Lower back pain
Lower back pain (lumbalgia, pain in the lower back, back pain) is a common problem. Almost everyone at some point in his life felt a pain in his back which interfered with work, daily activities, or recreation. Fortunately, most cases of lower back pain are solved within a few days. Other cases require a longer period to resolve or lead to more serious problems.
Acute lower back pain is pain that lasts from several days to several weeks. In most cases, acute low back pain is mechanical in nature - that is, due to injury of the lumbar region (including muscle strain). Low back pain is caused by traumatic sports injuries, work at home or in the garden or after an accident or other types of overload of the lumbar spine and muscles. Symptoms range from muscle pain to acute or dull pain, inability to stand up straight (static disfunction) or limitation of mobility. Some pain syndromes can lead to more serious problems if left untreated.
Chronic pain in the lumbar spine is pain that persists for more than 3 months. Usually this is a progressive pain and its cause is often unclear.
What is the structure of the spine?
Spine a is complex structure composed of bones, muscles and other tissues which make up the back of the torso, from the neck to the pelvis. The main structure is the vertebral column, which not only supports the weight of the upper half of your body, but also houses the spinal cord - the fine structure of the nervous system that conducts nerve impulses to/from the periphery, providing movement, sensitivity, as well as a number of other important functions. Vertebral column in turn consists of more than 30 vertebrae, complex shape bones fixed together via the intervertebral ligaments. Each vertebra has a circular hole which, when applied over another, forms a channel containing the spinal cord. The spinal cord descends from the base of the skull to the level immediately below the last thoracic rib (in adults). Between the spaces between the vertebrae, pair of spinal nerves called roots, are exiting from the spinal cord. Because the vertebrae continue to grow long after the spinal cord has reached its maximum length (in early childhood), the nerve roots in the lower back descend a few inches through the spinal canal before they get out of it. Because of its appearance, this bundle of nerve roots that descends the spinal canal was named cauda equina. The space between the vertebrae is occupied by elastic cartilage, intervertebral disc, which provides the flexibility of the spine and evenly distributes pressure on the vertebral body during movement. Bands of connective tissue called ligaments fix the vertebrae together.
Starting at the top, the spine has four areas:
- Cervical (neck): 7 cervical vertebrae (denoted C1-C7).
- Thoracic (upper back): 12 thoracic vertebrae (Th1-Th12)
- Lumbar (lower area of the back): 5 lumbar vertebrae (L1-L5)
- Sacrum and coccyx, the fused vertebrae that form the base of the spine
Lumbar region of the back, the place where most back pain is felt, supports the entire weight of the upper body.
What causes lower back pain?
With age, bone strength and muscle elasticity and tone decreases. Intervertebral discs begin to lose flexibility and elasticity, which leads to a reduced ability to absorb pressure on the vertebrae.
Back pain, for example, can occur when someone lift up too much weight, which causes stretching, tearing, or spasm in the muscles or ligaments of the back. If the pressure on the spine is too big a rupture and prolapse (protrusion) of the intervertebral disc may produce. This protrusion exercises pressure on one of the 50 spinal nerves. When the nerve root is compressed or irritated, pain in the back appears.
Back pain may indicate nerve, muscle or bone damage. In most cases, lower back pain occur after injury of the back, but the lower back pain may result of degenerative changes, such as arthritis or intervertebral discs pathology, osteoporosis or other bone disease, viral infection, joints and discs irritation or congenital disorders of the back. Back pain can be connected with obesity, smoking, weight gain during pregnancy, stress, poor physical condition, poor posture at work or during sleep.
Sometimes back pain may indicate a more serious health problem. Pain accompanied by fever or loss of sphincter control (bladder and bowel), pain when coughing or associated with progressive muscle weakness in the legs may indicate compression of spinal nerve roots or other serious diseases. People with diabetes may feel severe pain in the back or radicular pain that is associated with diabetic neuropathy. If there are such symptoms you should immediately seek medical attention to prevent permanent damage.
Lumbar pain and work
Factors that may contribute to low back pain at work include the wrong position in the workplace, being in a sitting or standing position for a long period of time, the work associated with driving long distances, improper technique of weight lifting, frequent weights lifting or lifting a heavy weight. The frequency of pain among workers who lift heavy weights is same with that of workers who spend a lot of time sitting.
Psychological factors at work are equally important in the development of lower back pain. These factors include stress, frustration at work, boredom and reactions to daily pressure. Solving these problems significantly increase chances to cure a work related lower back pain.
Who most often suffer from lower back pain?
Almost everyone at some point in their lives suffer from back pain. Men and women are equally susceptible. Back pain occurs most often between the ages of 30 to 50 years, partly because of aging and sedentary lifestyles. The risk of having low back pain associated with the pathology of the intervertebral disc or degenerative changes of the spine increases with age.
