Spinal & Back Pain Guide

From Symptoms to Specialist Care

Back and neck pain affects most people at some point. The great majority resolve with time and conservative management — but some conditions require specialist evaluation, and a few require urgent intervention.

1. Understanding Your Spine

The spine has 33 vertebrae across five regions:

• Cervical (C1–C7): The neck. Supports the head; nerve roots supply the arms.
• Thoracic (T1–T12): Mid-back, attached to the rib cage. Stable; less commonly affected by disc disease.
• Lumbar (L1–L5): Lower back. Carries the most weight; most common site of disc herniations.
• Sacral/coccygeal: Fused vertebrae forming the tailbone.

Intervertebral discs act as shock absorbers between vertebrae. Facet joints provide stability. Nerve roots exit at each level, supplying the arms and legs.

2. Common Conditions

• Herniated disc: Inner disc gel ruptures through the outer ring, pressing on a nerve root.
• Spinal stenosis: Narrowing of the spinal canal from disc degeneration, thickened ligaments, and facet arthritis.
• Spondylolisthesis: One vertebra slips forward over the one below — degenerative, isthmic, or traumatic.
• Spondylosis: Age-related disc and facet wear with bone spurs and disc space narrowing.
• Spinal tumours: Primary or metastatic. Cause progressive pain, neurological deficit, or instability.
• Vertebral fractures: Significant trauma or, in osteoporotic patients, minimal injury.

3. Mechanical vs Neurological Pain

Mechanical back pain:

• Localised to back or neck, no limb radiation
• Worse with movement, better with rest
• No weakness, numbness, or bowel/bladder symptoms
• Accounts for over 90% of back pain

Neurological back pain:

• Radiates into the arm (cervical) or leg (lumbar), following nerve distributions
• Associated with numbness, tingling, or weakness
• Suggests nerve root compression (radiculopathy) or spinal cord involvement (myelopathy)

Myelopathy — spinal cord compression, most common in the cervical spine — presents as clumsy hands, unsteady gait, and in advanced cases, bladder dysfunction. Requires prompt specialist assessment.

4. Red Flag Symptoms

Seek emergency care for:

• Cauda equina syndrome: Sudden bilateral leg weakness, saddle numbness (inner thighs, perineum), and loss of bladder or bowel control. Neurosurgical emergency — go to A&E immediately.
• Progressive myelopathy: Worsening hand clumsiness, balance problems, or bladder urgency.
• Possible spinal tumour: Constant pain, worse at night, at rest, with weight loss, or in a patient with known cancer.
• Vertebral fracture: Severe pain after trauma in elderly or osteoporotic patients.
• Fever with back pain: Possible spinal infection (discitis, epidural abscess) — progresses rapidly.

5. Investigations

• MRI spine: Investigation of choice for disc disease, stenosis, tumours, infection, myelopathy.
• CT spine: Best for bony detail — fractures, bony stenosis. Used after trauma or when MRI is contraindicated.
• X-rays: Spinal alignment, vertebral height, gross instability. Dynamic views identify abnormal movement.
• EMG/NCS: Confirms radiculopathy, identifies affected level, distinguishes spinal from peripheral nerve problems.

6. Conservative Management

First-line for most back and neck pain:

• Physiotherapy: Core strengthening, spinal mobility, posture. More effective than rest alone.
• Analgesia: Paracetamol, NSAIDs for pain control. Neuropathic agents (gabapentin, amitriptyline) for radicular pain.
• Activity modification: Stay active. Prolonged bed rest is not recommended and slows recovery.
• Education: Most disc herniations resolve over 6–12 weeks with the body’s own resorption process.

7. Interventional Options

For pain persisting despite conservative management:

• Epidural steroid injection (ESI): Steroid into the epidural space to reduce nerve root inflammation.
• Selective nerve root block: More targeted than ESI — medication directly to the affected level.
• Facet joint injections / radiofrequency ablation (RFA): For mechanical back pain from facet arthritis. RFA provides 12–24 months of significant relief in appropriate patients.
• Kyphoplasty / vertebroplasty: For painful vertebral compression fractures — restores height and stability.

8. When Surgery Is Indicated

• Cauda equina syndrome: Emergency surgery within hours.
• Progressive neurological deficit: Worsening weakness or myelopathy despite conservative management.
• Failed conservative treatment: Disabling radiculopathy not responding to 6–12 weeks of appropriate treatment.
• Spinal instability: Spondylolisthesis with progressive slip or fractures causing instability.

9. Surgical Options

• Microdiscectomy: Keyhole surgery for herniated lumbar disc. Highly effective for sciatica. 1–2 day stay.
• Laminectomy: Removal of the bony arch to decompress the spinal canal in stenosis.
• ACDF (cervical discectomy and fusion): Anterior approach to remove a cervical disc and stabilise with a cage. Effective for cervical radiculopathy and myelopathy.
• PLIF / TLIF (lumbar fusion): Decompression with stabilisation using cages and pedicle screws. For spondylolisthesis or instability.
• Minimally invasive surgery (MIS): Tubular retractors and navigation for smaller incisions, less blood loss, faster recovery.

10. Recovery

• Microdiscectomy: Walk same day. Home in 1–2 days. Desk work in 2–4 weeks.
• Laminectomy: Home in 2–3 days. Avoid bending/lifting for 4–6 weeks.
• Fusion: 3–6 months for full bone healing. Desk work at 6–8 weeks.

Post-operatively: no heavy lifting until cleared, no driving on opioids, prompt reporting of new weakness or bowel/bladder changes.

11. Preventing Recurrence

• Core strengthening: The single most important long-term protective measure.
• Ergonomics: Neutral lumbar curve when seated; avoid prolonged static postures.
• Weight management: Even modest reduction measurably reduces back pain.
• Smoking cessation: Smoking accelerates disc degeneration.
• Regular low-impact exercise: Swimming, walking, cycling maintain spinal health.

Schedule Your Consultation

If you have persistent back or neck pain, arm or leg symptoms, or any red flags — specialist assessment will clarify what is happening and what your best options are.

Dr Nor Faizal is an Oxford-trained neurosurgeon with expertise in complex spinal conditions, degenerative spine disease, spinal tumours, and minimally invasive spinal surgery.

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