Anatomy of the Back
Our waist is a structure that carries the weight of our body, transfers the load from the hips to the legs, and also ensures that our body is mobile in our daily activities. There are 5 vertebrae in our waist and cartilage pads (disc) connecting these vertebrae, joint structures and soft tissues supporting them. The lumbar vertebrae, like other parts of the spine, protect the spinal cord and nerve roots, as well as contributing to movement and carrying loads. Nerves pass through the lumbar vertebrae that control the muscles of the legs, carry the senses of the legs, and control urine, stool, and sexual functions.
Causes of Low Back Pain
Any event that develops in the vertebrae, disc and soft tissues in the low back can cause low back pain.
Low back pain is one of the most important reasons that limit the daily activities of the individual today. It is known that around 80% of the population all over the world have had at least one attack of low back pain at any time in their lives. Low back pain ranks second among chronic diseases seen in developed societies after heart diseases and ranks fifth among diseases treated surgically. Low back pain is most common in the 20-40s. Low back pain can be divided into two groups as acute and chronic. In acute low back pain, the pain usually decreases within a few days and completely disappears after a few weeks. If the pain lasts more than 3 months, this pain is called chronic low back pain. The complaints of 90% of patients with low back pain resolve spontaneously within the first 4 weeks, but only 5% become chronic. In most low back pain, the cause of the pain is determined by history and clinical examination, nothing can be found in auxiliary studies and radiological examinations.
This type of pain is generally referred to as “mechanical low back pain”.
The causes of low back pain can be grouped into two large groups.
1-Musculoskeletal diseases
2-Spine diseases
1-Musculoskeletal Diseases
The majority of low back pain falls into this group. It mostly occurs with minor damage to the muscles, connective tissue or joints. The term “myofascial pain syndrome” is used for the clinical picture caused by excessive stretching and injury of muscles and soft tissues. Other musculoskeletal problems that cause low back pain include bad and faulty body posture, a short leg, smoking because it causes low oxygenation of the spine and cartilage in the waist, and psychosocial factors such as stress.
2-Spine Diseases
Diseases in this group are seen proportionally less than musculoskeletal system diseases. The most common causes of low back pain in this group are: herniated disc (lumbar disc hernia), wear of disc tissue (degenerative disc disease), slipped back (lumbar spondylolisthesis), narrowing of the spinal canal (lumbar stenosis). Apart from these, there are less common but serious diseases of the spine, such as tumors, infections, trauma, and collapses due to osteoporosis.
a) Herniated disc (Lumbar disc herniation): The disc material consists of a relatively hard outer sheath between two vertebral bodies and gel-like soft tissue parts inside. It acts like a cushion and takes on the task of distributing the loads of the trunk. However, if too much load is placed on the lumbar spine (excessive weight gain and heavy lifting), other structures supporting the waist, especially if the waist and abdominal muscles are weakened (absence of exercise), or deterioration in these discs due to structural and genetic reasons may cause low back pain and herniated disc. If the outer sheath of the disc is weakened or ruptured, the inner part slides outward and begins to press on the nerves, it is called “lumbar hernia”. While weakening or tearing in the outer layer causes more low back pain, herniated disc, which can be defined as the outward displacement of the inner layer, causes pain especially on the leg as it puts pressure on the nerve root. Leg pain is more prominent than low back pain in lumbar hernia. Depending on the level of pressure on the nerves, pain, weakness and numbness may occur in the thigh and leg.
b) Lumbar slip (Lumbar spondylolisthesis): It is called forward or backward slip of a vertebral body on the other vertebral body. If there is pressure on the nerve roots due to this ailment, pain, weakness and numbness may occur in the thigh and leg in addition to low back pain.
c) Narrowing in the lumbar spine canal (Lumbar narrow canal): The spinal canal is the canal where the spinal cord and nerves coming out of the spinal cord travel within the vertebral bones. As a result of many factors such as trauma, abuse of the body, genetic factors, thickening and coarsening of the soft tissue and bone structures that make up the spinal canal can cause narrowing in this canal. As a result, compression occurs in the nerve roots. These patients complain of pain and numbness in the calf, especially when standing for a long time and walking. When they sit and lean forward, the pain symptoms are relieved or gone. This clinical picture that occurs with standing or walking is called “neurogenic claudication”.
d) Wear of disc tissue (Degenerative disc disease): The water rate of the part that forms the inner layer of the disc is higher in childhood and young age groups. With aging, the water content decreases, the disc height begins to decrease, and small tears develop in the outer layer. The load carrying and movement ability of the disc is reduced. Low back pain is caused by the stimulation of the nerve fibers in the outer part of the disc. Low back pain in these patients is more than leg pain.
