Low Back Pain
Low back pain can vary from mild discomfort following exercise or unaccustomed activity to a severe and crippling pain that is constantly present. Chronic severe back pain can have a devastating impact both on individuals and their families. Low back pain is extremely common, and over 75% of adults will suffer with low back pain at some stage during their life. The commonest cause of back pain is muscular back pain. As clinicians, we are very good at ruling out potentially serious causes of back pain. We are much less good at understanding / identifying the causes of muscular back pain.
Back pain can be classified in a number of different ways. Most commonly back pain is classified by whether it is acute or chronic, or by its cause.
Acute Low Back Pain
Acute low back pain describes a pain that comes on suddenly in a patient with no previous history of low back pain. There is often no apparent trigger or preceding injury. The first episode of acute low back pain in a healthy individual can be a frightening experience, as the patient is suddenly rendered incapable and often totally dependent on others. The majority of episodes of acute low back pain resolve within 2-weeks.
Chronic Low Back Pain
The term ‘chronic low back pain’ is used to describe low back pain that has persisted for more than three months. Many patients with chronic low back pain report pain going on for years with a fluctuating level of symptoms.
This may present as recurrent episodes of acute low back pain. Many patients learn to control the frequency of these episodes by avoiding activity that appears to aggravate the problem, by undertaking appropriate exercise, and by making other lifestyle changes such as avoiding heavy lifting. Care must be taken not to allow deterioration in general fitness and de-conditioning of the muscles that support the spine, as these factors may contribute to an ongoing problem.
The management of most cases of low back pain is primarily conservative (non-operative), and physical therapy (physiotherapy / osteopathy / chiropractor treatment) is usually the mainstay of treatment. Patients may be referred to see a spinal surgeon after conservative measures have failed. Surgical management of low back pain should only be considered when all conservative options have been tried and when a source of the pain can be identified.
Occasionally, patients may have a cause for their low back pain that requires a more urgent assessment with a spinal surgeon. To help identify patients with a potentially serious cause of their pain your doctor should listen out for warning signs in your history. These warning signs are called ‘red flags’. The following are red flag symptoms:
- Thoracic pain (pain in the middle of your back)
- Unexplained weight loss
- Bladder or bowel dysfunction
- Numbness in the ‘saddle’ area (between your legs)
- History of cancer
- Ill health
- Progressive neurological deficit (eg weakness)
- Change in the way you walk
- Age of onset <20 years or >55 years
- Continuous, progressive pain unrelated to posture
- Long term steroid medication
Causes of Low Back pain
- Muscular pain
- Facet joint arthritis
- Discogenic low back pain
- Spondylolysis / spondylolisthesis
- Inflammatory causes (eg. Ankylosing spondylitis)
- Spinal fractures
- Spinal infection
- Spinal tumours
- Non-specific low back pain
Muscular Low Back Pain
Muscular back pain is common. It typically occurs following unaccustomed activity or an accident, though it may be a protective response to an underlying lower back problem. It can also occur for no apparent reason. Muscular low back pain is characterized by muscle spasm, making any movement painful. The treatment for muscular low back pain is pain relief and activity. Lying still may be more comfortable, but this will not help your muscle spasm get better. You may get sufficient pain relief from over-the-counter medications such as ibuprofen and paracetamol, however, you may need to get something stronger from your GP. In addition, they may give you a muscle relaxant. You may also find that heat (such as a hot water bottle) helps.
As you get more comfortable you should try and do some gentle exercise. Both walking and swimming can be beneficial. Seeing a physiotherapist / osteopath / chiropractor can also be helpful. In the longer term it is important that you try and maintain some regular physical exercise, as well as some regular exercises that addresses your core stability muscles. Additionally, you need to look after your back by avoiding heavy lifting where possible (when it is not possible you must lift with your thighs not your low back muscles), maintaining good posture, and not smoking.
Facet Joint Arthritis
Facet joint arthritis causes low back pain with stiffness. This stiffness occurs following any prolonged period of immobility, especially first thing in the morning. The stiffness is due the joints being arthritic and inflamed, and it usually settles on movement. The pain from facet joint arthritis can also extend into your thighs, which may be confused with sciatica. Patients can also experience painful muscle spasms in their lower back. Treatment is generally conservative, and surgery is rarely considered. The mainstay of treatment is physical therapy to improve posture and muscle control (physiotherapy / chiropractic treatment / osteopathy). If you are really struggling with facetal pattern back pain or if you are unable to make progress with physical therapy, then you may be offered injections (medial branch blocks), and if you have a positive response to these injections a further procedure called facet joint radiofrequency denervation. Spinal fusion is only considered to be an option in very rare circumstances.
