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Back Pain: Could It Be a Herniated Disc?

It is common for city dwellers to experience back pain, but only a few actively seek treatment. Once back pain occurs, the most important thing is to seek medical advice to alleviate the symptoms and prevent recurrence.

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In addition to adequate rest, back pain can be alleviated with medications, physical therapy, and exercise as conservative treatments. If conservative treatments are ineffective, surgical intervention may be considered to address the root cause.

Identifying the Pain Point: Differential Diagnosis

Clinically, doctors will first identify the patient's pain point, distinguishing whether the pain is located in the muscle distribution area or the sciatic nerve. They will then assess whether the pain is bone-related, muscle-related, disc-related, or caused by nerve compression through a clinical neurological examination. This examination includes assessing muscle strength, pain sensation, tendon and nerve reflexes, and measuring calf circumference to check for muscle atrophy, thereby confirming whether sensory, motor, and tendon nerve reflexes are normal.

If the diagnosis reveals nerve compression, further evaluation is needed to determine which nerve root is affected and to assess the cause. For young patients experiencing sudden unilateral pain, a herniated disc may be suspected (see Figure 1). If pain is accompanied by weight loss, fever, or other symptoms, infection or tumour should be considered, especially in immunocompromised individuals such as those with diabetes or undergoing chemotherapy.

After the interview and neurological tests, patients may undergo X-ray imaging to observe the shape and alignment of the spine, bone integrity, disc height, and the presence of bone spurs or osteoporosis. If the X-ray results align with clinical judgement, medication can be prescribed, and physical therapy can be employed to relieve pain. If further evaluation suggests nerve compression or unclear aetiology of lower back pain, an MRI may be considered for a more precise diagnosis.




Fig.2 (left), fig.3 (right)

Acute Phase Focus: Reducing Inflammation and Pain

Once the cause of lower back pain is determined, doctors will provide treatment based on the patient's needs. In the acute phase, due to severe pain, patients may have difficulty sleeping, working, and their emotional state can affect pain tolerance. Given the inflammatory response in tissues, anti-inflammatory and pain-relief medications can be prescribed to reduce inflammation and pain. As these medications can irritate the gastrointestinal tract, they are typically prescribed for three to four weeks. In addition to medication, patients should rest in bed and adjust their work or posture to reduce lumbar pressure. While some patients find pain relief after taking anti-inflammatory pain medications, improper posture may lead to persistent pain and increase the chance of recurrence.

Besides medication, appropriate physical therapy can also benefit patients with lower back pain. Many patients are familiar with spinal traction devices, which reduce spinal pressure. For example, in patients with spinal stenosis, traction can expand the spinal canal, reducing pressure on nerves and other tissues. Even for those with herniated discs, traction can relieve symptoms by reducing spinal pressure.

Generally, over 90% of patients experience symptom relief with medication and physical therapy, and complete bed rest alone can lead to natural recovery. Only a few patients, who do not respond to medication and physical therapy and suffer from unbearable persistent pain, may require spinal surgery. The larger the area of compressed tissue, or if specific areas are narrow, even a slight disc protrusion can compress nerves, making conservative treatments less effective. In such cases, surgery becomes necessary to relieve severe nerve compression.

Surgical treatments are divided into decompression and stabilisation surgeries. Simply put, these involve removing tissues that compress nerves, including protruding bones or discs. If decompression surgery is expected to cause further spinal instability, stabilisation surgery, using bone screws or plates, is required to secure the spine.

Decompression surgery (see Figure 2) is primarily performed using microsurgery, utilising a surgical microscope. Simple herniated discs can be treated with microsurgery, which involves a small incision of about three to five centimetres, resulting in less postoperative pain. Patients can often get out of bed the day after surgery, or even a few hours later. With experienced spinal neurosurgeons, complications such as nerve damage or paralysis are rare. If necessary, a subsequent fusion procedure using a support frame (see Figure 3) or inserting a titanium artificial disc between two vertebrae can be performed. However, this approach is generally reserved for patients with herniated discs and spinal instability.

Be Cautious with Alternative Therapies

In addition to standard Western medical treatments, many patients seek help from Chinese medicine or alternative therapies. Acupuncture can stimulate points to relieve pain and target inflamed nerve roots. Chiropractic adjustments and manual mobilisation by physiotherapists are also commonly employed.

Regardless of the treatment—be it medication, physical therapy, surgery, or chiropractic care—it is recommended to first seek diagnosis from a spinal neurosurgeon to rule out nerve compression, tumours, or osteoporosis as causes of back pain, to avoid worsening the condition. While these treatments can effectively relieve symptoms, they address only the symptoms, not the underlying causes. Many cases of lower back pain are due to degenerative changes that cannot be halted by any treatment. Long-term relief can only be achieved through exercise to enhance muscle strength and flexibility, combined with correct posture to reduce undue stress on the spine and delay degeneration-induced back pain.

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