Low back pain
If you have lower back pain, you are not alone. Nearly everyone at some point has back
pain that interferes with work, routine daily activities, or recreation. Americans spend
at least $50 billion each year on low back pain, the most common cause of job-related
disability and a leading contributor to missed work. Back pain is the second most common
neurological ailment in the United States — only headache is more common.
Fortunately, most occurrences of low back pain go away within a few days. Others take much
longer to resolve or lead to more serious conditions.
Acute or short-term low back pain generally lasts from a few days to a few
weeks. Most acute back pain is mechanical in nature — the result of trauma to the
lower back or a disorder such as arthritis. Pain from trauma may be caused by a sports
injury, work around the house or in the garden, or a sudden jolt such as a car accident or
other stress on spinal bones and tissues. Symptoms may range from muscle ache to shooting
or stabbing pain, limited flexibility and/or range of motion, or an inability to stand
straight. Occasionally, pain felt in one part of the body may “radiate” from a
disorder or injury elsewhere in the body. Some acute pain syndromes can become more
serious if left untreated.
Chronic back pain is measured by duration — pain that persists for more
than 3 months is considered chronic. It is often progressive and the cause can be
difficult to determine.
What causes lower back pain?
As people age, bone strength and muscle elasticity and tone tend to decrease. The discs
begin to lose fluid and flexibility, which decreases their ability to cushion the
vertebrae.
Pain can occur when, for example, someone lifts something too heavy or overstretches,
causing a sprain, strain, or spasm in one of the muscles or ligaments in the back. If the
spine becomes overly strained or compressed, a disc may rupture or bulge outward. This
rupture may put pressure on one of the more than 50 nerves rooted to the spinal cord that
control body movements and transmit signals from the body to the brain. When these nerve
roots become compressed or irritated, back pain results.
Low back pain may reflect nerve or muscle irritation or bone lesions. Most low back
pain follows injury or trauma to the back, but pain may also be caused by degenerative
conditions such as arthritis or disc disease, osteoporosis or other bone diseases, viral
infections, irritation to joints and discs, or congenital abnormalities in the spine.
Obesity, smoking, weight gain during pregnancy, stress, poor physical condition, posture
inappropriate for the activity being performed, and poor sleeping position also may
contribute to low back pain. Additionally, scar tissue created when the injured back heals
itself does not have the strength or flexibility of normal tissue. Buildup of scar tissue
from repeated injuries eventually weakens the back and can lead to more serious injury.
Occasionally, low back pain may indicate a more serious medical problem. Pain
accompanied by fever or loss of bowel or bladder control, pain when coughing, and
progressive weakness in the legs may indicate a pinched nerve or other serious condition.
People with diabetes may have severe back pain or pain radiating down the leg related to
neuropathy. People with these symptoms should contact a doctor immediately to help prevent
permanent damage.
Low back pain is a symptom that affects 80% of the general United States population at
some point in life with sufficient severity to cause absence from work. It is the second
most common reason for visits to primary care doctors, and is estimated to cost the
American economy $75 billion every year.
Low back pain may be experienced in several different ways:
- Localized. In localized pain the patient will feel soreness or discomfort when the
doctor palpates, or presses on, a specific surface area of the lower back.
- Diffuse. Diffuse pain is spread over a larger area and comes from deep tissue layers.
- Radicular. The pain is caused by irritation of a nerve root. Sciatica is an example of
radicular pain.
- Referred. The pain is perceived in the lower back but is caused by inflammation
elsewhere-- often in the kidneys or lower abdomen.
Symptoms of Low back pain
Acute pain
Acute pain in the lower back that does not extend to the leg is most commonly caused by
a sprain or muscle tear, usually occurring within 24 hours of heavy lifting or overuse of
the back muscles. The pain is usually localized, and there may be muscle spasms or
soreness when the doctor touches the area. The patient usually feels better when resting.
Chronic pain
Chronic low back pain has several different possible causes:
Mechanical
Chronic strain on the muscles of the lower back may be caused by obesity; pregnancy; or
job-related stooping, bending, or other stressful postures.
Malignancy
Low back pain at night that is not relieved by lying down may be caused by a tumor in
the cauda equina (the roots of the spinal nerves controlling sensation in and movement of
the legs), or a cancer that has spread to the spine from the prostate, breasts, or lungs.
The risk factors for the spread of cancer to the lower back include a history of smoking,
sudden weight loss, and age over 50.
Ankylosing spondylitis
Ankylosing spondylitis is a form of arthritis that causes chronic pain in the lower
back. The pain is made worse by sitting or lying down and improves when the patient gets
up. It is most commonly seen in males between 16 and 35. Ankylosing spondylitis is often
confused with mechanical back pain in its early stages.