For further information please go to the page on ‘Facet joint arthritis’
Discogenic Low Back Pain
As we get older our discs dry out. We call this disc degeneration. The majority of degenarative discs are not painful. Occasionally a disc can be painful. We call this discogenic back pain. Discogenic low back pain is a mechanical pain that arises from the disc. As some discs begin to degenerate they can become inflamed and painful, and any movement that places stress on the disc can result in back pain. Discogenic pain is typically made worse by movement, in particular bending forwards and lifting. Patients can also feel pain in their buttocks and upper thighs, as well as experience painful muscle spasms in their low back.
Treatment for discogenic low back pain is generally conservative. Treatment options include physical therapy to improve posture and muscle control (physiotherapy / chiropractic treatment / osteopathy). Improving your posture and muscle control aims to reduce the stresses being placed across the disc. To get benefit from any exercises that are prescribed it is important that you make time to do them at least once a day. Patients who continue to struggle despite physical therapy will be further investigated with an MRI scan before any further treatment is considered.
Following a MRI scan you will be seen back in the clinic and the further options discussed with you. Patients will normally be offered diagnostic medial branch block (facet joint) injections first, as there can be considerable cross over between discogenic and facetal symptoms. If you experience only temporary symptom relief following facet joint injections then it may be appropriate to consider facet joint radiofrequency denervation. If there is no benefit following the facet joint injections or if your symptoms and scan are strongly suggestive of your disc being the ‘pain generator’ then you will be offered a discogram and disc block.
For patients in whom everything points to the disc as being the pain generator then a low back fusion may be considered. A low back fusion is always a procedure of last resort when treating back pain, as the results of fusion surgery for back pain are not as good or as predictable as when treating other conditions, such as a spondylolisthesis. Despite having had a technically successful operation and with satisfactory fusion, there is still a 25% chance that a one-level lower back fusion for back pain will not improve your symptoms. The chance of your symptoms persisting following surgery is higher if the fusion involves more than one-level in your lower back.
Spondylolysis and spondylolisthesis
A spondylolysis is a bony defect in the pars interarticularis. The pars interarticularis is a part of a lamina. The lamina is the bony arch that forms the back part of a vertebra. A spondylolysis is also known as a pars defect. A spondylolysis is often thought to be a stress fracture and can often be a cause of back pain in young, sporty people.
A spondylolisthesis is when one vertebral body slips forwards relative to the vertebral body beneath it. This will produce a gradual deformity of the lower spine and a narrowing of the spinal canal or the exit foramen. A spondylolisthesis can cause pain in the back, pain in the legs, or both.
For further information please go to the page on ‘Spondylolysis and spondylolisthesis’
There is a group of arthritic conditions that can cause an inflammatory process in the spine. This inflammation can cause tissue damage and destruction, resulting in back pain and stiffness. These conditions are called inflammatory arthropathies. Examples of inflammatory arthropathies are Ankylosing spondylitis and Rheumatoid arthritis.
Inflammatory arthropathies are diagnosed by a combination of blood tests, and x-rays and scans. A Rheumatologist rather than a Spinal surgeon generally manages these conditions.
Generally a significant amount of force is required to sustain a spinal fracture. A spinal fracture may also result in a spinal cord or nerve injury. Most spinal cord or nerve damage occurs at the time of the accident, and may be permanent. If a spine is unstable following a fracture then there is also the potential for spinal cord or nerve injury after the accident. It is imperative therefore that spinal fractures are properly assessed.
Spinal fractures are evaluated by x-ray, MRI and CT scans. Less severe, stable fractures can often be managed using some form of brace. A brace would normally need to be worn for at least three months. This would need to be followed by a period of physical therapy to help your spine regain strength and mobility. More serious fractures may require surgical stabilisation. Most fractures are stable and do not require any form of surgical correction.
The elderly population can sustain fractures following minimal trauma. These are called vertebral compression fractures and are usually secondary to osteoporosis.
For further information please go to the page on ‘Vertebral compression fractures’
Infections in the spine are rare. When a spinal infection does occur the infection usually develops in the disc space and causes destruction of the bones above and below the infected disc. This type of infection is called a discitis. Discitis generally causes severe and persistent back pain, and should be considered as a diagnosis in any patient with severe back pain who has been generally unwell with signs of infection. Normally, the infection will have travelled to the spine from elsewhere in the body via the blood. The elderly and patients with chronic illness (especially diabetes and immuno-deficiency) are at the greatest risk.
