Spinal Surgery
The spine is made up of a series of stubby, rounded bones called vertebrae which are joined together to support the trunk. It also serves to protect the nervous tissue as it passes from the brain to the limbs. In order to allow some movement of the trunk, the vertebrae are joined by specialised structures called ‘intervertebral discs’. These disc are made up of two parts; an inner ‘neucleus pulposis’ which is a jelly-like structure; and an outer a ring of fibrous tissue called the ‘annulus fibrosis’ and which looks somewhat like the tyre of a car. Various other ligaments bind the vertebrae together and the movement of the spine is brought about by the numerous muscles which surround it in layers and the muscles of the trunk.
In order to accommodate to the upright posture the human spine has developed a series of curves, if one looks at it from the side, in order to enhance its balance while standing. The cervical and lumbar spine are curved gently forward and the thoracic and sacral parts are curved in a backward direction. When viewed from behind, however, the spine is normally straight. Spinal disease will often cause an alteration to these normal curves.
The spine is subject to a wide variety of conditions which can lead to pain, deformity and, particularly as it carries the nerves of the body, loss of function of the body. It is generally concern for this last aspect that causes individuals suffering from a spinal problem to become very anxious about their condition despite the fact that paraplegia from back problems is uncommon..
Backache
Because of the complexity of the spine, with its numerous joints, muscles, ligaments, and intervertebral discs which can become injured or can degenerate with age, there is a lot of potential for pain in the spine or back.
Backache is a common cause for distress in any population. It causes pain and is a major cause for physical disability and psychological distress. It thus cannot be looked upon in isolation but must be viewed in terms of how the condition affects the individual; how it affects his or her family; and how it affects society as a whole.
The individual - Pain in the back can be extremely uncomfortable. It often leads to a period physical incapacity, leaving the affected individual feeling helpless and extremely anxious about his (or her) condition.
The family - It is distressing for the family to see one of its members suffering from backache and, in many ways, sharing his suffering. There is also an economic element to this as the affected individual is often unable to work and, if unsupported by his employer, will suffer significant loss of income.
The society - Back pain, on an accumulative basis, can be extremely costly to society. It is calculated that the cost to the United Kingdom in 1998, as a result of this condition, was in the region of £1632 million.
Mechanical Backache
Generally, if one is fit, the back can take a lot of strain and rarely gives a problem. However, the muscles around the spine give it much of its support and if these get ‘out of condition’ due to age or inactivity a sudden exertion can ‘sprain’the back which will result in some discomfort. Stressful working or social conditions cause an increase in muscle tension and can lead to diffuse aches and pains, especially around the neck and shoulders, and sometimes the lower back. Fortunately most of the pain arising from this cause will settle relatively quickly but there are some measures which you can undertake which may be of some assistance.
Prevention of backache is the best measure.
• Keep fit. Regular exercise strengthens the body and keeps the spine supple.
• Be careful how you lift items, especially if they are heavy.
• A large abdomen pulls on the spine. Keep your weight down.
• Reduce stress. This can be difficult but, if necessary, consult a Counsellor.
Further information on back care to prevent or reduce pain in the back can be obtained from Back Care and the Back and Neck Care Guide and SpineHealth. The small publication from the British Medical Association 'Understanding Back Pain' also gives a good review of the non-surgical aspects of back pain.
For various reasons, sometimes from prolonged strains or sometimes from an inherited predisposition, the structures in and around the spine begin to degenerate. In doing so the back becomes subject to more severe and prolonged episodes of backache. The structure which usually takes the brunt of this degeneration in the spine is the intervertebral disc. Degeneration of this structure can cause a localised pain in the back. The process, if it continues, sets up in turn a series of events which serve to exacerbate the pain further. These events include prolapse of the intervertebral disc, collapse of the ligaments between the vertebrae of the spine and, in the later stages, arthritis of the facet joints. The person who is suffering this degree of degeneration of the spine may well find that he (or she) is experiencing two different types of pain. There may be discomfort, localised in the back or neck, which arises from the damaged structures within the spine itself; and there may be pain, which passes down the legs or arms, caused by pressure on the nerves.
If pain is present in the back
• It is generally felt that it is better to keep moving, if possible, although it is usually necessary to modify ones activities to accommodate to the pain. A Physiotherapist will be able to guide you in the type of exercises and activities which you can undertake and advise on your posture.
• If at all possible, lose weight.
• Spinal manipulation from an Osteopath, Chiropractor or Physiotherapist is sometimes of great benefit.
• The use of effective ‘pain killers’ as a temporary measure is often invaluable. If necessary your doctor can prescribe these if you find that the simple analgesics, available ‘over the counter’, do not help.
• Muscle relaxants, if given for a short time, can help although they have side effects of dependence and drowsiness and can contribute to the risk of a fall, particularly in the elderly.
• A spinal support is sometimes of assistance
• Electrical interferential treatment can help. A transcutaneous, electrical nerve stimulation (TENS) machine can sometimes reduce much of the discomfort.
• In certain, very specific instances injection of facet joints or epidural injections can help but surgery may ultimately prove to be the only recourse to alleviate the discomfort.
If pain is present in an arm or leg it may be 'referred' or 'radicular'.
