapy are the first lines of defence.

Patients who don’t respond to conservative management may be offered epidural injections — a combination of local anaesthetic and steroids, a synthetic version of hormones produced by the adrenal glands, is injected into the spine.

The anaesthetic suppresses the pain and the steroids reduce inflammation, leaving the nerve numbed for up to three months.

‘it gives the body time to heal and gives the patient a window to rehabilitate and get moving again,’ says osteopath Tim Allardyce.

These injections work in about two-thirds of cases. Only if this fails is a sciatica sufferer likely to be offered surgery.

in an operation called a lumbar laminectomy, a section of bone at the back of a vertebra, the lamina, may be removed to relieve pressure. if necessary, a discectomy may also be performed to remove part of a slipped disc that is pressing on a nerve. A U.S. study in the journal Spine in 2012 compared the outcomes of hundreds of patients with sciatica who underwent any kind of decompression surgery with those who did not.

After four years those who’d had an operation reported ‘substantially greater improvement in pain and function’.

SLIPPED VERTEBRA

KnOwn as spondylolisthesis, this is when a vertebra slips out of position. ‘it sounds alarming, but many people are walking around without knowing they have it,’ says physiotherapist Laura Finucane.

There are four ‘grades’, relating to how far the vertebra has moved out of position, but even people with grade 4 may suffer no symptoms. Others may have lower back pain that’s worse when standing, sciatica or curvature of the spine.

Spondylolisthesis can be caused by degenerative changes to the spine in later life, or by trauma. Gymnasts or fast bowlers in cricket are particularly prone.

in many cases it can be managed with painkillers, exercise and physiotherapy, says Laura Finucane. if surgery is needed, it will involve fusing vertebrae.