Back Injuries in a Maryland Workers Compensation Claim

What are the different kinds of low back pain?

Eighty percent of adults experience low back pain at some point in their lifetimes. It is the most common cause of job-related disability and missed work days. Low back pain can range from a dull ache to a sharp sensation that leaves the person incapacitated. If the spinal cord is also impacted, back problems might include numbness, tingling, weakness in leg and possibly dysfunction of the bladder or bowels. Pain can begin abruptly as a result of an accident or by lifting something heavy, or it can develop over time due to age-related changes of the spine.

Most low back pain is acute and lasts a few days to a few weeks. It tends to resolve on its own with self-care. Subacute low back pain lasts between 4 and 12 weeks. Chronic back pain persists for 12 weeks or longer.

What causes low back pain?

The vast majority of low back pain is mechanical in nature-meaning the source of the pain may be triggered by the movements of the spine. The moving parts of the spinal column include ligaments, tendons, muscles, intervertebral discs, vertebral bodies, and facet joints. Other times, low back pain is associated with spondylosis, a term that refers to the general degeneration of the spine associated with normal wear and tear that occurs in the joints, discs, and bones of the spine as people get older. Some examples of mechanical causes of low back pain include:

• Sprains and strains account for most acute back pain. Overstretching or tearing ligaments are sprains, and tears in tendon or muscle are strains. Both can occur from twisting or lifting something improperly, lifting something too heavy, or overstretching. Such movements may also trigger spasms in back muscles.
• Intervertebral disc degeneration occurs when the usually rubbery discs lose integrity as a normal process of aging. In a healthy back, intervertebral discs provide height and allow bending, flexion, and torsion of the lower back. As the discs deteriorate, they lose their cushioning ability.
• Herniated or bulging discs can occur when the intervertebral discs become compressed and bulge outward (herniation) or rupture, causing low back pain.
• Radiculopathy is caused by compression, inflammation and/or injury to a spinal nerve root. Pressure on the nerve root results in pain, numbness, or a tingling sensation that travels or radiates to other areas of the body that are served by that nerve. Radiculopathy may occur when spinal stenosis or a herniated or ruptured disc compresses the nerve root.
• Sciatica is a form of radiculopathy caused by compression of the sciatic nerve, the large nerve that travels through the buttocks and extends down the back of the leg. This compression causes shock-like or burning low back pain combined with pain through the buttocks and down one leg, occasionally reaching the foot.
• Spondylolisthesis is caused when a vertebra of the lower spine slips out of place, pinching the nerves exiting the spinal column.
• A traumatic injury, such as from playing sports, car accidents, or a fall at work can injure tendons, ligaments or muscle resulting in low back pain. Traumatic injury may also cause the spine to become overly compressed, which in turn can cause an intervertebral disc to rupture or herniate, exerting pressure on any of the nerves rooted to the spinal cord.
• Spinal stenosisis a narrowing of the spinal column that puts pressure on the spinal cord and nerves that can cause pain or numbness with walking and over time leads to leg weakness and sensory loss.
• Skeletal irregularities include scoliosis, a curvature of the spine that does not usually cause pain until middle age;
• Low back pain is rarely related to serious underlying conditions, but when these conditions do occur, they require immediate medical attention. Serious underlying conditions include:
• Infections can cause pain when they involve the vertebrae, a condition called osteomyelitis; the intervertebral discs, called discitis; or the sacroiliac joints connecting the lower spine to the pelvis, called sacroiliitis.
• Tumorsappear in the back as a result of cancer that has spread from elsewhere in the body.
• Cauda equina syndrome is a serious but rare complication of a ruptured disc. It occurs when disc material is pushed into the spinal canal and compresses the bundle of lumbar and sacral nerve roots, causing loss of bladder and bowel control.
• Abdominal aortic aneurysms occur when the large blood vessel that supplies blood to the abdomen, pelvis, and legs becomes abnormally enlarged.
• Kidney stones can cause sharp pain in the lower back.
• Other underlying conditions that predispose people to low back pain include:
• Inflammatory diseases of the jointssuch as arthritis, including osteoarthritis and rheumatoid arthritis as well as spondylitis, an inflammation of the vertebrae, can also cause low back pain.
• Osteoporosisis a metabolic bone disease marked by a progressive decrease in bone density and strength, which can lead to painful fractures of the vertebrae.
• Endometriosisis the buildup of uterine tissue in places outside the uterus.
• Fibromyalgia, a chronic pain syndrome involving widespread muscle pain and fatigue.

