Worldwide, low back pain is one of the commonest causes of disability and work days lost. Commonly pain is a result of spondylitis or degeneration of the lumbar spine.

How do I know that the pain I’m having is back pain?

If the part of your back between the lower part of your chest an the upper part of your hips, also called the lumbar spine, feels sore or stiff, then you are probably suffering from low back pain. Pain can either be in the middle of your back or to one side which might feel like a muscle pull, soreness or stiffness. Back pain usually gets worse with movement like getting out of bed, standing up from sitting or sitting for a long time and gets better with lying down on a firm bed. Back pain can also be a symptom of disease elsewhere, in which case it is called referred pain. Diseases in the kidney, pancreas, and the back of the abdomen can also cause back pain which can be differentiated based on the nature of the pain.

Why do people suffer from back pain?

As part of the evolutionary cycle, when humans adopted the erect posture, a change occurred in the way that body weight was transmitted to the ground. Humans turned biped (two-legged) and so necessarily had to transmit body weight via the spine to the hip joints and the lower limbs. Unfortunately, the lumbar spine did not evolve at the same pace and has become the commonest area of the spine to be subjected to degenerative processes, also known as spondylitis. So taking care of your back by means of proper posture, spine exercises and avoiding strain assumes greater importance because of the evolutionary disadvantage.

Will I need surgery for my back pain?

Although spine surgery in the modern era has become safer and much less risky, primarily due to technological advances and improved anesthesia, most people with back pain do not need surgery. However, there are certain situations in which surgery may become necessary, when the risk of living with the disease is higher than the risk of surgery. These may include situations when there is pressure on the nerve roots arising in your back, which supply the lower limbs, manifesting as pain, weakness or numbness; when there is spinal canal stenosis or narrowing of the area for the nerves leading to pain on walking; compression of the nerve roots causing urinary disturbances; mechanical instability of the bones in the back which may lead to nerve compression in the future. The diagnosis confirmed usually after an MRI scan is done to clearly demonstrate the structures in the back, the area and cause of disease and the severity of nerve compression.

Will I be able to walk and go back to work after spine surgery?

Fallacious rumors about spine surgery abound. Admittedly, there is risk involved in any surgical procedure, but the fear of undergoing spine surgery is often irrational. With modern medical devices, newer modes of monitoring and improved techniques of anesthesia, spine surgery is as safe or risky as any other type of surgery. Moreover, the aim of surgery is to limit the degree and duration of disability. Patients are encouraged to walk on the day after surgery and return to work in about three weeks time. The operative area may remain painful for about a week but walking is still possible. During this time, I advise patients to abstain from bending, lifting weights, traveling by road particularly on two or three wheelers and sitting for prolonged periods. Most importantly, spine surgery is performed to relieve pressure on nerve roots or instability and not to reverse the degenerative changes already existing.

An MRI scan is necessary particularly when there is nerve root compression. The MRI will give your surgeon exact information about the extent and severity of spondylitis and in most cases will help decide the need for surgery.

What could happen if I wish to avoid spine surgery?

Although it is difficult to predict what could happen to an individual case if surgery is denied, medical literature suggests that in the presence of nerve compression with weakness, numbness or bladder disturbances, deferring surgery leads to irreversible changes in the nerves. Importantly, the degree and the duration of nerve compression are important factors in determining the reversibility of nerve damage. If surgery is advised for pain relief alone, it is usually so in the presence of severe radicular pain (leg pain) or pain unrelieved by rest, analgesics and physiotherapy. Surgery may also be advised if there is severe back pain in patients with instability. If surgery is avoided in the presence of a neurological deficit, it is highly likely that the deficit may progress or remain permanent and may not recover depending on the duration of the deficit.

What are the precautions I need to take after surgery and to avoid back problems in general?

Avoiding bending, lifting weights and sitting for prolonged periods in the wrong posture are definitely advisable. Losing weight if you are overweight, staying away from two wheeler and three wheeler rides, stopping smoking and performing relaxation exercises are strongly advised. Using the right type of mattress prevents bad posture when you are asleep. Performing regular exercise particularly spine strengthening exercises will go a long way in ensuring good health for your back.

What is spine fusion surgery and will it be harmful?

Spinal fusion is recommended when there is a condition known as instability, which may occur from a variety of diseases. The spinal column becomes weak and is unable to support the normal body weight. It usually needs to be surgically treated with implants (metallic or other devices that are implanted into the spine to make it rigid) and a bone graft. The outcomes of this surgery are usually excellent.

