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Straight talk on the crooked back

Back pain (or spinal pain) is the commonest orthopaedic disease (fractures are classified under trauma), affecting a high percentage of the population globally.

This has been recognised by doctors (directly or indirectly) for more than 200 years, though the first time any direct reference to spinal pain (not related to infections, fractures etc) in a text book was in 1915.

The word “orthopaedics” was coined by French paediatrician Nicholas Andry when he wrote a book titled Orthopaedia (Orthos = Straight, Paedia = Child), which was a self-help book for parents, in 1741. The universal symbol for orthopaedics was also adapted from the same book and it depicts a straight support tied to a crooked tree!

It is a fact that medical science is not a perfect science, but a dynamic one. Concepts of treatment (of various diseases) keep on changing based on understanding the natural history of the disease and gathering evidence of the result of any treatment. This is (what has become “almost a law” worldwide) also known as “Evidence Based Medicine” (EBM).

Understanding the spine, including the biomechanics, has made it a lot easier to treat back pain. Incidentally, the co-author of Clinical Biomechanics of the Spine (considered the Bible for a spinal specialist) is an Indian bio-medical engineer, Dr Manohar Punjabi.

Coming back to the topic, one has to understand the basic structure of the vertebral column to appreciate the unique structural masterpiece. When visualised from the front, there are seven cervical (neck), 12 dorsal (mid-back), Five lumbar (lower back), Five sacral (rear part of the pelvis) and Four coccyx (tail bone) vertebrae. Of these, the sacral and coccyx vertebrae are fused whereas the cervical, dorsal and lumbar vertebrae have the disc (a combination of soft jelly-like material which is contained in a semi-solid outer ring) between them.

When visualised from the side the cervical & lumbar vertebrae concavity (curvature) faces the back and the vertebral concavity (curvature) of the dorsal along with the sacrum and coccyx faces the front. The first two are the mobile segments of the vertebral column and the last two are the fixed segments of the vertebral column. The curvature of the neck develops when a child starts to lift the head and the lower back curvature develops when he or she begins to stand and walk.

The two mobile segments (cervical and lumbar) and, to a certain extent, the dorsal segment are subject to a lot of wear and tear in any individual’s lifetime as they are “used” in various forms of day to day activities. For example, the disc can take a load equivalent to 10 times the body weight when an individual runs down a flight of stairs.

The disc comprises 90 per cent soft (fluid and cartilaginous material) and 10 per cent hard material in young individuals (below 30 years of age). These figures change to 40 per cent and 60 per cent respectively in older individuals (above 60 years of age). Hence, ageing brings the vertebrae of all three (cervical, dorsal and lumbar) segments nearer to each other, which may also lead to back pain if the back muscles are not strong.

The muscles on the two sides of the vertebral column counter-balance the pull of gravity from the front to maintain the erect posture of every individual. This explains the importance of having strong back muscles to avoid back pain.

Here I would like to mention two frequent questions asked by patients: What exercises to do? How many repetitions? My answer to these two questions is: All exercises are good for all of us, provided there is no pain and no breathlessness. LISTEN TO YOUR BODY!

Another cause of back pain is weak bony architecture. This is also referred to as rickets, osteomalacia, osteopenia and osteoporosis (depending on the age and results of various tests of the individual). The importance of insufficient levels of vitamin D, resulting in rickets, was identified in the early part of the 20th century and nearly 100 years later, vitamin D deficiency has been identified as a potential global health concern.

It is important to note that low vitamin D levels are more common in the coloured population compared with the white population. Some researchers have attributed this to higher melanin levels in the coloured population, which protects the skin from the harmful rays of the sun, which may contribute to a lower level of vitamin D synthesis.

Therefore, one should understand the importance of the following:

nMaintain healthy eating habits by reducing extra carbohydrates and add vitamin D and calcium supplements (after consulting a doctor). This will help keep body weight under control.

nMaintain an active lifestyle by engaging in exercise (gymming, sports, yoga).

nAll forms of passive modalities, for example, traction (which has no scientific basis at all), ultra sound, short wave diathermy are for short term pain relief only and have no long-term benefit; external aids which move the joints and stretch the muscles on behalf of the patient have no proven benefits in building muscles or reducing body weight to prevent back pain.

At the same time, follow some of the dos and don’ts (see box) to avoid back pain.

To summarise, one should not ignore back pain as this may lead to nerve compression and, in severe cases, may require surgical treatment. Therefore, it is better to seek expert advice in the early stages. And once an exercise regime, along with postural care (as advised by a physiotherapist), diet (as advised by a nutritionist) and medication (as advised by the doctor) is chalked out, one should stick to it strictly, probably for the rest of the patient’s life. One should also maintain a proper follow-up schedule with all experts so that there is no recurrence of back pain.