Back pain is very common and many different things can cause it. It's the second most common neurological problem after headaches. Dr. Charles Sansur, associate professor of neurosurgery at the University of Maryland School of Medicine and neurosurgeon and Director of Spine Surgery at the University of Maryland Medical Center answers questions about some of the causes and treatments for back pain and the role of spine surgery, when needed, for conditions like scoliosis.
Tell us about the spine and what causes back pain.
The spine is composed of multiple features that have one main goal, to provide us with structural integrity for our back. But it also provides us with motion. The interplay between stability and motion and structure is the spine's responsibility. The main features of the spine are the cervical spine, which is the top part in your neck, followed by the thoracic spine, the main portion attached to your rib cage and finally the lumbar spine, which is the lower back. Each part of the spine has vertebrae which are made of bone. In between each vertebra is a disk and there are nerve roots that come out on the sides throughout the entirety of the spine. Depending upon what the condition is, you can either have irritation of nerve roots or stretching of the ligaments adjacent to the bony structures that can result in symptoms.
Back pain is multi-factorial. You can have back pain that results from nerves being compressed. You can also have back pain that results from muscles being used excessively. The other causes of back pain could be the stretching of the membrane that surrounds the bone called the periosteum. Sometimes you can have bone tumors in the spine that can cause back pain, but those are very rare cases. By and large the most common cause of back pain is muscle strain. Second most common would be stenosis and nerve compression.
When someone has a muscle spasm in their back, what does that mean? Why would that happen?
Muscle spasms can happen as a result of over use or as a result of an underlying problem with the nerve where there's compression of the nerve and muscle spasms as a result of that compression. For instance, lifting heavy objects or doing exercises that are in excess of what you normally are accustomed to doing.
Does back pain increase with age?
There's no question that as you age back pain increases in its commonness. As people age, there's a normal tendency to lose your overall posture. When degenerative changes develop in any part of the spine, the tendency is to develop a curvature where the degeneration has occurred, shifting the center of balance from above the pelvis to directly in front. When that happens, it puts more strain on your muscles and that strain, in conjunction with the balance being off, can cause chronic overuse of the muscles.
When that happens, you get muscle pain with increased activity and you're no longer able to tolerate the same activities that you were tolerating before. It happens as we get older because the most common part of the spine to degenerate is the disk. As you lose height in the disk, or the space in between the bones collapses, you lose height in the front of the spine causing the spine to have a tendency to lean forward and develop what we call positive sagittal balance
What are some of the common signs of a back problem? Do things come on suddenly or does this happen gradually over time?
It can be either or. Depending on the chronic nature of the problem in terms of whether or not there is a positive sagittal balance that would be something that would be associated with a chronic development of lower of back symptoms. If a patient comes in and says that during some kind of physical activity he developed pain in his back that could either be a muscle strain or a herniated disk causing some nerve compression.
What is chronic back pain?
Chronic back pain is any type of pain that does not go away with routine measures targeted at alleviating the pain. Most back pain goes away naturally, after a few days or several weeks, or after doing physical therapy. Chronic back pain is most often some kind of problem with overall posture and balance.
Is it important to seek a diagnosis to find out exactly what's causing the back pain or should you wait a little while to see if it goes away on its own?
I think a lot of patients end up having a under diagnosed problem with back pain. Certainly I think a referral to a specialist is indicated, because quite often back pain is not recognized by primary care doctors. The different etiologies of back pain aren't always directly discovered until it's worked up to a further degree.
Is there a minimally invasive way to prevent the continuation of the back pain or the continuation of the degeneration of the disks?
Certainly. Maintaining a balanced diet, maintaining your overall bone health is the best way to maintain your overall sagittal balance in conjunction with routine strengthening of the core muscles. The core muscles are the muscles that not only wrap around the spine and support the spine, but also support the torso. If those muscles are strong, there is less stress imposed on the disks and vertebrae themselves and that can result in the preservation of your spine.
What would you suggest for safe exercise?
In my opinion, depending upon what the patient's functional capacity is, the most gentle way to exercise and strengthen the muscles that surround the spine is to do a therapy program in the water. An aquatic-based physical therapy program is ideal because the buoyancy of the water allows you to exercise your spine and the muscles that surround the spine without the effect of gravity.