Discitis is treated with intra-venous antibiotics. These may need to be given for several weeks, and followed by a prolonged course of oral antibiotics. The response to treatment is monitored with regular blood tests. Surgery may be required if the infection spreads to other tissues despite antibiotic treatment, or if an abscess forms putting pressure on the nerves.
Tumours in the spine are usually secondary to a cancer that has spread from elsewhere in the body. It is possible to have primary tumours of the spine, but these are comparatively rare. Patients often present with a history of constant and increasing pain that is not related to any particular activity. There may well be an associated history of feeling unwell, weight loss, loss of appetite, and night sweats.
Spinal tumours must be properly assessed. This will usually require a number of blood tests, scans, and often a biopsy. A decision is then made as to whether the tumour requires surgical treatment. Radiotherapy or chemotherapy may also be necessary.
Non-Specific Low Back Pain
Non-specific low back pain accounts for the majority of cases of chronic low back pain. Non-specific low back pain is when there is no specific cause for your pain. Most of us will have something wrong with our backs on a MRI scan, but those structural abnormalities do not necessarily cause pain. Many patients with non-specific low back pain become very anxious, not just about their back but also about their general health and their future. This can lead to significant stress and tension resulting in further episodes of back pain. This can create a vicious cycle of fear and recurrent symptoms.
Factors that may contribute to the unnecessary continuation of non-specific low back pain include:
- Poor general health
- Lack of fitness
- Psychological Distress
- Work-related problems
- On-going compensation claim
- Fear of illness and disability
Exercise is vital to maintaining a healthy spine, and to help combat back problems. However, if you have a history of back problems you must talk to your doctor or physical therapist before you start an exercise routine as you need to make sure the exercises you choose are appropriate for you.
Tips for Managing your Low Back Pain
Treatment for your back problem may be as simple as reassuring you that there is nothing seriously wrong with your back. However, anyone who has had a back problem should consider some preventive measures to protect their back from further problems in the future. Most patients will benefit from seeing a physiotherapist, an osteopath, or a chiropractor.
There are a number of things that you can do to help you manage your back pain:
Stretching: The aim of stretching is to maintain the range of movement of your spine. You should also stretch your hamstrings and the rest of your body, as this will reduce the amount of movement required of the spine.
Core stability: The strength of the spine comes from the muscles of the stomach, back and upper thigh. These muscle groups form your own ‘internal muscular corset’ that serves to support and protect your spine. Your physical therapist (physiotherapist / osteopath / chiropractor) will teach you specific core strengthening exercises. As you become more comfortable with these exercises then you may benefit from joining a Pilates class.
Developing and maintaining your core muscle strength is most important part of your back rehabilitation, and is an investment against back problems in the future.
Anti-inflammatory medication: Inflammation of structures in the lower back is a big factor in lower back pain. Anti-inflammatory medication can be very effective in helping to reduce this inflammation and improve your symptoms.
When taking any medication always follow the instructions on the leaflet, and do not exceed the recommended dose. Anti-inflammatories are not be suitable for everyone, especially if you have a history of asthma, high blood pressure, kidney or heart failure, or heartburn or stomach ulcers. You should check with your GP or pharmacist if you have one of these conditions or if you are taking any other form of medication.
Lifestyle modification: Many people with low back pain will have particular things that they like or have to do in their daily lives that aggravates their back. You should consider your daily activities both at home and at work. Rather than giving up some activities, you should aim to reduce or modify those activities that appear to aggravate your back. This may bring down the amount of strain that you place on your spine to below the level at which you experience the onset of symptoms.
There are a number of activities in our daily lives that can contribute to back pain and which can be easily modified:
Workstation modifications: The back of your chair should be high enough to support your shoulders, and the back of the chair should be at right angles to the seat. The chair should be at a height that allows your knees to be bent at 90 degrees with your feet resting on the floor. Your computer screen needs to be raised off the desk, as the position of your screen determines the position of your head. You should never sit at your desk for more than one hour at a time.
If you spend a lot of time on the telephone then use a headset so that you do not sit with your head and neck tilted over to one side.
If your back is aggravated by long journeys in the car, allow a bit more time for your journey so that you can take regular breaks. Likewise, if you have to do heavy physical tasks at home such as hovering the house or digging the garden, then try to avoid doing it all at once and have regular breaks. Ideally you should try and avoid heavy lifting, but if this is not possible then make sure you lift by bending your knees, keeping your back straight.
