08th, Oct 2020
It's Back Care Awareness Week, so we spoke to Dr Michael Stafford, Consultant in Anaesthesia and Chronic Pain Medicine on why we experience back pain, how we can avoid it and what are the options available to help back pain.
Low back pain is very common. Up to 90% of us will experience it at some time in our lives.
Fortunately for majority of us, this is a temporary episode and settles down with rest and pain relief. If the pain lasts for more than 3 months, we can think of it as chronic back pain.
The majority of cases of back pain come from the muscles or surrounding soft tissues. Most of the remaining cases are related to degeneration, or ‘wear and tear’, in the facet joints (the joints between adjacent vertebral bodies). The proportion of us with facet joint pain gets bigger as we get older. Up to 60% of the over 60’s have facet joint related pain. Only a very small proportion of cases are related to pathological causes such as fractures or cancer.
Back ache can be caused by many day-to-day activities such as lifting, bending, twisting or sitting with a poor posture at a computer or work-station. This type of back pain is very common and is related to muscle or soft tissue strain. The pain usually settles with rest, simple pain killers and education about back care to prevent re-occurrence. Regular back exercise is the best way to prevent this pain re-occurring
The best way to prevent back ache is to be educated on ways of looking after our backs. For those with physical jobs, education on lifting and carrying techniques and avoiding twisting movements can be helpful. For those with sedentary jobs, spending time at a workstation, education on posture and ergonomics can be helpful.
It is also important, if you do develop back pain to continue to do the exercises. Fear of pain and avoidance of exercise due to the mistaken idea that this will cause more damage, can actually exacerbate the problem and makes the muscles tight and stiff, ultimately making the pain worse.
The first step in the management of back pain is to rest and gently exercise the back muscles. For the majority of cases this is sufficient and the pain tends to settle in a matter of weeks. If the pain persists for more than 3 months, we can think of it as chronic back pain.
The vast majority of cases of back pain are due to muscle pain or facet joint degeneration. Only a very small number of cases of back pain are due to pathological conditions such as cancer or fracture. The way we check for these cases is by asking about ‘red flag’ symptoms.
The ‘red flags’ are:
If there are none or only one ‘red flag’ present, it is highly unlikely that the pain is pathological and no further investigations are needed.
If more 2 ‘red flags’ are present, or there is a very strong element of suspicion on 1 ‘red flag’, more investigations such as a scan or some blood tests may be needed.
While it may be reassuring that the pain is unlikely to be pathological, it may be necessary to seek specialist help if the pain does not settle within 3 months.
There are generally 3 stages to back pain management:
Step 1: Self-help
This is usually rest and simple pain relief. If you have had a previous episode of back pain and seen a physiotherapist in the past, step 1 may also include doing the exercises shown at that time.
Step 2: GP / Physiotherapist (Community care)
This involves prescription of anti-inflammatory and paracetamol and codeine combinations (cocodamol) as well as physiotherapy. The physiotherapist will aim to show you exercises that you can do yourself to improve and maintain function.
Step 3: Specialist help
You may be referred to a Specialist if your back pain doesn’t settle after 3 months.
If your back pain doesn’t settle after 3 months, your GP may consider referring you to a specialist. The main role of the specialist is to try to figure out where the source of the pain is. If no red flag symptoms are present, we can be confident that we have mechanical low back pain. If red flags are present, more investigations and a referral to a spinal surgeon may be necessary.
If we have mechanical back pain, we then need to decide if the pain is coming from joints or soft tissues. This is done by a procedure called Medial Branch Blocks. In this procedure, the joints we think are causing the pain are frozen up with local anaesthetic. If significant pain relief is obtained, we can conclude that the joints are the source of the pain. Conversely, if no pain relief is gained, the joints are NOT the source of the pain ie it is muscle or soft tissue.
If the joints are identified as the pain source, the next step is Radiofrequency Ablation (RFA), which is the only treatment recommended by NICE. In this case, instead of freezing the nerves with local anaesthetic, they are instead heated up and killed off with radiofrequency waves. These are purely sensory nerves and killing them off does not affect function. Although the nerves eventually grow back, this can give pain relief for up to 18 months.
For more information please see NICE guideline NG59.
If you would like to book an appointment with Dr Stafford, please contact 028 9066 7878.
For further information on our Chonic Back Pain services, please click here