There are many causes of low back pain. It sometimes occurs after a specific movement such as lifting or bending. Just getting older also plays a role in many back conditions.
As we age, our spines age with us. Aging causes degenerative changes in the spine. These changes can start in our 30s — or even younger — and can make us prone to back pain, especially if we overdo our activities.
These aging changes, however, do not keep most people from leading productive, and generally, pain-free lives. We have all seen the 70-year-old marathon runner who, without a doubt, has degenerative changes in her back!
Over-activity
One of the more common causes of low back pain is muscle soreness from over-activity. Muscles and ligament fibers can be overstretched or injured.
This is often brought about by that first softball or golf game of the season, or too much yard work or snow shoveling in one day. We are all familiar with this "stiffness" and soreness in the low back — and other areas of the body — that usually goes away within a few days.
Disk Injury
Some people develop low back pain that does not go away within days. This may mean there is an injury to a disk.
Disk tear
Small tears to the outer part of the disk (annulus) sometimes occur with aging. Some people with disk tears have no pain at all. Others can have pain that lasts for weeks, months, or even longer. A small number of people may develop constant pain that lasts for years and is quite disabling. Why some people have pain and others do not is not well understood.
Disk herniation
Another common type of disk injury is a "slipped" or herniated disc.
A disk herniates when its jelly-like center (nucleus) pushes against its outer ring (annulus). If the disk is very worn or injured, the nucleus may squeeze all the way through. When the herniated disk bulges out toward the spinal canal, it puts pressure on the sensitive spinal nerves, causing pain.
Because a herniated disk in the low back often puts pressure on the nerve root leading to the leg and foot, pain often occurs in the buttock and down the leg. This is sciatica.
A herniated disk often occurs with lifting, pulling, bending, or twisting movements.
[Picture of herniated disc between L4 and L5]
[Cross-section picture of herniated disc between L4 and L5]
Disk Degeneration
With age, intevertebral disks begin to wear away and shrink. In some cases, they may collapse completely and cause the facet joints in the vertebrae to rub against one another. Pain and stiffness result.
[Disc degeneration]
This "wear and tear" on the facet joints is referred to as osteoarthritis. It can lead to further back problems, including spinal stenosis.
Degenerative Spondylolisthesis
(Spon-dee-low-lis-THEE-sis). Changes from aging and general wear and tear make it hard for your joints and ligaments to keep your spine in the proper position. The vertebrae move more than they should, and one vertebra can slide forward on top of another. If too much slippage occurs, the bones may begin to press on the spinal nerves.
[Spondylolisthesis]
Spinal Stenosis
Spinal stenosis occurs when the space around the spinal cord narrows and puts pressure on the cord and spinal nerves.
[Spinal stenosis]
Scoliosis
This is an abnormal curve of the spine that may develop in children, most often during their teenage years. It also may develop in older patients who have arthritis. This spinal deformity may cause back pain and possibly leg symptoms, if pressure on the nerves is involved.
Additional Cause
There are other causes of back pain, some of which can be serious. If you have vascular or arterial disease, a history of cancer, or pain that is always there despite your activity level or position, you should consult your primary care doctor.
Differential Diagnosis :
[Low back pain in athlet]
- Mechanical:
- Apophyseal osteoarthritis
- Diffuse idiopathic skeletal hyperostosis
- Degenerative discs
- Scheuermann's kyphosis
- Spinal disc herniation (slipped disc)
- Spinal stenosis
- Spondylolisthesis and other congenital abnormalities
- Fractures
- Leg length difference
- Restricted hip motion
- Misaligned pelvis - pelvic obliquity, anteversion or retroversion
- Abnormal Foot Pronation
- Inflammatory:
- Seronegative spondylarthritides (e.g. ankylosing spondylitis)
- Rheumatoid arthritis
- Infection - epidural abscess or osteomyelitis
- Neoplastic:
- Bone tumors (primary or metastatic)
- Intradural spinal tumors
- Metabolic:
- Osteoporotic fractures
- Osteomalacia
- Ochronosis
- Chondrocalcinosis
- Psychosomatic:
- Tension myositis syndrome
- Paget's disease
- Referred pain:
- Pelvic/abdominal disease
- Prostate Cancer
- Posture
- Depression
- Oxygen deprivation
Back pain varies. It may be sharp or stabbing. It can be dull, achy, or feel like a "charley horse" type cramp. The type of pain you have will depend on the underlying cause of your back pain.
Most people find that reclining or lying down will improve low back pain, no matter the underlying cause.
People with low back pain may experience some of the following:
- Back pain may be worse with bending and lifting.
- Sitting may worsen pain.
- Standing and walking may worsen pain
- Back pain comes and goes, and often follows an up and down course with good days and bad days.
- Pain may extend from the back into the buttock or outer hip area, but not down the leg.
- Sciatica is common with a herniated disk. This includes buttock and leg pain, and even numbness, tingling or weakness that goes down to the foot. It is possible to have sciatica without back pain.