High impact sports should be avoided if possible. These include squash, long distance jogging, fast bowling and rowing. Less high impact sporting activities such as tennis, cycling, badminton, golf, and football are usually fine. You will often feel sore the day following heavy exercise, rather than at the time of exercising. If you have a longstanding history of back pain then it is important that you increase your activity levels in small amounts so that you hopefully avoid getting into a cycle of activity followed by pain and subsequent inactivity.
What Patients Say
I would like to express my sincere thanks and gratitude for curing my pain. For months I have suffered in agony day and night. I was in despair and you were my last hope. Now I am not in pain! I am continually smiling and enjoying life again! March 2020
Mr Langdon was great from start to finish. I know that he saw me at the end of an already full clinic and on top of that arranged an immediate MRI…making him much later than he needed to be in getting home! I was in a great deal of pain and I very much appreciated his help in getting me sorted as fast as possible. He made sure I was early on in the running order of procedures on the day of my treatment and everything was explained well to me both before and afterwards. Cannot fault in any way. Thank you very much.
Very patient took his time explaining the surgery and aftercare. Very knowledge about my condition. Made me feel relaxed and in safe hands as I was very scared of the surgery itself and the possible risks.
Very caring, explained fully what was wrong and what he was going to do. December 2019
He was very professional and helpful before, during and after my minor treatment. December 2019
Mr Langdon was extremely helpful and reassuring. December 2019
Mr Langdon was clear and confident with his communication. This is reassuring for a patient. December 2019
Professional and treated to a high standard. Mr Langdon was excellent, he knew everything on my condition explaining all the options available. December 2019
Mr Langdon’s manner was very polite, professional and efficient, he answered all her questions and came to see her quickly after her epidural. June 2017
I have just completed a 102 mile walk over 7 days. Thank you so much for patching me up and making this experience possible. June 2017
Thank you for your specialist surgical and operational skills as well as your patient friendly approach. The two don’t always go together. We need people like you to maintain such high standards of surgery and care. October 2017
I wanted to take the opportunity to thank you and your team following my surgery. It has been so long since I felt so well and without pain. The surgery and my recuperation has far surpassed my expectations and has made a huge difference to my lifestyle. December 2017
Three months on from my back operation and I am feeling so much better. Thank you for all the kindness and support you showed when I was in such desperate pain. February 2018
Thank you so much for the work that you have done. What an incredible job you have and do. Life changing. March 2018
Thank you for all you have done for me during the last few weeks. I am most grateful not only for the main work but also the extras like telephoning to keep me informed. April 2018
I cannot thank you enough for the success of my back operation. Everyone was so pessimistic and you were so positive. May 2018
I was at all times given all necessary information, listened to, and I had confidence that Mr Langdon would complete the operation successfully. August 2018
Highly skilled and intuitive. October 2018
He was brilliant, I felt so comfortable that he would look after me even though I felt so anxious, and he made sure to give me all the information I needed. Also, every nurse and employee of Spire had nothing but brilliant things to say about Mr Langdon – I didn’t even need to ask. They would look on my notes and see I had Mr Langdon and say I was in excellent hands, and so I felt extremely happy. My partner also has disc problems so I will very much be pointing him to Mr Langdon October 2018
Very understanding and caring chap from start to finish, and a great bedside manner, unusual for some consultants. He is trying hard to understand my problems and working with me on a treatment plan for the present, and the future. November 2018
My consultant is obviously a very competent person and comes across as such. My procedure was fully explained both before and after my surgery. He also has a professional sense of humour, which helped as I was very nervous November 2018
Mr Langdon was always prepared to fully explain what was wrong and what he could do about it, he gave me a lot of confidence to make the decision to operate, and so far so good. Albeit early days. November 2018
Mr Langdon was very professional and helpful, he came in on his day off because my treatment had to be moved. November 2018
Excellent, extremely knowledgeable on his speciality. I managed to get an appointment to see him at very short notice for which I was very grateful. December 2018
Excellent surgeon, great manner, explained procedure well. December 2018
A good sense of humour, understanding and non-judgmental. They explained everything very clearly. January 2019
Mr Langdon, very professional and calm, did not push the treatment on me which I really liked, but advised and let me make up my own mind. January 2019
James Langdon is a really good person to have on your side. He’s smart, attentive and very dedicated. January 2019
I felt very safe with Mr Langdon, he fully explained the procedure, the risks and the recovery. January 2019
