A bluffer’s guide to back problems

Common back pain — the kind doctors refer to as non specific low back pain — is predominantly a middle aged curse, striking between the ages of 35 and 45, and sometimes (more frequently in women) between 55 and 60. As we age, it tends to diminish, though it can unfairly persist into those supposedly golden years. Unfortunately, there are a number of other back woes that may surface as we age, including spinal stenosis, DISH (see below) and osteoporosis. Here’s a rundown:

Bulging disc: As we age, the gel like nucleus of a disc may dry out. Without its shock absorbing elasticity, the disc flattens, causing the annulus, the tough outer casing of the disc, to bulge which it’s designed to do as part of weight bearing. However, if it distends too far, the disc may brush against a nerve root or ligament, causing pain.

Herniated disc: If the annulus weakens before the disc’s nucleus dries out, the pressure from the nucleus may cause the annulus to fray, or even blow, like an overinflated tire, so that some of the nucleus’s gel seeps out. The process is actually fairly rare, affecting no more than one or two out of 100 people with back pain.

Sequestered disc:&t;B> In some cases, a bit of the nucleus oozes out of a herniated disc, breaks away and drifts up against a nerve root again, causing pain.

Degenerated disc: All discs degenerate to some extent; x ray studies have shown that 85 to 95 per cent of 50 year olds with absolutely no back pain nevertheless show evidence of disc degeneration; a disc is usually labelled degenerate because it’s considered old for the age of the individual. As a disc degenerates, it loses thickness, which may stimulate the growth of osteophytes bony growths that can be harmless or painful, depending on whether they rub against nerves and other soft tissue.

Facet joint pain: Facet joints are neatly aligned in a normally healthy back, but if there’s a change, such as a degenerative disc causing a joint space to narrow, the facet joints can be thrown out of alignment. Thereafter, during any normal motion, the two sides of the joint rub against one another improperly, leading to a slow erosion of cartilage and, eventually, pain.

Spinal stenosis: There are two basic forms of spinal stenosis (stenosis means "narrowing"): central and lateral. In central spinal stenosis, the spinal canal is either congenitally narrow or constricted by bony encroachments with age. With lateral spinal stenosis, the intervertebral foramen at the back of the vertebrae narrows, usually as a result of osteophyte encroachment, again, due to age. As Judylaine Fine points out in The Ultimate Back Book, it can also be caused by "an injury, severe settling of the facet joints due to a disc that has lost an abnormally large amount of height, spondylolisthesis (see below)… or an abnormal variation in the shape of a vertebra." Spinal stenosis may be painless unless a nerve root in the foramen is being pinched in which case the pain can be severe.

Spondylolisthesis is a condition in which one vertebra slips over another. As Dr. Hall explains in The New Back Doctor, it can happen "for any one of five reasons: a defect within the interlocking joint system at the back of the spine… [spondylolysis; see below], a congenital abnormality in the design of a facet joint; an advanced case of wear in a set of facet joints; a major trauma; or a bone ailment, such as Paget’s disease, which changes the shape of the bone." In severe cases, surgery may be required to arrest the pain; otherwise, it’s usually treated much as other common forms of backache.

Spondylolysis is a defect in the posterior, or back, of a vertebra, which is thought to result from an early childhood fracture that fails to properly heal. The result, Hall writes, "is an abnormal separation between the upper and lower sets of vertebral joints. Intermittent back pain is the typical symptom."

Other back disorders

The back can also fall victim to other complex and often serious conditions, including primary or secondary cancer, which can take root in the vertebrae, bone marrow or soft tissue just as it does elsewhere in the body. Treatment is also similar to elsewhere in the body, including surgery (where possible), radiation and/or chemotherapy.

Many forms of arthritis and arthritis related disorders can affect the spine. Osteomyelitis, for instance, is a bacterial infection affecting bone; it’s treated with antibiotic drugs.

Rheumatoid arthritis (RA), an immune system disorder and arguably the most serious form of the disease sometimes attacks the bones and joints of the spine; it’s treated with anti inflammatory and disease modifying drugs, as well as analgesics, exercise and lifestyle changes. Ankylosing spondylitis, one of the rare forms of arthritis to predominantly affect men, can cause pain and disability and lead to components of the spine literally fusing together. It’s treated with many of the same interventions as RA.

Scoliosis is a lateral "S" curvature of the spine that chiefly affects adolescents, mainly girls; if the curve isn’t severe and doesn’t appear to be progressing, it’s often simply ignored, since it may not cause the child any discomfort or further problems.

More severe cases are treated with braces, exercise and, occasionally, surgery.

Spondylitis simply refers to a condition of inflammation (itis) in the spine (spondylo) as the result of an inflammatory form of arthritis, such as RA or lupus, or an infection, as in osteomyelitis or, more rarely, as a reaction to a chemical irritant.

Osteoarthritis (OA): Most of us will develop at least a touch of OA as we age. In fact, the vast majority of people over 50 will have asymptomatic OA of the spine, otherwise known as lumbar spondylosis, involving the facet joints and the intervertebral joints; the bony osteophytes that play a role in spinal sclerosis result from OA, as well. In other words, most of us will show degenerative change to the bone and joints of our spines on x rays, whether or not we feel any pain or discomfort from those changes; those who are affected may experience pain, stiffness and decreased flexibility in the back and neck. Treatment aims to reduce pain, increase flexibility and maximize joint function through a combination of analgesic and sometimes anti inflammatory drugs, non medicinal pain relief strategies, exercise and, where appropriate, weight loss.

DISH is an acronym for Diffuse (widespread) Idiopathic (cause unknown) Skeletal Hyperostosis (increased bone growth). DISH was only identified as a distinct disorder by Vancouver rheumatologist Dr. John Esdaile in 1975, but it’s now thought to be the second most common form of arthritis after osteoarthritis (OA); it may affect as much as 10 per cent of the elderly population, and it’s capable of causing significant disability. Its chief characteristics are bony outgrowths on the spine and often severe pain. DISH patients may have arm, neck and heel pain, tennis elbow, knee cap problems, difficulty swallowing, nerve abnormalities and reduced joint flexibility. It can affect people in their 30s, thought it’s most common in people over 70, especially elderly, overweight people with diabetes.

DISH is another form of arthritis to affect more men than women. The pain it causes is different from mechanical low back pain: It tends to be on the right side and may fluctuate between extreme pain and no pain at all. Diagnosis is made with the aid of a thoracic spine or chest x ray; treatment generally consists of anti inflammatory drugs and a specific exercise routine.

Osteoporosis (OP) is a progressive disease of the skeleton that results in loss of bone mass, leaving them weak and prone to fractures. In fact, some doctors argue that osteoporosis is merely a risk factor; the real disease is fracture the most frequent kind being compression fractures of the spine.

The disease is caused by an imbalance in the body’s bone rebuilding cycle, which affects everyone eventually, though women sooner and in far greater numbers than men: One in four women over 50 has osteoporosis, whereas in men, bone loss only begins to become statistically significant after age 65. Treatment includes diet, exercise and medication, as well as estrogen replacement therapy for women.