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BACK INJURIES - a patient's guide
Dr Chris Milne - Sports Physician
Overview
Back injuries are very common.
Most acute back injuries resolve rapidly.
It is best to remain active and at work if possible.
A few serious problems can occasionally result from back
injuries.
What causes back injuries?
Usually the cause will be a single event, where the tissues
at some vulnerable spot in the back are stretched beyond
their usual tolerance for stress.
The back is a very complex structure, with a delicate
spinal cord encased within angled bones at the rear of a
column of bones arranged like building blocks. Between these
blocks are discs, which have a tough outer casing and a
jelly-like centre.
In certain types of back injury, the casing of the disc
can split and allow the centre contents to squeeze out.
This is referred to as a "slipped disc".
If the disc presses on an adjacent nerve root, it can
cause pain along the distribution of that nerve root, down
the leg. This type of leg pain is called sciatica.
Other structures that can cause pain when injured include
small joints at the rear of the spinal cord. These are called
facet joints (between the vertebrae). In some athletes,
e.g. fast bowlers in cricket, pain may arise from a stress
injury to the bone.
Pain may also arise from irritated muscles which then
go into spasm.
Other causes of back ache are much rarer and include infiltration
of the bones of the spine with tumour deposits from spread
of a cancer elsewhere in the body.
The exact identification of which structure is causing
the pain is often difficult, and is not necessary in most
cases.
What symptoms occur?
Back pain, generally at the level of the structure that
is injured
Leg pain down the back of the leg if a nerve root is being
irritated or pinched
Muscle weakness, if persistent squeezing of a nerve root
occurs
Pins and needles in a particular part of the leg or foot
if persistent squeezing of a nerve root exists
Rarely, disturbance of bowel or bladder function (e.g.
inability to pass urine) may occur. This is serious and
requires urgent evaluation in hospital
What treatment is recommended?
Firstly, it is important to see your doctor for a medical
evaluation. Your doctor is aware of the serious symptoms
that require urgent referral to a specialist (see below).
If these are not present, the following advice is recommended:
1. Avoid activities that provoke pain, at least in the
first few days after injury. Bed rest is rarely needed,
but if so, it should be limited to 2 days or less. Longer
periods of bed rest can impair recovery.
2. If back or leg pain is significant, regular doses of
analgesics (pain killers) are advisable in the first week
or two. Paracetamol is purely a pain reliever, whilst aspirin
and other anti-inflammatory drugs also relieve inflammation.
If you have a pervious history of peptic ulcer, your doctor
may recommend newer cox-2 anti-inflammatory drugs (e.g.
celebrex) that do not upset the stomach.
3. Gradually increase physical activity over the first
week or two as symptoms subside. In most cases, it is advisable
to remain at work performing modified duties. Particular
activities that may have contributed to the injury (e.g.
heavy lifting, bending or twisting) should be reviewed and
modified if possible.
4. Manual therapy can be very helpful in the first few
weeks after a back injury. Physiotherapists, osteopaths,
chiropractors and some doctors are trained to provide this
treatment. The most important aspect is to find a person
with hands-on therapy skills who has a good record of success.
Avoid people who spend most of their time hooking you up
to a machine while they treat someone else.
5. If you have persistent sciatica which has not responded
to manual therapy after 2-3 weeks, you may be referred for
an epidural steroid injection. This is an injection of cortisone
via a very fine needle designed to shrink down the swelling
around a disc which is pressing on a nerve root. It can
be dramatically effective, but is only worth considering
if sciatica is present.
What about x-rays and scans?
In most back injuries, x-rays and scans are not necessary.
If there has been enough force to cause a fracture (e.g.
fall from a significant height, high speed motor vehicle
accident) then x-rays are worthwhile.
In older people with back injuries, x-rays may reveal
disc space narrowing. However, these findings need to be
interpreted cautiously, as there may not be much correlation
between the person's condition and the appearance of their
x-ray. We treat people, not their x-rays.
Other investigations (e.g. CT scans and MRI scans) are
much more detailed and much more expensive. Their major
role is when surgery is being considered.
What are the serious symptoms?
The following symptoms are considered "red flags". That
is, they may be a pointer to an underlying serious problem
such as rheumatic disease or an associated fracture. Your
doctor is the person who is best placed to evaluate those
symptoms in your particular case.
Disturbance of bowel or bladder function
Bilateral sciatica - pain down both legs
Significant trauma
Weight loss
History of cancer
Fever
Intravenous drug use
Steroid use (e.g. prednisone tablets for asthma or arthritis)
Patient aged over 50 years
Severe, unremitting night pain
Pain worse on lying down
What about surgery?
Surgery is not magic. It has a small but definite place
in the treatment of some back problems. The most common
indication for surgery in back disorders would be for a
disc pressing on a nerve causing severe persistent leg pain,
that is no better after an epidural steroid injection. Another
less common indication would be for limiting slippage of
one part of the spine on another part.
In summary
Most back problems resolve rapidly - within days to weeks.
Pain relief and manual therapy can speed progress in the
early stages. Leg pain (sciatica) may require an epidural
steroid injection. There is a small role for surgery.
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