Back Pain: Treatment and Care

Back Pain: Treatment & Care

By Dr. Raghava Dutt Mulukutla, Consultant orthopedic and spine surgeon. He holds an experience of over 32 years, his expertise include spinal deformity surgeries, scoliosis and back pain management.

“If you are one of the few lucky ones who have not yet suffered from low back pain,do not be too happy. Second only to common cold, low back pain is increasing in incidence the World over. Almost 80-90% of population is affected by this problem in urban areas and is the commonest cause of absenteeism from work for people under 45 years of age in the Western World. Most suffer for a few days to weeks and in others it becomes a chronic problem with umpteen visits to various specialists,homeopaths,Auervedic massage treatments, acupuncture, magnetotherapy,Rieki etc. In India friends, neighbours, barbers, medical shop owners ,grand mothers are all specialistst have their own special remedies to offer and stories to tell. And of course that consultation with the foreign doctor – when I went to USA……… and the stories go on!

Who is at risk?

Almost 90% have a mechanical reason for their back pain, and in 10% various diseases and disorders are responsible for low back pain. Many risk factors have been identified : lifting weights beyond a workers physical capability, repeated bending and twisting in awkward positions , prolonged sitting especially in slouched position is well known to produce low back pain. Obesity, cigarette smoking, lack of physical exercise, weak abdominal and back muscles are some of the very potent factors in causing low back pain.

What causes back pain?

The very fact that we are born as humans – our upright posture places tremendous stress and strain on the back.

  • bad posture
  • prolonged sitting : IT industry/ executives
  • Weak abdominal and back muscles
  • weak bones ( osteoporosis )
  • smoking
  • driving 2 wheelers with bad shock absorbers
  • over weight
  • lack of exercises during and after pregnancy
  • un-accustomed bending forwards and lifting weights

 

Let’s get to know some of the common conditions that cause low back pain:

THE SLIPPED DISC: The human spine consists of individual bones called vertebrae separated by discs- which simply put is a jelly surrounded by fibrous tissue. When the discs get damaged or degenerated, it slips backwards and presses on the spinal cord and nerves causing pain in the lower back or along the leg – known typically as sciatica.

Slipped Disc
Arrow pointing to the slipped disc, pressing on the spinal cord

Non surgical management:

Over 90% of patients with slipped discs do not require surgery and get better with rest, physiotherapy and medication. You do not have to sleep on floor or hard beds. A firm bed is all that is required, and rest for more than one week is not advisable. There is no need for strict bed rest and you can move about if pain permits. Exercises should be commenced after the pain subsides and your physiotherapist would be the best person to teach you the exercises to strength the back and abdominal muscles.

The Surgery

Traditional surgeries such as laminectomy have no place in the management of disc prolapse. Surgeries such as Fenestration, Microscopic surgery or Endoscopic microdiscectomy(Key hole surgery) offer the best results. The minimally invasive surgeries do not weaken the back muscles and return to work is much quicker.

SPINAL STENOSIS: As we get older , the spinal canal gets narrowed due to arthritis and degeneration of tissues in the spine-resulting in pressure on the nerves. Typically the patient may experience low back pain, buttock pain and leg pain. Patients find it difficult to walk for long distances and have to rest after walking for a few minutes. He/she can resume walking once the pain subsides. Majority of the patients get better with change in life styles, physiotherapy and epidural steroid injections in to the spinal canal. Modern surgical techniques once again give lasting relief in those who do not get better with non operative treatments.

SPONDILOLYSTHESIS: This is slipping of one vertebra over the other, resulting in pressure on the nerves and again is responsible for back pain and sciatica. In those who do not get better with non operative measures, surgery offers good relief from pain.

OSTEOPROSIS: Again a common condition in women, is responsible for significant back pain and vertebral fractures. Exposure to sunlight, physical exercise, balanced diet, go a long way in managing this problem. In those who suffer from fractures, minimally invasive procedures such as Vertebroplasty : which is injection of synthetic material (bone cement) under local anaesthesia gives excellent results.

OTHER CONDITIONS: Curvature of spine (hunch back-scoliosis, TB, Cancers and tumors and a variety of disorders can affect a human spine. Prompt consultation and investigations would help in diagnosis and treatment.

Who should be consulted for spine surgery? 

Orthopaedic surgeon or Neuro surgeon? That is the doubt in almost everyone’s mind. Traditionally both operate on Spines.Today we have a sub-speciality – Spine Surgery. Spine surgeons are specially trained to perform spine surgeries and it would not be too long when Neuro surgeons would be operating only on Brain and Orthopaedic Surgeons on bone and joints and Spine surgeons alone would be performing Spine surgeries.

