Clinical features
The common physical signs especially of mechanical low back pain are local tenderness over the spine, postural changes.

Management
Conservative treatment is most likely the course of action for back pain. Although back pain can be debilitating, the pain improves without surgery in most cases (85-90%). Physicians usually recommend 6 to 12 weeks of conservative therapy before considering surgery. Explanation reassurance along with simple analgesics, bed rest and physiotherapy for a definite duration can ameliorate most episodes (85-90%) of mechanical low back pain. More severe cases (10-15%) may require surgical intervention.

Non operative treatments: Non operative treatment usually involves relieving the inflammation around the nerve. Mild cases of back pain often respond well to rest or anti-inflatmmatory medication such as NSAIDs. Other conservative treatments include physical therapy, steroid injections, traction, ultrasound, electrical stimulation, acupuncture, heat or ice and massage. Patients often are advised to change their lifestyle.

1. Hot or cold: Hot or cold packs or sometimes a combination of the two can be soothing to chronically sore, stiff backs.
2. Exercise: Although exercise is usually not advisable for acute back pain, proper exercise like felxion, extension, stretching, aerobics can help ease chronic pain
3. Medications: A wide range of medications are used to treat chronic back pain. They are usually analgesics and nonsteroidal anti-inflammatory drugs (NSAIDs).
   Muscle relaxants and certain antidepressants also prescribed for chronic back pain.

   The combination of Vitamin B1, B6 and B12 are also used to block the pain pathway and ultimately may relieve the low back pain.
   But all medications should be prescribed by a registered physician.

4. Traction: Traction involves using pulleys and weights to stretch the back. Traction pulls the vertebrae apart to allow a bulging disc to slip back into place.
5. Corsets and braces: They are designed to limit the motion of the lumbar spine, provide abdominal support, and correct posture.
6. Behavioral modification: Developing a healthy attitude and learning to move the body properly during daily activities. Adopting healthy habits, such as exercise, relaxation, and regular sleep, and dropping bad habits, such as smoking and eating poorly will also help to get rid of pain.
7. Injections: When medications and other non-surgical treatments fail to relieve chronic back pain, injections are recommended for pain relief.

Operative treatments: Role of surgery
Operative treatment is required in 10-15% cases, when conservative approach fails after a definite period of treatment or persistent pain and signs of neurological compression exist. The purpose of surgery is decompression and stabilisation of spine and restoration of maximum functional state.

Prevention: Correct posture
Posture is the position to hold the body upright against gravity against gravity while standing, sitting or lying down. Posture is just as important as a good diet, exercise and sleep, but is rarely discussed as a health issue. Good posture encourages our muscles, joints and ligaments to work as nature intended.

Standing: While standing, it is advised to keep the body straight with ears, shoulders and hips vertically aligned. Shoulders should not be rounded inwards or tilted forwards. Hips should not be flexed or hyper-extended. Abdomen should be tucked in. Abdominal muscles should be used to keep the chest lifted and back supported.

Sitting: While sitting the back and thighs should be at a 90-degrees angle. Back should be straight, the hips in a neutral position and feet flat on floor. The chairs that support the lower back with proper seat height and seat depth should be used. Sitting in a slouched posture will hurt the back. In order to prevent frequent twisting of the back, a rotary chair can be used. It is advised to avoid prolonged cross-legged sitting.

Lying: While sleeping, it is advised to sleep on a firm mattress to support the back. It should be about 2 inches thick, on a wooden board. If required, one can put a pillow or a rolled up towel under the knees when sleeping on the back. when Sleeping on the side, knee should be bent, perhaps with a pillow between them. It is advised not to sleep on the stomach.

Daily activities: Bending the body forward puts a lot of stress on the spine. In daily activities, it is important to protect the spine by always keeping it straight. Instead of bending the back, bend the knees. This applies when carrying a heavy load or even when merely tying the shoelaces or picking up small objects. After bending movements, it is advised to maintain the natural curve of the spine.

Lifting and transfer: The proper and safe method for lifting and maneuvering objects is to squat to lift the box, then stand up straight, and turn with feet to place it on the table. To put less strain on the spine, it is advised not to twist the body when the back is bent. While getting out of bed, it is advised to turn to the side first. Then put both the feet on the floor and then get up by pushing both hands on the bed. The reverse process should be used when lying down in bed.

Exercise
Appropriate exercise helps to maintain back health and general fitness. Through exercise, the strength and flexibility of the back can be maintained or improved. However, if the exercise is performed incorrectly, one might hurt one's spine. The structure of the spine is very complicated and back pain can be difficult to cure. Therefore proper posture is very important in keeping the health of the spine. Physiotherapist can advise for proper treatment and appropriate exercise to relieve the pain. Exercise guideline for lower back is given in the page 12.

<Back pain during pregnancy
Back pain is prevalent in approximately 80 percent of women who are pregnant. This pain may start during pregnancy, or within three weeks of delivery. Usually during the third trimester, 50 percent of pregnant patients will experience back pain. The cause of pain is probably related to a combination of mechanical, metabolic, circulatory, and psycho-social contributing factors. Most probably cause is due to a change in hormonal influence that causes change at the insertion point of ligaments to the bone.

In most cases, pain does improve certain period after delivery. patients are instructed to avoid excessive weight gain, exercise to strengthen the back muscles, maintain correct posture and to wear sensible shoes (not high heels). Treatment options are available including a pelvic belt, exercise, appropriate rest, medication, massage and standard back exercises. Bed rest and exercise appeared to be the best treatments resulting in that rapid recovery of 65 percent.

Conclusion
Regarding low back pain, change in life style and exercise has got a tremendous role. Most of the cases can be improved by conservative treatment. In our country now a days the outcome of surgery is really auspicious.

Dr Md Shah Alam, MBBS, FCPS (General Surgery), MS (Orthopaedics), FRCS (Orthopaedics) is an Associate Professor of Sir Salimullah Medical College and Mitford Hospital, Dhaka.