Regardless of your age or symptoms, if your back pain does not get better within a few weeks, or is associated with fever, chills, or unexpected weight loss, you should call your doctor.
Red flag signs :
- Recent significant trauma
- Milder trauma if age is greater than 50 years
- Unexplained weight loss
- Unexplained fever
- Immunosuppression
- Previous or current cancer
- Intravenous drug use
- Osteoporosis
- Chronic corticosteroid use
- Age greater than 70 years
- Focal neurological deficit
- Duration greater than 6 weeks
Medical History and Physical Examination
After discussing your symptoms and medical history, your doctor will examine your back. This will include looking at your back and pushing on different areas to see if it hurts. Your doctor may have you bend forward, backward, and side to side to look for limitations or pain.
Your doctor may measure the nerve function in your legs. This includes checking your reflexes at your knees and ankles, as well as strength testing and sensation testing. This might tell your doctor if the nerves are seriously affected.
Imaging Tests
Other tests which may help your doctor confirm your diagnosis include:
X-rays: Although they only visualize bones, simple X-rays can help determine if you have the most obvious causes of back pain. It will show broken bones, aging changes, curves, or deformities. X-rays do not show disks, muscles, or nerves.
Magnetic resonance imaging (MRI): This study can create better images of soft tissues, such as muscles, nerves, and spinal disks. Conditions such as a herniated disk or an infection are more visible in an MRI scan.
Computerized axial tomography (CAT) scans: If your doctor suspects a bone problem, he or she may suggest a CAT scan. This study is like a three-dimensional X-ray and focuses on the bones.
Bone scan: A bone scan may be suggested if your doctor needs more information to evaluate your pain and to make sure that the pain is not from a rare problem like cancer or infection.
Bone density test: If osteoporosis is a concern, your doctor may order a bone density test. Osteoporosis weakens bone and makes it more likely to break. Osteoporosis by itself should not cause back pain, but spinal fractures due to osteoporosis can.
Nerve test
Electromyogram or EMG is a test that involves the placement of very small needles into the muscles. Electrical activity is monitored. Its use is usually reserved for more chronic pain and to predict the level of nerve root damage. The test is also able to help the doctor distinguish between nerve root disease and muscle disease.
In general, treatment for low back pain falls into one of three categories: medications, physical medicine, and surgery.
Nonsurgical Treatment
Medications
Several medications may be used to help relieve your pain.
- Aspirin or acetaminophen can relieve pain with few side effects.
- Non-steroidal anti-inflammatory medicines like ibuprofen and naproxen reduce pain and swelling.
- Narcotic pain medications, such as codeine or morphine, may help.
- Steroids, taken either orally or injected into your spine, deliver a high dose of anti-inflammatory medicine.
Physical medicine
Low back pain can be disabling. Medications and therapeutic treatments combined often relieve pain enough for you to do all the things you want to do.
- Physical therapy can include passive modalities such as heat, ice, massage, ultrasound, and electrical stimulation. Active therapy consists of stretching, weight lifting, and cardiovascular exercises. Exercising to restore motion and strength to your lower back can be very helpful in relieving pain.
- Braces are often used. The most common brace is a corset-type that can be wrapped around the back and stomach. Braces are not always helpful, but some people report feeling more comfortable and stable while wearing them.
[Braces for low back pain]- Chiropractic or manipulation therapy is provided in many different forms. Some patients have relief from low back pain with these treatments.
- Traction is often used, but without scientific evidence for effectiveness.
- Other exercise-based programs, such as Pilates or yoga are helpful for some patients.
Surgical Treatment
Surgery for low back pain should only be considered when nonsurgical treatment options have been tried and have failed. It is best to try nonsurgical options for 6 months to a year before considering surgery.
In addition, surgery should only be considered if you doctor can pinpoint the source of your pain.
Surgery is not a last resort treatment option "when all else fails." Some patients are not candidates for surgery, even though they have significant pain and other treatments have not worked. Some types of chronic low back pain simply can not be treated with surgery.
Spinal Fusion
This is essentially a "welding" process. The basic idea is to fuse together the painful vertebrae so that they heal into a single, solid bone.
Spinal fusion eliminates motion between vertebral segments. It is an option when motion is the source of pain. For example, your doctor may recommend spinal fusion if you have spinal instability, a bad curvature (scoliosis), or severe degeneration of one or more of your disks. The theory is if the painful spine segments do not move, they should not hurt.
Fusion of the vertebrae in the lower back has been performed for decades. A variety of surgical techniques have evolved. In most cases, a bone graft is used to fuse the vertebrae. Screws, rods, or a "cage" are used to keep your spine stable while the bone graft heals.
The surgery can be done through your abdomen, your side, your back, or a combination of these. There is even a procedure that is done through a small opening next to your tailbone. No one procedure has been proven better than another.
The results of spinal fusion for low back pain vary. It can be very effective at eliminating pain, not work at all, and everything in between. Full recovery can take more than a year.
Disc Replacement
This procedure involves removing the disk and replacing it with artificial parts, similar to replacements of the hip or knee.
