Disease of the month: Backache

Back pain is a common condition and is the largest cause of work related absence in the UK. Fergus Bescoby investigates

Second only to the common cold, back pain accounts for almost seven million GP visits per annum and estimated annual costs to the NHS of around £481 million. In addition to this, a further £197 million per annum is spent on non NHS costs such as private consultations and prescriptions.

Back pain, and in particular, low back pain account for a large proportion of both long-term disability and long-term income protection claims. It is difficult to diagnose and to treat and there are no specific tests to verify that the pain is genuine and disabling. With this in mind then it is not surprising that the insurance industry take a fairly conservative approach to this condition.

What is the function of the lower back?

The lower back, or lumbar area, serves a number of important functions for the human body. These functions include structural support for the majority of the body’s weight, movement, and protection of certain body tissues.

It would not be presumptuous to assume that the incidence rates will increase significantly in forthcoming years due to the overall population becoming increasingly obese.

When we stand, the lower back is functioning to support the weight of the upper body. When we bend, extend, or rotate at the waist, the lower back is involved in the movement. Therefore, injury to the structures important for weight bearing, such as the bony spine, muscles, tendons, and ligaments, often can be detected when the body is standing erect or used in various movements.

Protecting the soft tissues of the nervous system and spinal cord, as well as nearby organs of the pelvis and abdomen, is a critical function of the lumbar spine and its adjacent muscles.

Common causes of lower back pain

These include lumbar strain, nerve irritation, lumbar radiculopathy bony encroachment and certain conditions of the bone and joints (see individual boxes).

How is low back pain treated?

Long periods of inactivity in bed are no longer promoted, as this treatment may actually slow recovery. Spinal manipulation for periods of up to one month has been found to be helpful in some patients who do not have signs of nerve irritation. Future injury is avoided by using back-protection techniques during activities and support devices as needed at home or work.

As mentioned above, treatment very much depends on the precise cause of the low back pain and each patient must be individually evaluated and managed in the context of the underlying background health status and activity level.

A very important aspect of the individual evaluation is the patient’s own perception of their particular situation. British researchers found that those who believed that their symptoms had serious consequences on their lives and that they had, or treatments had, little control over their symptoms were more likely to have a poor outcome. This research points out to physicians the importance of addressing the concerns and perceptions that patients have about their condition during the initial evaluations.

Underwriting considerations

It is imperative to take the insured’s occupation into account at underwriting stage as certain occupations will be more of a risk than others. In some cases, individuals might become permanently disabled for heavy physical occupations or those that require a specific posture applying pressure to the back (for example, a dental surgeon).

The underwriter must also take into account the client’s age, when the back problems started, when the most recent symptoms were and whether surgery has taken place or is contemplated in the future. Details of time spent off work due to back problems will also help to create a better picture of the risk.

Generally speaking if the symptoms have been within three years and appear to be ongoing, the back will be excluded from any TPD or IPC benefit. The actual exclusion will depend on how much information is available regarding the back problem but more often than not a general back exclusion will be applied.

Lumbar strain (acute, chronic)

A lumbar strain is a stretch injury to the ligaments, tendons, and/or muscles of the lower back. The stretching incident results in microscopic tears of varying degrees in these tissues. Lumbar strain is considered one of the most common causes of low back pain. The injury can occur because of overuse, improper use, or trauma. Soft-tissue injury is commonly classified as ‘acute’ if it has been present for days to weeks. If the strain lasts longer than three months, it is referred to as ‘chronic’.

Lumbar strain most often occurs in people in their forties, but it can happen at any age. The condition is characterised by localised discomfort in the lower back area with onset after an event that mechanically stressed the lumbar tissues. The severity of the injury ranges from mild to severe, depending on the degree of strain and resulting spasm of the muscles of the low back.

The diagnosis of lumbar strain is based on the history of injury, the location of the pain, and exclusion of nervous system injury. Usually, X-ray testing is only helpful to exclude bone abnormalities.

The treatment of lumbar strain consists of resting the back (to avoid reinjury), medications to relieve pain and muscle spasm, local heat applications, massage, and eventual (after the acute episode resolves) reconditioning exercises to strengthen the lower back and abdominal muscles.

Nerve irritation

The nerves of the lumbar spine can be irritated by mechanical impingement or disease anywhere along their paths – from their roots at the spinal cord to the skin surface. These conditions include lumbar disc disease, bony encroachment, and inflammation of the nerves caused by a viral infection.

Lumbar radiculopathy

Lumbar radiculopathy is nerve irritation that is caused by damage to the discs between the vertebrae. Damage to the disc occurs because of degeneration (‘wear and tear’) of the outer ring of the disc, traumatic injury, or both. As a result, the central softer portion of the disc can rupture (herniate) through the outer ring of the disc and abut the spinal cord or its nerves as they exit the bony spinal column. This rupture is what causes the commonly recognised ‘sciatica’ pain that shoots down the leg. Sciatica can be preceded by a history of localised low-back aching or it can follow a ‘popping’ sensation, and be accompanied by numbness and tingling. The pain commonly increases with movements at the waist and can increase with coughing or sneezing. In more severe instances, sciatica can be accompanied by incontinence of the bladder and/or bowels.

Lumbar radiculopathy is suspected to be based on the above symptoms and increased radiating pain when the lower extremity is lifted supports the diagnosis. Nerve testing (EMG/electromyogram and NCV/nerve conduction velocity) of the lower extremities can be used to detect nerve irritation. The actual disc herniation can be detected with imaging tests, such as CAT or MRII scanning.

Treatment ranges from medical management to surgery. Medical management includes patient education, medications to relieve pain and muscle spasms, cortisone injections around the spinal cord (epidural injection), physical therapy (heat, massage, ultrasound, electrical stimulation), and rest (not strict bed rest, but avoiding reinjury). With unrelenting pain, severe impairment of function, or incontinence (which can indicate spinal cord irritation), surgery may be necessary. The operation performed depends on the overall status of the spine and the age and health of the patient. Procedures include removal of the herniated disc with laminotomy (a small hole in the bone of the lumbar spine surrounding the spinal cord), laminectomy (removal of the bony wall), by needle technique (percutaneous discectomy), disc-dissolving procedures (chemonucleolysis), and others.

Other causes of lower back pain
Kidney problems

Traumatic bleeding of the kidney (hematoma) are frequently associated with low back pain. Diagnosis can involve urine analysis, sound-wave tests, or imaging studies of the abdomen.

Pregnancy

Pregnancy commonly leads to low back pain by mechanically stressing the lumbar spine (changing the normal lumbar curvature) and by the positioning of the baby inside of the abdomen. Additionally, the effects of the female hormone estrogen and the ligament-loosening hormone relaxin may contribute to loosening of the ligaments and structures of the back.

Ovary problems

Ovarian cysts, uterine fibroids, and endometriosis frequently cause low back pain. Precise diagnosis can require gynecologic examination and testing.

Tumours

Low back pain can be caused by tumors, either benign or malignant, that originate in the bone of the spine or pelvis and spinal cord (primary tumors) and those which originate elsewhere and spread to these areas (metastatic tumors). Symptoms range from localised pain to radiating severe pain and loss of nerve and muscle function (even incontinence) depending on whether or not the tumours affect the nervous tissue. Tumours of these areas are detected using imaging tests, such as plain X-rays, nuclear bone scanning, and CAT and MRI scanning.

Fergus Bescoby is underwriting development manager at PruProtect