Lower Back Pain

The Injury Hub specialises in lower back pain having been created by the co-founding director of Spine Plus one of London’s most eminent spinal injury clinics. 

Back pain is multifactorial, there are dozens of reasons for back pain most of which are due to local issues such as spinal joints, intervertebral discs and stress within the adjacent vertebral bones. There are many rheumatological conditions and body parts such as the kidney, uterus, bladder, blood vessels that can refer and cause lower back pain. This is why it’s important to see a practitioner for a thorough examination and diagnosis. 

Most lower back pain patients can relate to suffering central lower back pain or unilateral back pain (affecting one side only). More often than not a patient will report suffering pain in their buttock combined with back pain this is because the back is very good at referring symptoms in to the buttock. Back pain can occur for no specific reason such  as on waking, to sneezing, lifting, sitting for too long, following a trauma, twisting whilst bending…the list is endless. Quite often a patient will have difficulty on straightening up and will be held in an antalgic posture, tilted to one side. SO, what’s the underlying problem? In order to understand the cause we will have to have a quick understanding of the anatomy. 

The spine has many components ranging from ligaments, muscles, vertebral bones, discs and lots of nerves. The 3 most likely tissues that cause back pain are the spinal discs, joints and vertebral bodies. 

Spinal Discs are made of two components, fibrocartilage rings known as the annulus fibrosis and they house a central nucleus known as the nucleus pulposes. The central nucleus consists of a jelly like material that actually act as a spring/shock-absorber. The outer portion of the disc is highly innovated with pain sensitive nerves. When a force, such as lifting a weight or an innocuous sneeze occurs one or some of the cartilage rings that surround the nucleus can become over stretched or even tear. The local nerve endings monitor a change in the pressure of the disc and quickly tell the local muscles to spasm stopping the patient from creating any more stress or damage to the disc. Hence why some patients will present tilted to one side. In some cases the annular fibrosis casing can bulge on to a local nerve or the annular fibrosis can split causing the jelly nucleus to nestle up against a local nerve both scenarios can lead to a patient suffering sciatica (compression of a nerve as it exits the spine). 

Facet Joints

You may have heard your doctor or physio/osteopath talking about numbered bones in the spine. The lower back or lumbar spine as it’s known is made up of 5 bones. They’re numbered L1, L2, L3, L4, L5. There are two sets of facet joints on one vertebral bone. Superior Facets articulate with the bone above and the inferior facets articulate with the bone below. They allow smooth transition of movement when an individual bends forwards and backwards. The joints/vertebral bones are separated by a disc. Now, heres the interesting part. The disc we mentioned in the paragraph above ultimately acts as a shock-absorber but it’s an integral piece of scaffolding that keeps two vertebral bones apart. If a disc starts to lose its plumpness/height then the bone above will come closer to the bone below thus causing the facet joints to absorb more pressure. When excessive stress is put on a facets the same fail safe mechanism occurs when a spinal disc is stressed the nervous system tells the brain TOO much stress on the facet joint so the brain tells the local muscles to spasm causing the individual to be tilted to one side, pulling the pressure away from the irritated facet. 

Vertebral Oedema

This section is poorly understood by many doctors and practitioners and quite often can be one of the top 3 causes of lower back pain. The word Oedema is better known as inflammation or swelling. Anyone reading this who has an MRI report that mentions MODIC TYPE I, will have a better understanding once they have read this next paragraph. A spinal disc is ultimately a piece of scaffolding  combined as a shock absorber that separates two bones. Discs consist of a watery jelly central nucleus. As we age water can diffuse/leak out of a disc as a part of the normal aging process. or, as explained above a trauma can occur leading to the casing of the disc to tear allowing some of the jelly to herniate out. Vertebral oedema occurs when the disc is struggling to absorb all of the forces put through it due to the minor cracks and tears. This causes extra pressure on the adjacent vertebral bone. Bone is made up of fine hair like structures called trabeculae, almost similar to a honey comb architecture. If repetitive stress is put on a bone due to an adjacent ailing disc long term swelling/oedema occurs within the bone leading to weakening of the fine hair like trabeculae and hence causes lower back pain. This scenario is known as MODIC TYPE I on a radiologist report. This can occur anywhere within the spine.  

