Avoid stoop, Always sit with straight back.
Dr. Ketan Khurjekar
M S (Ortho), D N B , M N A M S , M Ch (UK)
Head of Spine Surgery Dept, Sancheti Hospital, Pune.

In true sense Spine is a Back bone of our Body. Strength in our back is rendered by calcium densed vertebrae and toned paraspinal muscles. Function of vertebral column is to protect the delicate spinal cord and to give a good posture.

Few days back, in out patient clinic, I saw one 60 years young lady and one 45 years old lady. The former one had mild low back pain while the later complained of generalised back pain of moderate to severe grade. What exactly must have happened?

I explained both of them the same thing; Strength in back is rendered by calcium densed vertebrae and toned paraspinal muscles. If you loose on either, the back pain will start.
The 60 year old lady had started developing early changes of decreased calcium in bones which we call as osteopenia, but she had good strength in her paraspinal (back) muscles which supported her weaker vertebrae. As against that, the 45 year old lady had weaker paraspinal muscles as well osteoporotic bones. She was the victim of osteoporotic back pain. 

What is Osteoporosis? 
Osteoporosis is a systemic skeletal disease, characterized by low bone mass and microarchitectural deterioration of bone tissue, leading to enhanced bone fragility and a  consequent increase in fracture risk (WHO, 1994). In other words weaker bones which are fragile and amenable to easy fractures. 



Normal Bone as against the Osteoporotic Bone



Very commonly we are put forward with series of questions. Is it a disease?
  • Is it hereditary?
  • Is it only in women?
  • Is it only a condition of old age?
  • And the most important - Can we prevent Osteoporosis?
As we grow old, it is accepted that bones are going to become weaker. If fragility of bones is going to be in physiological limit then definitely it is not called Osteoporosis. Age related Osteoporosis is called senile one. Estrogen is stimulator in increasing bone mass. After women achieve menopause or after the surgical removal of uterus (Hysterectomy), the symptoms of osteoporosis are felt. Osteoporosis is commoner in women because of postmenopausal hormonal changes. 

Osteoporosis- A Silent Killer
Bone loss occurs without symptoms, making osteoporosis, a “silent killer.” Many people do not realize they have osteoporosis until they have a fracture. Fractures can cause pain or occur without pain. It is commoner to get hip and spine fractures with osteoporosis. As against the western population, osteoporosis is greatly under diagnosed and under treated in our country, even in the most high risk patients who have already fractured. The problem is particularly acute in rural areas but as well as seen in urban areas.

Following are the facts which we are absolutely unaware of- 
  • Each year, there are an estimated 500,000 spinal fractures, 300,000 hip fractures, 200,000 broken wrists, and 300,000 fractures of other bones.  About 80% of these fractures occur from relatively minor falls or accidents. 
  • Between 25% and 60% of women over 60 years of age develop spinal compression fractures. A woman’s risk of developing an osteoporosis-related hip fracture is equal to her combined risk of developing breast uterine and ovarian cancer. 
  • By age 90, one third of all women and 17% of men have sustained a hip fracture.
Though all above facts appear scary, they pose realistic picture and most important- they are preventable.
Bone is built in the first two decades of life. The critical years for building bone mass are from prior to adolescence to about age 30. The best prevention for osteoporosis is to build strong bones (maximize peak bone mass) during childhood and early adulthood. Prevention consists of a combination of adequate calcium and vitamin D intake, weight-bearing exercise and healthy lifestyle, including avoiding smoking and excessive alcohol intake. It is difficult to cure osteoporosis; we can slow down the process. Prevention takes edge over treatment. 

Signs & Symptoms of Vertebral Fracture
  • Sudden onset of back pain.
  • Limited spinal mobility.
  • Height loss.
  • Deformity & Instability.
  • Back pain worsening on standing. 
Osteoporotic Spinal Fractures pose a major concern, and we need to identify individuals at high risks.
  • Early menopause and associated back pain
  • Less calcium intake in diet and those who don’t get enough vitamin D
  • Age > 70
  • Lack of exercise, immobilisation
  • Malabsorption syndromes, Diabetes Mellitus 
  • Patient on treatment with Phenytoin, Steroids
  • Smoking and excessive alcohol 
Radiograph of the thoracolumbar spine is mandatory to document Osteoporosis, normal alignment of the vertebrae, disc spaces, and spinal curves. Bone densitometry, also known as Dexa scan is a choice of investigation to grade the severity of osteoporosis. T score being the indicator; result below -1 is considered normal. T score value more than -2-5 is osteoporosis, while between -1 and -2.5 is considered as osteopenic.
 


A . Normal Vertebra, B. Osteopenia, C. Osteoporosis, D. Osteoporosis with fracture.

Why Working people are more afflicted?
  • Decreased bone mass.
  • Increased tendency to fall.
  • Impaired protective neuromuscular responses which will lead to repetitive fall.


Osteoporosis Preventation
1.Calcium rich diet – 
  • Vegetable: beet root, methi, spinach, lady finger, cauliflower, rajgira, nachani.
  • Fruits: Grapes, Orange, Banana, apple, Khajur.
  • Poultry & dairy products: milk, cheese 
  • Nuts: Ground nuts, Almonds, Pista.
2.Regular Physical Exercise.
3.Diet Modification.
4.Change in life style habbits.
5.Prevention of repeated fall.
6.Stop Smoking and Alcohol Intake.