Herniated spinal disk
Disk herniation is a disorder in which a spinal disk begins to bulge outward between
the vertebrae. Herniated or ruptured disks are a common cause of chronic low back pain in
adults.
Psychogenic
Back pain that is out of proportion to a minor injury, or that is unusually prolonged,
may be associated with a somatoform disorder or other psychiatric disturbance.
The diagnosis of low back pain can be complicated. Most cases are initially evaluated
by primary care physicians rather than by specialists.
Initial workup for Low back pain
Patient history
The doctor will ask the patient specific questions about the location of the pain, its
characteristics, its onset, and the body positions or activities that make it better or
worse. If the doctor suspects that the pain is referred from other organs, he or she will
ask about a history of diabetes, peptic ulcers, kidney stones, urinary tract infections,
or heart murmurs.
Physical examination
The doctor will examine the patient's back and hips to check for conditions that
require surgery or emergency treatment. The examination includes several tests that
involve moving the patient's legs in specific positions to test for nerve root irritation
or disk herniation. The flexibility of the lumbar vertebrae may be measured to rule out
ankylosing spondylitis.
Imaging studies
Imaging studies are not usually performed on patients whose history and physical
examination suggest routine muscle strain or overuse. X rays are ordered for patients
whose symptoms suggest cancer, infection, inflammation, pelvic or abdominal disease, or
bone fractures. MRIs are usually ordered only for patients with certain types of masses or
tumors.
It is important to know that the appearance of some abnormalities on imaging studies of
the lower back does not necessarily indicate that they cause the pain. Many patients have
minor deformities that do not create symptoms. The doctor must compare the results of
imaging studies very carefully with information from the patient's history and physical
examination.
Treatment of Low back pain
All forms of treatment of low back pain are aimed either at symptom relief or to
prevent interference with the processes of healing. None of these methods appear to speed
up healing.
Acute pain
Acute back pain is treated with nonsteroidal anti-inflammatory drugs (NSAIDs), such as
ibuprofen, muscle relaxants, or aspirin. Applications of heat or cold compresses are also
helpful to most patients. If the patient has not experienced some improvement after
several weeks of treatment, the doctor will reinvestigate the cause of the pain.
Chronic pain
Patients with chronic back pain are treated witha combination of medications, physical
therapy, andoccupational or lifestyle modification. The medicationsgiven are usually
NSAIDs, although patients withhypertension, kidney problems, or stomach ulcers should not
take these drugs. Patients who take NSAIDs for longer than six weeks should be monitored
periodically for complications.
Psychotherapy is recommended for patients whose back pain is associated with a
somatoform, anxiety, or depressive disorder.
Low back pain with leg involvement
Treatment of sciatica and other disorders that involve the legs may include NSAIDs.
Patients with long-standing sciatica or spinal stenosis that do not respond to NSAIDs are
treated surgically. Although some doctors use cortisone injections to relieve the pain,
this form of treatment is still debated.
Alternative treatment for Low back pain
A thorough differential diagnosis is important before any treatment is considered.
There are times when alternative therapies are the most beneficial, and other times when
more invasive treatments are needed.
Chiropractic
Chiropractic treats patients by manipulating or adjusting sections of the spine. It is
one of the most popular forms of alternative treatment in the United States for relief of
back pain caused by straining or lifting injuries. Some osteopathic physicians, physical
therapists, and naturopathic physicians also use spinal manipulation to treat patients
with low back pain.
Traditional Chinese medicine
Practitioners of traditional Chinese medicine treat low back pain with acupuncture, tui
na (push-and-rub) massage, and the application of herbal poultices.
Herbal medicine
Herbal medicine can utilize a variety of antispasmodic herbs in combination to help
relieve low back pain due to spasm. Lobelia (Lobelia inflata) and myrrh (Commiphora
molmol) are two examples of antispasmodic herbs.
Homeopathy
Homeopathic treatment for acute back pain consists of applications of Arnica oil
to the sore area or oral doses of Arnica or Rhus toxicodendron. Bellis
perennis is recommended for deep muscle injuries. Other remedies may be recommended
based on the symptoms presented by the patient.
Body work and yoga
Massage and the numerous other body work techniques can be very effective in treating
low back pain. Yoga, practiced regularly and done properly, can be most useful in
preventing future episodes of low back pain.
Prognosis of Low back pain
The prognosis for most patients with acute low back pain is excellent. About 80% of
patients recover completely in 4-6 weeks. The prognosis for recovery from chronic pain
depends on the underlying cause. |
