Many times, throughout our day here at Lenchig Spine and Pain Institute we will inevitably hear a question that goes along these lines, “I already had the shots, why does my back still hurt?” or “The pain in my lower back is gone, but I’m still having pain in my legs.” In other words, they had an injection with some degree of improvement, but they still have pain elsewhere or “different” pain in the same place. Let’s look into why this might be happening and how it could affect you.
Our spine is composed of about *24 individual bones called VERTEBRAE, and about 10 more vertebrae that are fused together in the sacrum and coccyx. They are stacked on top of each other. It gives us both rigidity and flexibility while also protecting our spinal cord. We divide it into 5 sections: Cervical with 7 vertebras, Thoracic with 12 vertebras, Lumbar with 5 vertebras and Sacrum and Coccyx region usually with 5 fused vertebras each. Muscles, tendons, and ligaments hold it together and help us maintain an erect posture.
Problems with the spine can arise from misalignment of the vertebrae (kyphosis, scoliosis, or spondylolisthesis) or structural problems of the actual vertebrae (Stenosis, Osteophytes, Compression Fractures) As well as problems with the muscles and ligaments and other soft tissues of the spine (Herniated Disc, Degenerative disc disease, calcification, etc.). These problems result in either limited flexibility or instability due to too much flexibility. To make things even more complicated, these can present in conjunction, and the presence of one does not necessarily rule out another. In other words, you can have a patient that has all these problems going on with their spine at the same time.
The vertebral column houses and protects the spinal cord within it and the spinal nerves that branch out form it. Many of the problems that cause back pain due to changes in the spatial relationship between the nerves and vertebrae,
Let’s look at these images so you can begin to see how a vertebra is shaped, and how this shape interlocks with the one above and the one below it.
As was previously mentioned many of the problems that result in pain are due to a change in the spatial relationship between the nerves of your spinal cord and the bone and ligaments of the vertebra. This refers to the space between them. For the most part it is a reduction of this space that ends up causing problems. This reduction can come about in several ways.
For example, in spondylolisthesis one vertebra is displaced forward from its regular position resulting in a stretching and compression of the space occupied by the spinal cord.
In this conceptual sketch you can see how the stacked column is displaced.
In this model seen from the side you can see what happens to the space where the spinal cord would be, its displaced forward thus stretching and compressing the spinal cord. Typically, a patient affected with this would feel generalized pain in the areas innervated at or below this point.
Other conditions such as Spinal Stenosis (Stenosis Definition: the abnormal narrowing of a passage in the body) also reduce the space for the nerves but not necessarily because of mechanical displacement like we saw with spondylolisthesis but by bone growth around the FORAMEN (which are the circular or oval spaces formed by bones through which nerves or blood vessels pass through). Abnormal bone growth like that caused by OSTEOARTHRITIS can reduce the space available in the spinal canal affecting the spinal cord or it can attack the pedicles and reduce the size of the foramen formed between vertebras, compressing the nerve roots and causing distinct left vs right side pain.
Back pain can also originate from problems of the vertebral body, the most common being compression fractures. You can picture the vertebral body as shaped like a tuna can or hockey puck. A compression fracture changes this shape into a wedge and compromises the spines structural integrity.
This disc between the vertebra can also cause pain in several ways such as degenerative changes that are common with aging like desiccation and annular tears, that result in lost height of the disc and reduced space for the nerve like that shown in the previous examples for spondylolisthesis and stenosis. Most of us have heard about Disc Herniation, this happens when a disc is compressed and its contents project outwards from the center and into the spinal canal or foramen and compress the nerves.
Another spot on the Vertebra that can cause pain are the facet joints. This is what keeps the spine aligned when bending forwards or backwards (tying your shoe) and limits your side-to-side flexion (picking up a bucket) as well as torsion (reaching for something in the back seat of your car). The smooth flat articular surfaces of the facets help it slide on top of the one below it while its shape make it act like a sort of guide rail or canal. When conditions such as Osteoarthritis affect the joint, they can change the shape of a smooth surface into a rough one or it can form Osteophytes which are irregular bony growths that can fuse the vertebrae together or otherwise impede movement.
These are just some of the most common sources of back pain along with some very generalized explanations of the mechanics and pathology of each part. As you can see, each part of each individual vertebra on its own can cause or present problems that result in pain. Now multiply that by the number of vertebras in your spine and you can begin to see why there is an entire subspecialty in medicine that deals with back pain.
Treating back pain is not always a straightforward process that gets you from point A to point B, as you have seen in the previous texts there are many causes of pain that can also present in combination. We hope this helps clear up some questions you might have and as always, we are available to help you with any questions you might have. You can contact the office at 954-493-5048 or email me at firstname.lastname@example.org
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