It is most important to ascertain that the pain is of vertebral origin. Pain due to infection, inflammation, tuberculosis, tumour of the spine, osteomyelitis, cancer or other diseases should be excluded.
A sudden dramatic pain is most likely due to a derangement of the spine. Pain which increases relentlessly without any intermission suggests that it may be due to inflammation or malignancy. In such cases, an X-ray has to be done to check out the condition of the spine and the disc. However if there is an acute prolapse, the X-ray may not show any abnormality, but may show the extent of osteoarthritis as being extensive or mild. It may be remembered that there are many patients with the same radiological changes who do not experience pain, and they continue to show the same changes even after they obtain complete relief.
An injury or strain may indicate the time when the annulus fibrosus of the disc was torn. The nucleus pulposus will bulge from this torn annulus. As the nucleus pulposus is gelatinous, there is a time gap between the injury and the advent of acute pain. If this bulging material lies behind the posterior longitudinal ligament, the patient suffers from acute lumbago; if the nucleus pulposus herniates through the weakened ligament, it impinges on the nerves and there is radiation of pain in the lower limb.
Acute lumbago may also be due to other mechanical disorders of the spine: the sudden nipping of the synovial membrane in one of the fact joints; or subluxation due to constant ligamentous strain, bad posture, disc degeneration or osteoarthritis.
There is great controversy among doctors and orthopaedic surgeons regarding the treatment of lumbago. Some may not allow their patients to be manipulated at all, while others may manipulate each and every case under general anaesthesia. At a meeting of the World Orthopaedic Association, a panel of seven experts under the chairmanship of Professor Mc Farland discussed the problem: even though thirty-three per cent of all orthopaedic outpatients complained of low back pain, the panel had no unanimous suggestions for coping with such a vast number.
Treatment of low back pain is controversial. There is no other condition where treatment varies so much from doctor to doctor. Moreover, treatment depends more on the severity of the symptoms rather than on the severity of the lesion. The arbiter of the result is the patient himself, and different patients have varying sensitivities towards pain.
Backache, lumbago and sciatica result largely from disc lesion, and so the correct mode of treatment should be manipulative reduction, rather than vitamins, heat, diathermy, massage and exercise.
The whole procedure of treatment can be divided as follows:
Postural prophylaxis
Manipulative reduction
Maintenance of reduction
Prophylaxis. Back extension exercises should be a part of the school gymnastics curriculum. Students should be taught to lift weights by using their knees and not with their backs arched. The medical officer in an industrial unit should teach workers how to lift weights safely. They should also see to it that manipulative reduction is available to their workers. An architect should see that the sink is placed at a proper height, a little higher than customary. The car seat too should be designed in a way that the right posture is maintained.
Patients must be instructed not to do toe-touching exercises. It is much better to do extension exercises so as to keep the muscles strong. If a patient is engaged in heavy work and has had several relapses, the employer must be asked to give him a lighter job.
Manipulation
If the pain is of recent origin and started after bending down or lifting a weight or pushing an almirah, why should it not be cured in an equally short time? The treatment of a slipped disc by manipulative treatment is logical and ethical. Treatment should be by manipulative reduction. But before manipulation, a definite diagnosis should be made and all contraindications for manipulation excluded through the patient’s history, clinical examination, X-ray and laboratory tests. If there is any doubt about the diagnosis, it is better to postpone manipulative treatment.
Manipulation should not be done if a patient has acute pain and is not able to move in bed. A few day’s bedrest and formentation should follow manipulation. Different variations of manipulative procedure are adopted to suit each individual case. In the case of sciatica, a mechanical irritation of the nerve by the disc after intermittent pressure, produces inflammation and swelling of the move. This leads to pain and an abnormal sensitivity in the area distributed by the nerve. Adhesions around the nerve roots are formed and often remain even after the inflammation has completely subsided; then the pain is felt only when the nerve is stretched.
The secondary effect of nerve root irritation or compression arises when the patient tries to escape pain by adopting a position of comfort. In this process different curvatures in the spine, called scoliosis, may occur. If there is no inflammation, the patient is able to adopt a pain-free position. If the nerves are inflamed and swollen, the pain increases during the night. Once mechanical irritation leads to inflammatory change, the rate of recovery is slow and the pain is prolonged.
The treatment in such cases is as follows:
Removal of pressure from the nerve through manipulation
Avoidance of further irritation
Treatment of residual muscle weakness, if any
Precaution against recurrence
Here is a very recent report which should be used as a guide before deciding whether we should resort to surgical interference in disc cases or not. The Karolinska Institute, USA, made a study of 583 patients after their first attack of sciatica. Surgery was performed on twenty-eight per cent of them. A close watch was kept on the groups of both operative and non-operative patients for seven years. The study showed that an acute attack of sciatica ran a relatively similar brief course in most cases, regardless of whether the treatment has been conservative or surgical.
There is a noteworthy reduction in the number of disc operations being performed the world over. This is due to the poor results obtained and complications following such operations. A neurological deficit including muscle and motor weakness, is not a compelling factor for surgical interference.
Uncontrolled urine and bowel movement which occurs in a small number of cases, however, does call for surgical interference. Surgery should not be done if the pain is severe. It is much better to wait. It should only be considered in cases where manipulative manoeuvres have been tried and failed. When the Pain is severe, a pillow can be put under the knee. A few patients may find a sitting position more comfortable.
Complete bedrest and traction should be given and continued till the pain is reduced. But if the pain persists after two weeks of bedrest, manipulative reduction to shift the pressure upon the nerve can be attempted. If there is a deformity in the spine, sustained traction is often effective at the acute stage. Bedrest and traction should be continued till the pain subsides. Patients may need the support of a corset, but it should not be used for more than 3-4 weeks, otherwise, the lower back muscles become weak, and strengthening them later on becomes a problem.
When the pain has subsided, exercises should be started. If a particular exercise causes pain, it should be avoided. The aim should be to increase muscle strength. A soft bed and low chairs should also be avoided.
Posture
The patient should be taught how to use his knee joints so as to avoid over-bending. He should be made to sit and rise again with the object being lifted.
When turning, the patient should avoid twisting his body. It is much better to change the position of the feet instead and change direction.
Lumbar and abdominal exercises must be demonstrated. It is better to do one simple exercise than a set of exercises.
Exercises
Lie on your tummy. Place your hands flat on the ground in front with shoulders back, and lift your shoulders and head up as far as you can. Hold the position for 20 seconds, return to rest for 5 seconds, then repeat the exercise again. Repeat it 20 times morning and evening. If it hurts, do it a less number of times and increase the number by one every day.
If the tummy is big, it also pulls forward the lumbar spine, causing a constant strain. Reduce your tummy by lying on your back. Keep your arms on your side; lift your leg upto about 45 to 70 , or even to 90 , and bring it down again. Repeat this 20 times. Do it morning and evening.
Correction of lordosis is important. The patient should lie on his back. He should pull in his abdomen and hold his buttocks close together to push his lower back against the floor, and then relax and start it over again. This may be done for 2-3 minutes at a time and 3-4 times a day. It must be done on the floor or on a wooden plank with a rug over it. It should not be done on a mattress.