Acute and chronic low back pain is an enormous world-wide problem and is a burden not only on the patient but also society and the economy in lost employment.

The burden of backache on society in the USA is greater than the combined burden of diabetes, hypertension, heart disease and cancer.

Abnormalities in the spine may cause local discomfort in the neck, and back as well as pain spreading into the arm, the chest or leg. The local pain is usually due to a problem affecting the structure of the spine and muscles, while the spreading pain into the arm or leg may be due to pressure on the nerves leaving the spine.  That spreading pain is known as a radiculopathy. The radiculopathy passing into the leg is known as sciatica.

There are many causes of local spine pain and the spreading nerve pain. By far the commonest cause of this discomfort are the natural aging processes that occur in the spine. For some that “aging process” or degenerative change may commence early in life. Lumbar and cervical disc protrusions are part of this degenerative change and often occur in young adults. The degenerative changes in the spine go under the broad term of spondylosis.

Diagnosing Spine Problems

Not every person with a painful back suffers from cervical or lumbar spondylosis.  There are many other causes of local back pain and radiculopathy. The many other causes of discomfort should not be ignored when assessing a patient with back pain.  The first responsibility to a person presenting with spine pain is to establish an accurate diagnosis.

A diagnosis can usually be reached by paying attention to the patient’s general health, recent and past life activities, a thorough physical examination and  appropriate x-rays of the spine.  An MRI of the affected region of the spine will often clinch the clinical diagnosis. MRI examination is an essential part of any preoperative assessment of the spine and gives guidance to the surgeon when considering the nature of surgery that is to be performed.

The What and When of Spine Surgery

The comments below are directed at spondylosis and lumbar disc protrusion; these conditions account for the vast majority of spine symptoms.  Other forms of spine disease deserve their own special attention which is beyond the scope of this short account of the problem.

Many patients do not require any surgical intervention and get over their current difficulty with conservative treatment.

Conservative therapy includes rest, an alteration in life activities, appropriate pain and anti-inflammatory medication and time to recover.

Some patients will try various forms physical therapy such as physiotherapy, pilates exercises and various forms of manipulation. These forms of treatment have had their vogue and are still popular. They may or may not be beneficial.

Thus, while there is some evidence for the effectiveness of pilates for low back pain, there is no conclusive evidence that it is superior to other forms of exercises. The decision to use pilates for low back pain may be based on the patient's or care provider's preferences, and costs.

SMT produces similar effects to recommended therapies for chronic low back pain, whereas SMT seems to be better than non-recommended interventions for improvement in function in the short term. Clinicians should inform their patients of the potential risks of adverse events associated with SMT.

When conservative treatment has failed, surgery to the spine may be an option.

Surgery is seldom required as an urgent matter. The exception to this would be evidence of a disturbance in bladder or bowel control that is due to a disturbance to the nerves in the low lumbar spine, the cauda equina syndrome.

Surgical options vary according to the specific diagnosis that has been established. Different spine surgeons may adopt differing attitudes towards the need for surgery. Some surgeons tend to adopt a very conservative approach to operating while others may find themselves advising surgery sooner and more often. Surgery may be a life-changing event for the good when well indicated and well done, as it very often is.  Yet it may also be a life-changing event for the worse despite the best intensions of the surgeon.