Say goodbye to back pain
Dr. SAJAN K. HEGDE
There may be various causes for back pain, but there are ways and means to deal with it to lead a pain-free life.
Sensitive SPOT: Back pain is a very common complaint.
There are various causes for back pain. The reported incidence of back pain is nearly 40 per cent. Nearly 80 per cent of the population suffers from back pain at least once in their lifetime. In most patients it is self-limiting and a definite cause cannot be found. In less than 15 per cent, a cause can be found. Inter-vertebral disc disease is a major cause of recurrent back pain. This is a soft cushion-like structure present between all the mobile vertebrae. A soft gel-like substance in the centre, the nucleus pulposus, is contained within a tough surrounding structure, the annulus fibrosis.
The disc has ability to absorb water and swell, acting like a shock absorber. This process is dynamic one. When the disc's ability is altered inter-vertebral disc disease sets in. It progresses in three stages: Dysfunction; Instability and Stabilisation.
The fist stage is usually seen in the age group 15 to 40. The disc shows numerous tears in the annulus and a minimal change in the nucleus. The facet joints (that connect the vertebrae at the back) show evidence of inflammation. The patient has back pain of gradual (insidious) onset, which may be relieved with rest. The stage of instability is between 40 and 60 years. The nucleus pulposus hardens and fragments. The annulus shows numerous tears. The facet joints tend to slip as the joint covering (capsule) becomes weak and lax.
The patient has repeated attacks of back pain often associated with pain radiating down the back of the thighs and legs due to the nerve being pinched or pressed by damaged and extruded fragments.
The unstable spinal segment gradually loses its mobility and often stiffens. The intensity of pain then reduces. But there are other symptoms for the narrowing of the spinal canal (stenosis).
A patient who complains of recurrent back pain is evaluated to rule out a definitive cause. Routine X-Ray, blood investigations, MRI and Disco gram are done.
A variety of treatment options exist for different types of back pain. The overall goal is to make a patient comfortable as quickly as possible, reduce further degeneration and help get back to normal activity.
Once Disc Degenerative Disease is confirmed, the patient is first put on a course of conservative non-operative treatment with physiotherapy, medications and belt or corset to support the spine. Certain lifestyle modifications like avoiding sitting on the floor, squatting and bending forwards are also suggested. If the pain is persistent then surgical options are explored.
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SUCHITA KADAM developed back pain in 2002. She was diagnosed with tuberculosis of spine and put on an anti-tubercular treatment. After a month and a half, she developed weakness in both her lower limbs and within a week became a paraplegic. Surgery relieved the pressure on her spinal cord but the damage had already occurred before the surgery. Any expected improvement could come only from rehabilitation and physiotherapy. She was admitted to the All India Institute of Physical Medicine and Rehabilitation (AIIPMR), Mumbai.
Constant and debilitating
While there she developed constant burning pain in both her lower limbs and painful debilitating spasms in both legs. Her doctor referred her to Dr. Lakshmi Vas. Kadam was offered three options: Intrathecal pump; Epidural port (for pain relief but not for spasm) or Oral medication along with acupuncture (to partially relieve pain with a minimal effect on spasms).
Intrathecal pump keeps pumping small amounts of potent painkillers like morphine and antispasmodic to the cerebrospinal fluid around the spinal cord. The pump is surgically implanted in the wall of the abdomen and the drug is conveyed from the pump to the cerebrospinal fluid through a fine tube (catheter) to the spinal cord. The risks of infection are minimized as the pump is implanted.
Epidural port is a thin tube placed in a compartment just outside the cerebrospinal fluid and connected to an injection port under the skin by surgery. An external pump is connected to the port through a needle in the skin.
The drug is close enough to the spinal cord to achieve acceptable results but since it is outside the spinal fluid higher doses are required. Since the pump is external and has to be connected to the port through a needle there is a risk of infection through skin.
Since Kadam could not afford the first two, she was put on oral medication. However this could neither control her pain nor the spasms despite the highest allowable doses.
She also developed an unpleasant reaction to morphine. She gradually deteriorated to a level of constant and painful spasms.
An epidural port was donated and implanted. Her pain was considerably reduced but the spasms continued unabated. Since pain from the spasms was negligible she managed quite well but was still bedridden. Unfortunately three months later she developed an infection of the needle site and the epidural port had to be removed.
This meant escalation of the pain that had been held in abeyance. Despite high doses of intravenous morphine and ketamine, the pain was unbearable.
By now it was established that only spinal drug delivery would relieve this vicious, aggressive pain. Dr.Vas implanted an intrathecal pump and it changed Suchita's life. She gained about 5-7 kg in a month, could do her physical therapy and improved significantly.
She required staggeringly high doses of medicines to remain pain and spasm free. Once she stabilised on these doses she was sent home. She continued to improve and her family heaved a sigh of relief and started limping back towards normalcy. Unfortunately her doses were so high that she had to come to Dr. Vas for refills every week (normally refills are done once in three to four months). Slowly she gained total control over her bowel and bladder functions and was able to move her legs a little.
She was readmitted to AIIPMR for physical therapy to improve her motor skills. She gradually improved to a stage where she could stand and walk for around 15 minutes.
But soon, she again developed spasms, which seemed unresponsive to increasing doses of intrathecal medication. But it was found that the problem was due to the pump. So it was replaced and Kadam improved rapidly, going back to her original improved status of walking within a month. She is now walking for 15-20 minutes a day. Since the pump is a high volume reservoir, refills need to be done every 20 days.
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