Problems with the lumbar spine causing back and leg pain are very common. These can occur as the result of an acute injury causing a tear to a muscle, a sprain to a spinal joint (disc or facet) or even a fracture of the bones. Usually, however, they are the result of “wear and tear” changes that have built up over the course of our lives with ageing changes taking place in the joints and associated ligaments. Developments of this kind are more prone to injury and, therefore, injury and ageing changes are inextricably linked.
There are a number of treatments available to help with your symptoms and these should be seen as an escalation of treatments through measures to help with natural healing, medications, hands on treatments, cortisone injections and as a last resort operations.
The reason you have developed a problem with the joints of your lumbar spine is linked to both your genetic makeup (60%) but also the different stresses and strains you have put your body through over the years (40%). Some people can develop disc problems with very little “wear and tear” and no obvious accident or provocation but other people can work arduous lives and be involved in multiple falls and accidents but develop no problems with the joints of their spine. Your pain is an unfortunate development and should be seen as the unlucky chance occurrence in a multifactorial process.
The joints between your vertebrae slowly over time have developed wear and tear changes with hardening of these joints and degeneration with disintegration of some of the joint components. This is an ageing process akin to grey hairs and wrinkles on the outside. The joints are there to provide flexibility, but also some shock absorbance and hence over time are less able to absorb shock or energy at worn or degenerate levels, which is the reason for the development of pain and stiffness in these joints. The expansion of these joints is caused by a tear in the disc or facet joint with the prolapse or slipping of the joint contents but is also caused by formation of bony spurs and thickening of ligaments all of which can press on the nerves of the spine and cause leg symptoms.
The symptoms you suffer are a combination of joint pain (arthrogenic) and nerve pain (neurogenic). The nerves of the legs have their roots in the lumbar spine and the “wear and tear” of joints, that on its own can cause back pain, can also start to irritate and even compress nerve roots. With irritation you may be aware of very fleeting pain shooting down the leg perhaps associated with some pins and needles or numbness.
With compression of the nerve root the pain becomes both more persistent and severe and maybe associated with weakness of part of the leg. The nerve pressure may suddenly develop (slipped/herniated/prolapsed disc), or develops slowly (bony spurs) both as a result of wear and tear changes in the joints. It would be very rare for an emergency situation to develop but occasionally a very large disc prolapse can compress all of the nerve roots in the lumbar spine, which would cause pain shooting down both legs, along with numbness over the bottom and problems with bowel and bladder control. Presentation to Accident & Emergency would be advised if this combination of symptoms should develop.
When you are examined your doctor or physiotherapist is looking, in particular, for signs indicating the level of your problem, both in terms of the joints of your spine but also the specific part of the nervous system involved. This would involve getting you to move, bend and stretch your legs as well as doing a neurological examination looking at the strength of muscle groups, the presence of absence of reflexes and the awareness of different sensations such as touch, temperature and pinprick.
An understanding of your symptoms and the examination findings will lead your doctor/specialist to come to a diagnosis which will need confirmation with investigations.
These could be simple x-rays looking at the bones of the spine and sometimes looking at the alignment of the bones when bending forward and arching backwards. X-rays are best to look at the bones and to make sure the vertebrae themselves are solid and stable and that there is no disease process affecting them. Further detail may be required in the form of a CT scan of the spine, which again gives good bone clarity. This is a safe scan to undergo for people with metal implants such as pacemakers, but does carry a small risk from the radiation exposure. The insertion of x-ray dye (contrast) into the spinal fluid (lumbar puncture for myelogram) is now a rare investigation.
The commonest way to investigate the lumbar spine to get a good view of the joints and the nerves of the spine is with an MR scan (Magnetic Resonance Scan). This is safe for most people in that there is no radiation exposure but is not allowed in people who have implanted metal devices such as pacemakers. Most other surgical implants are now MR compatible, but it would be important to check before undergoing your MR scan.
It is rare for surgery to be essential for problems with the lumbar spine and it should normally be seen as a last resort. Other treatments are usually very effective: –
Most nerve pain would settle over a six week period, due to a combination of disc prolapse resolution, reduced nerve sensitivity and calming down of the acute inflammatory changes. Back pain may persist for longer because it takes often years for the joint to start to stabilise and not provoke pain when weight bearing. This process can be helped by maintaining an active life and neither taking to bed nor pushing yourself through “the pain barrier”. It is important not to fear your symptoms and know what they are due to. Lifting or carrying should be avoided and it is important to maintain a good lumbar posture with a lumbar support and not to slump or remain in uncomfortable positions. Contact and impact sports (road running, squash, and horse riding) should be avoided whilst symptoms remain and returned to only slowly. Sensible activities should be with gentle sports such as yoga, Pilate’s or Tai Chi and then building into more cardiovascular exercises with swimming or use of an exercise bike. These tend to put less strain on the spine whilst keeping muscles active.