Information on the Internet: Beware! Not all information on the net is accurate and current. Newer technologies that appear on the net, are like fashions that keep changing and are industry driven.

Are Spine Surgeries safe?

Spine surgery is complicated and needs expertise. One need not worry too much about the complications and a well planned and well executed surgery in an understanding and cooperative patient gives excellent results.

Is there an age limit?

No! Today we perform spine surgeries on infants to aged persons and age certainly is no bar.

The second opinion?

 When in doubt take a second opinion. But seeing too many doctors is quite confusing”

For a healthy back

Correct your posture – do not slouch
Get out off your chair every 20 minutes – stand or walk for a few minutes
Getting out of chair is more important than buying expensive chairs
Exercise regularly –  yoga/walking/swimming/sports
Quit tobacco

Patient dilemma: Following the doctor’s orders as opposed to a relative’s or friend’s opinion

Sometimes it seems like patients have already made up their minds before they arrive at my clinic. To my surprise they are told by friends and relatives to not follow Doctors’ orders!

My biggest rivals seem to be friends and family of my patients and not other doctors in the city. This I have concluded after about two years of my practice in Hyderabad.

Here is a typical scenario:
Doctor: “Mrs K you have very severe arthritis in your knee. You’ve tried many tablets and treatments from local quacks as well as doctors and none of them work for you. You are now in a wheelchair because you cannot walk more than a few steps. I think you will benefit from a knee replacement”
Mrs K: “Oh doctor, I don’t want surgery. They say that knee replacement is a failure. They say that my knee will not bend after surgery. They also say that I won’t be able to walk after surgery. Please give me some very good tablets”
Doctor: Mrs K, are these people who are guiding you orthopaedic surgeons?
Mrs K: No doctor, these are just some members of my family?
Doctor: So Mrs K, why have you come to me? I am an orthopaedic surgeon. I am giving you a long term solution for your pain and you are educating me that I should not offer that solution. Then what do you want from me?
Mrs K: Just some very good tablets doctor!
Doctor: Ok, I’ll give you some tablets.
Mrs K: I don’t want painkillers doctor.
Doctor: Why?
Mrs K: Because they cause kidney failure and holes in the stomach!
Doctor: Ok, I can give you an injection that will lubricate your knee and may reduce the pain for a year.
Mrs K: No doctor, they say that injections are very bad for your knee. I don’t want an injection.
Doctor: Who are these people telling you these stories??
Mrs K: They are just some people who live in our area doctor.
Doctor: Please tell these people to treat you as I seem to be completely unqualified to manage your condition.

This is just an example of how citizens in this city refuse appropriate treatments from highly qualified doctors. How do we change this behaviour in our people?

On behalf of the medical fraternity, I request patients to take a discerning view, to not delay treatment and help the doctors do their job to the best of their ability.

Joint Replacement Surgery- Primary or Revision Hip/ Knee

By Dr Udai Prakash, Chief Joint Replacement Surgeon.

Hip and knee replacement surgery has a dramatic effect on patients’ lives. It is generally recommended if conservative measures have been ineffective or are likely to be ineffective. Most patients are able to go back to their former active lifestyle as their pain is relieved and mobility restored. Age is not a bar to joint replacement surgery. Modern materials and techniques have largely overcome the problems of wear and loosening of the implant. This brief introduction to joint replacement surgery will give you a flavour of the different types of joint replacements of the hip and knee performed by our surgeons.

Total Hip Replacement 

Total hip replacement is probably the most successful operation performed by any surgeon of any specialty.

Total Hip Replacement

It involves replacing both the acetabulum and the femoral head components of the ball and socket joint. It is indicated in painful conditions of the hip such as osteoarthritis, rheumatoid arthritis, avascular necrosis and certain fractures and in a vast majority of cases it results in a dramatic improvement in the quality of life. Modern hip replacements are made of materials like titanium or high grade stainless steel and contain bearings such as ceramics, cobalt-chrome and highly cross-linked polyethylene that make them very durable. Age is not generally a concern when considering someone for a hip replacement as long as they have the right level of fitness and the operation is done for the right indication. The probability of most good hip implants surviving 10 years is over 90%.