Evaluation and Diagnosis of Patients with Low Back Pain
Most of the causes of low back pain, as stated above, are excessive stretching or minor injury to the muscles and soft tissues. These patients usually do not need to be examined, as their pain symptoms will regress spontaneously within a few days. However, the following reasons require immediate medical attention.
Recurrent attacks of low back pain
Chronic low back pain
Gradual increase in pain intensity
Pain in thigh and leg accompanying low back pain, numbness, weakness, voluntary urination Having symptoms such as inability to pass stool and sexual dysfunction
Low back pain that does not go away with rest
Low back pain accompanied by excessive weight loss, fever, chills and chills
The patient’s low back pain While investigating the causes, after taking the history and performing the necessary examination, the tests should be done in line with the pre-diagnosis.
a) If herniated disc, excessive strain on muscles and soft tissues are thought to be the cause of acute low back pain, bed rest (not exceeding 5 days) and drug therapy are recommended for these patients.
b) In cases with chronic low back pain, who have been given rest and medical treatment for acute low back pain, but whose pain does not go away, spinal tumor or spine infection is suspected, we should start our examination with direct X-ray and follow up with magnetic resonance imaging (MRI) by detecting the lesion level. disease must be diagnosed. In addition to these examinations, if an infection or tumor is suspected in the patient, blood tests and bone scintigraphy should be performed.
Treatment for Low Back Pain
Treatment for low back pain should be determined according to the cause of the pain and the location of the disease.
1-Treatment in acute low back pain
Painkillers, muscle relaxants and short-term bed rest alone in low back pain (Mechanical low back pain) due to overstretching of muscles and soft tissues or minor injuries are used in most cases. enough.
Low back pain due to trauma and infection: if there is weakness in the legs due to compression on the nerves and/or inability to urinate and stool voluntarily, if there is instability (abnormal mobility) in the spine, surgical intervention should be performed, and if the cause is infection, additional antibiotic treatment should be given.
Tumor-related low back pain:
i- If there are complaints of weakness in the legs and/or inability to urinate and stool voluntarily due to compression on the nerves, or if it causes instability (abnormal mobility) in the spine, surgical intervention can be performed and according to the tissue diagnosis radiotherapy-chemotherapy is recommended.
ii- If there is no sign of compression on the nerves, firstly, after determining the type of tumor by biopsy, surgical intervention and/or radiation therapy and chemotherapy should be performed depending on the situation.
Low back pain due to herniated disc, spinal stenosis:
i- If there are complaints of weakness in the legs and/or inability to urinate and stool voluntarily due to compression on the nerves, if there is instability (abnormal mobility) in the spine surgical intervention is absolutely necessary. Although there are no neurological findings such as loss of strength, if the quality of life of patients is affected due to prolonged pain, pain alone may be the reason for surgical intervention. While choosing the surgical intervention method, each patient should be evaluated separately and the appropriate technique should be selected for that patient.
ii- If there is no sign of compression on the nerves, pain relievers, muscle relaxants and bed rest (not exceeding 5 days) are recommended.
2-Surgical intervention in chronic low back pain, if there are progressive neurological findings (muscle weakness, voluntary stool and inability to urinate) in cases with lumbar hernia, lumbar slippage, narrowing of the spinal canal, and wear of the disc tissue, if not, first of all painkillers Physical therapy and muscle exercises are recommended, followed by muscle relaxants and short-term bed rest.
Prevention of Low Back Pain
In order to prevent recurrent low back pain, the patient should get rid of excess weight, stop smoking if any, regularly and continuously perform muscle exercises for the waist, back and abdominal muscles, improper posture, sitting and correcting their sleeping positions.
