As the pain reduces the activity increases. A group of muscles which has been unused because of pain is suddenly made to work after pain relief. This produces fatigue pains as well as pain from improper use of muscle.
A list of common clinical complaints in patients of backache is presented below
1. Pain in low back
2. Pain in the buttocks,
3. Pain in the hips,
4. Pain in the thigh and calf going to the soles
5. Pain going from back through the buttocks, thigh, and legs to the feet .
6. Tingling numbness in legs
7. Weakness in the legs
8. Inability to walk, stand, sit or turn in bed
9. Cramps in the calf at night ,etc.
10. Back pain persisting after surgery
Low backache is one of the most common causes of patient disability and suffering. The cause of pain depends the diagnosis of the pain generator or the structure causing the pain. The tissues that make up the back are,The bony cage comprising
The paired facet joints at each level
The intervetebral discs and ligaments.
The muscles with their fascial covering that stabilize the back and move it in flexion extension, side bends, rotation etc
The spinal cord made up of the nerves.
The connective tissue layers covering the spinal cord.
X rays and CT scans high light the bones and joints of the spine. MRI highlights the soft tissues inside as well as outside the spinal canal.
Some of the better understood causes of back pain are ,
1. Acute and Chronic Disc protrusion / prolapse/ extrusion with Radiculopathy (disc slipping back onto the nerve & compressing it to cause pain shooting down the leg)/ Sciatica
2. Facet joint pain (Facet joint arthritis)
3. Spondylolysis (a crack in the spine between the facets)
4. Spondylolisthesis (the vertebra sliding anteriorly or posteriorly with respect to the adjacent upper or lower vertebra). Sometimes spondylolisthesis is secondary to the spondylolysis
5. Lumbar canal stenosis,(hard bones and firm ligaments of vertebral canal narrowing onto the soft spinal cord)
6. Sacroiliac joint pain.
7. Failed Back Surgery Syndrome.
8. Sports Injuries- Usually pains from the muscles tendons and ligaments.
9. Any muscular pain in back and lower limb – e.g. Pain from Pyriformis syndrome, Calcaneal spur, Plantar fasciitis, burning feet, etc.
10. Mechanical back pain( Mechanical back pain ( the most common and least understood where there may or may not be any demonstrable abnormality on X-ray, MRI etc )
Whatever the pain generator, all these conditions produce a tremendous spasm of the muscles on either side of the spine. Most back pains are a DIRECT result of this spasm.
A major stressor in the genesis of back pain is the erect posture. When man evolved from a quadruped to a biped posture, the weight that was well distributed between 4 legs became transferred to just 2 legs. In addition, the centre of gravity shifted upwards making constant muscular effort essential to maintain stability. In addition, the upper extremities pivot on the lumbothoracic junctional area for all movements. All this puts a lot of load on the back. The areas particularly stressed are neck, the thoracolumbar junction and the lumbar region where the load is maximum. It is well to remember that back is not a stable fixed structure but is supported by the 2 legs which are themselves mobile. So the way the feet are placed on the ground, and the tensioning of the muscles around the ankle and knee can determine whether the back is tilted forward or backward. Thus the equilibrium of back in health is extremely complex even at rest. When dynamics of body movement, and of the upper and lower limbs are added to the situation it becomes well nigh unpredictable and incomprehensible . Little wonder then, that the incidence of back pain is what it is. Modern lifestyle adds to the problem because of the lack of exercise to the back, prolonged sitting especially working at the computer, slouching on soft sofas in front of TV etc. Nature however, has designed our body well. So the body tolerates a lot of abuse before it expresses its distress by way of pain. By the time pain is felt considerable damage would be done to the back. This can be reversed in most people with well planned exercises, Physical therapy and IMS (Link ). However if the result of the negligence has already caused a disc to prolapse or even a small tear in the disc then interventional procedures (link) may be necessary to reverse the damage so that IMS and Physical therapy can then restore normalcy.
Ashirvad offers its patients a complete rehabilitation package for low backache, from preventive pain management to comprehensive treatment strategies that includes a correct diagnosis of the pain generator and a specific target treatment for the pain generators .
Let us take the example of a common situation of a prolapsed intervertebral disc to illustrate the logic of this approach :
1. We perform a transforaminal epidural injection of steroid (triamcinolone) to reduce the irritation of the nerve root by the disc ( either a mechanical pressure or from the chemicals released from the disc)
2. This is followed by IMS ( please give a link to IMS ). It is our experience that whatever the pain generator (disc facet etc), the pain is invariably expressed through the muscles. The muscles go into spasm with any insult which is initially painless and later becomes a painful spasm This spasm squeezes the vertebrae together to press on the disc causing the pressure inside the disc to rise. This in turn maintains or increases the nerve irritation. Unless this muscle spasm is specifically relieved the pressure on the nerve by the disc does not subside in toto. This is the reason why many properly performed blocks seem to relieve pain for a few days but the unrelieved muscle spasm once again reaches the threshold which had originally irritated the nerve with a return of the pain.
