Lower back pain is the pain in the lower third of the spine. I will be discussing neck pain separately.
Lower back pain can be acute or chronic. Pain lasting less than three months is classified as acute back pain and pain lasting more than three months is chronic back pain. I recommend the readers to read this article in combination with my last week’s article in the Sunday Observer (15/11/20) on back pain.
In this article I will discuss the causes of lower back pain. Last week I was following an international zoom meeting on back pain. At this meeting the percentages given as causes of chronic lower back pain were:
A. Pain due to disc problems - 40%
B. Pain due to facet joints - 40%
C. Pain due to Sacroiliac joint issues - 20%
But I would like to add muscular pain as a cause of lower back pain which is not uncommon.
The causes of lower back pain can be divided into six main groups. I have summarised it as a simple classification so that the layman can understand.
1. Muscular pain
2. Ligamental pain
3. Vertebral pain
4. Pain due to discs
5. Facet joint pain
6. Sacroiliac joint pain
Muscular Pain
This can be a common cause of acute LBP. In some it can last for more than three months and become a cause for chronic lower back pain.
Muscle pain can be due to tension on para lumbar muscles on either side of the lumbar spine. This can be due to trauma i.e. injuries, sprains due to sleeping patterns, weight lifting, exercise, etc. There is also a common condition known as Fibromyalgia which can cause chronic muscular pains. I find more patients in England with this condition compared to Sri Lanka.
Depression and anxiety is closely associated with this condition. I find the Sri Lankan population less depressed than the western population, probably due to close family ties and the weather. This may be the reason for not having many patients with fibromyalgia in Sri Lanka.
On examination the patient may have tender points (trigger points).
Diagnosis
No X rays, MRI scans or blood investigations are necessary.
It’s mainly a clinical diagnosis.
A good history and a good physical examination of the patient will give a clue to the diagnosis.
In my experience in Sri Lanka I find patients with many blood investigations multiple X rays and MRI scans carried out unnecessarily.
Treatment for muscular pain:
- Simple analgesics
- No bed rest
- Acupuncture
- Physiotherapy - Referred by a pain consultant to a physiotherapist.
- Trigger point injections
- Botox injections for spasticity
- Antidepressants depending on the patient’s psychological status.
Lower back pain due to inflamed and stretched ligaments in the spine
Inflammation of the ligaments also cause pain in the back. The main cause is trauma.
The ligaments connected to the spine from organs can cause pain due to stretching. The best example is the lower back pain in pregnant women.
Ligaments holding the heavy uterus is connected to the spine. Increased pulling of ligaments towards the latter part of the pregnancy can give rise to back pain. Back pain usually subsides when the baby is born.
Lower back pain due to changes in the vertebrae
Fracture of the vertebral body can lead to severe back pain. Fractures can result due to trauma and osteoporosis. Spontaneous fractures of the vertebral body can take place due to severe osteoporosis.
Osteoporosis leading to fractures of the vertebrae
Carrying out a dorsal root ganglion block for a fracture of a vertebral body causing pain is an accepted therapeutic procedure of the spine.
Dorsal root ganglion - Anatomy
Below is a procedure that was carried out on November 19 on a young man from Afghanistan. He is 21 years old and a university student based in Sri Lanka. He suffers from lower back pain and pain down the left leg (sciatic pain).
On examination para lumbar muscles on the left side was tensed (spastic) and there were many trigger points. There was no visible kypho scoliosis (crooked spine) on examination. He had Trigger point injections to the para lumbar muscles, Caudal Epidural, Epidurogram, Bilat L3-S1 facet injections. I noticed a mild scoliosis in the lumbar region while X raying the lower back during the procedure.
This article is written from Dr Namal Senasinghe’s personal experiences. Dr Senasinghe MBBS Dip in Pain Med FFARCS FFPMCA is a consultant in pain medicine with international experience. He lived and worked in U.K. for 25 years and opened the London Pain Management Centre at No. 31, Horton Place, Colombo 7, Sri Lanka on September 2, 2020. The occasion was graced by Prime Minister Mahinda Rajapaksa.