Back injury Talk - main page
Back to basics for backache sufferers
Dr Thomas Stuttaford
Accurate diagnosis and conventional medicine are more effective than manipulation
(March 2006) Unlike our distant ancestors, whose weight was distributed between their upper and lower limbs as they swung from tree to tree or raced through the forest, modern man’s spine bears a greater load than four-legged mammals.
Our backs are not up to it. In many cases it is only in old age, when vertebral joints become arthritic and the spinal canal is narrowed, that the wear and tear becomes obvious, or even crippling. The spine may also give trouble from over-use or misuse in otherwise fit, young people. At any age, the efficiency of the back may also be undermined by conditions that affect the spine.
Some people assume that because the spine is so important, and because it encases and protects the central nervous system, any abnormality in its alignment may account for otherwise inexplicable symptoms in parts of the body other than those supplied by the cranial nerves originating in the brain. Correcting the alignment of the spine has been claimed to ease such diverse troubles as infantile colic, headaches, asthma, allergies, period cramps and dizziness, as well as numerous causes of back and neck pain.
For generations, practitioners have been treating the back by manipulation, stretching and massaging. Other devices such as electrical stimulation or ultrasound have also been used.
The advent of MRI and, to a lesser extent, CT scans revolutionised diagnosis and treatment. The trouble at the source of the pain, and frequently the cause of the spasm that affects muscles if a nerve is touched, could now be seen. Diagnosis was less a matter of conjecture, and no longer relied on clinical experience and examination (still very important) but on the interpretation of radiological and pathological findings.
Prolapsed discs, popularly known as slipped discs, the cause of much back trouble, could now be demonstrated. Discs may prolapse centrally or laterally and once prolapsed may press on to a nerve leading to the spider’s web of nerves (the sacral plexus) and cause pain. This is initially agonising and frequently radiates down the leg. In some cases there may also be muscle-wasting and weakness and, in the most worrying instances, the pain may be associated with disturbance of bowel or bladder function, impotence or inexplicable pain in the groin or genitalia.
Scans and X-rays can also reveal signs of osteoarthritis, in which spicules (or spikes) of bone from the degenerating joint may press on a nerve and give rise to similar, but not usually such acute, pain as from a prolapsed disc.
Tests also reveal the inflammatory processes associated with ankylosing spondylitis and the joint degeneration and later fusion that accompanies it. The spine may also be affected by tumours. When malignant these may have originated in the vertebrae, or may have spread from other parts of the body.
The vertebrae may be infected by bacteria or tuberculosis. Backache can also be caused by pressure on the spine from a swelling, such as an aneurysm of the aorta, pressing against it.
When there is such a multitude of causes of backache, the danger of manipulation without detailed diagnosis is obvious. It is wildly optimistic, not to mention hazardous, to suggest that manipulation cures many spinal conditions, let alone symptoms that are unrelated to its anatomical and physiological function.
It is small wonder that Professor Edzard Ernst has found “ little evidence that spinal manipulation is effective in the treatment of any medical condition”. However, in the treatment of some forms of backache, presumably prolapsed discs, he said that spinal manipulation was better than nothing — but not better than conventional treatment. He also cautioned against the occasional catastrophic damage that it could induce; in his research 50 per cent of those treated were made worse.
The accepted treatment for acute disc lesions — my report in The Times of March 22 was abbreviated — is with analgesics and anti-inflammatory drugs, two days off work, followed by resumption of normal activity.
If after three weeks the pain is still incapacitating or interfering with sleep, the patient needs an MRI scan. The standard treatment is now a comparatively minor operation.
Patients under 16 years old, or in any age group if there is loss of muscle power in the legs, interference with the bladder or bowel or impotency, should be investigated immediately. Six weeks lying on boards and other forms of rest is now considered to be counterproductive