Low Back Pain and Discopathy

Lumbalgia y Discopatía

Low back pain is a term for pain in the lower back caused by a musculoskeletal syndrome; that is, disorders related to the lumbar vertebrae and soft tissue structures such as muscles, ligaments, nerves and intervertebral discs. It originates from different causes and forms, the most common being muscle contracture due to physical over exertion or poor posture.

There are other sources or types of back pain: facet or joint pain in the back of the vertebrae, which produces a specific discomfort characterised by hyperextension pain in the spine (bending backwards). Another type of back pain is the discogenic, where the intervertebral disc has a lesion or discopathy that generates a diffuse pain that is aggravated by flexing the spine (bending forward).

Other sources of pain would be the compression of a nerve root, where a hernia or arthrosis compresses the exit of the nerves that go towards the legs (pain irradiated towards the legs) known as sciatica, the dysfunction of the sacro-iliac joints, or pain emanated by any organsreflecting their dysfunction in the lower back such as the kidneys or the small intestine.

What is the operation of a lumbar discopathy?

The type of surgical operation will depend on the type of discopathy or underlying disease that the patient suffers from. It will be necessary to individualise each case according to the findings of the clinic and the imaging tests performed.In general terms, some guidelines could be:

Young patients with a discopathy of one or two levels, with a decrease in the height of the disc where the lumbar pain predominates with respect to the pain irradiated to the leg: anterior lumbar disc prosthesis.

Patients with instability between two vertebrae demonstrated by X-rays in flexion and extension where there is an anomalous movement: placement of screws in the vertebrae and intervertebral box replacing the disc to perform an arthrodesis or posterior immobilisation of said vertebrae.

Patients with a spondylolisthesis (one vertebra displaced forward or backward with respect to the other) with instability: placement of screws in the vertebrae and intervertebral box replacing the disc, to perform an arthrodesis or immobilisation of said vertebrae.

Recommended treatments for non-specific low back pain

Most episodes of low back pain are solved with conservative treatment, that is, with analgesic medication, relative rest and,in the face of persistent pain or repeated episodes, physiotherapy.

There are a series of general recommendations to take into account:

• Avoid bed rest – recommendations based on the available scientific evidence coincide in discouraging bed rest as a treatment for back pain. In some patientsthe intensity of pain may force them to stay in bed for a few days, usually no more than 3, especially when there is irradiated pain. But that must be considered a consequence of pain and avoided when possible. It is therefore not a treatment, since it has no beneficial effect on the duration of the episode.

• Avoid overloading your back –do not bend over with your backbut by flexing your legs.

• Do not sit on soft low surfaces like sofas and armchairs.

• Weight reduction – overweight is directly related to low back pain so, if it exists, a weight-loss diet is recommended.

• First-line drugs – painkillers, minor opiates, anti-inflammatory drugs and muscle relaxants (for no more than 5-10 days) as long as there is no contraindication.

• Application of local heat – the application of dry heat in the lumbar area is still recommended. Although its final efficacy is not evaluated, it seems to calm the pain even if it is unknown whether it improves low back pain or not. In any case, it should not be done excessively or repeatedly (maximum twice a day - 20 minutes, or three times -15 minutes).

• Exercise – in general it should be avoided during acute crises.

• Second line drugs –some antidepressants can help alleviate chronic low back pain.

• Psychological treatment (cognitive-behavioural) –in patients with long-term or intense chronic low back pain.

• Third line drugs –major opiates (tramadol,tapentadol, morphine, oxycodone). Only for patients with intense exacerbations of chronic low back pain that do not respond to other treatments.

• Rehabilitation / physiotherapy treatment.

• Facet infiltrations or rhizolysis – incases of chronic or persistent low back pain where there is a mechanical discomfortwhen standing or sitting for a long time, or when it is aggravated by hyperextension of the spine, it may be indicated to treat the nerve that picks up the sensitivity of the inflamed vertebrae’s posterior joints.

• Surgical intervention – in case of persistent lumbago due to discopathy without pain irradiated to any leg, having ruled out a major cause (vertebral fracture, infection, tumour), an operation will be indicated only in strictly necessary cases and for patients who have performed a correct medical and physiotherapy treatment for a period of more than 6 months.

Lumbar Arthrodesis: Post-operative course

When the head practitioner decides the discharge, you will receive a clinical report detailing the characteristics of your illness, the type of intervention performed and the treatment to be followed at home. Likewise, it will be sent to Neurosurgery Outpatients within a specific period, in order to follow up on the evolution of your case. Recovery could be lengthy after a lumbar arthrodesis operation; sometimes you should wait up to 6 months to resumeyour normal activity. Initially you may need several medications to keep pain at bay and sometimes rehabilitation sessions could be requested to facilitate a correct recovery. 


Advice after discharge from hospital

The postoperative recovery period is variable and can range from one to six months. Below you will be given a series of useful tips during the first month after surgery. Remember that during this time you should try to keep physical and mental rest, avoid trips and journeys, and take the series of measures listed below:

FIRST TWO WEEKS

Usually the patient operated on a lumbar arthrodesis is discharged between 4-7 days if there are no complications. This should not make you believe that when you go home everything is over – you must accept that you will continue the period of hospitalisation at your home for at least one more week. Take the medication exactly as prescribed by your surgeon.

If you are receiving any other treatment for any other disease, you should continue to do so unless you are instructed otherwise. The surgical wound should be kept clean and dry. You can shower, with assistance, and then dry well with a sterile pad or gauze, brush the wound with povidone-iodine (PVP-I, Betadine) and finally cover the wound with sterile dressing. Please be very careful when in the shower. Skin sutures should be removed after seven days of surgery.In case of reoperation, wait at least 14 days.

Try not to sit in low chairs or seats for a period of two weeks. Avoid a sofa if yourback is not going to be completely straight. You may sit on a high stool, or place one or two cushions on a chair, preferably with armrests. During the first week you should alternate periods where you sit on a comfortable chair, 5-10 minute walksaround your house and bed rest. Do not leave home until sutures are removed.

From the second week on, walk for brief periods of time (15 min.) every day, progressively increasing the distances. Do not travel by car or other means of transport during these two weeks (except to go to a health centre or visit the doctor). The first month you will find yourself more comfortable with a lumbar belt. You must place it when you get up – there’s no need to use it in bed. Try not to get too used to wearing the girdle as you should do without it after a month.

THIRD WEEK AND FOURTH WEEK

You will feel more and more recovered. It is possible that some residual symptoms– in the form of tingling or lack of sensitivity – persist in the leg(s), or that you notice pain in the lumbar region when moving. Keep in mind that complete healing requires between 6 and 8 weeks. Be patient.

The wound must be completely healed and will not require any dressing but, if you wish, you may place a piece of gauze over the scar to avoid rubbing with your clothes.

Start leaving home and walking increasingly long journeys, always on flat terrain and with sports shoes.Avoid stairs and slopes. Avoid unpaved roads. At the end of the fourth week you should go to the doctor’s practice for a review.