The Way This Back Behaves

The acute phase

Acute segmental instability is arrived at after being chronic for some years and suddenly taking a turn for the worse. Being unfit, putting on weight and sleeping in a very soft bed are background factors which together can tip the balance, but strong physical exertion can often be the final straw. Strenuous pushing activities—such as a car, wardrobe or lawnmower—are often linked to the back getting worse, no doubt from the backward shearing action of the spine on the flaccid disc which it is ill-equipped to prevent.

Then the variety of symptoms—and the emergence of new ones— can make the problem very difficult to unravel. Except for extra rigidity in the back, its worst features are often indistinguishable from acute disc prolapse, with an angry pain and paraesthesia (disturbed sensation) down the leg. What differentiates instability is the long history leading up to the present crisis.

At the peak of the acute phase, the erector spinae stand up like cables, making it impossible to hump your low back to bend. Try as you might, the muscles will not let go. Everything appears stuck, like a puppet with its strings pulled too tight, and then as you get further forward you elicit a crippling pain down the leg as the tension stretches the sciatic nerve. At this point, the back will be doubly disinclined to bend: both to ward off any slippage at the weak link and to avoid further stretching the inflamed nerve root.

You will be uncomfortable in most positions, even turning over in bed, because your spine has lost its serpentine control of all the segments as it undulates across the mattress. You will know from experience the best way to do this is either rolling over like a log, or very slowly with the tummy braced, so the spine does not 'disjoint' at the weak link. But if the instability is severe and the leg pain intractable, you will hardly know what to do with yourself. You will be pathetically crippled by your leg, and only comfortable lying in the foetal position with a pillow between your knees. Sitting may be impossible and walking may be reduced to a shuffle by the nerve root's painful inability to take stretch (see Chapter 5). Invariably at this point the condition needs surgical intervention.

What causes the acute pain?

With acute instability, there will be intense back pain, quite probably from more than one structure. It is arguable whether more pain will come from the side of the motion segment which became unstable first, although in the early stages the facets—with their propensity for inflammatory response and their sophisticated nerve supply—will always register a lot more pain than a disc. Broadly speaking, the true picture of instability is often a time-lapsed composite of the different conditions which have afflicted the segment during the course of its breakdown.

At one and the same time there may be symptoms from the stretched disc wall (see Chapter 2), from the inflamed facet joint (see Chapter 3), or from a localised bulge in the wall (see Chapter 5). As a result, there may be deep central back pain in addition to a pain spreading over the buttock. There may also be sciatica, numbness and weakness in the leg from both the capsular inflammation and disc prolapse. And just to complicate matters, there may also be referred pain in the leg from the facet joint arthropathy. It certainly can be complicated.

The sub-acute phase

If there is no sciatica it is easier to recover from this problem without surgery. If you persevere, your back will grudgingly regain segmental strength and learn to bend, especially if you pull your tummy in and hump the low back first. Soon enough, you will notice a tell-tale wriggle or kinking movement in the lower back emerging through the stiffness, even when your back is still quite cast.

The wriggle may come about as your spine tries to avoid skidding on the flaccid disc. Watching the movement happening from behind, the spine appears to do a lateral semicircular movement as if attempting to roll around the rim of the flattened disc as it goes forward. It can go around either the left or right side of the rim but either way, sometimes the aberrant movement can be more unnerving than painful. Until you build up the strength of your intrinsics, you can minimise this by pulling your tummy in hard and drawing up your pelvic floor, both before you bend over and as you come up again.

With the widespread armour-plating of the muscles you often feel more pain in your upper back as stiffness spreads to the better-off regions. Sometimes there is soreness right up to your shoulder blades and you may also complain of headaches. Sufferers often seek spinal manipulation at this point, which is ill-advised. Although manipulation comes into its own with other spinal conditions—particularly segmental stiffness if the vertebra is twisted on its axis, or with acute facet locking—there is no way, for even the most experienced operators, to accurately localise the manipulative thrust to the stiff segments while sparing the weak one nearby.

The so-called 'million dollar roll' (where the patient is put on his or her side and the low back clicked one way then the other) often wrenches the weak link, even though the sense of release which coincides with the characteristic popping sound can be profound. People usually get increasingly uneasy about having the same treatment over and over again when there is no long-term improvement. With manipulations becoming more frequent, and the benefit shorter-lived, many decide to look deeper and search out a more permanent (if not instantaneous) solution—and indeed to have some understanding of what is wrong in the first place.

