Back Pain- How a surgeon can help :: Causes of back pain
Back Pain – How can a surgeon help?
The spinal column is a complex structure made of a series of connected bones, which are called vertebrae. The cushioning area between two vertebrae, which is made up of strong connective tissues is called the disc. This disc is made out of a tough outer layer called annulus, and a gel like centre called the nucleus. A herniated disc usually refers to this gel squirting out through a defect in the annulus into the spinal canal behind the body of the vertebrae where it can compress nerves. However, the majority of the injuries to the spinal column do not involve a direct injury to the nerve.
Spinal surgeons try to understand back pain depending on age of the patient, for how long pain has been present and whether it effects only the back or if there is associated leg pain. Further whether the pain is associated with or without deformity of the spinal column.
It may help if we discuss back pain as either acute or chronic.
Acute Back Pain
Nearly 95% of living human beings will suffer at least one episode
of back pain. Majority of them, that is nearly 80-85%, will have the
back pain resolve within three days to three weeks. We do not believe that rest helps
“improve” back pain; however, one may be required to rest to avoid
aggravation of pain and spasm. In the early days simple analgesic like paracetamol (Panadol) may be
A small percentage of patients in the acute phase (about 1-2%) will develop herniation of the nucleus which is also called sciatica. However,
most of these patients, will improve without surgery. A small number
of patients who have
herniation of the nucleus of the disc, may require surgery in the
This is dependent on the amount/size of the herniation. In short, the
of acute pain of the lower back, whether it involves the disc or it
does not involve
the intervertebral disc, is quite good. There are only a few
situations where one
may require surgery and most of them relate to consequences of nerve
compression, which may include weakness around the foot and ankle or
the inability to pass
urine. The operation normally performed in the acute phase is called
Chronic Back Pain
What then will happen if one continues to have pain three months after the first injury/or episode?
This situation is then labelled as chronic back pain. If there is
a significant sized herniation it can be addressed with a discectomy
(as discussed above) however, on most occasions, pain continues
without any obvious source. A spinal surgeon may then try to find the
source by performing advanced investigations, which include functional
x-rays and/or CT myelograms, MRI scans, an injection program involving
the facets or the epidural space.
On numerous occasions the choice of facet injections or epidural
injections, which include injection of a locally acting steroid, may
be an effective treatment and relieve the pain. If, however, your
pain continues to be disabling beyond the six month mark, the
likelihood that you become completely symptomatic and do not have any
recurrence diminishes. The majority of such patients, which chronic
back pain have periods where they do not have any symptoms and other
times where there is exacerbation of the problem.
It is our understanding that if left to nature, these conditions do
not resolve. In such an event it may be a reasonable option (though
not necessary) to consider the option of stabilization of that spinal
segment which may be a potential source of pain.
A surgeon can stabilize the segment, depending on the extent of the
disease, either by a spinal fusion operation or by a disc replacement
If you have any associated canal stenosis (the older the patient
the more likely this is), this can be addressed by performing a
canalicular decompression (previously also known as laminectomy). A
number of patients may have a pars defect or a spondylolisthesis.
This condition requires surgical stabilization if the sufferer has
disabling or unbearable pain.
Another effective mechanism of preventing the recurrence of pain is
by improving the core stabilizers (Abdominal muscle envelop), which
can be performed by numerous techniques including Pilates or real time
ultrasound guided feed back mechanisms. These are good to try out in
the three month to nine month period.
In summary, a spinal surgeon may be able to help a patient with
acute back pain, who has a significantly large herniation of the
nucleus with compression of his nerves and patients who have ongoing
back pain despite excellent supervised conservative treatment at the 6