The spine is made up of a column of 33 bones and tissue. These bones enclose and protect nerve tissues known as the spinal cord. Between each one of the vertebra is a disk, cartilage serving as a shock absorber between the vertebrae. The types of vertebrae are:

• Cervical: the seven vertebrae forming the upper part of neck
• Thoracic: the 12 bones between the neck and the lower back
• Lumbar: the five largest and strongest vertebrae located in the lower back between the chest and hips
• The sacrum and coccyx are the bones at the base of the spine. The sacrum is made up of five vertebrae fused together, while the coccyx (tailbone) is formed from four fused vertebrae.
• Tiny nerves known as roots exit the spinal canal through spaces between the vertebrae. The space between these vertebrae is maintained by round, spongy discs of cartilage known as intervertebral discs. Ligaments and tendons also help to hold the vertebrae in place and they attach muscles to the spinal column.

What is the  treatment for back injuries?

Treatment for back injuries depends on the diagnosis, level of pain, and whether there is loss of function or quality of life.

Conservative Treatment

• Cold Therapy reduces inflammation, edema, pain, and muscle spasms associated with acute back injury.
• Heat therapy is used to reduce pain and alleviate sore and stiff muscles.
• Activity: Bed rest should be limited. Individuals should begin stretching exercises and resume normal daily activities as soon as possible, while avoiding movements that aggravate pain. Strong evidence shows that persons who continue their activities without bed rest following onset of low back pain appeared to have better back flexibility than those who rested in bed for a week.
• Strengthening exercises, beyond general daily activities, are not advised for acute low back pain, but may be an effective way to speed recovery from chronic or subacute low back pain. Maintaining and building muscle strength is particularly important for persons with skeletal irregularities. Evidence supports short- and long-term benefits of yoga to ease chronic low back pain.
• Medication: Non-steroidal anti-inflammatory drugs) or acetaminophen can be taken to reduce mild to moderate pain associated with back injuries. NSAIDs are suggested to be more effective for persistent pain than for acute pain. If pain remains intolerable while taking over the counter, a stronger pain medication such as a narcotic or a muscle relaxant can be prescribed at a physician’s discretion. The following are the main types of medications used for low back pain:
• Analgesic medicationsare those specifically designed to relieve pain. They include OTC acetaminophen and aspirin, as well as prescription opioids such as codeine, oxycodone, hydrocodone, and morphine. Opioids should be used only for a short period of time and under a physician’s supervision. People can develop a tolerance to opioids and require increasingly higher dosages to achieve the same effect. Opioids can also be addictive.
• Nonsteroidal anti-inflammatory drugs(NSAIDS) relieve pain and inflammation and include OTC formulations (ibuprofen, and naproxen sodium). Several others, including a type of NSAID called COX-2 inhibitors, are available only by prescription. Long-term use of NSAIDs has been associated with stomach irritation, ulcers, heartburn, diarrhea, fluid retention, and in rare cases, kidney dysfunction and cardiovascular disease. The longer a person uses NSAIDs the more likely they are to develop side effects
• Anticonvulsants—drugs primarily used to treat seizures—may be useful in treating people with radiculopathy and radicular pain.
• Antidepressantssuch as tricyclics and serotonin and norepinephrine reuptake inhibitors have been commonly prescribed for chronic low back pain.
• Creams or sprays applied topically stimulate the nerves in the skin to provide feelings of warmth or cold in order to dull the sensation of pain.
• Therapy and alternative medicine: an active approach to recovery is recommended over bed rest for most cases of back injury. Activity promotes strength and functional rehabilitation and counters atrophy associated with disuse. Physical therapy can help reduce pain and regain strength and function.^[The gentle movement of yoga and tai chi are suggested to improve function and to counter the negative psychological effects that can be secondary to injury.
• Spinal manipulation are approaches in which chiropractors use their hands to mobilize, adjust, massage, or stimulate the spine and the surrounding tissues. The techniques have been shown to provide small to moderate short-term benefits in people with chronic low back pain. Evidence supporting their use for acute or subacute low back pain is generally of low quality. Neither technique is appropriate when a person has an underlying medical cause for the back pain such as osteoporosis, spinal cord compression, or arthritis.
• Biofeedbackis used to treat many acute pain problems, most notably back pain and headache. The therapy involves the attachment of electrodes to the skin and the use of an electromyography machine that allows people to become aware of and self- regulate their breathing, muscle tension, heart rate, and skin temperature. People regulate their response to pain by using relaxation techniques. Evidence is lacking that biofeedback provides a clear benefit for low back pain.
• Acupunctureis moderately effective for chronic low back pain. It involves the insertion of thin needles into precise points throughout the body. Evidence of acupuncture’s benefit for acute low back pain is conflicting and clinical studies continue to investigate its benefits.
• Tractioninvolves the use of weights and pulleys to apply constant or intermittent force to gradually “pull” the skeletal structure into better alignment. Some people experience pain relief while in traction, but that relief is usually temporary. Once traction is released the back pain tends to return. There is no evidence that traction provides any long-term benefits for people with low back pain.
• Injections: Spinal nerve blocks and epidural injections are options available to alleviate pain and neurological symptoms. Injections of anesthetics alleviate pain while steroid injections can be used to reduce the inflammation and swelling surrounding spinal nerves. Epidural steroid injectionsare a commonly used short-term option for treating low back pain and sciatica associated with inflammation. Pain relief associated with the injections, however, tends to be temporary and the injections are not advised for long-term use. An NIH-funded randomized controlled trial assessing the benefit of epidural steroid injections for the treatment of chronic low back pain associated with spinal stenosis showed that long-term outcomes were worse among those people who received the injections compared with those who did not. Nerve block therapies aim to relieve chronic pain by blocking nerve conduction from specific areas of the body. Nerve block approaches range from injections of local anesthetics, botulinum toxin, or steroids into affected soft tissues or joints to more complex nerve root blocks and spinal cord stimulation. The success of a nerve block approach depends on the ability of a practitioner to locate and inject precisely the correct nerve. Chronic use of steroid injections may lead to increased functional impairment.
• Transcutaneous electrical nerve stimulation(TENS) involves wearing a battery-powered device consisting of electrodes placed on the skin over the painful area that generate electrical impulses designed to block incoming pain signals from the peripheral nerves.
• Non-Conservative treatment
• Surgery is considered when symptoms persist after attempting conservative treatment. It is estimated 10-20 percent of individuals with low back pain fail to improve with conservative measures.

