So picking up where we left off from our previous article on this topic. By the way, if you haven’t read our last article now would be the time to do so as it covers the basic concepts of the lower back and why it is susceptible to injury. Anyway, as we were saying, injuries of the lower back are in fact a very serious matter, as the lower back plays such a vital role in our daily mobility as human beings. Lower back injuries may present acutely due to a sudden harmful force or significant trauma.
Or it can be a chronic issue that builds up overtime and progressively gets worse. This is usually due to postural issues or imbalances in your biomechanics. Lower back injuries can also show up as common injuries such as sprains or strains of the connective tissues or it can present as something far less common such as ankylosing spondylitis. Now, if you are like most of the general population that went: “Sondy-what?!” after reading that last sentence, then you have come to the right place.
As we will be covering injury types, definitions, signs and symptoms as well as how to go about a diagnosis and acute treatment options.
Common Lower Back Injuries
These are known as “bread and butter” cases in the medical world, not that they're any less significant but because they are so commonly seen that it feels like we encounter these injuries almost everyday. These types of injuries can be both acute and chronic with differing levels of intensity or severity of pain and discomfort.
These common injuries include the following:
Sprains and Strains
These injuries are colloquially defined as “pulling” a muscle, tendon or ligament in the back. This is usually as a result of poor biomechanics when doing a lifting, pulling or twist movement that predominantly involves your lower back. Other causes of sprains and strains within the lower back musculature can be poor posture resulting in detrimental loading patterns and compensations. And finally excessive sudden forces exerted externally on the lower back that exceed the internal stability and strength of the lumbar region. The connective tissue structure gets compromised resulting in the fibers being overstretched. This results in damage to the integrity of the connective tissue fibres.
Just for clarification, sprains occur between connective tissue structures that connect bone to bone like a tendon for example. On the other hand strains occur in structures that predominantly connect bone to muscle tissue this mostly occurs in muscle fibers and the occasionally ligament. Regardless, both can occur at varying ranges of severity and require different levels of intervention.
The most commonly accepted and used classification of strains and sprains is the traditional grading system. In this system sprains and strains are graded on a scale of 1 to 3, where a grade one sprain or strain is regarded as the least problematic usually characterized by some damage to the overall structure of the tissue. Contrastingly, a grade 3 sprain or strain is characterized as the complete rupture of the connective tissue fibers. While a second degree or grade 2 sprain or strain falls somewhere in between these two classifications and it usually ranges between being moderately severe tear within the fibers to a borderline rupture of the fibers.
The extent of the injury and the ultimate classification will determine the exact protocol needed for treatment and rehabilitation. But more on this a bit later in the series.
Signs and Symptoms of Strains and Sprains
The most common symptom you usually expect to see with this type of lower back injury is a popping sensation experienced at the moment of injury. This is characterized as the moment the connective tissue was pulled or stretched too far and micro or macro tears occur within the fibers. Other symptoms include:
Herniated or Bulging Vertebral Discs
Your vertebral discs or rather intervertebral discs, form your vertebral column. This column’s main function is to protect our spinal cord and its affiliated structures. These individual discs are made up of a harder, more rigid and thicker outer layer known as your annulus fibrosus. And then there is the more gelatin-like inner core known as the nucleus-pulposus. The main purpose of these discs is to absorb force so think of a car’s shock absorber, a simple concept yes, but they pretty much share the same basic functioning.
Okay, yes the Latin might be making your head spin but my first year anatomy lecturer had a very cool way of or rather a cool analogy to make it all a little less confusing. She used to describe intervertebral discs as jam donuts. Or jelly donuts if you're residing in the United States. The cartilage annulus is the outside of the donut that maintains a solid outer ring, while the nucleus is the soft gooey centre filled with fluid that can absorb pressure applied from both the top and the bottom of the “donut”. This liquid is known as cerebrospinal fluid and it acts like the spinal cord’s own hydraulic fluid absorbing forces and protecting the fragile structures within the spinal canal.
Now regarding the jam donut analogy, we have all had that moment when the excitement to take a bite out of said jam donut is so big that we bite and squeeze simultaneously resulting in the jam squirting out the back or sides of the donuts. I am pretty sure most of us have had this devastating experience happen resulting in the loss of a very special donut. Okay, that’s overdramatic, but you get the just of what I am trying to say, right? Now this is exactly what happens to our intervertebral discs when an excessive external force or forces are placed on the vertebral column. The integrity of the discs gets compromised, a fracture or a break occurs and the cerebrospinal fluid starts to leak out of a disc, resulting in a bulge or a herniation.
The cerebrospinal fluid leak usually causes inflammation and or irritation of the surrounding structures.
Now just like the sprains and strains of the lower back, disc herniations range in severity and will be treated based on multiple factors.