• 'Referred pain' arises from an area of inflammation or some other painful lesion, such as fibromyalgia, present somewhere about the shoulders or in the lower back or buttocks. The pain, however, appears to be present in the limb rather than in the back. This occurs as a result of the brain misinterpreting the site of origin of the pain because the nerves which supply the area of inflammation in the trunk also have branches which pass down the adjacent limb. With 'referred pain' the discomfort in the limb is present only in association with the pain in the trunk. It is generally not of a sharp, shooting nature. It may, however, be associated with mild 'pins and needles' in the fingers or toes. Treatment of the originating lesion will usually alleviate the referred pain.
• 'Radicular pain' arises when a nerve itself is directly irritated, usually by pressure from prolapsed intervertebral disc, a thickened ligament or an enlarged osteoarthritic joint in the spine. This irritation causes pain which seems to be originating in the limb, in the area of distribution of the affected nerve and often goes right down the limb. The pain may, or may not, be associated with pain in the back. The pain in the limb, in this instance, has a sharp, 'shooting' nature. It is more likely to be associated with definite 'pins and needles' in the hands or feet. It is also likely to be associated with weakness and/or loss of sensation in the limb. Radicular pain will not subside until the pressure on the nerve is reduced. This may occur spontaneously. If not, surgical decompression may need to be considered.
• It is important to differentiate between 'referred' and 'radicular' types of pain but, in addition to these causes, there are some conditions which cause an inflammation or degeneration of the nerve itself. These too can also cause pain or altered sensations in the limbs.
Non-Mechanical Backache
Not all pain in the back is 'surgical' in nature. In many instances the discomfort which an individual experiences will be be found to be originating from a small localised mass within the soft tissues of the lower back and buttocks, and other areas of the body. These masses are termed 'trigger points' or 'myosfasciitis', but may be described in a number of other terms. In essence they are small areas of degenerate issue which, in themselves, are generally not too serious but the constant pain which they generate is ‘boring’ in nature and is particularly distressing for the affected individual. Typically myofasciitis gives rise to 'referred' pain down the limb which may emulate a problem in the spine. The myofascial nodules can be associated with hypersensitivity to pain and can be difficult to treat.
Many of those affected have difficulty in accepting that the severe discomfort which they experience can be arising from a condition which is not life threatening. Physiologically it is known that there is frequently an alteration in the normal 'pain pathways', the net result being that instead of diminishing the pain the brain, in fact, enhances it. Although the problem can be very distressing to the affected individual the underlying cause for this group of conditions remains relatively unknown. Many possible causes have been postulated. These include previous injuries to the spine or back, an underlying mechanical cause such as scoliosis of the spine, hyper-laxity of the joints, food allergies, iron deficiency, vitamin deficiencies and hypothyroidism. Treatment of the problem can be difficult. Exercises and physiotherapeutic manipulation can be of assistance, as can injection of a steroid solution into the mass. Correction of any obvious deficiencies can help. Reduction of psychological stress is important as this tends to perpetuate the pain. Cognitive behavioural therapy, by helping the affected individual to change his attitude to the pain can often be of assistance.
Fibromyalgia is an even more complex condition. The affected individual frequently exhibits several of these painful myofascial nodules (or 'trigger spots') and is usually accompanied by sleeping disorders and depression. As with myofasciitis, there is often 'sensitisation' of brain to the pain and this may manifest in widespread pain and hypersensitivity to touch in the affected individuals. The UK Fibromyalgia Association gives a broad overview of this subject and the book 'Fibromyalgia' by Dr Don L Goldenberg, published by Piatkus, gives good insight into this perplexing and distressing condition from the affected individual's point of view.
There is a group of conditions which, when present, have generalised effects throughout the body. As part of their symptomatology they can give rise to backache. Sufferers from the Irritable Bowel syndrome quite often experience pain in the back for no apparent cause. However, in others of this group the spinal manifestations are very specific. This applies particularly to Rheumatoid arthritis and Ankylosing spondylitis. A relatively uncommon but benign condition also giving rise to pain in the back is Forrestier's disease; manifesting with small, hyperostotic outgrowths of bone between the thoracic vertebrae.
Chronic Backpain
If the pain in the back or in the neck becomes prolonged it is termed 'chronic'. In this situation the affected individual may not wish to undergo an operation or the underlying cause of the pain may not be amenable to surgical treatment. If this case relief of pain may be obtained from attending a Pain Clinic which specialise in treating back pain using non-operative methods.
Pathological Backache
Rarely tumours or infection may affect the vertebrae. The pain, in these instances, is generally a deep, constant ache which may be accompanied by systemic conditions such as a raised body temperature or marked loss of weight. You should especially consult your General Practitioner under these and the following circumstances.
• If the backache is prolonged
• If the the pain is severe and radiates down one or more limbs.
• If there is paralysis of one, or part of a limb.
• If there is a problem with bowel or bladder function.
• If it is a child or adolescent who is experiencing backache.
In these instances it is important to know what is causing the pain. The physical examination will usually suggest the diagnosis but, to accurately localise the cause and site of the pain it may be necessary to assess the back using some of the specialised radiological investigations such as an MRI or CAT scan, or a bone scan. Occasionally more invasive procedures such as discography may be necessary.
Surgical treatment of back pain
The Spine Health web site discusses many of the conditions which affect the back and gives much useful information in this respect. Although most cases of backache settle down within a relatively short period there are a few common conditions of the spine for which surgery may possibly be the best treatment option. These include many of the degenerative disc conditions, spondylolysis, spondylolisthesis, severe deformities and tumours. These conditions and their surgical procedures are considered in the following sections; and further information and discussion can be obtained from the website of the North American Spine Society.