Unlike low back pain, which most often signifies degenerative disease, neck pain has many causes and varied symptoms. Clinically, neck pain needs more attention and timely investigation and treatment to avoid the possibility of major disability.

What are the causes of neck pain?

Neck pain has many causes. Mot often, the reasons are due to wear and tear of the vertebrae in the neck (the cervical spine). However, there are many other causes of neck pain such as tuberculosis, congenital abnormalities in the spine which can manifest in early adulthood, instability and tumors. Therefore, neck pain needs medical attention early and promptly particularly in a young person. Whereas the lumbar spine is related to nerve roots (small branches of the spinal cord), the cervical spine is in close relation to the spinal cord itself, compression of which can leave the person with serious permanent disability.

When should I start worrying about my neck pain?

Some amount of neck strain is common during our day to day activities. However, if you are suffering from severe, persistent neck pain; pain radiating down your arms and hands; tingling, numbness or weakness of your hands; stiffness of your legs or difficulty in walking; urinary disturbances; headaches, blurred vision or blackouts associated with neck pain then you need to seek a consultation with a neurosurgeon early.

What investigations are required after I see the doctor?

By and large, if your clinical evaluation does not arouse suspicion of a major illness, you will require very few investigations for neck pain. Most often, the investigation ordered would be a simple X-ray of the neck. Sometimes, if there is need to exclude major disease, you may be asked to undergo an MRI, sometimes a CT scan as well and a few important blood tests.

Will I need surgery for my neck pain?

Much of the management of neck pain does not involve surgery. If the neck pain, is due to a relatively benign form of degeneration then rest, use of a cervical collar, physiotherapy and pain medication are all that is required. However, if there is nerve compression, compression of the spinal cord or any process compromising neural function then surgery may become necessary. Often, surgery in the neck is combined with some form of instrumentation as well as bone grafting (from the redundant area of the hip bone) because of the inherent instability of the cervical spine. Surgery may be required from the front of the neck or the back, sometimes both.

Is spine surgery on the neck going to make me paralyzed and unable to do my day to day activities?

By no means! Spine surgery is largely safe and the outcome depends to a large extent on how ambulant and active you are before the surgery. The degree of activity after surgery should improve or remain the same immediately after spine surgery, except for a small interval when post-operative pain may limit mobility.

What long term precautions are necessary for me to stay away from spine disease?

Many of the congenital problems are structural and genetic and cannot be really prevented. Prevention applies mainly to degenerative diseases like spondylitis, which is degeneration of the spine due to wear and tear. Prolonged bending of the neck, vigorous massage, and excessive strain during road journeys, improper neck support while resting and subjecting the neck to heavy impacts are causative factors for spine degeneration. Prevention includes ensuring proper posture during work, avoidance of strain during journeys by providing proper neck support, use of appropriate pillows, and avoidance of smoking will help to prevent progression of disease.

Headaches are a common cause of suffering, but all headaches are not created equal. The main challenge to affording relief from various forms of "cephalgia," or "head pain," is categorizing a headache by type, and then proceeding with the therapy most likely to help.

The International Headache Society’s landmark work on headache classification has allowed important advances in headache study, but is somewhat awkward to use in clinical practice. One practical approach is to first distinguish "urgent" headaches (those that may be life-threatening) from others that may be less urgent, if no less distressing. Identifying "special" headaches (those that may only benefit from specific therapy) is the next step. Finally, if neither of these classifications fit, treatment of tension or migraine headache (the most common) is in order.

Urgent Headaches

Urgent headaches may be immediately life-threatening, and should be treated promptly.

Subarachnoid hemorrhage ("aneurysm")

Patients typically describe a headache related to a leaking aneurysm as a sudden, "thunderclap" headache, often the "worst headache of my life" (an "aneurysm" is a swelling of a blood vessel in the brain). After this sudden onset, the pain may persist at a high or low intensity for days. Abnormal neurological symptoms may occur, including brief loss of consciousness at the onset of the headache, a stiff neck, or eye movement abnormalities.

Such a headache mandates prompt evaluation by a physician, since a missed aneurysmal leak can result in a catastrophic stroke or death. Evaluation typically takes place in an emergency department, and includes a brain computed tomography (CT) scan. A spinal tap (looking for leaked red blood cells) may be necessary to completely rule out the diagnosis. An MRI may be useful, but typically requires neurology or neurosurgery consultation.

The definitive treatment for subarachnoid bleeding is surgery, although calcium channel blocking drugs (nimodipine) may limit damage.

