Back pain low - the Real Scoop!

Over 80% of Americans will develop lower back pain at some point in their lives. A sizable percentage of those people will have disc problems that cause the back pain. Some low back pain cases are due to sprains and strains which involve overstretching and/or tearing of the muscles, tendons and ligaments that connect into the spine. Ligaments connect bone to bone over a joint. Tendons connect muscles to bone. When they get overstretched or torn, the pain can be excruciating. Rest and physical therapy modalities such as ice, heat, ultrasound, diathermy, and electrical muscle stimulation can enhance the healing process.

Causes of Back Pain can be Complex

There are many causes of low back pain and very often a patient may be suffering from multiple causes. In other words, two or more causes may be superimposed resulting in pain either in full or in part. Perhaps a mechanical spinal problem causes lower back pain while disc pathology causes the pain in the buttock and leg. Or two problems cause similar overlapping pain in the same patient.

Subluxations: One of the most common causes of back pain is subluxations of the spinal vertebrae. This is a condition where the vertebrae move out of place and become locked in the misaligned position. Once this occurs, it places great stress on the spinal joints, the discs and the nerves. Treatment consists of chiropractic adjustments to correct the misalignments and relieve the stress on the joints, discs and nerves. Facet syndrome is directly related to subluxations. The articular joints that are between the vertebrae are called facet joints. When facet joints are under stress, they can misalign and the vertebra can tip backwards, placing great pressure on the nerves. The joints can degenerate and the body reacts by developing bone spurs or osteophytes. This is called facet hypertrophy and arthrosis and is a permanent condition.

Degenerated disc usually develops as a result of stress on the spine. The discs cannot handle the stress and they gradually wear away. As the discs thin out, the vertebrae get closer together and the nerves can become compressed or irritated. The discs also have very small sinu vertebral nerves in them and when they become irritated, they can also cause pain.

Herniated discs can be compared to jelly donuts. There is a gel in the middle of the disc surrounded by annular ligaments. The gel can push out the annular fibers causing direct pressure to the nerves. This will cause pain along the course of the spinal nerves. If the irritated nerve travels down the buttock to the thigh and leg, then the symptoms will be in those areas. When nerves are irritated, symptoms can range from pain alone to pain, tingling, numbness and weakness in the leg. This is commonly referred to as sciatica. This simply means pain along the course of the sciatic nerve. This can be a very debilitating condition and if the weakness gets severe enough, it can result in what is known as "foot drop". The patient has difficulty lifting his toes and foot upward so the foot drags on the floor as he walks. As the condition worsens, he may require an assistive device and eventually, a wheel chair. Surgery may or may not be effective with foot drop, depending on the severity of nerve damage. This is determined with multiple tests called electromyography (EMG) and nerve conduction studies.

A Ruptured Disc is a herniated disc where the gel (nucleus pulposus) has broken through the annular ligaments and presses on the nerve.

Sacroiliac Syndrome involves a slippage of the sacroiliac joint (SI). When the ilium or hip bone subluxates, it rotates and slips against the articular surface of the sacrum. The joint becomes inflamed and this can cause low back pain. Stenosis is a condition where a protruding, herniated or ruptured disc and/or ligament hypertrophy (enlargement of the ligaments surrounding the spinal cord and vertebrae), facet arthrosis and osteophytes narrow the spinal canal and place pressure on the spinal cord and/or spinal nerves. In most cases, the patient will get relief sitting or standing and bending forwards because it slightly opens the space where the spinal cord and nerves are located. Lower back pain requires a very extensive examination, consisting of a multitude of orthopedic, neurological and structural tests to help isolate the cause(s) of the pain. Sometimes x-rays are necessary to further evaluate the condition. An MRI is valuable because it takes "minute cuts" of the spine in different directions in order to better visualize the joints and the discs.