Surgical options include:

• Vertebroplasty and kyphoplastyare minimally invasive treatments to repair compression fractures of the vertebrae caused by osteoporosis.
• Spinal laminectomy(also known as spinal decompression) is performed when spinal stenosis causes a narrowing of the spinal canal. During the procedure, the lamina, along with any bone spurs, are removed. The aim of the procedure is to open up the spinal column to remove pressure on the nerves.
• Discectomy may be recommended to remove a disc, in cases where it has herniated and presses on a nerve root or the spinal cord. Microdiscectomy involves removing the herniated disc through a much smaller incision in the back and a more rapid recovery. Laminectomy and discectomy are frequently performed together.
• Foraminotomy is an operation that “cleans out” or enlarges the bony hole (foramen) where a nerve root exits the spinal canal. Bulging discs or joints thickened with age can cause narrowing of the space through which the spinal nerve exits and can press on the nerve.
• Intradiscal electrothermal therapy (IDET)is a treatment for discs that are cracked or bulging as a result of degenerative disc disease. IDET is of questionable benefit.
• Nucleoplasty, also called plasma disc decompression (PDD), is a type of laser surgery that uses radiofrequency energy to treat people with low back pain associated with mildly herniated discs. Under x-ray guidance, a needle is inserted into the disc. A plasma laser device is then inserted into the needle and the tip is heated to 40-70 degrees Celsius, creating a field that vaporizes the tissue in the disc, reducing its size and relieving pressure on the nerves.
• Radiofrequency denervationis a procedure using electrical impulses to interrupt nerve conduction (including the conduction of pain signals). Using x-ray guidance, a needle is inserted into a target area of nerves and a local anesthetic is introduced as a way of confirming the involvement of the nerves in the person’s back pain. Next, the region is heated, resulting in localized destruction of the target nerves. Pain relief associated with the technique is temporary and the evidence supporting this technique is limited.
• Spinal fusion is used to strengthen the spine and prevent painful movements in people with degenerative disc disease or spondylolisthesis (following laminectomy). The spinal disc between two or more vertebrae is removed and the adjacent vertebrae are “fused” by bone grafts and/or metal devices secured by screws. The fusion can be performed through the abdomen, a procedure known as an anterior lumbar interbody fusion, or through the back, called posterior fusion. Spinal fusion may result in some loss of flexibility in the spine and requires a long recovery period to allow the bone grafts to grow and fuse the vertebrae together. Spinal fusion has been associated with an acceleration of disc degeneration at adjacent levels of the spine.
• Artificial disc replacement is considered an alternative to spinal fusion for the treatment of people with severely damaged discs. The procedure involves removal of the disc and its replacement by a synthetic disc that helps restore height and movement between the vertebrae.

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