It is a well-known fact that the majority of the population experience pain in the neck or back at some point in their life. Many estimates put the figure at about 80 percent. This would simply mean that up to eight out of ten readers of this magazine might find this article helpful.
For simplicity, we can divide back pain into upper and lower back pain. The origin of upper back pain is commonly in the neck or cervical spine while low back pain, defined as pain below the lower rib margin, is commonly associated with problems in the lumbar spine.
While this anatomical division is necessary to help the patient and doctor describe and decide on the origin of pain, it is less useful in addressing the question of when or whether is it necessary to see a doctor.
I would suggest that important factors are the intensity and duration of pain. A patient having intense pain, say a score of seven or more on a scale of one to ten, is likely to look for treatment spontaneously and quickly.
It is the patient that has mild to moderate pain that needs some guidance as to when to see a doctor or orthopaedic surgeon.
To begin with, the duration of pain is an important factor. It is advisable for patients to seek consultation if back pain goes beyond two weeks. This is because the vast majority of pain due to strains on ligament or muscles, disappear within a few days. It is thus perfectly reasonable for a person having some back pain to observe the condition for a while. Simple over – the – counter medications like paracetamol, aspirin or ibuprofen might give additional relieve while awaiting resolution of symptoms.
During this period of observation, it is important that the patient try to rest as much as possible while looking at ways to reduce stress on the strained part. For example, a patient having some low back pain might use a small pillow to support the lower back, and a patient having neck pain may want to look at the ergonomics of his work place. Generally, it is advisable that in the prolonged usage of computers, the monitor should be at the centre and not off-set to the side, and the upper edge of the computer be below the level of the eyes. This is to reduce prolonged extension of the neck, which is one of the commonest causes of repetitive stress to the neck.
In the period of rest and lifestyle modification there should be gradual improvement in terms of pain reduction and improvement in mobility. Lack of improvement is thus a reasonable and important marker which should trigger a person to seed medical advice. This article now goes slightly beyond the first few indications to see a doctor, which to summarize at this stage, are severe pain, duration of more than 2 weeks and pain not improving with rest and simple counter measures.
Other symptoms which should also trigger an early consultation are:
- Significant trauma (e.g. A fall) prior to the onset of pain.
- Fever
Fever is associated with infection and some autoimmune conditions. Certainly when fever is persistent together with neck or back pain, it is necessary for a medical consultation to rule out an infective cause.
Viral infections are often associated with myalgia and arthralgia (muscle and joint pain). In the case of viral infection, the pain usually resolves when the body recovers from the viral infection. It may however take some time.
Bacterial infections involving the spine are a primary concern if a patient presents with persistent back pain and fever. Bacterial infections may be of fairly sudden onset but can also be fairly insidious. Healthy individuals seldom get bacterial infections per se, as our immune system mops up any bacteria attempting to infect the spine, hence bacterial spine infections are more common in immune compromised individuals such as patients with diabetes, renal impairment or other chronic illnesses. An individual who is immunosuppressed is thus advised to seek treatment early, not just for back pain but for other ailments in general.
- Loss of appetite and weight
Back pain is seldom associated with loss of appetite and weight. These constitutional symptoms should alarm patients and the treating doctor to investigate the pain thoroughly, as prolonged loss of appetite is a simple yet accurate marker of a patient’s lack of well-being. The doctor will have to do some tests to rule out any underlying malignancy, infection or metabolic conditions. Obviously a past history of malignancy makes early review of back pain necessary.
- Pain which wakes patients from sleep
A warning sometimes missed is the simple fact that the pain awakes patients from sleep. Musculoskeletal pain, which forms the bulk of back pain is mechanical in nature. What this means is that musculoskeletal pain is usually worse on increased physical activity. Pain due to more sinister causes such as infection, malignancy and pain originating from viscera (internal organ such as kidney or pancreas) is felt at any time, often irrespective of activity or movement. If pain wakes a patient at night, it needs to be investigated. I would just like to put a footnote that pain which wakes a patients from sleep is to be differentiated from pain that is felt fairly sharply in the morning, which is less alarming.
Pain and stiffness felt in the morning is often secondary to inflammation and these symptoms are common in musculoskeletal pain and do not constitute a ‘red flag’. Pain, weakness or numbness radiating to the limbs. Generally pain from muscles and ligaments are fairly localized. Radiating pain, numbness or weakness are frequently associated with nerve root irritation or compression. These symptoms often prompt and warrant further investigation.
- Disturbance of bowel or bladder function
Disturbance of control of the bladder and bowel rarely occur but if it happens are red flags which warrant immediate investigation and treatment.
In summary, pain in the upper or lower back is common and in the vast majority of cases are self-limiting and should not cause undue anxiety. It is important to recognize ‘red flags’ or symptoms which should alert patients and doctors that the pain warrants further investigation and treatment. It is certainly hoped that this article enlightens its readers.