Temporal (giant cell) arteritis

Patients with temporal arteritis (TA, an inflammatory process involving the walls of medium-sized arteries) are usually over age 50. Its symptoms are newly experienced localized headache, scalp tenderness and diminished pulse over the temple area, fevers, and aches. An unusual symptom highly suggestive of TA is "jaw claudication," or cramping of the jaws while chewing.

Blindness (due to involvement of the ophthalmic artery) is a frequent complication, and may be prevented with prompt therapy. Blood tests reveal intense inflammation (with a high "ESR" test), and definitive diagnosis is made by finding inflammation on a biopsy specimen taken from the temporal artery.

Treatment consists of prompt therapy with high-dose corticosteroids (such as prednisone), which should be instituted if the syndrome is suspected (even before definitive biopsy results return.

Bacterial meningitis

Acute bacterial meningitis is a virulent infection, and is typically manifest by an ill-appearance, fever, headache, stiff neck, and photophobia (avoidance of bright light). A rash may be present some forms.

Diagnosis consists of a spinal tap showing white blood cells, chemical tests, and bacteriology studies. Treatment requires prompt antibiotic therapy.

CT scans and MRIs

While a "negative" CT of the brain is reassuring, the cost of imaging every person with headache is prohibitive (up to $3 billion/year in the US). Moreover, a CT scan will find an identifiable cause of headache (blood, tumor) in no more than 0.5 to 2.5% of patients, and most of these patients have abnormal clinical findings. The Table lists indications for CT scan or MRI for headache.

• Findings Suggesting Need For Neuroimaging
• "Worst headache of my life"
• Headache onset after exertion
• Decreased alertness
• Stiff neck
• Abnormal neurological findings
• Decline during observation
• New headache lasting > 2 months in patient 40-60 years old

Special Headaches

Brain tumor

Though a fear for many headache sufferers, brain tumors are uncommon. Indeed, fewer than 20% of patients with brain tumors experience only headache as a symptom (the most frequent symptom is seizure and/or neurological abnormality on exam). Waking with a headache is said to be an important sign of a tumor-related headache, although this occurs frequently in chronic headaches.

Treatment is determined by consultation with a neurosurgeon.

Cluster Headache

Cluster headache commonly affects young- to middle-aged men. It is of short duration (30-90 minutes) and causes headache behind one eye, with eye redness, tearing, and nasal stuffiness on the involved side. Headaches are clustered over time (often separated by weeks to months); in times of headache activity, headaches may occur up to 6 times a day, often causing insomnia.

Diagnosis is based on its classic presentation.

Treatment includes high-dose anti-inflammatory medications (ibuprofen, others). For unknown reasons, over half get relief from breathing 100% oxygen by face mask.

Coital Headache

Coital headache occurs around the time of intercourse, and lasts from minutes to hours, and may be indistinguishable from subarachnoid hemorrhage.

Diagnosis may require CT and spinal tap to rule out subarachnoid hemorrhage.

Sinus Headache

Typically occurring in conjunction with upper respiratory tract infection or allergic rhinitis/sinusitis, sinus headache is usually dull and constant, worse when bending forward, and may be associated with colored nasal discharge.

Diagnosis may be made clinically, by x-rays, or on CT.

Treatment is based on cause (antibiotics if bacterial, antihistamines/decongestants/intranasal steroids if allergic), and are supplemented by interventions to promote drainage (brief course of nasal spray, intranasal saline mist).

Eye Strain Headache

This headache is associated with prolonged reading or staring at a computer screen (but not with astigmatism or refractive errors).

Hormonal Headache

While temporally related to menstrual cycle, menopausal flushing, or hormone use (oral contraceptives), this headache has no distinguishing features otherwise.

Pain tends to diminish cyclically, or after menopause is completed (but only in 1/3 who develop menopausal headaches), or after hormone discontinuation.

Benign Intracranial Hypertension

Also known as "pseudotumor cerebri," this syndrome typically affects young, overweight women on certain medications (oral contraceptives, tetracycline, certain steroids, or vitamin A). The headache itself is nondescript, but exam findings include swelling of the optic nerve, which usually raises the specter of brain tumor.

CT scan looks essentially normal, and a spinal tap reveals high pressure.

Therapy includes corticosteroids.

Post-Traumatic Headache (Concussion)

"Concussion" is defined as loss of consciousness associated with head injury. Symptoms include headache, dizziness, and confusion; long-term symptoms are headache, irritability, fatigue, anxiety, insomnia, memory disturbance, and impaired concentration may persist for up to 18 months.

