Lower Back Pain

The presence of symptoms may not indicate that an underlying identifiable or correctable disorder or condition exists. Symptoms can be quite generic in nature and range from focused pain at a particular spot or pain across the whole back. Most lower back pain resolves itself over a period of time. Chronic lower back pain is the most debilitating where patients are affected over a long period of time and experience repeated flare ups.

Lower back pain can be accompanied with radicular symptoms which occurs due to nerve root compression (pressure on a spinal nerve). This group of symptoms tend to be the most amenable to surgical treatment. Radicular symptoms include:

• Sensation changes such as numbness or pins and needles (paraesthesia)
  
• Weakness or motor deficit
  
• Loss of spinal reflexes
  
• Shooting pain that travels down the leg (radicular pain/sciatica)
  
• Change in control of the bowel or bladder

A red flag (or ‘warning sign’) may indicate serious but uncommon disease or condition that is causing lower back pain and make up the minority of cases (<5%). If red flags are identified, further specialist medical attention is needed.

• Disc prolapse (herniation/bulging)
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• Lumbar spinal stenosis
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• Spondylolisthesis
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• Nerve root compression
  
  
• Arthritic/rheumatological conditions

Functional causes of low back pain include pregnancy, obesity, unequal leg length, Hip joint pathology and other abdominal pelvic conditions.

Tests needed depend on the presentation but may include blood tests, x-rays, Computed Tomography (CT) and Magnetic Resonance Imaging (MRI) scan. The MRI scan is the one radiological test that provides the most information to assist in the diagnosis and cause of lower back pain, especially when radicular pain or ‘red flag’ signs are present.

When to order an MRI:

• Symptoms of cauda equina syndrome (urgent)
  
• Failed conservative management
  
• Weakness and/or sensory deficit
  
• History of cancer
  
• Suspected infection

Diagnosis of the cause of lower back pain requires getting a good patient history, physical examination and relevant tests. Findings of the clinical examination will be correlated with relevant tests to make a diagnosis.

In most cases, back pain will improve with non-surgical treatment which should be managed by your General Practitioner (GP) and other specialists.

Non-surgical treatment for lower back pain includes but is not limited to exercise, physiotherapy, clinical pilates and medication. If you have risk factors of back pain, you will be advised to make lifestyle modifications.

A comprehensive treatment plan for you must be put in place. This treatment plan will need involvement from you, your GP and other specialists such as your Physiotherapist.

Medication for back pain may include NSAIDs, analgesics and muscle relaxants as prescribed by your doctor. Opioid analgesic agents may be appropriate in some situations.

A referral to a Pain Physician, Neurologist or Rheumatologist may be required. This will either be for further non-surgical treatment or evaluation prior to surgery.

Spinal injections may be used for the investigation and treatment for lower back pain with radicular symptoms. They are used to alleviate pain and can help identify the specific pain generators. These can be ordered by either the GP, in consultation with a pain physician or Mr Gomes depending on the complexity of the symptoms, signs and imaging findings.

The common forms of spinal injections include:

• CT Guided Nerve Root Injections
  
• Epidural steroid injections
  
• Facet joint injections

Local anaesthetics and/or steroid is injected thought the skin at the back under CT guidance. Patients may obtain a significant benefit and surgery can sometimes be delayed or avoided all together.

Only a very small number of patients with lower back pain with radicular symptoms require surgical intervention. This will be assessed and discussed at your consultation with Mr Gomes.

Mr Gomes performs a number of surgical procedures which will be recommended taking into account the underlying condition and individual patient factors. Specific procedures are dependent on which part of the spine is affected. Refer to the specific spinal region for further detail.