Search GoToMy Page	Simple Sprain The Lumbar Spine extends from L1 (adjacent to the thoracic spine) down to L5 where it conncets with the sacral bone. Simple Sprains usually occur when the low back is in a vulnerable position e.g. bending forwards and bent to one side while lifting shopping out of the boot of the car, or violent sneezing while bent forwards. The sprained part is usually in the superficial part of the spine (muscle, joint or ligament). The sprained tissue becomes inflamed, causing pain signals to be sent to the spinal cord.  If the incoming pain signals are strong enough and go on for long enough, processing centers (dorsal horn) in the spinal cord become sensitized, sending out signals to the muscles in the vicinity of the sprain to contract to produce muscle spasm. This is initially a protective reflex which may prevent further injury to the sprained part.  If the muscles in the area are contracting quite strongly, then the tension receptors in the local muscles and joints are activated. Strong signals from the tension receptors can be interpreted in the spinal cord as pain, adding to the pain signals from the inflamed tissue. These two kinds of signal combine together to keep the spinal cord dorsal horn in a sensitized state, and also keeping the spinal muscles in a contracted state through a feedback loop. The sequence of events can be therefore summarised in the diagram below:- Severe muscle spasm is a type of cramp, and like any other cramp in the body it hurts, causing restricted painful back movements. Over a variable period of time the initial back sprain heals, reducing the signals to the spinal cord, and also reducing the degree of spinal cord dorsal horn sensitization. Once this sensitization has declined, the outward signals to the muscles in the area of the sprain also lessen, allowing the pain and muscle spasm to resolve naturally. In about 10% of adults the back pain continues despite healing of the the initially sprained area. In this situation there is a perpetual loop as shown below, without there being any sprain or inflammatory process involved. This situation may leave individuals susceptible to further sprains due to the back muscles being in a contracted and shortened state, and also due to there being pre-existing dorsal horn sensitization. In most of these cases the muscle spasm and restricted joint mobility can be treated successfully with Spinal Manipulation. This has the effect of resetting the abnormal tension receptors in the muscles and joints, reducing the spinal cord sensitization, and  allowing rapid resolution of the pain. Back Exercises are important after treatment to improve and maintain spinal strength and flexibility, helping to reduce the vulnerability to further injury. People with complex back pain can also be vulnerable to simple sprains. It is important to realize this fact, and not believe that the pain is due to the primary condition becoming worse. Postural Backache Postural Backache usually occurs when the spine is held in an abnormal posture for too long e.g. sitting for hours in an uncomfortable car/train/airplane seat or sleeping on an uncomfortable mattress or when the equilibrium of the spine is unbalanced e.g. by having one leg longer than the other.  The muscles, joints and ligaments of the spinal column are packed full of position and stretch receptors, which are constantly monitoring and maintaining posture.  People who suffer from postural back pain usually have some ongoing problem with the Mechanical Balance of the spine, and quite frequently have areas where the spinal cord dorsal horn shows pre-existing sensitization. When these sensitized areas are held in abnormal positions for prolonged periods, there is stimulation of the spinal stretch and position receptors, increasing the signals going to the spinal cord.  As the spinal cord dorsal horn is already partly sensitized, it more readily becomes fully sensitized by the extra signals coming in. The result is that there is an increase in the out-going signals to the local spinal muscles, producing muscle spasm and pain.  The situation can normally be resolved by moving and stretching the affected parts of the spine, so that the position and stretch receptors no longer respond by firing off excessively, allowing the dorsal horn to be less sensitized. This explains why people with postural back pain cannot maintain a single posture for very long, and why they are constantly shifting posture to cope with the situation. Posture and Lifting Advice Posture Correct posture is important for spinal equilibrium. When looking at the spine from the side, the sum of the inward curves (lordosis) equals the sum of the outwards curves (kyphosis) i.e. neck + lumbar lordosis = thoracic + pelvic kyphosis. If any one of these areas has an increase in curvature, then the other areas have to compensate. For example:- Slouching for prolonged periods (see picture above) tends to encourage a round shouldered posture (exaggerated thoracic kyphosis). Over time this leads to permanent increased curvature in the thoracic spine. As it would be impractical to walk around looking at the floor all the time, the neck and lower back compensate by increasing their degree of lordosis to allow us to be able to look straight ahead. Over time this extra lordosis can lead to neck and back pain, and also an