Total Knee Replacement 

Total Knee ReplacementKnee replacement is a surgical procedure to replace the weight-bearing surfaces of the knee joint to relieve the pain and disability of osteoarthritis. It may be performed for other knee diseases such as rheumatoid arthritis and psoriatic arthritis. This is a well established procedure giving consistently good outcome with long term results often matching and sometimes exceeding those of total hip replacement. In general, the surgery consists of resurfacing the diseased or damaged joint surfaces of the knee with metal and plastic components shaped to allow continued motion of the knee. During the operation any deformities must be corrected, and the ligaments balanced so that the knee has a good range of movement and is stable. In some cases the articular surface of the patella is also removed and replaced by a polyethylene button. Functionally, most patients get back to their formal lifestyle including most non-impact leisure activities like golf.

Unicondylar Knee Replacement

Unicondylar Knee ReplacementThis is an excellent procedure for limited arthritis or the knee. Usually performed through a smaller incision than total knee replacement, only the part of the knee that is diseased is resurfaced. The joint therefore feels and behaves more like a normal knee. Recovery is rapid and the patient is often discharged within 2 -3 days of surgery.

Hip Resurfacing

Hip ResurfacingHip Resurfacing is an alternative to hip replacement surgery in some patients. It is a bone conserving procedure that places a metal cap on the femoral head instead of amputating it. There is no long stem placed down the femur so it is more like a natural hip and may allow patients a return to many activities. It seems the ideal option for young individuals with severe hip osteoarthritis who are likely to outlive any prosthesis that they receive and who are keen to carry on with an active lifestyle. In the unlikely event of the resurfacing failing many years down the line the bone stock that has been preserved in the first instance makes the revision in most cases almost as easy as doing a primary hip replacement. According to the Australian Registry data for 2009, performance of hip resurfacing for men under 65 years of age is better than total hip replacement.

Revision Hip and Knee Replacement

Revision Knee ReplacementRevision Hip ReplacementPrimary hip and knee replacements do fail in time for a number of reasons. Revising them is highly specialised surgery requiring extensive training and access to sophisticated equipment, implants and hospital facilities. In most cases the old prosthesis is removed and replaced with a new implant. The surgery is often long and the risk of complications is higher than after a primary operation. Patients tend to spend the first 24 to 48 hours after the procedure in the high dependency unit. Surgery may involve the use of ultrasonic devices to remove the old cement used for fixation of the prosthesis, bone graft and/or custom made implants. Identifying failing joint replacements and performing the revision early is crucial for a successful outcome and therefore a regular follow-up by an orthopaedic surgeon is advisable for all patients carrying a hip or a knee replacement.

Frequently Asked Questions

  1. When is joint replacement surgery recommended?
    The reasons are many. Most patients with severe hip or knee pain as a result of advanced arthritis may be candidates for joint replacement. Joints can also get damaged due to previous injury or infection. There are many more indications including congenital disorders, childhood disorders leading to arthritis in later life, avascular necrosis etc.
  2. How long do joint replacements last?
    On average a hip or knee replacement has a 90% chance that it will survive 10 years and a 80% chance that that it will last 20 years if done by a well trained surgeon at a specialist hospital. The survival is highly dependent on the quality of surgery and the implant used.
  3. What are they made of?
    Modern joint replacements are made of many different materials – these include Cobalt-Chrome alloy, surgical grade stainless steel, titanium. Your surgeon should be able to give you more information depending on what joint you are having replaced. All joint replacements done at UDAI OMNI are imported at the moment.
  4. How long will I need bed rest for?
    You will almost never need any bed rest. The aim of the surgery is to get you out of bed as soon as possible after surgery. You will need intensive physiotherapy during the recovery phase of 6-8 weeks.
  5. How long will I stay in the hospital?
    On average a patient after joint replacement will stay between 5-7 days in the hospital.
    Following complex joint replacement, the stay may be longer.
  6. Will I be able to sit on the floor?
    Many patients can sit on the floor after joint replacement surgery whether it is the hip or the knee. However, your surgeon will guide you on this depending on what you are having done and the complexity of the surgery. Kneeling might be difficult after knee replacement surgery. Again, the quality of surgery is the key. If done well and if the patient is motivated, most activities of daily living are possible.
  7. Can I ride a scooter or drive a car afterwards?
    Most patients can start driving after about 6 weeks but please discuss this with your physiotherapist or your surgeon.
  8. At what age is joint replacement recommended?
    Joint replacement can be done at any age. Most patients are between 55 – 80 years of age but the range can be from teenage to over 90 years. As long as the patient is reasonably fit, joint replacement can be done. Your doctor should be able to advise on this.
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