What Is An Acute Locked Back

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An acute locking episode is when an unguarded movement causes an agonising jolt of pain like a high voltage current to shoot through your back. The pain always strikes at the beginning of a movement, like a bolt from the blue, and leaves you bent over rigid and unable to straighten.

Usually the pain catches you so badly you cannot stir. You cannot go forwards or back, or put one foot after the other. It is a real crisis. Often it makes the knees buckle so you collapse to the floor and an injection of pethidine may be needed before you can be moved. It is always a very frightening experience, and often clearly remembered many years later.

There are an infinite number of minor ways you can suffer an attack like this. You can do it turning over in bed, getting out of a car, pulling your chair out, bending forward to pick up a toothbrush, lifting a bale of wool. One of my patients did it zipping up a ball dress! Common to all is the unexpectedness and a certain lack of exertion. In fact, absence of effort and preparedness for what you were about to do, seem to play a key part.

As a therapist, I find acute facet locking one of the most daunting

Figure 4.1 A facet joint locking can make it impossible to move.

conditions to treat. At the time of the crisis patients are in extremis; they are loath to move and almost hysterically fearful of doing anything that might cause another jolt of pain. Long after the original episode has passed they remain fearful of it happening again and often feel their back is never the same again (indeed some feel their life is never the same again).

Over the years, many opinions have been put forward as to what goes wrong. Although acute locked back feels as if something has slipped out, it is most definitely not a 'slipped' disc. However there is never any objective evidence to explain exactly what has happened. There is nothing to see on the X-rays or other forms of imaging, and the neurological assessment is usually clear. Yet there is a fellow human cast down and immobilised, often on the floor as if caught in a freeze frame, literally rigid with pain.

One popular explanation is the jamming of a meniscoid inclusion (a tiny wedge of cartilage from the margins of the facet joint) between the two joint surfaces, which sends all the muscles of the spine into a gust of protective spasm. A similar, more plausible, explanation

tiny extraneous movement of upper facet surface disc may be thinner

Figure 4.2 Sometimes an unguarded movement without the tummy muscles adequately braced can allow one of the facets to slip slightly askew in its joint.

tiny extraneous movement of upper facet surface disc may be thinner

Figure 4.2 Sometimes an unguarded movement without the tummy muscles adequately braced can allow one of the facets to slip slightly askew in its joint.

points to the nipping of the sensitive folds of synovial membrane between the facet joint surfaces.

I believe the main cause of facet locking is a momentary lapse of spinal coordination, causing one of the facets at the back of the spine to slip slightly askew in its joint. Almost before a movement has begun, the spine is caught unawares and the facet moves slightly out of alignment. If pinching of the synovial lining does happen, I suspect it is only part of the wider picture of the facet 'mis-jointing' and then jamming.

The degree of movement is infinitesimal so it is never possible to take a picture and see any joint dislocation. But the actual slip is not the problem. The reaction is: an instantaneous and massive protective response from the muscles which takes your breath away as they lock up the spine.

A joint being 'out' anywhere else in the body does not arouse the same defence. (We have all experienced a wonky knee when our kneecap temporarily mistracks.) However, the spine's heavy responsibilities for structural support and protection of its fragile festoonery of nerves inside make it keenly alert to any threat to its integrity.

When facet locking happens in the neck it is relatively easy to manipulate back into position. The neck's slender accessibility makes it much easier than the low back where bulky protective spasm quickly sets in, making it difficult to pull the segments apart. If you are lucky and get to an osteopath/chiropractor/physiotherapist soon enough, a small high-speed manipulative thrust, with its characteristic popping sound, can break the jamming of the joint and realign the vertebra correctly.

These are the wonder cures you occasionally hear of. The technique momentarily gaps the joint open and lets it slot back together in proper apposition. If it is successful, the joint immediately rides freely again, and you can walk away on air with none of your former pain. Any residual muscle spasm will be gone within a day or so.

More usually though, by the time you get to a practitioner the stiffness of the muscles is so well established it stops the joint being physically opened. Attempting manipulation at this stage only makes matters worse. It alarms the patient (because it hurts) and causes the protective hold of the muscles to intensify.

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