Posts Tagged ‘low back pain’

My aching back: What caused it? What's on the treatment horizon?

Thursday, May 16th, 2013

I have chronic low back soreness in spite of having two neurosurgical operations over the fourteen years that we've been in Colorado. So I was excited to see a Medscape article, dated April 15, 2013, on a promising new treatment, one that clearly needs a prospective controlled trail, but a concept that offered me some hope.

My last post went over the anatomy of the spine, both the bony part, the spinal column &  the nerve part, the spinal cord, cauda equine and nerve roots. Now I'd like to focus on low back pain (LBP), while acknowledging that many of us (including both my wife and myself) have problems with the upper spine, AKA the cervical spine.

The most frequent problem seems to be that strange entity called degenerative disc disease (DDD).  When I've looked at a variety of sources on this condition, the feature that many  of us with DDD have in common, is age. The Cedars-Sinai webpage on DDD mentions a critical point: as we age nearly all of us will show at least a modicum of signs of waer and tear on our final discs, yet many will have no symptoms. So the term, DDD, conventionally is used to refer to those who have pain from their damaged discs.

I copied the illustration below from the webpage of Dr. Jeffrey Goldstein, a New York City orthopedic surgeon and back specialist. He emphasizes that disc degeneration is a normal part of aging, but it can cause damage to nerves or cause pain by bones rubbing on each other.

 As I mentioned briefly in my previous post, spinal discs are rubbery, so they can act like shock absorbers for the vertebrae. They also help the facet joints in allowing us to twist and turn; at the same time they are exposed to and resist tremendous forces. They have a tough outer layer and an elastic (more fluid) core.

They have minimal blood supply, so if they get damaged there's no repair mechanism built in. Then, much as my medical history reveals, over a considerable period of time, the injured disk causes acute pain limiting back movement, then pain may occur off and on as the bone that was injured loses some of its stability and eventually the portion of the spine injured restabilizes and pain occurs less frequently.

By the time we are sixty, partially depending on our sports and daily motion, we're quite likely to have disc degeneration, but, as noted above, we may or may not have back pain.

Sometimes, under various stresses, a disc pushes right through its outer membrane. We call this a ruptured or herniated disc. Roughly 90% of the time, if a disc herniation happens, it's in the low back. And most of those who rupture a disc are age 30 to 50. As we age beyond 50, our discs dry out and are less likely to rupture.

On the other hand, we can develop arthritic changes in the vertebrae (see illustration above) that cause pain by pressing on nerve roots leaving the spinal column. This is termed spinal osteoarthritis and, although it may occur in the younger set because of trauma/injury (under age 45 this is more common in men), it's typically seen and is more common in women over that age. There may be neck or back stiffness or pain, often lessened by lying down. It's even more frequent in those who have excess poundage.

Facet joint disease is another form of this osteoarthritis (the term osteo refers to bone). It may be associated with inflammation of the facets and cause the back muscle to spasm with increased pain on any motion of the area.

Sometimes the space in which the spinal cord lies gets narrowed; this is called spinal stenosis and occurs mostly in the neck or low back regions. It may be a congenital condition (one you are born with), but much more commonly is caused by overgrowth of bone, a ruptured disc, tightening of the ligaments that help keep your vertebrae together or even by injuries or a tumor. It's more commonly seen in those of us over 50 and, if severe can lead to complications (numbness, weakness, incontinence or even paralysis)

When I had an MRI and saw my neurosurgeon for the first time, I had all three conditions: a ruptured disc, facet disease and spinal stenosis.

I was fortunate in that, under light anesthesia, the surgical team did tests to determine exactly what levels of my spine needed fixing. Now I'm by no means a neurosurgeon or orthopedic back surgeon (My initial residency was in Internal Medicine), so I can't tell you exactly what my doc did.

I have a scar like this

I have a scar like this

But as best I know, he poked in a protruding disc, reamed out a facet joint opening and expanded whatever was causing my spinal stenosis.

That led to considerable improvement of my symptoms and signs (back pain and leg numbness and weakness with some shrinkage of the muscle above and to the inside side of my right knee) But some of the symptoms came back after six years and I had a second operation.

Now all I have is fairly regular low-grade back soreness; I'd sure like to get rid of that too. So when I found that article online in, with the title "Autologous Bone Marrow Grafts Promising for Low Back Pain," I read it quite carefully.

It clearly is research at this stage and, as I mentioned, needs a large, prospective controlled trial, but researchers from Missouri reported a series of 24 consecutive patients (averaging 45 years old and with 17 men and 7 women) who had chronic LBP unresponsive to a number of therapy trials and all having lumbar disc disease. They took some of their own (AKA autologous) bone marrow from a hip, concentrated it and injected some into the lumbar disc affected and more just outside those discs.

This only took a short time (20 to 60 minutes) and most of the patients had considerable pain relief that lasted over a two-year followup period.

I'm eager to see more data on this new modality for treating chronic LBP.



