| In a busy primary clinical practice, at least one patient | | | | except perhaps in the case of an elderly person with |
| a day comes in with a backache. It is one of the | | | | osteoporosis. There are five lumbar vertebrae, five |
| most common human ailments. Most of the problems | | | | sacral vertebrae (which are fused), and four coccyx |
| are with the lower back; and no wonder. The lower | | | | vertebrae. They are held together with ligaments on |
| back is the "axle" on which most of the other muscle | | | | the front, sides, and back. There are cushions |
| movements base their action. By going through an | | | | between the lumbar vertebrae called discs which |
| approach which looks at the history of the pain and | | | | have gelatinous centers and fibrous outer sheaths. |
| the mechanics of the lower back, the doctor can | | | | Sometimes the gelatinous center ruptures out |
| hopefully come up with a successful plan of | | | | through the fibrous sheet and this is commonly |
| treatment. | | | | referred to as a "ruptured disc." The gelatinous |
| The history is very important, i.e., when did the pain | | | | material can impinge on a spinal nerve coming out of |
| first appear? Is it something which occurs frequently, | | | | the spinal cord, and cause pain down the back of the |
| or is this the first time? What is the nature of the | | | | leg. This is called "sciatica." Sometimes the disc can |
| pain: Sharp, dull, intermittent or constant? Does it | | | | rupture inward and actually push on the spinal cord. |
| "radiate" somewhere or does it remain in one area? | | | | This may cause bowel and bladder problems and |
| What were the activities prior to the pain? Maybe | | | | other neurological symptoms. |
| you were moving railroad ties around your garden, or | | | | The doctor examines you continually looking for clues. |
| continuously leaning back to paint a ceiling. Maybe | | | | Is the pain localized to one of the muscles of the |
| you've been sleeping on a roll-away bed while guests | | | | back or to its ligamentous attachments, or does it |
| are visiting and it has a six inch mattress with a metal | | | | seem to be a deeper process? In looking for a |
| bar halfway across it. Do you have fever or blood in | | | | deeper process, the examination often focuses on |
| your urine (kidney stone)? By this process, your | | | | the legs. The doctor might look to see if there is |
| doctor tries to "sift out" the exact nature and | | | | muscle atrophy due to a nerve injury up around the |
| specific history of your back pain. | | | | spine. Are there precisely located areas where the |
| The second step is to look at the back. Starting with | | | | skin is numb or has decreased sensitivity? Are the |
| the skin, is there an isolated rash that might be | | | | reflexes brisk and equal at the knees and ankles |
| shingles? Is there an infected cyst or an area of skin | | | | (looking for the same nerve injury indications)? Is |
| infection, such as one surrounding a tick bite? Now | | | | there weakness in pushing down with the great toe |
| look at the posture. Is the back too straight, as from | | | | (a sign of L5-S1 nerve impingement)? |
| muscle spasm? Does it curve to the left or right | | | | Now it's time to consider other potential causes of |
| (scoliosis), and is this a permanent finding or is it due | | | | back pain. A kidney infection or kidney stone can |
| to muscle spasm? Does the back curve too far | | | | cause back pain over the areas of the kidneys. |
| toward the front (lordosis), maybe due to a | | | | Sometimes a dysfunctional gallbladder can cause back |
| prominent "pot belly?" As part of this process your | | | | pain. As people grow older, particularly if they smoke, |
| doctor might make other observations. Do walking | | | | they can get aneurysms of the abdominal aorta, |
| and standing make the pain worse, and is it primarily | | | | which the doctor might pick up by x-ray or listening |
| movement of one leg that seems to cause the | | | | to the mid-abdomen. The next step is to decide |
| problem? When one sits in a chair, does he slouch | | | | what tests might be needed to diagnose the back |
| with poor posture, or sit too straight from muscle | | | | pain. X-rays cannot visualize the muscles and |
| spasm? | | | | ligaments, so your doctor may decide how to |
| The next thing I do in evaluating back is imagine that | | | | proceed. However, if he or she suspects arthritis, a |
| I have "x-ray vision", and using the anatomic map I | | | | narrowed disc, a kidney stone or aortic problem, an |
| have in mind, go down through the back one layer at | | | | x-ray may be correct. If the doctor thought it was |
| a time looking for something wrong. The outermost | | | | your kidneys, they would order a urinalysis. If they |
| muscle of the back is the latissimus dorsi which goes | | | | think it is a deep process involving a disc or the spinal |
| all the way from below the "wing" bones (scapulae) | | | | cord, the doctor would order either a CT or an MRI. |
| to the crests of the hip bones. Weight lifters like to | | | | Let's talk about treatment. First of all, he or she |
| build these up for aesthetic purposes. It has a very | | | | might put you on a "no lifting" physical profile, with no |
| broad ligament which stretches over and attaches to | | | | prolonged standing or sitting. If you have a muscle |
| the entire lower back. It has a lot of cutaneous | | | | strain, they might prescribe an anti-spasmodic |
| nerves which come through the muscle and can be | | | | medicine and an anti-inflammatory medicine like |
| pinched by muscle spasm. The very broad ligament is | | | | Ibuprofen. They might inject a localized strain with a |
| like any other ligament of the body: it can be | | | | local anesthetic, and perhaps a cortisone-like medicine. |
| stretched or torn causing pain and swelling. Under | | | | If it just happened, the doctor might tell you to apply |
| that is a very large fascia which is like a ligament, and | | | | ice packs, and gradually change to warm soaking |
| is called the lumbo-dorsal fascia. Deeper muscles of | | | | baths after 5-7 days. If they find a deeper problem |
| the sides of the back attach to this, and the whole | | | | like a ruptured disc, he or she would probably refer |
| structure is subject to often multiple varieties of | | | | you to an orthopedist or neurosurgical specialist, to a |
| strains and tears. Finally, in the third layer are the | | | | kidney specialist for a stone, or to a vascular surgeon |
| deep muscles of the back which run parallel to and | | | | for an aneurysm. |
| attach to the spine. They have ligamentous | | | | By far, most of the day-to-day back problems are |
| attachments to the lower back and are subject to | | | | tears and strains of the back muscles and ligaments. |
| strains and tears. | | | | By knowing the anatomy and the mechanisms of |
| Underneath these layers of the back muscles are the | | | | back pain, your primary physician can successfully |
| actual spine bones. They are very large and sturdy, | | | | treat and resolve the majority of back pain problems. |