In younger groups, back pain tends to be due to poor posture, especially at the desk or computer. A small number of young patients, usually male, may have an inflammatory arthritis called ankylosing spondylitis (see under section on ‘Arthritis’). In middle age, we see more patients with degenerative disease of the intervertebral discs. Herniation of the central core of the disc, the nucleus pulposus, through the outer disc perimeter may result in compression of a nerve as it leaves the spine causing arm pain (brachalgia) or leg pain (sciatica). This may sometimes be referred to as a “slipped disc”, a bit of a misnomer as the whole disc doesn’t slip, just a small fragment of the disc. In later life, patients may have wear and tear arthritis of the spinal facet joints as well as disc disease. Degeneration of the discs and facet joints, sometimes called spondylosis, may present in different ways – localised back pain, referred pain to the buttock and leg, or pain and sensory symptoms in both legs after walking (canal stenosis).
There are a number of other causes of spinal pain, including osteoporosis, infections and malignancies. These different causes present in very different ways and the diagnosis usually becomes clear during the consultation. MRI scanning is a very effective investigation in aiding the diagnosis and determining the severity of a condition.
Investigations and Treatments
Most spinal conditions can be managed using a combination of manipulation (chiropracty, osteopathy), acupuncture, analgesics and patient specific exercise programmes. Supervised exercise programmes are undoubtedly the single most important method of managing long-term spinal pain. These are best initiated by a physiotherapist who has a specialist interest in spinal disorders.
Epidurals and imaging guided steroid injections, which target specific spinal joints and nerve roots, can be useful for those patients with unremitting back, leg or arm pain. Surgery may be the right approach for patients with specific conditions and for whom other treatment programmes have failed. Only a small percentage of patients with spinal pain require surgery.
Recent studies have shown that certain MRI scan findings, called Modic change, can be associated with a low grade chronic infection of the intervertebral discs. This can caused further spinal stiffness and pain, especially at night and in the mornings. A long course of antibiotics has been shown to be helpful in this group.