my aching back

Monday, August 1, 2011

There is a design flaw that exists in the body. Walking upright on two legs instead of all fours puts significant stress on the low back and may be one of the reasons that low back pain is such a common complaint. In fact, mechanical low back pain is the most common cause of disability in people younger than 45 and is most often work related. Boston Red Sox pitcher, Clay Buchholz, can relate. He’s had low back pain for weeks that didn’t respond well to treatment. Because of the poor progress, an MRI was performed that showed Mr. Buchholz had sustained a stress fracture of his low back.

The medical term for a vertebral stress fracture is spondylolysis, which describes a break of the pars interarticularis, one section of the vertebral body. This type of fracture is common in athletes, especially those who weightlift, dive or do gymnastics, all activities that put pressure on the low back. Heredity may also play a part. Those at risk may have a family tendency towards thin bones. Since each vertebral body has two pars and if only one is broken, the major complaint is pain. However, if both pars interarticularis break, one vertebra can slip or move in relationship to the one below and may cause damage to the nerves as they leave the spine.

Medical terms can be confusing, especially when the words look and sound alike:
Spondylolysis: stress fracture of the pars interarticularis
Spondylolesthesis: a vertebra is displaced or slipped forward or backward in relation to the one beneath it.
Spondylosis: osteoarthritis of the joints between vertebrae
Spondylitis: inflammation of the vertebra

While pro athletes often get medical pampering, it seems that the doctors looking after Mr. Buchholz followed the guidelines of the American College of Physicians and the American Pain Society.

The diagnosis begins with a thorough history to learn what activities might have caused or aggravated the back pain and whether there are symptoms that might be associated with sciatic nerve irritation. Perhaps the strangest questions have to do with bowel and bladder function associated with cauda equine syndrome. If not recognized, it may lead to irreversible spinal cord damage and paraplegia. Physical exam including neurologic testing of reflexes, power and sensation, confirms that the nerves are intact.

No x-rays are recommended at this point and treatment includes pain control, initially with acetaminophen or ibuprofen and self-care with stretching, ice and heat and activity as tolerated. Bed rest isn’t usually recommended. When symptoms resolve, there is opportunity to start preventive measures to increase core strengthen and flexibility. For those who need it, weight loss is also helpful. And if there was a specific movement of work activity that was the instigator, avoiding that movement might prevent future injury.

Some people don’t get better and this is where imaging is appropriate. Guidelines recommend MRI or CT (as opposed to plain x-rays) to help understand the anatomy and look for the cause of pain.

The treatment for spondylolysis, the vertebral stress fracture that has Mr. Buchholz on the bench is rest and perhaps a back brace. If the vertebra slips (spondylolesthesis), the treatment remains the same, unless neurologic damage occurs and then surgery may be required to stabilize the back.

It is thought that worldwide more than 80% of people will experience low back pain in their lifetime. Fortunately, most episodes last less than two weeks. The take home message is that while low back pain is common, complications are not. Rest, ice and heat and over the counter pain medications may prevent a doctor’s visit. But if there are signs of sciatica including pain radiating down the leg, numbness or muscle weakness, seeking medical care is most appropriate. And should bowel or bladder issues arise, it’s time to find help emergently.

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