IMS, by relaxing the muscle is about the only treatment that addresses this serious problem. As our experience has shown, a systematic IMS of the muscles of back and legs has the potential to completely resolve this problem of paravertebral muscle spasm. For performing IMS a comprehensive knowledge of the anatomy of back musculature as well as their functioning at rest and during movement is essential. IMS does not mean just the insertion of a few needles here and there, but is a very thorough and deliberate release of countless spastic areas of the spine muscles from the giant erector spinae muscle to the tiny muscles guarding the nerve root foramen.
Physical therapy: Is an essential adjunct to the nerve block and IMS. The electrical modalities further relax the muscles and then specific exercises stretch out the muscles released by IMS. A localized release of spastic areas of the muscle may be performed by specific myofascial release techniques performed by a trained physical therapist.
All the patients who follow this algorithm of Pain block , IMS physical therapy and medications recover while those who stop treatment just after the block appear to have a higher likelihood of a recurrence of pain.
Thus at Ashirvad we make a special effort make patients understand the importance of this comprehensive therapy rather than have just a “ pain block”
Pain blocks include transforaminal epidural injection, Interlaminal epidural injection ( similar to what is given for labour epidural ) facet injection, nerve root injection, injection of Pars, caudal epidural injection etc.
ozone injections into any of the above or into the disc,
Intramuscular stimulation or dry needling of muscles,: In our experience this is the treatment that addresses the root of the problem in back pain in a logical manner by systematically reducing the paravertebral muscle spasm. Physical therapy can then stretch the muscles, ironing out the kinks as it were, from the spastic muscles. This is followed by conditioning and strengthening exercises for these muscles to restore back health so crucial to a long term solution to the problem of back pain
Trigger injections, Botox injections for muscles ,and targeted physical therapy. If the result of these is not satisfactory & Advanced interventions like spinal cord stimulator or intrathecal pump are available
Failed back surgery or post laminectomy pain syndrome ( FBSS): This is a condition where the patient has a back surgery but the patient remains unrelieved because
1. There is no relief of the pain for which the surgery was performed, either the back pain or radicular pain down the legs.
2. There is a different and new pain that comes on after surgery.
3. A combination of both old pre operation pains and new post operation pains.
4. New symptoms other than the pain that come on after surgery like tingling numbness, heaviness, weakness etc.
All these symptoms may be in the back ( axial pain ) or in the leg ( radicular pain)
Failure of back surgery to relieve pain is a phenomenon that happens in the best centers all over the world. As a matter of fact any surgery anywhere in the body can give rise to “ Post surgical pains” For example, many patiets suffer pain after hernia surgery, cardiac surgery, cholecystectomy, even surgery on the brain. The term “ failed back surgery has to be understood in the correct perspective. Surgery is done for many indications like weakness, sensory symptoms like pins and needles , numbness etc as well as for pain . Most patients improve in several of the problems for which they were operated but continue to have some pain. This means that other problems have been solved by the surgery but not the pain. There are many explanations of why this occurs. Some of the explanations are,
1. The swelling of tissues in then spinal canal ( induration oedema ) in reaction to the surgery.
2. Later scarring (fibrosis) which is also an expected and normal reaction of the body to any surgery. This scar can press on the nerve in much the same way as the disc did before the surgery, or the scar can entangle the nerve to put uneven pressures on it with movements etc .
3. The blood supply to the spinal cord or the nerves which passes through the same area as a surgery may be compromised either because of the surgery or because of the scarring.
Whatever the cause This is a very distressing as well as disheartening situation for the patient who expects to do well after surgery and is worse instead. Nor is it easy for the surgeon who would have done his best with utmost goodwill. He/she invests time, skill and expertise in performing the surgery optimally.
The only answers for post laminectomy pain syndromes, , if any, for this problem lie in Pain management.
Fortunately pain management offers quite a number of alternatives for the pain of failed back surgery, with the following.
2. Physical therapy
3. Interventions like transforaminal epidural injections, Facet injections Radiofrequency denervations , Racz procedure or advanced interventions like spinal cord stimulator.
IMS - This is an option we believe to be very important in the treatment of FBSS because it addresses the most vital factor in the causation as well as the maintenance of back pain. We have used it with significant success in a large number of patients.
Counselling and coping strategies : Are very important in putting the patient’s perceptions, expectations, demands from self as well from treatment in the proper perspective. Many patients assume and demand that any treatment should abolish pain forever. Unfortunately they forget that pains can never be static but is triggered and worsened with activity. After all the human body is not a static doll in a showcase! but is a dynamic mobile structure that can collect injuries with every movement. This is particularly true for any patient who has been in bed rest because of illness and pain. With prolonged bed rest the muscles of the body are deconditioned and have to be slowly rehabilitated over a period of time. This time frame is determined by the level of deconditioning, the patient’s age and the will power to put in the effort required for rehabilitation. It is quite easy for the patient to be disheartened by the slow improvement interspersed with regressions in relief. This is because the muscles( the main pain generator ) seems to have a memory to go back into painful spasm with trivial provocations. As the pain reduces, the activity returns. A group of muscles which has been unused because of pain is suddenly made to work after pain relief. This produces fatigue pains as well as pain from improper use of muscle. Even physical therapy can trigger a recurrence of spasm. The patient has to understand that this regression is temporary in that it can be reversed by IMS and this pattern of yo-yoing pain and relief is a part of the rehabilitation process. The understanding that pain is being managed to allow a comfortable life has to be clearly understood. In this coping strategies are invaluable.