A very professional consultant. Showed great care and understood me as a person and patient. Saw me pre procedure and after in recovery room and own room. Visited again before going home in late evening and yet again first thing the next morning. It felt like I was Mr Langdon’s only patient which I know is far from the truth. Unfortunately, I am a nervous patient but could not have been in better hands. Many thanks January 2019
Explained everything in detail, understood my concerns, excellent bedside manner, very professional. January 2019
James Langdon is very patient – he answers questions and really listens to you and explains again if you haven’t quite got something. March 2019
Mr James Langdon was in every way, courteous, clearly good at his particular area of expertise, took time out every day to see me and check that all was ok. Was happy to answer any questions I had. April 2019
Mr Langdon was very understanding about my condition and talked me through every procedure that could help me get more mobile again. I was always at ease with him with his caring attitude. A true professional thanks. April 2019
Mr Langdon gave a full explanation of the procedure and what would happen and what to do afterwards. Perfect. May 2019
Fully informed by Consultant Surgeon and Consultant Anaethetist who put me at ease with procedure. May 2019
I saw Mr Langdon before I had the operation and he explained everything that would happen on the day of the operation. June 2019
Very attentive, understood exactly what I was saying and made me feel confident that what I was doing was the right thing. June 2019
Mr. Langdon gave you complete confidence that all would be well and that he was available if needed at any time. He showed kindness and consideration. June 2019
Calm, professional, helpful. July 2019
Everything went off so smoothly. So pleased that the operation was so successful & the next day I was able to walk around without pain. July 2019
In overall terms he was absolutely brilliant. Clearly he is a brilliant surgeon but also a wonderful and understanding human being who, whilst pointing out the risks involved in the operation, filled me with absolute confidence that if success was possible, it would definitely be achieved – and I am delighted to say that it was. He is certainly a hero to me! It was also abundantly clear that all the staff at the hospital have absolute confidence in him and hold him in the highest regard. August 2019
Excellent, he fitted me in with an early appointment and treated me extremely well. September 2019
Extremely helpful explained everything very clearly. September 2019
Mr Langdon has been very clear and concise about the treatment he would be providing and the possible outcome. He has a very professional manner and I felt very at ease with him. He provided me with lots of information and visited me numerous times after my operation to see how I was and to explain what was done and what I should expect. I would be very happy to see Mr Langdon again in the future should I have a need to. September 2019
Caring conscientious and totally professional in all respects. September 2019
Mr Langdon gave me the confidence to go ahead with surgery that I was very worried about. He is very professional and thoroughly explained all the pros, cons and side effects that could possibly happen. All of the above helped me to make a more informed decision. October 2019
James Langdon was the consummate professional. He explained his diagnosis in plain language that was easy to understand and interpret from a layman’s point of view. He was careful to manage expectations and clear about potential risks keeping them in perspective and proportionate to the circumstances. His manner was direct whilst always retaining a caring attitude listening to the patient and answering questions clearly; even taking time out to follow up with my wife whilst I was still in post Op recovery. Very thorough and I would highly recommend James. October 2019
Fully explained the treatment I required and the reasons why. I felt very confident I was in good hands. October 2019
Professional, inspires confidence. October 2019
He was very understanding explaining everything very carefully and advising me on altering medication for the procedure and when to restart normal regime. November 2019
He was courteous, listened, understood the issue very quickly. Explained everything well and was sure to confirm I understood and asked if I had questions. I didn’t feel hurried. He provided an effective and efficient service. I’d definitely recommend him. November 2019
Professional and approachable. November 2019
Extremely happy. Care was first class throughout the stay and looked after all my needs November 2019
Very approachable, caring, friendly, put me at ease. December 2019
Very approachable and knowledgeable. Felt I was in very safe hands. December 2019
Very professional throughout. December 2019
Mr Langdon diagnosed my problem, explained fully the options I had regarding treatment also all the risks involved if I chose to have an operation. Mr Langdon organised a scan to confirm his diagnosis, and explained to me prior to my operation all that was involved in the procedure. Post operation Mr Langdon visited me in my room to check on my recovery and gave me the opportunity to ask any questions on the operation. I am very satisfied with Mr Langdon and his team on my treatment. December 2019
My marks of 10 across all questions reflect my opinion of James Langdon. Brilliant in all respects, in particular his explanation to a non medical man of my problem and his solution. December 2019
Spire Harpenden Hospital
(01582) 714 304