Low Back Pain / Lumbago

Condition

The term is used to describe pain across the lower back. It is not a specific disease but a symptom, which can have different underlying causes. It is very important to distinguish between different forms of low back pain (LBP) and the underlying cause. Almost every person will experience LBP at some point in life. The vast majority is ‘mechanical’ or ‘musculoskeletal’ in nature and no specific diagnosis is made. There are different structures in the spine, which usually play a part: muscles, tendons, discs, small joints (facet joints) and bones. It is often very difficult to pinpoint exactly which part is responsible and in almost all cases it is a combination. However, a good examination and careful analysis of the development of the symptoms by an expert can narrow it down. The pain can be either acute or chronic (longer than 3 months). In cases of acute pain patients can sometimes identify an incident which started it but commonly there is no specific event. Fortunately, the pain settles in the vast majority of cases within a few weeks or months.

In chronic LBP patients often experience intermittent symptoms. At times the patient can be almost symptom free for several weeks or months just to wake up the next morning again with severe pain. This may then take days or weeks to settle.

The influence of so called ‘psycho-social factor’ has been well established. Depression, anxiety, low mood, difficulties at work or in the family can all play a part. This is not to say that these factors cause the pain but they play an important role in the perception and management of the pain. It is an experience of everyone that pain on a good day feels different than on a bad one. It is important that these factors are taken into account and openly talked about during a consultation. It does not mean that the pain ‘is just in the head’ and therefore is not taken seriously. It is the exact opposite!

Low back pain can be a co-existing symptom together with leg pain, which can arise from the facet joints (referred pain) or pressure on a nerve (sciatica /radiculopathy).

Symptoms

Most patients experience pain across the lower back, which feels like a dull ache or spasm. It is often worst in the morning when the back feels very stiff and might take an hour or two to loosen up. It also gets worse when being stuck in the same position (sitting in the car or behind a desk). This is usually due to the back muscled going into spasm. As the muscles get tired in the evening, the back pain may also worsen.

The pain might go up the spine between the shoulder blades and top the neck and often patients feel that it is moving around rather being in the same place all the time. Many patients find it difficult to find a comfortable sleeping position or may wake up when turning in bed.

Red Flags

There can be more sinister causes behind LBP, in which case it is important to make a quick diagnosis. For this purpose, so called red-flag symptoms have been described. The possible causes include tumours, infection, fractures, spondylolisthesis, rheumatism and other rare diseases. The symptoms are not specific for a certain disease and do not mean that there is necessarily a serious cause for the LBP. It is the history and often combination of the symptoms which may give a clue. However, they act as a warning system and patients displaying these should be seen by a specialist and if necessary be investigated quickly.

The following list is not exclusive but covers most of the symptoms:

First presentation age less than 20 or over age 55

Violent Trauma: e.g. fall from a height or accidents

Constant, progressive, non-mechanical pain

Pain in the middle part of the spine (Thoracic pain)

History of cancer

Long term use of steroid medication (tablets or injections, not creams)

Drug abuse

HIV/Aids

Generally feeling unwell

Unexplained weight loss

Persisting severe restriction of movements in all directions

Cauda equina syndrome/widespread neurological symptoms and signs

Progressive weakness in the legs or gait disturbance

Loss of feeling in the legs / trunk

Inflammatory disorders (ankylosing spondylitis, rheumatism and related disorders)

Peripheral joint involvement

Investigations

For simple musculoskeletal LBP in the absence of red flag symptoms there is no need for specific investigations such as MRI scans, blood test or even x-rays provided the symptoms improve and there is no progression. In patients with red flag symptoms, an MRI scan and a referral to a specialist should be considered as soon as possible. In case of severe or persistent/ worsening LBP simple x-rays and MRI scans can be helpful. Depending on the suspected underlying cause, x-rays, CT scans, bone scans or blood test may also be indicated.

Treatment

This depends on the underlying cause and severity.