A CT scan is typically normal.

Treatment involves support with mild analgesia and reassurance.

Migraine With Aura (Classic Migraine)

A typical headache is heralded by an aura (blinking lights with partial vision loss, then sight restoration) followed in 25 to 60 minutes by a throbbing, unilateral headache associated with nausea, vomiting, and photophobia lasting 6-8 hours.

Abortive treatment includes non-steroidal anti-inflammatory medications, anti-nausea medications, ergot derivatives, and other agents; preventive treatment involves various agents.

Common Headaches

While these headaches may have somewhat different causes, their manifestations (and treatment) are similar. Both may be triggered by stress.

Migraine Without Aura (Common Migraine)

Migraine headache tends to be throbbing and one-sided (typically over the temporal area), and precipitated by certain foods, strong smells, or the menstrual cycle (the ratio of female to male sufferers is 3 to 1). The time of day of onset varies.

Diagnosis is based on symptoms and lack of neurological abnormalities.

Treatment is the same as above.

Tension Headache

Often located in a both-sided "hatband" and neck distribution, tension headache is constant, precipitated by stress, has no associated symptoms, and usually occurs later in the day; female to male ratio is 1 to 1.

Diagnosis is by clinical characteristics.

Treatment involves a step-wise approach, beginning with over-the-counter non-steroidal medications or acetaminophen, followed by prescription-strength doses when necessary. Worse headaches may require migraine-type medications, such as Midrin (isometheptene, dichloralphenazone, and acetaminophen). Medications containing caffeine or butalbital are sometimes used (though risk of rebound headache increases). Prophylactic treatments similar to those used for migraine may be useful.

Myth 1

Head injuries need expert treatment and intensive care to ensure a good outcome in victims.

Fact

Although it is true that once a head injury has occurred, especially if the head injury is a severe one, it is best managed by expert neurosurgical and intensive care- it is also true that the best way to manage head injuries by and large is PREVENTION. Once a severe head injury has occurred, many of its effects are immediate and at times, permanent. Prevention in the form of enforcing safe driving habits, use of helmets, use of safety equipment and just being prudent and careful are the best ways to prevent a head injury from occurring at all. Minor injuries by and large do not need intensive care. However, ensuring a good outcome in a severely injured patient is challenging and requires expert intensive care and neurosurgical management.

Myth 2

Once a head injury has occurred it is vitally important to shift the patient to a neurosurgical setup to mange the head injury, no matter how far it is.

Fact

Not true. The first steps in managing a head injury are much the same as for any other injury. Of primary concern are ensuring that the patient has a clear air passage, good breathing and is maintaining adequate circulation of blood. This is often called the ABC of resuscitation (A=airway, B=breathing, C=circulation). Ensuring the ABC prevents some of the most common secondary complications such as low oxygen levels in the blood and low blood pressure, which can be more damaging to the brain than the head injury itself. Trying to shift an injured patient without first administering good first aid will waste precious time. Once the patient is stabilized with respect to the ABC’s, it is important to transport the patient to the nearest trauma facility with multi-speciality involvement, so that the patient can be managed for all his injuries, under one roof.

Myth 3

A CT scan is mandatory in all head injured patients.

Fact

Most minor head injuries, even ones in which the patient has lost consciousness for a short while or does not remember the circumstances of the injury, do not need a CT scan. However, if the patient continues to remain drowsy or has certain other features, a CT scan may be needed. Remember too that a CT scan means exposure to radiation and is not recommended unless it is truly indicated. Also, a CT scan done very early after a head injury may not fully reveal the true extent of the brain injury. Moreover, some injuries may evolve over a period of 1-2 days and a scan done early may give a false sense of security. CT scans are definitely recommended in moderate and severe head injuries.

Myth 4

If a patient regains consciousness after a head injury, it usually means that he is alright, and does not need hospitalization.

Fact

While it is true, in most instances, that patients who regain consciousness after a head injury are usually out of danger, it is also true that a small minority of patients can again lose consciousness after a few hours. For this reason, it is recommended that even patients with minor head injuries should be admitted for observation for a period of 18-24 hours after the injury.

Myth 5

Pillion riders are not at as much risk and need not wear helmets.

Fact

Pillion riders are at the same or higher risk of sustaining a serious head injury than the rider.

Much of the time, in accidents, it is the pillion who suffers the worse injury. Pillion riders are sometimes unaware of an impending accident and cannot take compensatory, evasive action like riders can.

It is extremely important that pillion riders also wear a helmet.