You are usually at your most comfortable sitting, because the reduced hollowing in the low back lessens the forward inclination of the lumbar vertebrae and thus the tendency for the weak one to slip forward. But rising from sitting to standing can be agony. There is often a painful catch as you straighten and you may have to push yourself up through the final part with your hands on your thighs. Basically you will be unhappy about feeling the movement of the vertebra, and there is good reason for this. You will always be on guard against it letting you down.

You will know from experience that the more clicking and grating there is in your back, the stiffer it will become. As the back tightens, there is a dawning of the familiar pain down your leg, which starts off as an ache and then turns into a cramp. Sometimes the leg pain arrives before your back stiffens but either way, the re-emergence of familiar symptoms is a sign the link is inflaming again. It usually corresponds with a period of excess, when your exercise routine has lapsed or you have put on some extra pounds. Bear in mind too that the pain can also intensify if you do too much spinal strengthening (see 'Spinal intrinsics strengthening' Chapter 7).

As the back re-stiffens, you find it increasingly awkward to do everyday things. You may notice your actions becoming more laboured before the pain becomes obvious. Even something as simple as picking a belt up from the chair can become a farce. Your back stays ramrod straight and you feel safer bending sideways with your bottom out and bending your knees, rather than going forward normally.

The chronic phase

You can cope with a chronically unstable back indefinitely, if you can stop the weak link inflaming. You are usually the best judge of the way to do this, as you are more in tune with your back than most practitioners. Although pain may not be a big factor with the low-grade instability, you are strikingly susceptible to minor misadventure. Strengthening of the weak link is imperative, to stop you being catapulted into difficulty at a moment's notice.

With chronic instability, there is muscle stiffness all over the back and a soreness which is pretty well localised to the problem level. However, the level of pain is unpredictable and varies with what the back has to endure. Something as simple as stepping off a curb can set it off—because the lack of support allows the spine to strain at the weak link—but so can heavy jarring exertions which rattle the link.

When the condition is truly quiescent, the back rarely gives way when you go to bend forward and you hardly ever feel it clicking and grinding. You can set off a peaceful back however (and you will be annoyed with yourself that you should have known better) by overdoing sustained bending activity, such as vacuum cleaning or laborious sweeping or raking, or pushing anything heavy, like a wardrobe. (It is always better to turn around and push with your bottom.)

Difficulty with straightening after bending is a sure sign things are wrong. Because the pooling of interstitial fluid causes a transient wedge of waterlogging at the back of the over-mobile segment, it is difficult to close the gapping at the back of the spine to let you straighten. For the first few steps you get about like an old person with knees bent and bottom out, and both hands on the back of your hips to help winch you straight.

More often than not it amounts to nothing more than that. Your back feels normal again within a few steps and the stiffness fades. But occasionally you stay doubled over and a generalised stiffness sets in across the back which you cannot throw off. It can linger for several days, making it increasingly awkward to do things—until you do something thoughtlessly, your back gives way, and you are tipped into an acute phase again.

Although the mishap usually happens when your back is caught off-guard, it is unlike acute facet locking (see Chapter 4) in that you can sense your back getting ready to slip at the weak link and you can avoid it by stopping the movement short. Sometimes if you are quick enough you can stop yourself collapsing to the floor by getting your hands to your thighs before your back gives way. Then you can unfurl yourself to vertical by thrusting your pelvis forward under the spine and pushing up with your hands.

You will see from the self-treatment section how important it is to stop the spine stiffening up all over at this point; it is essential to prevent your back getting so rigid that the deep muscles automatically inhibit and you lose control of the individual segments. As soon as possible you have to get down on the floor and roll back and forth along the spine to prevent the segments jamming up.

What causes the chronic pain?

The pain of chronic instability is probably caused by a combination of the micro-trauma stretching the fibres of both disc and facets, and the compression of the runaway segment by the spine's defense mechanisms. In practice, however, it is impossible to differentiate between the two.

As fibres right across the motion segment are progressively damaged by the excessive movement, toxins are released which stimulate free nerve endings, thus alerting the brain that all is not well. This manifests in the form of pain—both from the disc wall and the facets—plus a greater or lesser degree of muscle spasm. The spasm is not only painful in itself but contributes in its own way to more instability.

Meanwhile, there can also be pain from the vascular engorgement of the weak link when it is locked up tight by the large muscles of the spine holding the whole back stiff. When the cable-like muscles clench all the segments together, as if they were in a mechanical vice, the weak problem link in the middle can bloat up painfully because the circulation through it is hampered by the compression.

Then, you not only get pain from the oxygen deprivation (anoxia) of the tissues (because there is no fresh blood coming through to bring more oxygen), but you also get pain from the rising concentration of metabolites or waste products in the tissues because the old blood cannot get away.

How To Win Your War Against Back Pain

How To Win Your War Against Back Pain

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