increased risk of foraminal stenosis. High Heel Shoes - wearing excessively high heels causes shortening of the calf and hamstring muscles, and an increased forward tilting of the pelvis. Over time this causes compensatory changes in the shape of the rest of the spine, producing increased lumbar lordosis, thoracic kyphosis, and cervical lordosis. Lifting Lifting in the correct way is important to protect the spinal column from unnecessary loading, and to avoid sprains. The principles of correct lifting are:- Use lifting aids to carry heavy objects from A to B. Share the heavy load between 2 or more people. At all times keep the load close to your trunk. Holding objects held at arms length increases the load on the spine through leverage effects. When lifting up and dropping down, squat down with your knees bent and apart, keeping your back as straight as possible. Use your leg muscles rather than your back muscles to go down and straighten up. If you have to turn while holding a heavy load, turn using your feet, keeping the load close to you. Resist the temptation to rotate your trunk while keeping your feet still. Remember your spine is at it's most vulnerable when it is flexed forwards and/or rotated at the same time. Mechanical Imbalance Mechanical Imbalance due to abnormalities of lower leg function can contribute to complex back pain in the following ways:- Lower Limb Length Inequality (short leg) on one side causes the pelvis to tilt towards that side. This produces a series of compensatory spinal curves from the low back up to the top of the neck, with associated muscle imbalance, back and neck pain. The leg length difference may need to be greater than 1/2" before it causes major problems, although lesser differences can still be symptomatic. The cause may be due to:- Anatomical Shortening with a measurable difference between the two legs. This can be due to leg fractures, hip and knee problems in childhood OR simply being born that way. Treatment Correcting the shortening with a shoe heel raise of the appropriate height (start with half the difference). Spinal Manipulation can also be useful to re/set the dysfunctional areas of spinal muscle spasm that may occur in the compensatory curves in the lumbar, thoracic and cervical spine. Functional Shortening is where there is no measurable difference in leg lengths, but with functional shortening of certain leg muscles groups, or due to a fallen inside arch of the foot. Treatment Identifying, stretching and re-training the shortened muscle groups (ilio-psoas, quadriceps, hamstrings, gastrocnemius). Spinal Manipulation can be useful for the back pain in the short term. Shoe heel raises are not useful in this group as there is no true leg shortening. Arch supports may help.  The Bad Sprain Mechanism:  after a severe injury there is initial protective muscle spasm which usually settles in a few weeks (see Simple Sprain). Those who do not improve spontaneously may improve with Exercises and Spinal Manipulation techniques.  Progression - a small percentage may go on to develop chronic LBP with extreme tenderness over the back of the hip bone (iliac crest - where the small dimples are in your back). It appears that this group have sustained a soft tissue sprain where the spinal ligaments and muscles attach to the iliac crest - a type of "pull-off" injury. These injuries can produce long standing chronic LBP, with an increased vulnerability to re-injury. It appears that most of the pain fibres are at the junction between the ligament/muscle and the lining of the bone (periosteum). Treatment for this condition consists strengthening this junctional area.  Medications and local cortisone injections may reduce the inflammation and allow a focused strengthening program to succeed. Prolotherapy: can be performed by injecting a sclerosant solution around the area of the sprain on 2 / 3 occasions 3 / 4 weeks apart. The sclerosant solution initially causes local fibrosis at the point of injection, which then becomes converted into strong collagen tissue at about 2 months after the treatment. This can reduce pain and increase the apparent strength of the spine (see Prolotherapy). Spinal Ligament Syndrome Mechanism Disc degeneration leading to loss of disc height causes increased tension in the lumbo-pelvic spinal ligaments at the base of the spine. Spondylolisthesis with forward shift of one vertebra in relation to another increases tension in the iliolumbar ligaments at the base of the spine. Symptoms - Chronic low back pain is worse on standing and sitting for too long, worse on performing partially bent forward activities like washing dishes, brushing the teeth etc. Pain may refer to the groin, buttock, hip and outside thigh. Common complaint in the over 40's. Treatment: Local cortisone injection and spinal strengthening or a course of Prolotherapy may be helpful. Facet Joint Syndrome Mechanism - a small proportion of people have complex LBP due to inflammation of one or more of the small spinal joints (facet joints , ). X-rays may show arthritic changes in the joints, but there is a poor correlation between the degree of wear and the severity of the LBP. There is also a poor correlation between the part of the spine on the x-ray which shows the arthritic joints, and where the actual pain is when the back is examined clinically. An bone scan may give a