Low back pain, which is not connected with trauma or other known causes, is rare in childhood. However, the heavy bag with textbooks can quickly overload the back and cause muscle fatigue and back pain.
What diseases are associated with lumbar pain?
Diseases that manifest itself with back pain and may require medical consultation are:
Protrusion of the intervertebral disc (also called a bulging, herniated, ruptured disc) . Intervertebral discs are constantly under pressure. The more disk degenerates and weakens, its capsule can protrude, or it can be embossed into the space containing the spinal cord and nerve roots, causing pinching and pain. Studies have shown that most often herniated disc appear in the lower part of the spine, lower back.
A more serious complication of a herniated disc is cauda equina syndrome, which occurs when part of the disk is included in the spinal canal and compresses the lumbar and sacral roots. If this syndrome is not treated it may cause permanent neurological deficit, so if you have a bowel movement or urination disorder, desensitization of inner thighs or bilateral weakness in the lower extremities, it is advisable to consult a doctor immediately.
Sciatica is when the hernia or the protrusion of the intervertebral disc is pressing on the roots that form the sciatic nerve, the largest nerve of the body, which descend on the back of the thigh and suply inervation of the leg muscles. This entanglement leads to stabbing or burning pain in the lumbar region radiating to the buttocks and lower, in one of the legs, knee, or sometimes to the heel. In more severe cases, symptoms include not only pain, but numbness and weakness of the muscles in the leg due to interruption of transmission of nerve impulses through the nerve. Rarely sciatica can be caused by tumors, cysts, metastases, or degeneration of the sacral nerve roots.
Degenerative changes of the spine can lead to a narrowing of the spinal canal. People with degenerative changes may complain back stiffness on awakening or may feel pain after prolonged walking or standing.
Spinal stenosis is associated with a congenital narrowing of the spinal canal that may predispose some people to pain associated with diseases of the intervertebral discs.
Osteoporosis is a metabolic disorder characterized by a decrease in bone density. Osteoporosis often causes vertebral fractures, vertebral body "collapsing" under pressure. The risk of osteoporosis is 4 times higher in women than in men.
Skeletal deformities causes stress or injury of the vertebrae, muscles, tendons, ligaments, and tissues that support the spine. These deformations include scoliosis, a curvature of the back to the side; kyphosis - the natural curvature of the thoracic spine segment is excessive; lordosis - emphasizing the natural curve of the lumbar region; back extension - curvature of the spine back; and back flexion - back bent forward.
Fibromyalgia is a chronic disease that is characterized by widespread musculoskeletal pain, fatigue and painful trigger points, especially in the neck, back, shoulders and hips. Additionally, fibromyalgia can also cause problems with sleep, morning stiffness and anxiety.
Spondylitis refers to pain or stiffness in the back, caused by an infection or inflammation of the vertebral body. Other painful inflammations in the lower back include osteomyelitis (inflammation of the bones of the spine) and sacroileitis (inflammation of the sacroiliac joints).
How does the pain in the lower back manifest itself?
Radiculopathy - is a common feature of low back pain. Radiculopathy occurs when a nerve root is irritated or compressed by a herniated disc or inflamed intervertebral joints. Radiculopathy causes irradiating pain, decreased sensation, numbness and muscle weakness in specific areas innervated by the affected spinal roots. Most people with this type of pain comes to a normal lifestyle with minimal or without treatment.
Sciatica - is the most common symptom in radiculopathy and arises when one of the five nerve roots (L4-L5-S1-S2-S3) which form the sciatic nerve, is irritated. Pain of sciatica has stinging or burning character, and extends down the posterolateral part of the leg, usually up to the knee or heel. If sciatica is caused by a herniated disc, the pain may increase when coughing, sneezing or bending forward.
Neurogenic claudication - is a type of sciatica, which occurs when walking or in orthostatic position, and which could result in lameness, and cand be improved in the supine position or flexion of the spine (sitting, bending forward).
When to contact your doctor with pain in the lower back?
Most patients with back pain are treated by a family doctor. If back pain is caused by a serious illness, usually is advised to consult a neurosurgeon or an orthopedic surgeon specializing in spine surgery. Individuals who notice any of the following situations should contact your doctor:
- If you have more than 70 years and recently you have noticed the emergence of lower back pain.
- Pain that does not go away even at night or in the supine position.
- Muscle weakness in one or both legs, bladder control disorders, trouble of defecation or sexual disfunction may be signs of cauda equina syndrome, which occurs due to compression of the beam of roots at the base of the spine. These symptoms are signals that require to contact a neurosurgeon immediately.