Low back pain: the "background"

Tuesday, May 14th, 2013

I have a family history of back problems as well as a personal one. I don't know exactly what my Aunt Millie's (Dad's sister) back issue was, but it bothered her for many years; otherwise she seemed completely healthy until she died abruptly of cardiac disease at age ninety. My Dad never had back surgery, but often had back problems. Those may have been muscular, as his golf game seemed to be connected to his pain. He'd say, "I shouldn't have used that three-iron; it twisted up my back."

It happens to many of us

It happens to many of us

The website of the NIH's National Institute of Neurological Disorders and Stroke has a ten-page Low Back Pain Fact Sheet with the comment that Americans' LBP is our most common job-related disability and, as a neurological affliction, trails only headache in frequency. Much of it resembles Dad's three-iron comment; it's often exercise or work-associated and lasts just a few days.

But some is chronic and overall the amount of money spent on LBP is staggering, $50 billion a year.

My wife has also had low back pain (LBP) problems and wrote a story for one of the Chicken Soup books with her title being, "How Pilates Saved me from Surgery." That concerned her first episode of severe LBP eight years ago when an MRI showed disc disease in her lumbar area (below the ribs and above the sacrum). At that time she saw the same Denver neurosurgeon who has operated on me and he said, "It's too soon for surgery. I'll arrange for an injection by an anesthesiologist in Fort Collins (I played the D card, calling for her and saying  this is Doctor Springberg, and she got her shot the very next day).

She mentioned Pilates to the neurosurgeon and he approved her going to a class with some caveats. She told her instructor about her back problem and the health club's experienced teacher said, "That's no problem; there are some exercises I'll modify for you and some you should not do at all."

I had seen the online story of a woman who hadn't had the same positive experience; she and others have cautioned that Pilates is not the answer for everyone, unless you have an instructor familiar with the limitations necessary for some students.

Lynnette has remained slender and exercised five or six days a week (Pilates on three days and a class called "Strong women, Strong Bones " twice a week + stretches every day and one or two trips to the gym with me). Then she had a flareup over the last few months. She saw our favorite physical therapist, got new exercise and posture ideas and is back to low-grade soreness (two on a pain scale of one to ten). There's no surgery in sight.

She also has a strong family history of chronic LBP; her mother had it for years and her sister has had two operations thus far and numerous injections of either steroids or pain medication.

My  first episode of acute LBP happened forty-four years ago when I was a clinical Nephrology fellow at Duke, was relatively inactive and had gained lots of weight (I was at 216 pounds and had wrestled at 155 in college). The NIH Fact Sheet says most acute LBP is mechanical in nature, happens most commonly to those aged 30 to 50 who have a sedentary lifestyle and may be overweight.

I certainly fit that picture back in 1969 except I was only 28; today I weighed 149.4 pounds.

Chronic LBP, defined as pain that persists for at least three months, is another matter. It has lots of causes, especially disk disease. That statement requires considerable background. Your spinal cord is a major part of the nervous system with literally millions of nerve fibers that transmit information to and from the brain and the arms, legs, organs, and trunk of your body. It's fairly delicate so to protect it you have a series of barriers and cushions starting with the spinal column (AKA the spine), a series of bones called vertebrae. There are seven in the neck region (the cervical vertebrae) twelve in your upper back (thoracic area technically), five in the lumbar (low back) area, and then a set that are fused together (your sacrum and coccyx, AKA tail bone), making up a rough and slightly variable total of thirty.

a typical lumbar vertebra

a typical lumbar vertebra

Each one of the vertebrae has a body, the main area for weight bearing, and an off-round hole that the spinal cord passes through. Branches of the cord, AKA nerve roots, pass through other spaces in each vertebra; these are called foramina (the term comes from Latin and means a natural opening). The bony structures are separated by intervertebral discs , rubbery pads held in place by muscles and ligaments. The posterior part of the vertebrae has a portion termed the spinous process. That's what you can feel when you touch somebody's back and move your hands up and down.. It also has wing-like bony structures (transverse processes) on each side where back muscles attach. A particular vertebra is connected to the next vertebra up and downstream by facet joints, stabilizing links which allow twisting motions especially in the neck and low back (very limited in the chest area).

The spinal cord itself is cushioned by a fluid called the cerebrospinal fluid or CSF. It is produced in the skull and serves multiple purposes for the brain: buoyancy, allowing the brain to be densely packed without cutting off its own blood supply; protection from being jolted or hit; chemical stability by removing metabolic waste and allowing distribution of neuroendocrine chemicals (e.g., the nine hormones from the pituitary gland).

One more bit, then I'll quit this prolonged anatomy lesson; The spinal cord ends higher in the back than the spinal column. At the bottom of the cord is a bundle of nerve roots that send messages to and from the legs and pelvic organs. These are called the cauda equina (Latin for horse's tail). Rarely they can get compressed by a ruptured disc, tumor, infection, car crash, a significant fall, gunshot  or knife wound, fracture, or narrowing of the spinal canal.

When that happens, it's a surgical emergency, called the cauda equina syndrome.

So your spine is a highly articulated, complex structure and lots can go wrong with it.

More on that in my next post.