Treatment Options

If the problems stems from soft tissues (muscles, ligaments, tendons, joint capsules), then physical therapy is the most likely the best treatment. The extent of treatment depends on the damage to the soft tissues. If it involves an overstretching of the muscles, a few weeks of treatment should be sufficient. If there is tearing involved, then more treatment will be necessary to elicit the healing process. However, in most of these cases, due to spasms and or weakness in muscles, the vertebrae can subluxate, thereby complicating the problem. If the disc is damaged and this is determined to be the cause of the back and/or leg pain, then there are two conservative treatments that may help. (The reason I say that the disc is determined to be the cause, is that 31% of all adults who do not have low back pain, have herniated discs according to MRI studies. The first is Cox lumber/cervical Distraction, which is a manual, painless, safe procedure performed by a chiropractor to remove the pressure and stress to the discs and nerves.

The second disc treatment for the more problematic patients is Vertebral Axial Decompression or VAX-D. VAX-D decompresses the lumbar spine and discs to remove the pressure on the discs and nerves, not only relieving pain and other related symptoms, but elicits retraction of the nucleus pulposus, commonly called the "gel". The challenge is trying to get the "toothpaste back into the tube" and VAX-D has a 71% success rate. Be aware of simple traction devices that are promoted as "decompression". They are not equal by any means. Take your time to compare the research. VAX-D is performed by various types of doctors, including some neurologists and some chiropractors. In my experience, physical therapy does not get great results with disc problems because it does not address the disc specifically. The goal of physical therapy is to reduce inflammation and pain with the modalities such as heat, ice, ultrasound and electrical muscle stimulation and then strengthen the muscles surrounding the spine. This approach just does not help the discs.

Acupuncture helps to assist the body in healing itself by harmonizing the energy patterns throughout the body. Some people claim it numbs the nerves. If it helps a patient, I encourage him to continue because it is not going to hurt him, except in one case, where there is nerve damage and the acupuncture delays treatment of the disc and allows it to get worse. The same can be said for physical therapy.

Subluxations and facet syndrome can be treated with chiropractic adjustments, which are gentle procedures performed with the chiropractor's hands to move the subluxated vertebrae back into their normal functional positions. This takes the stress off of the nerves, joints and discs. Usually, a patient has to go for his adjustments several times per week for a few weeks to stabilize his condition.

VAX-D can help some cases of stenosis if the discs are involved. If VAX-D is not successful or not indicated, the only other option is surgery. There are several types of surgeries such as a discectomy, a laminectomy, natural fusion and prosthetic fusion. The various surgeries depend on the extent of the disc damage. I am not a surgeon and therefore these types of surgeries are beyond my scope and I prefer not to get into great detail about them. Suffice to say that a discectomy is the milder, least invasive surgery and fusion using hardware is the most invasive. The long term benefits are limited and should be carefully weighed when considering any form of surgery. However if cauda equina syndrome is present, usually immediate surgery is necessary because this causes bowel and/or urinary bladder dysfunction.

If you are suffering with constant low back pain or occasional low back pain, you should be examined by a specialist to determine the cause and the extent of your problem before it is too late! The earlier spinal problems are taken care of, the better chance for a successful outcome. Patients need to understand the potential causes and why certain testing may be necessary. Unfortunately, in these days of managed care, many insurance carriers insist on treatment without appropriate diagnostic testing. This presents a challenge for both the patient and the doctor since a decision needs to be made as to whether guesswork should be used to care for the patient. If a diagnosis is wrong because the appropriate tests were not performed, then the correct problem will not be addressed and therefore a delay in the proper treatment for that condition will ensue. Patient education is an important component of this process.

Jay H. Schwartz, DC, DIBE
drschwartz@vaxdny.com
http://www.vaxdny.com
Dr. Schwartz is board certified in Chiropractic and is a diplomate of the International Board of Electrodiagnosis. He has a unique chiropractic practice where he concentrates on electrodiagnosis to determine nerve damage and the treatment of herniated, bulging and degenerated discs. For further information about this and other health issues, please visit his website.