Other causes of lower back pain

• Spinal Stenosis (There are two types lateral & central stenosis) 
• Micro Instabilities 
• Ligament tears, Sprains
• Disc protrusion (Cartilage bulge)
• Disc extrusion ( Nucleus has herniated)
• Sacro-iliac joint
• Spondylolisthesis / Retrolisthesis
• Ankylosing spondylitis
• Psychological
• Muscle Strains/tears (very rare, yet it’s likely your GP will diagnose it as being muscular)

Sciatica

Sciatica is a condition characterised by pain that radiates along the path of the sciatic nerve, which extends from the lower back, through the buttocks, and down the back of each leg then on to the foot. Typically, sciatica affects only one side of the body. A common cause of sciatica is a protruded disc or disc extrusion often referred to as a slipped disc nestles or compresses one of the 5 individual nerves forming the sciatic nerve. Another cause is the narrowing of the spinal canal or exit foramen (the spaces in the spine through which nerves pass), which again can compress the individual nerves that form the sciatic nerve.

Quite often a patient will report pain that radiates from the lower back down through the buttock and the back of the leg and calf. Symptoms may range from mild to severe and is often described as sharp, burning, or shooting, numbness, tingling, or muscle weakness in the affected leg or foot.

It’s also important to note that not all sciatic symptoms are due to a compressed sciatic nerve. A spinal disc and spinal joint can also refer to the buttock and leg. Studies have shown these structures can refer as low down as the ankle known as a somatic referral. The majority of patients presenting with a “pseudo sciatica” tend to have lower back, buttock and posterior thigh symptomology but rarely symptoms travel beyond the knee.  At the he Injury Hub we manage sciatica with specific orthopaedic, hands on therapy. We also know when it’s time to obtain an MRI scan and refer for surgical intervention when needed. Rather than offering multiple treatments prolonging a patients pain and in some instances delaying a surgical referral can lead to long term dysfunction. Our knowledge in this area is unrivalled. 

Deep Gluteal Syndrome refers to various soft tissues and bony architecture of the hip and pelvis that can lead to sciatic symptoms / sciatic nerve compression. 

Deep to the larger buttock muscles is as space which is occupied by various smaller muscles two of which are piriformis and quadratus femoris. Deep Gluteal Syndrome is a relatively underdiagnosed condition characterised by pain with altered sensations in the buttock, hip, and back of the leg.  These presenting symptoms can emanate from the sciatic nerve but, unlike sciatica caused by spinal pathology, deep gluteal syndrome results due to two main conditions.

Piriformis Syndrome

As the sciatic nerve passes through the buttock in some individuals it can pass through a muscle called Piriformis, which on contraction of the muscle can cause irritation of the nerve and hence cause “Sciatic Symptoms” however, this is a rare condition. At the Injury hub we have been fortunate to scan the sciatic nerve on many patients suffering sciatica and rarely do we see piriformis being the sole cause of a patients symptoms. Unfortunately, when patients google their symptoms piriformis tends to come up as one of the main causes of sciatica but this is definitely untrue. If you’ve ever been diagnosed of having piriformis syndrome without MRI imaging we would strongly recommend you take that diagnosis lightly, until proven with specific imaging. 

Ischio-femoral Impingement Syndrome

Another rare condition but this is more likely to cause sciatic nerve irritation compared to piriformis syndrome. Some individuals have a narrowing at the back of the hip due to altered bony architecture this in turn irritates a local muscle called quadratus femoris and if this muscle becomes swollen it can irritate the passing sciatic nerve. 

Other causes of sciatica

• Spinal cord cysts
• Arthritis
• Facet joint cysts
• Spondylolisthesis 
• Spinal cord tumours (very rare)
• Spinal fractures
• Neurogenic claudication

“We’re absolute experts in all of the above and work with the best surgeons. If any of our patients are looking for treatment, rehab or a surgical opinion or a referral we cover it all at the Injury Hub.”