Signs and Symptoms of Herniated Discs
This type of injury usually has a much more of a neurological set of symptoms. This is because the surrounding nerves are more often than not the most affected tissues by disc herniation. Symptoms include:
However, that being said in some cases disc herniation presents asymptomatically and more often than not a patient will go about his or her daily life without knowing that they have the injury.
Vertebral Fractures
Vertebral fractures more often than not present as compression fractures. A crushing vertical force such as a fall, causes the bony vertebra to crack or even in some severe cases disintegrate, but that usually only happens in some rare and extremely traumatic cases.
The underlying cause of fractures of this nature is more often than not weakness of the bone caused by aging, osteoarthritis or osteoporosis.
Signs and Symptoms of Vertebral Fractures
Vertebral fractures present symptoms that are far more “straightforward”. And this is because fractures tend to follow the same symptomatic patterns. The most significant symptom is acute and or chronic pain. In some cases the pain can be very severe, usually as a result of a traumatic fracture.
However, what remains unique to vertebral fractures that doesn’t often present in fractures in other areas of the human body, is that vertebral fractures can significantly affect your height and posture. Resulting in a loss of height and or developing a hunched over posture.
This is a general overview of the more common lower back injuries, their pathophysiology and how they present with regards to specific signs and symptoms. Please note that it doesn’t always present in this fashion as every injury is unique to the patient's specific anatomy and biomechanics.
The Uncommon Lower Back Injuries
Now in some instances a patient presents with a unique set of symptoms that doesn’t necessarily fit the mould of any of the more common injuries of the lower back. These injuries usually require a more thorough investigation process to diagnose and present with a different prognosis than the common injuries. These injuries can become very technical and very rare so for the sake of continuity we are going to take a look at the two most common-uncommon lower back injuries… Yes, we know that makes for difficult reading but bear with us, we're after all trying to convert extremely technical concepts into layman's terms.
The two categories of injuries we will be covering are:
Now we must admit, these types of injuries are becoming more common especially given the fact that the diagnostic tools have significantly improved and the research surrounding these conditions is getting updated on a yearly basis. However, these two injuries are not classified as bread and butter cases making them less common than the list of injuries we mentioned earlier in this article. Make sense?
But as we were saying, radiculopathy or radiculopathies is defined as the irritation or damage of nerves and or nerve function. This usually occurs in and around the entry and exit points of the nerves of the spinal cord within the vertebral column. More often than not this type of injury is caused by some form of compression experienced along the vertebral column. This compression can lead to actual damage of a or in some cases, multiple spinal nerves.
Other causes of radiculopathies include:
Signs and Symptoms of Radiculopathies
We do believe it’s helpful to note that radiculopathies may present a myriad of signs and symptoms. This is because the condition affects the nerves of the spinal cord directly. So the specific symptoms will all depend on what level of the spinal column is affected and how that relates to the over central nervous system.
Spondylolisthesis is much more brute in it’s presentation, this condition is simply characterized as an underlying defect within a vertebra that leads to said vertebra slipping out of place. This condition mostly occurs within the lumbar region at the base of the spine. This slipping of the vertebra can present anteriorly (forward), posteriorly (backward) or laterally (sideways).
This may be the result of a congenital defect that has presented from birth, or due to some form of acute or chronic trauma that exerted stress on the vertebral column. In very rare cases, infection or systemic disease could cause weakness in the vertebra leading to a form of spondylolysis.
Signs and Symptoms of Spondylolisthesis
As you can see both radiculopathies and spondylolisthesis share significant overlap with strains, sprains, herniated discs and fractured vertebra. The ability to distinguish between these common and lesser common injuries of the lower back relies on accurate diagnostic tools. Being able to distinguish and differentiate between these categories of injuries will significantly affect the odds of successful recovery.
How Lower Back Injuries are Diagnosed
The gold standard for diagnosing most lower back injuries remains imaging. This ranges from traditional x-rays, CT scans, sonar scans and MRI’s. Unfortunately, not everyone can afford or have access to these diagnostic tools, for that reason doctors and physical therapists have, through extensive research, developed a bunch of special diagnostic tests that can be performed to “confirm” certain injuries. However, we’re not going to get into these tests because they lack sufficient efficacy and accuracy. Not to mention that most of the tests require extensive knowledge of anatomy with some clinical experience. Ultimately, a combination of the two diagnostic methods would be the ideal situation to cover all your bases.
Final Thoughts
The fact remains that there is significant overlap between injuries of the lower back. Overlap of signs and symptoms and mechanisms of injury. Being able to distinguish and differentiate between these categories of injuries will significantly affect the odds of successful recovery. With regard to the prognosis of lower back injuries both common and uncommon, follows a similar pattern to most orthopaedic injuries but does have a few unique aspects that we need to consider. That being said, this will be covered in our next piece of this series.