The goal of disk replacement is to allow the spinal segment to keep some flexibility and maintain more normal motion.
The surgery is done through your abdomen, usually on the lower two disks of the spine.
Tips for preventing back strain :
- Don't lift by bending over. Lift an object by bending your knees and squatting to pick up the object. Keep your back straight and hold the object close to your body. Avoid twisting your body while lifting.
- Push rather than pull when you must move heavy objects.
- If you must sit at your desk or at the wheel of a car or truck for long hours, break up the time with stops to stretch.
- Wear flat shoes or shoes with low heels (1 inch or lower).
- Exercise regularly. An inactive lifestyle contributes to low back pain.
Low Back Pain At A Glance :
- Functions of the low back, or lumbar area, include structural support, movement, and protection of certain body tissues.
- Symptoms in the low back can relate to the bony lumbar spine, discs between the vertebrae, ligaments around the spine and discs, spinal cord and nerves, muscles of the low back, internal organs of the pelvis and abdomen, and the skin covering the lumbar area.
- Treatment of low back pain is optimally directed toward a diagnosed or suspected specific cause.
Nonsurgical Treatment
Medications
Several medications may be used to help relieve your pain.
- Aspirin or acetaminophen can relieve pain with few side effects.
- Non-steroidal anti-inflammatory medicines like ibuprofen and naproxen reduce pain and swelling.
- Narcotic pain medications, such as codeine or morphine, may help.
- Steroids, taken either orally or injected into your spine, deliver a high dose of anti-inflammatory medicine.
Physical medicine
Low back pain can be disabling. Medications and therapeutic treatments combined often relieve pain enough for you to do all the things you want to do.
- Physical therapy can include passive modalities such as heat, ice, massage, ultrasound, and electrical stimulation. Active therapy consists of stretching, weight lifting, and cardiovascular exercises. Exercising to restore motion and strength to your lower back can be very helpful in relieving pain.
- Braces are often used. The most common brace is a corset-type that can be wrapped around the back and stomach. Braces are not always helpful, but some people report feeling more comfortable and stable while wearing them.
- Chiropractic or manipulation therapy is provided in many different forms. Some patients have relief from low back pain with these treatments.
- Traction is often used, but without scientific evidence for effectiveness.
- Other exercise-based programs, such as Pilates or yoga are helpful for some patients.
Surgical Treatment
Surgery for low back pain should only be considered when nonsurgical treatment options have been tried and have failed. It is best to try nonsurgical options for 6 months to a year before considering surgery.
In addition, surgery should only be considered if you doctor can pinpoint the source of your pain.
Surgery is not a last resort treatment option "when all else fails." Some patients are not candidates for surgery, even though they have significant pain and other treatments have not worked. Some types of chronic low back pain simply can not be treated with surgery.
Spinal Fusion
This is essentially a "welding" process. The basic idea is to fuse together the painful vertebrae so that they heal into a single, solid bone.
Spinal fusion eliminates motion between vertebral segments. It is an option when motion is the source of pain. For example, your doctor may recommend spinal fusion if you have spinal instability, a bad curvature (scoliosis), or severe degeneration of one or more of your disks. The theory is if the painful spine segments do not move, they should not hurt.
Fusion of the vertebrae in the lower back has been performed for decades. A variety of surgical techniques have evolved. In most cases, a bone graft is used to fuse the vertebrae. Screws, rods, or a "cage" are used to keep your spine stable while the bone graft heals.
The surgery can be done through your abdomen, your side, your back, or a combination of these. There is even a procedure that is done through a small opening next to your tailbone. No one procedure has been proven better than another.
The results of spinal fusion for low back pain vary. It can be very effective at eliminating pain, not work at all, and everything in between. Full recovery can take more than a year.
Disc Replacement
This procedure involves removing the disk and replacing it with artificial parts, similar to replacements of the hip or knee.
The goal of disk replacement is to allow the spinal segment to keep some flexibility and maintain more normal motion.
The surgery is done through your abdomen, usually on the lower two disks of the spine.
Tips for preventing back strain :
- Don't lift by bending over. Lift an object by bending your knees and squatting to pick up the object. Keep your back straight and hold the object close to your body. Avoid twisting your body while lifting.
- Push rather than pull when you must move heavy objects.
- If you must sit at your desk or at the wheel of a car or truck for long hours, break up the time with stops to stretch.
- Wear flat shoes or shoes with low heels (1 inch or lower).
- Exercise regularly. An inactive lifestyle contributes to low back pain.
Low Back Pain At A Glance :
- Functions of the low back, or lumbar area, include structural support, movement, and protection of certain body tissues.
- Symptoms in the low back can relate to the bony lumbar spine, discs between the vertebrae, ligaments around the spine and discs, spinal cord and nerves, muscles of the low back, internal organs of the pelvis and abdomen, and the skin covering the lumbar area.
- Treatment of low back pain is optimally directed toward a diagnosed or suspected specific cause.
[Colicky abdominal pain]
