Back Injuries

Back pain is the fifth leading cause for office visits in the United States. Treatment must be based on the cause, and tailored to the patient's health and lifestyle. Medications may decrease inflammation and ease pain. Osteopathic manipulation has been shown to be of benefit in low back pain, and physical therapy may help as well. Surgery is reserved for severe pain or where neurological function is impaired. Back injuries are the most frequent cause of back pain, and have a variety of causes.

Understanding anatomy may help in understanding injury types. The front of the spine consists of round bony structures (vertebral bodies), separated by springy objects (intervertebral disks), which act as shock absorbers for the spine during movement. The disks have a central gelatinous core (nucleus pulposus), surrounded by a tough cartilaginous ring (annulus fibrosis). The posterior spine protects the spinal cord, and also provides a site for attachment of muscles/ligaments. Congenital/developmental injuries occur during the perinatal period; for example, spondylolysis is a bony defect in part of the spine. Spondylolisthesis is anterior slippage of the vertebral body, which can cause nerve root injury.

Sprains or strains from sudden stresses to the back (a fall or heavy lifting) may occur anywhere on the back, causing problems based on the severity of injury. With enough force, the vertebrae may break. Structures surrounding nerves may push on these nerves, causing numbness/tingling of the legs/toes, and if severe, loss of bowel or bladder control. Magnetic resonance imaging (MRI) is the tool of choice to detect disk herniation (protrusion of the nucleus pulposus through the annulus fibrosis) and establish the level of injury, but is reserved for patients not improving with conservative therapy, or those with “red flags,” such as loss of bowel or bladder control, muscle weakness, numbness in the groin or leg, and other worrisome signs and symptoms.

Back injury may result from spread of cancer to the bone (metastasis), which weakens the bone, making it susceptible to fracture. Many types of cancer spread to the spine, and back pain in these patients is usually constant, dull, and unrelieved by rest. MRI and CT-myelography are the studies of choice for metastasis.

Infection of the spine (vertebral osteomyelitis) can lead to back pain and fractures. CT and MRI are sensitive and specific for osteomyelitis, and some blood tests may help determine infection (the white blood cell count) or inflammation (the erythrocyte sedimentation rate).

The most common cause of atraumatic vertebral body injury is postmenopausal osteoporosis, which often leads to compression fractures and can result in severe pain, loss of function, and diminished quality of life, especially in older patients. Studies have shown that regular exercise can slow age-related bone loss and is an effective means of preventing falls. Adequate intake of calcium and vitamin D should be encouraged in all patients at risk for osteoporosis.

Vertebral body fractures can also result from flexion injuries, seen in falls or motor vehicle accidents. [Page 201]If a fracture occurs with minimal trauma or spontaneously, a metabolic cause should be suspected, such as osteoporosis or cancer. The physical exam and radiographic appearance of the fractured vertebra help make the diagnosis.

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