By Dr Jacques Conradie — Neurosurgeon
What is the leading cause of disability globally? It’s not trauma or stroke-related. The answer might shock you: it’s lower back pain. As we approach World Spine Day on 16 October, it is important to raise awareness about spinal pain, the disability it can cause, and the importance of prevention and appropriate care.
Around 619 million people globally live with lower back pain, and most people will experience it at some point in their lives. It is one of the most common reasons for missed days at work. These numbers reflect a widespread, global and serious condition. Yet, most of us think of back pain as something trivial. Just take some Panado, rest and get over it. The pain will go away.
But the pathophysiology of lower back pain isn’t that simple. Just looking at the anatomy, the spine consists of multiple facet joints, intervertebral discs, ligaments, muscles and nerves. Each one is a potential pain generator. Each one is treated differently. Each one presents with a slightly different pattern of lower back pain.
But as medical professionals, both GPs and non-spine specialists, we sometimes package them together as a single entity: lower back pain. Not taking into consideration the actual cause of the pain. Examples include radiculopathy causing unilateral leg pain; central stenosis causing gluteal and bilateral leg pain; facet joint arthropathy causing midline pain worse on extension; disc-related pain worse on flexion; and muscle pain worse on palpation. Though finding the cause is never this simple.
Most patients have multiple parts of the spine affected. Discs, joints and nerves. It’s part of the ageing process. To make it even more difficult, many people over 70 have abnormal spine imaging but no symptoms. Meaning imaging and patient presentation might not even be related in some cases.
This discrepancy between imaging findings and pain has led to the treatment of lower back pain shifting from an anatomical strategy to a biopsychosocial strategy. Where the physiology, the psychological impact and social circumstances are considered in the treatment. Someone with depression, working a manual job, might develop debilitating pain with no major abnormality on imaging. As a GP, you might prescribe analgesia with physical therapy and hope for the best, and as a spine surgeon, you are expected to find a surgical solution. Though the pain generator here might not be something that surgery can fix.
Therefore, not everyone should be treated the same. Some patients might need a psychology referral, others social services, others occupational services for work ergonomics. Some just need activity modification, others simple rest. And some genuinely just need a short course of analgesia. Very few need a spine surgery referral.
When is more urgent care and referral required? Not all lower back pain is benign, and everyone should be aware of the red flags to check for in back pain. These red flags point to conditions such as cancer, fractures, infection and cauda equina syndrome. A few include progressive neurological deficit, recent significant trauma, a history of cancer, unexplained weight loss, fever, urinary retention or incontinence, saddle numbness, and risk factors for infection such as diabetes, HIV or intravenous drug use. When someone has lower back pain with these risk factors, further urgent imaging and referral is required. In this case, urgent referral to spinal surgery after work-up is vital.
Back pain is common, complicated and at times debilitating. Treating it effectively means identifying the cause: the pain generator. This relies heavily on a good history and physical examination. Very rarely is imaging or advanced diagnostics needed in the early phase. The emphasis lies on a good approach and a multidisciplinary team. No physician is an island, especially when it comes to lower back pain.