The two most common options are painkillers and physiotherapy. There are also other manual treatment by osteopaths and chiropractors and a combination of all of these can bring the vast majority of cases under control.

Drugs

There are many different painkillers on the market and patients should always consult their GP or pharmacist. Some drugs are available over the counter, others need a prescription. Many drugs have different ways of acting in the body and can be taken in combination. The principle should always be: as few/ little as possible. All drugs have potential side effects. Paracetamol is a simple painkiller and works for many conditions. It can be effective for mild to moderate LBP. Codeine based drugs (Codeine Phosphate or Dihydrocodeine) are generally stronger than Paracetamol. One very common side effect is constipation. There are several drugs available which contain a combination of Paracetamol and Codeine (Co-codamol, Co-dydramol). A group of drugs which are very effective for any musculoskeletal pain including LBP are so-called ‘non-steroidal anti-inflammatory drugs’ (NSAIDs). Brufen, Iboprofen, Naproxen and Diclofenac belong to this group. Unfortunately, these drugs can upset the stomach and should not be taken if there is a history of stomach ulcers or heart burn. In cases of severe LBP Tramaldol can be very effective. This should always be closely monitored by a doctor and long-term use should be avoided. Even stronger painkillers like Morphine should only be used in extreme cases and close supervision by a doctor is essential. Some muscle relaxing drugs like Diazepam can help in very acute LBP. Its use should be limited to a few days and always be supervised by a doctor. The addictive qualities are well established. Pain clinics can help managing the drug treatment of patients with severe chronic LBP.

There are other drugs which usually help nerve pain better than the drugs mentioned above. Amitriptylline (an anti-depressant) or Gabapentin/ Pregabalin (drugs originally designed for the treatment of epilepsy) can be very effective for severe nerve-related pain. They need to be taken on a regular basis and often cannot be stopped at once but gradually reduced.

These need to be prescribed and monitored on a regular basis by a doctor.

Physiotherapy and Pilates forms an important part as it improves the strength of the muscles and improves their co-ordination. Often muscles are in spasm and physiotherapy can help this. Even if patients are usually fit and well it is worth learning specific exercises to strengthen the core muscles in the back (core stability). The most important part is the exercise program the patient does him/herself at home. Like training for the London marathon, it does not work overnight! However, the strength of any muscle can be improved and if physiotherapy becomes too painful the exercise program should be reduced and carefully tailored to the patients abilities rather than just stopped. Physiotherapy often focuses on the so called ‘core stability’ and aims to improve posture and muscle balance.

Chiropractor or osteopath treatments are other manual therapies which can be very helpful. One important difference to physiotherapy is that the treatment is passive rather than active as in physiotherapy. In my opinion, these treatments should be done in addition to physiotherapy rather than instead.

Yoga, although not a back exercise as such, can be useful for muscle and body relaxation and might me very helpful. It is important to understand the 'dos and don'ts' of physiotherapy to know whether certain positions or exercises can be done with a specific back condition.

It is also very important to address psychosocial factors. Assessment by a psychologist or pain specialist can usually be arranged through the GP. There is good evidence, that the pain is unlikely to improve unless these issues are addressed.

Spinal Injections (epidural or facet joints) may improve the pain and play a role in the management of acute pain and acute flare ups of chronic pain. Unfortunately, these do not provide a good long term solution and effects can be short lived.

Surgery

The role of surgery is very limited unless there is a specific cause like spondylolisthesis, deformity (scoliosis) or severe inflammation / degeneration. In some selected cases, there might be an indication for surgery and some patients undoubtedly have good benefit from this. There are various procedures including spinal fusion, disc replacement or dynamic stabilisation procedures, which may be indicated. This should be discussed with a surgeon on an individual basis. Surgery should only be considered if all conservative treatment has failed.

Further information about the management of back pain can also be found on the website of the National Institute for Health and Care Excellence - NICE . Click here for further information.