Understanding the back pain

Saturday, August 11, 2012

by Dr V Daya Thirumala Rao

Orthopaedic Spine Surgeon
Nova Medical Centre

Back pain comes from problems in the lower part of the spine called lumbar spine. Low back pain is the most common type of chronic pain. Most back pain comes from sprains and strains caused by stressful movements: lifting something without using proper techniques or a sudden twisting motion. If back pain is caused by a muscle sprain or strain, that usually heals on its own — just give it time. Sometimes, back pain is caused by a more severe spinal condition, such as a herniated disc or spondylosis.

Dr V Daya Thirumala Rao

Spinal column is made up of vertebrae. In the neck – cervical spine, chest – thoracic spine, abdomen – lumbar spine, buttock – sacrum. Spine protects the spinal cord. Spinal cord starts from brain. Nerves come from spinal cord. Some parts of the nerve controls muscles and other part carries sensory signals from sensors of the skin etc. These nerves pass out through the hole (foramen) in between the vertebrae. In the lower part of the spine, these spinal nerves combine to form sciatic nerve. This sciatic nerve starts from buttock then passes through the back of thigh to foot. That’s why in sciatica the pain comes from back passes down to leg. Disc is present in between the vertebrae thus shears the loads of the spine. Central part of the disc is soft called nucleus covered by firm layers called annulus. In the routine and abnormal movements of the spine, tears develop in the annular zone of the disc thus allowing soft part of disc (nucleus) to come out under pressure. This protruded disc presses the nerve coming out of the foramen, thus resulting in pain radiating down to leg and foot.

If the pain does not get reduced with medication and physiotherapy within six weeks or if they are very severe, they need surgical intervention. Only 5 per cent of the people need surgery to treat back problems. Surgery is an absolute last resort for the treatment of back pain where the protruded part of the disc has to be excised (discectomy) thus relieving pressure on the nerve, which alleviates pain.

Surgical procedures for the treatment of protruded disc are:

1.    Open and traditional treatment – Laminectomy
2.    Microdiscectomy
3.    PELD (Percutaneous Endoscopic Lumbar Discectomy)

Laminectomy is an open procedure started in the year 1934, where parts of the vertebrae called lamina is completely removed after spinal muscles are separated from their position to visualize the disc.

In Microdiscectomy, the part of lamina is removed along with stripping of spinal muscles to visualize the disc.

Both the procedures are performed under general anaesthesia. During the removal of lamina, if accidentally the most important part of the vertebra called pars is removed, the whole procedure is likely to fail causing instability in the spine.

PELD is a step advance from Microdiscectomy. This procedure involves removing the problem disc fragment through an endoscope — a small tube inserted through a tiny opening in the skin of the back. A miniature video camera is attached to the tube. Using specially designed surgical instruments on the end of the tube; a surgeon can cut away parts of the disc and remove them through the tube. This leaves structures important to stability practically unaffected. The procedure is performed under local anaesthesia and safely discharged on an outpatient basis (without an overnight hospital stay) with one stitch.

Advantages of PELD

PELD offers a number of advantages in comparison to conventional methods:

- Immediate pain-relieve in 95% of the cases
- No general anaesthesia, only a sparing local anaesthetic necessary
- Outpatient treatment
- Shorter rehabilitation
- Faster return to profession and every day life
- Small incision (only one stitch) = hardly any scarring

It is also suitable for elderly patients, patients with cardiovascular problems, pregnant patients, and patients who are afraid of surgery and general anaesthesia.

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