Treatment.
1.Daily Oral Calcium Supplement 1200 mg. calcium daily
2.Vitamin D Supplement (Calcitriol).
3.Exposure to early morning sunlight.
4.Other newer medications.
5.Surgical – Vertebroplasty.

X-ray:- Osteoporotic Vertebral Fracture treated in the form of Cement Augmentation of the vertebra called Vertebroplasty.
 
Vertebroplasty and Kyphoplasty are minimally invasive procedures which aim at pain relief, and stabilization of the vertebral body. Kyphoplasty, has the ability to provide some correction of deformity with partial restoration of vertebral body height
 
On whom to perform vertebroplasty or kyphoplasty ?
  • Painful vertebral fracture at the end of 3 to 6 weeks
  • Disabling back pain leading to immobilization 
  • High Roland – Morris and ODI scores (High Pain scores)
  • MRI showing change in bone marrow signals- suggestive of non-healing fracture
    

Procedure of Vertebroplasty (Cement Augmentation in Fractured Vertebra)
 
Advantages of Vertebroplasty
  • Quicker pain relief
  • Early mobilisation of patient
  • Patient as well as Surgeon friendly
Procedure of Vertebroplasty:





 
BACK PAIN : Enigma in Itself
 
Back pain has become an epidemic. Ten years back in initial days of my practice, I used to see Back pain as a symptom and complain of grey hair individuals; but today every age group individual comes with back pain. Causative factors would be different for a school goer as against a post pregnancy back pain as against an elderly individual. When a patient with Back pain comes, his cause of back pain gets classified into either a bony/ vertebral cause or it’s a neural/ nerve related cause or musculoligamentous cause. But sometimes the pain may appear to be muscular but it is coming from deep within, eg. Kidney stone Pain (Renal Pain). The difference is, it’s a continious Back pain which has specific radiation from loin to groin. Identification of such pains is paramount to give a quick and assured relief to the patient.
Commonly we see following pathologies, which can mimic as Back Pain. Identifying these Organic causes of Back pain need more vigilance. Eyes don’t see, what mind doesn’t know. Common organic causes which mimic or get represented as back pain.
1. Renal Colic: Kidney stones can be in someones body for a long time, once they get blocked in narrow area of ureter, and then they lead to severe muscular back spasm. They are associated with Loin to groin pain and sometimes fever.
2. PID (Pelvic Inflammatory diseases): These gyanec related problems in reproductive age group can often lead to dull low back pain in women. Identifying the nature of the illness, associated complaints will differentiate the cause. USG abdomen and pelvis will rule out PID Vs PID i.e. Pelvic Inflammatory disease Vs Prolapsed intervertebral disc (slipped disc)
3. Pleuritis: Irritation of pleura which an outer layer of lungs, when gets inflamed causes upper and middle back pain. Pain is all along the rib cage and gets exacerbated on coughing and sneezing. This aggravating point rules out the muscular cause of Upper back pain from Pain which coming from Pleuritis. Many a time pleuritis is associated with TB- tuberculosis. So identifying rightly in time pays rich dividends.  CT scan Chest  is the choice of investigation to rule out pulmonary TB
4. Liver Abscess: Liver is located under the diaphragm. Any accumulation of abscess, granulation and inflammation can lead to Mid back pain located on right side., Back pain which is increasing with respiration, inspiration specifically and associated with fever should ring the bells. Detail clinical abdominal examination and USG abdomen and pelvis can rule out Liver being the cause of back pain
5. Axial Inflammatory Arthritis: Inflammatory conditions do exist together. Irritable bowel, redness of eyes, skin conditions like – lichen planus and low back pain is known to exist together and can be a part of Sjogren s Syndrome. Inflammatory cause can be ruled out by detail clinical history of associated complaints and blood markers like –ESR and CRP. Morning stiffness associated with back pain is generally a Inflammatory type of back pain
6. Tuberculosis (TB): Tuberculosis of any internal organ or peritoneum will eventually lead to upper, middle and lower back pain. Because of the peritoneal inflammation patient gets continuous back pain. Night cries and fever associated with back pain, the first suspicion should be tuberculosis. Simple blood test with hemogram , ESR n CRP and Montoux test can rule out association of tuberculosis
7. Thyroid Problems:Are known to be associated with neck pain. Clinical examination with blood tests like Thyroid function test will rule out thyroid related neck pain from muscular cause of neck pain. Simple history can give a suspicion of Thyroid problems.
8. Pancreatic cyst and carcinomas: It is very common presentation of acute pancreatitis, that patient presents with severe back pain. Acuteness of back pain shd raise the tentatckles. On clinical examination of abdomen with rigidity will differentiate pancreatitis from muscular cause of back pain
9. Leukemia:In children if continuous back pain which is disturbing sleep, one should get the work up to rule out Leukemia (blood cancer). Leukemia is not uncommon.
 
All above are just examples of Organic causes which can mimic back and neck pain. Smarter is the clinician who can have the maximum suspicion and can correlate to reach out to the final diagnosis. 
Following things are strongly suggested:
 
1. To seek a clinical help from the specialist doctor and not to self medicate
2. To tell complete history and symptoms with earlier medication history to the consulting doctor
3. Not get scared but should be attentive to every small complaints and should consult your doctor at the earliest
 
One of the major side effects of self medication for Back pain with pain killers is – KIDNEY FAILURE. Kidney failure is a disaster and can be absolutely avoided.
 
SUCCESS OF ANY TREATMENT IS ACCURATE DIAGNOSIS !