When a patient comes to see you for recurring back pain, how do you evaluate them?
It is very important to get an idea of what the spine looks like when the patient is standing upright in addition to when the patient is bending forward and extending themselves backwards.
One imaging test we use is an x-ray called the long cassette. The long cassette provides us with the ability to assess how one's posture is relative to the patient's pelvis. Specifically we're looking at the very bottom part of the spine at the L5-S1 junction which is the transition between the lumbar spine and sacrum. We want to be sure that the spine is well balanced. The long cassette x-rays determine whether or not the spine is balanced and they also show us if the spine has abnormal curvature.
There is also MRI for assessing soft tissue structures such as the disks, spinal cord, nerve roots and ligaments.
What is scoliosis?
The spine normally has several different curves to it. When you're looking at scoliosis you're looking at the spine from a front to back perspective. If the spine has a curvature in the middle plane, then that would be what we classify as scoliotic curve. When the spine has scoliosis, the muscles around the spine are subjected to increased strain. That is usually the etiology of pain in someone with scoliosis.
There are several different causes for scoliosis, one being that you could be born with it. The other type of scoliosis is what we would call degenerative scoliosis, and that's scoliosis that results from the degeneration of the fassett joints, which are the structures in the back of the spine. These joints are the main joints that give your spine flexibility. Sometimes these joints can degenerate in an asymmetric way. So the right joint might degenerate faster than the left joint. If that happens, you can develop a curvature in your spine.
When is surgery considered as treatment for scoliosis?
It depends a great deal on the nature of the situation. If you're an adolescent that has scoliosis, typically surgery is reserved for curves that are over 50 degrees. If you're an adult and you have degenerative scoliosis and you have evidence that the scoliosis is progressing, that's an indication to intervene.
Braces can help in an adolescent scoliosis patient, while their bones are still forming and while they're still developing. Braces can also help in an older patient with degenerative scoliosis. However, chronic use of the brace will result in muscle wasting and loss of muscle tone around the spine. Traditionally I don't use braces, but in someone who is not capable of tolerating surgery and who has other medical comorbidities that make surgery too risky, a brace may help with some of the pain symptoms.
What is spinal stenosis? Is it common? Can it be treated with surgery?
It means the narrowing of the space that normally is there for the nerve structures. Normally the spinal canal is large and there's adequate space for both the spinal cord and the nerve roots. However, as time passes and people develop degenerative changes of the spine, you can have some bulging of the disks or some overgrowth of joints. The combination of the overgrowth of the fassett joints and bulging disks results in crowding of the spaces in the spine, in essence that is spinal stenosis.
As narrowing in the spine occurs the combination of motion with the narrowing results in stretching or compression of nerve roots. If the stenosis is so severe that the fassett joints would need to be removed in their entirety, surgery would be performed. The treatment would be to decompress the nerves by removing the fassett joints in what we call the lamina which is the shell of bone that sits in the back of the spine. Then supplement that decompression with the placement of instrumentation in the form of screws and rods.
I always mention to patients that having one spine surgery puts you at high risk of needing another spine surgery in the future. Quite often if one does spine surgery they have degeneration of the area above or below where surgery was done, especially if a fusion was performed. That puts extra stress on the adjacent levels and those adjacent levels due to the excess stress can degenerate therefore requiring further intervention.
Does the hardware used in spinal surgery ever get loose?
One of the risks of surgery is having what we would call hardware failure. Sometimes, especially if patients have history of poor bone quality, the screws can loosen. It's best to have a spine surgeon who is dually trained in neurosurgery and orthopaedic surgery. I think it is that class of spine surgeons who are able to not only address the neuro elements to the greatest degree, but also the bony elements to the greatest degree. Having a fellowship trained spine surgeon is very important.
Is the vast majority of back pain something that will go away on its own?
That's correct. The vast majority of back pain is something that will go away with conservative measures and rest and relaxation. There's only a small subset that actually require surgery. But certainly a referral to a specialist will put a patient in the right direction and will determine whether or not any kind of further intervention is needed.
For more information about the University of Maryland Departments of Neurology and Neurosurgery, or to make an appointment, call the University Physicians Consultation and Referral Service at 1-800-492-5538 (patients) or 1-800-373-4111 (physicians).