better correlation by showing up inflammation as increased joint blood flow. Groups at Risk - Facet joint syndrome is more common in the elderly where there may be associated loss of disc height at the level concerned. It is more common at the L4/5 and L5/S1 levels. It is also more common in those people with inflammatory spinal disease (ankylosing spondylitis, psoriasis, systemic lupus etc). People with long standing spinal imbalance may be more prone to developing facet joint inflammation due to differential wear on one side of the spine. Symptoms - back ache is often worse after sitting and standing still for long periods. It is usually better keeping on the move. More be provoked by spinal extension (bending backwards). May be a cause of referred pain to the legs (non-nerve root). Treatment initially consists of injecting the facet joint diagnostically with a solution containing local anaesthetic and steroid. These injections need to be performed under x/ray screening. If there is a positive outcome to this diagnostic test, then facet joint radio/frequency denervation (rhizolysis) should be considered next (see Facet Joint Injections). Spinal Nerve Root Pain See Spinal Nerve Root Pain for Sciatica (Lumbar Radiculopathy) caused by Annular Tears, Disc Prolapse, Spinal Stenosis, Foraminal Stenosis, Spondylolisthesis, Referred Pain, and the Sacroiliac Joint. Spinal Osteoporosis Definition - progressive thinning of bone structure with loss of bone calcium, leading to an increased risk of fractures. Associated most commonly with immobility, the menopause, and old age. Normal Spinal Curves Early Osteoporosis Late Osteoporosis Types of Vertebral Wedge Fractures Symptoms - Spinal osteoporosis is usually asymptomatic between events. Minor injuries can produce a partial collapse or "wedge" fracture of a spinal vertebra. When viewed from the side on an x-ray the vertebra is scooped out or V shaped rather than the usual square shape. It commonly affects the thoracic and upper lumbar spine. There is sudden onset of severe pain in the back which lasts about 6 weeks and then resolves spontaneously. Investigation - DEXA scanning (Densitometry) can examine bone density in the spine (L4) and hip (neck of femur). Those who are found to be osteoporotic or osteopaenic should consult their doctor for prophylaxis advice (see treatment below) Treatment Analgesia / initially pain can be severe enough to warrant the use of morphine. See Analgesic Flow Chart for medication suggestions. Prophylaxis - all those at risk of developing further osteoporotic fractures should ensure a normal dietary intake of calcium and vitamin D. In addition treatment with biphosphonate medications like alendronate or editronate can help to strengthen weakened bones, reducing the risk of fractures in the future. Please see your doctor for further advice. Vertebroplasty is relatively new technique, and involves using a needle to inject a type of cement into the vertebral body. This helps to resolve the pain and give the affected vertebra more strength (see Vertebroplasty). Persisting pain may occur in some patients after the wedge fracture has healed. Examination often reveals continuing spinal muscle spasm in the area of the wedge fracture. Treatment with Trigger Point Injections and gentle Spinal Manipulation may help. Referred Pain Referred pain from the lumbar spine Any structure in the lumbar spine (discs, nerves, muscles, facet joints, spinal ligaments) can refer pain to other areas of the body. This occurs because the affected part of the spine shares the same nerve supply as the area that the pain is referred to, making the brain believe the source of the pain is somewhere else. Spinal structures with a nerve supply originating from L1 to S1 refer pain to the legs, while those with a nerve supply originating from C4 to T1 refer pain to the arms. Referred pain to the lumbar spine Spinal Causes Lower thoracic spine muscle spasm can often refer pain downwards to the lumbar region. This is typical of muscle pain where the cause of the pain is found at its origin (where it starts), and where the brain seems to think that it's coming from its insertion (where it ends). Visceral Causes Problems with the internal organs of the abdomen and pelvis can often cause referred pain to the lower lumbar region. In women this can be due to abnormalities of the kidneys, uterus, ovaries, bladder and lower bowel. In men this can be due to abnormalities of the kidneys, lower bowel, prostate, bladder and testicles. See your doctor for further evaluation. Rare Causes include a rupture of an aortic aneurysm (main artery from the heart), and tumours of the spine and surrounding areas. Failed Spinal Surgery Those with chronic spinal and nerve root pain who did not obtain relief from surgical intervention (discectomy, fusion), are often labelled as "Failed Spinal Surgery". This group also includes those who feel that surgery may have worsened their condition. Where conservative treatments (Acupuncture, TENS, Exercises, Manipulation, Facet Joint Injections, Prolotherapy, Epidural Injections, Nerve Root Blocks, Epiduroscopy), and maximal oral drug therapy (see Analgesic Flow Chart) have failed to improve the pain, two further options include Spinal Cord Stimulation or an implanted Intrathecal Morphine Pump .

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