Painkillers – regular painkillers, such as Paracetamol, Codeine or Morphine, do help take away the pain from the both joint and the nerve.
Anti-inflammatories – in the acute phase anti-inflammatory medications are useful to help resolve the heat and swelling due to the slipped disc or disrupted joint of the spine.
Muscle relaxants – if a lot of muscle spasm has occurred muscle relaxants may be useful, but the spasm is often a local reflex to protect the nerves of the spine.
“Nerve-blockers” – such as Amitriptyline or Gabapentin, which are usually prescribed for depression or epilepsy, can also settle down a trapped nerve and reduce the pain that is caused by the nerve root compression.
Gentle treatment such as heat, ultrasound, massage or acupuncture, along with exercises to strengthen muscles (core stability exercises) and even traction, are usually advantageous. However, activities that provoke pain should be avoided. Osteopathy or Chiro treatment may also be recommended, but before manipulation is undertaken, it is usually best to have an MR scan, particularly if there are signs or symptoms of significant neurological involvement.
A particular crisis or slow resolution may be helped or speeded up to recover by the administration of a cortisone injection into the inflamed/painful area. This is a procedure performed under local anaesthetic to place a needle into the spine at the correct spot and in 60-70% of patients offers considerable help. However, pain my occur weeks or months later and there is a rare chance of severe headache or causing nerve damage to the legs or bladder (less than 1 in a 1000).
Surgery of the lumbar spine is usually seen as the last resort and often is a “take it or leave it” procedure depending on the symptoms and the impact these are having on your life. Occasionally nerve damage with marked weakness or numbness may indicate that earlier surgery is indicated. Surgery is very successful helping nerve pain in the leg (90% of the time) but not so good at improving weakness (70%) or numbness (60%).
In patients with little “wear and tear” change an acute disc prolapse can be removed and the disc joint repaired using a small wound with vision aided with an operating microscope. Convalescence is quick, with only a two to three day hospital stay (sometimes even a day case) and return to a normal, but gentle life, after three weeks. Heavy physical activities should not be undertaken for a full three months to allow the disc joint to fully recover.
This requires a larger incision with trimming back of wear and tear changes (bone and ligament) to allow removal of the disc prolapse and decompression of the nerve root. Hospital stay becomes slightly longer (4-5 days) with a convalescent period up to six weeks.
Discectomy plus non-fusion interspinous support (Wallis ligament):
Sometimes your surgeon will feel that the disruption to the segment of the spine where he or she is operating necessitates support of your spine to prevent back pain problems into the future. This is not essential but is done with a view to minimise future back pain. Non-fusion support achieves this by limiting the movement of the vertebrae taking away some of the joint pain. This should be seen as a halfway house between a simple discectomy, which although taking away pressure from a nerve gives you no additional support, and a spinal fusion which connects one vertebra to the next absolutely with bony fusion.
In this case more extensive decompression of the nervous system is required from bony and ligamentous changes that have occurred over time. This may lengthen the hospital stay to one week and the convalescence to seven to ten weeks. Microscopic or minimally invasive techniques may be tried first but run the risk of the problem re-occurring (10%).
If a segment of the spine is unstable causing severe arthrogenic pain then it may be suggested that a spinal fusion is undertaken. This requires more extensive surgery with fixation of the spinal segments using metal screws and bone graft. The hospital stay may be 6 – 7 days with a three to six month period of convalescence.
All surgery being invasive carries a risk of complications that may cause harm. The bigger the surgery the larger the risk would be of problems affecting your life, limbs or bladder. However, the risks of these developments is small with usually less than 1 in 10,000 risk to life and less than 1 in 500 of serious nerve damage affecting the bladder or legs causing significant handicap.
The reason you have developed your problem is often seen as multifactorial, but essentially it is an unlucky development of ageing changes in the joints of the spine. The situation is not usually dangerous and often given enough time natural healing will help the situation. Pressure on the nerve roots of the lumbar spine when relieved usually gives very good resolution of symptoms and should be seen as a pain relieving operation although may also improve strength and numbness.
Surgery for the joints of the lumbar spine causing back pain should normally be seen as a last resort because natural healing and other non-surgical methods often settle the situation down, but this may take years. If pain is persisting to a high level with a poor quality of life then a non-fusion support or fusion may be considered. It is unusual for operations to be essential, but should be seen as a potential solution to your problem, but only if your symptoms are not settling and warrant escalation of treatment.