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Back Pain – Dealing With It

Iona Collins FRCS, MRCS, MBBS, BMedSci(Hons)Iona Collins FRCS, MRCS, MBBS, BMedSci(Hons)
Consultant Orthopaedic Spinal Surgeon
It’s a fact: in the Western world, 80% of people will experience back pain at some point in their lives. Almost half of Western people experience sciatica, or pain from a trapped nerve in the back. By contrast, in developing countries, back pain and sciatica are rarely reported.Many reasons are suggested for this big difference, including healthcare systems not recording data, secondary gains in the West for having pain eg disability benefits, genetic predispositions in different populations etc.But, one major change that occurred coincidentally with the massive increase in spinal pain and trapped nerve symptoms was the emergence of the “white collar” worker, or office-based work. This type of industry developed in the 1930s along with urbanisation. As lifestyle changes from physically-demanding activities to more sedentary work involving lengthy times sitting down, then spinal problems have emerged as a major problem.
The World Health Organisation focussed on spinal problems in it’s overview of musculoskeletal problems experienced worldwide .
There is a lot of evidence to show that exercise helps to reduce the symptoms of spinal pain, yet, it seems that athletes are as prone to back problems as anyone else, so, why are we so prone to spinal problems?
One of the consequences of spinal pain is the industry that has grown around it. Commercialisation of back pain is a multi-billion dollar industry in North America, and a multimillion pound industry in the UK. The National Health Service employs spinal surgeons, physiotherapists and chronic pain specialists to try and address the problem, yet, in the NHS, both of these services can be regarded as a “quick fix”, whereby up to six sessions of physiotherapy can provide significant improvements in pain, but when the sessions stop, the pain returns. Surgeons can perform discectomy operations with immediate relief of pain, yet the risk of needing another operation due to a recurrent disc prolapse is around 8%. Back pain does not go away and stay away with short episodes of attention being paid to it- the spine needs life-long attention and maintenance to keep it in good working order.
The common sense advice of  good posture, spinal flexibilty and stretching the spine in extension seems to have been forgotten, or somehow lost in the overwhelming amount of information available to us. The spine is designed as a spring, yet when we constantly lean forward, bend down, sit and slouch, we are encouraging our spines to adopt a flatter overall contour, eventually changing over the decades to a stiff, bent spine. The shock-absorbing discs are forced to not only bear more weight due to the forces created by “lever arms”, but the loads applied to the discs are uneven, with more loading at the front of the discs rather than the back of the discs. This eccentric loading has the effect of creating a backward-directed pressure within the discs, encouraging the disc to bulge backwards where the spinal nerves are found within the spine. Eventually, as the discs fail, back pain becomes an issue, followed by the symptoms of sciatica in the leg, or shooting pains in the arms when the discs in the neck are involved.
When the spine is used in extension as well as flexion, with correct posture allowing the spine to work as a spring and the discs to bear weight uniformly, then back pain should not develop, since the back is being used in the way that it was designed.
For those who require an MRI to investigate back pain or symptoms of sciatica, please ask to see how the muscles which extend the spine appear in comparison with the muscles which flex the spine. You will find that flexor muscles appear dark, dense and healthy in comparison with the deconditioned extension muscles. Then, ask to see the difference in muscles where the discs are at their worst- this will coincide with the greatest difference in muscles masses. ADanish group performed a study to compare the amount of fatty infiltration seen in the multifidus muscles (one of the three extensor muscles grouped together into a complex called the “posterior paravertebral muscles”) and whether people with low back pain had more fatty infiltration of the muscle. The study conclusively showed this positive association, but could only observe this association instead of demonstrating causality. Interestingly, the same study showed that muscle deconditioning was also seen on the MRIs of teenagers, yes, teenagers. In this age-group, there was no major back pain to analyse, but doesn’t this observation raise alarm that we are neglecting our spines from a young age?
When it comes to keeping our spines fit for life, evidence to support a specific type of exercise is lacking. “We are as young as our spines”, quote the yoga and pilates enthusiasts, who pay frequent attention to posture, core strength and flexibility. There is an excellent publication which showcases the structural spinal perfection of yoga instructors. There is also good evidence to support frequent exercise and Amazon has gifted us with unbiased patient recorded outcome measures (PROMs) for Robin McKenzie’s 35 year old publication “Treat Your Own Back“, which emphasises spinal extension (392 feedback reports, with 283 people giving the book 5 stars = 73% 5 star feedback, when accessed online April 23rd 2016).
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