- Lumbar pain associated with fever or unexplained weight loss
- If you have a history of cancer, you have a weakened immune system, osteoporosis or if you use corticosteroids for a long period of time.
- If the lumbar pain is the result of an accident, especially if you have more than 50 years
- If the pain irradiates in leg, especially if it is accompanied by muscle weakness.
- If back pain does not go away after 4 weeks.
How lower back pain is diagnosed?
Anamnesis and a thorough physical examination usually can determine the more serious causes of back pain. During the consultation, the patient describes the beginning, the area and the severity of pain; duration of symptoms and any restriction of movement; history of previous episodes or any health problems that may be associated with back pain. The doctor will examine the patient's back and will perform a series of neurological tests to determine the cause of pain and the appropriate treatment. Sometimes it is necessary to perform some blood tests. Radiological studies will be needed to rule out tumors or other possible sources of pain.
There are a number of instrumental studies to confirm the causes of lower back pain:
Radiography includes a simple and contrasting radiography. The simple radiography is often the first imaging modality, and is used to locate bone fractures or spinal cord lesions. Any lesions of muscles, ligaments or pathological conditions such as a herniated disc can't be seen on plain radiography.
Discography involves injection of a special contrast in the intervertebral disc which is suspected to be the cause of low back pain. Contrasting agent emphasises damaged area on radiography performed immediately after contrast injection. This procedure is sometimes indicated in patients who are candidates for surgery or whose pain has not responded to conventional treatments. Nowadays discography is rarely used.
Computed tomography (CT) is a quick and painless procedure used in cases of suspected herniated disc, spinal stenosis or spinal cord injury as the cause of pain. X-rays pass through the patient's body at different angles and then are intercepted using a computerized device, and then the two-dimensional image of the body sections are reconstructed.
Nuclear magnetic resonance (MRI) is used to study the lumbar segment (and not only) for the detection of degenerative changes of the spine or intervertebral disc, bone, nerve roots, spinal cord, ligaments, muscles and blood vessels injury. MRI generates a strong magnetic field, which rearranges the water molecules in the tissue, then through the body passes radio waves which detect the "relaxing", i.e. resetting of the water molecules, and generates a resonance signal detected by a computerized detector. As a result, from these signals the analyzer restores the three-dimensional or two-dimensional image in analyzing segments. This procedure is commonly used for identification of certain pathologies that require emergency surgery.
Electrodiagnostic studies include electromyography (EMG), nerve conduction studies and evoked potentials (EP). EMG assesses the electrical activity of muscles and can determine whether the pathology is caused by muscle weakness or nerve innervating this muscle. During electromyography very thin electrodes are inserted into muscles and one record their electrical activity. Nerve conduction studies are used for measuring nerve conduction velocity. Two types of electrodes are used: one is attached to the skin surface over the examined muscles and the other electrode is used to stimulate nerve innervating the muscle. The first type electrodes allows to record electrical signals from the nerve and to determine the presence or absence of nerve damage. Evoked potentials also require two sets of electrodes, one stimulates the peripheral sensory nerves and the second placed on the scalp, records generated response in the cerebral cortex.
Bone scintigraphy is used to diagnose an infection, fracture or other pathology of bone. For carrying out a scintigraphy a small amount of radioactive substances is introduced into the bloodstream, which then accumulates in bones and particularly in regions with pathological changes. After that, the body is scanned by radiation detectors that will generate images, on which are visible the fields of intensive accumulation of radioactive substances, which will correspond to areas of bone destruction.
How to treat back pain?
In most cases, lower back pain can be treated without surgical intervention. Treatment involves using analgesics, reducing inflammation, restoring function and preventing relapse. Most patients with lower back pain recover without residual functional deficits. Patients should consult a doctor if they do not notice a significant reduction in pain and inflammation after 72 hours of treatment at home.
Even if ice and heat have never been found to be effective for the rapid treatment of lumbar lesions, compresses may help reduce pain and inflammation, and in some cases allow for better mobility. Immediately after the injury it's indicated the application of cold compresses or ice pack to the painful area several times a day for 20 minutes or less. After 2-3 days of treatment with cold compresses, it's indicated the use of warm compresses for a short time to relax muscles and increase blood flow to the damaged tissue. Warm baths may also help relax muscles.
Bed rest - for 1-2 days maximum. A Finnish study found that people with lower back pain, which continued to function in everyday life (without exercise) had better mobility back than those who followed bed rest for 1 week. Other studies have shown that bed rest in turn can aggravate lower back pain and can create complications such as depression, decreased muscle tone and blood clots in the vessels of the legs. Patients with lower back pain should return to normal activities as soon as possible. At night or during rest, patients should lie on their side with a pillow between your knees, or if supine pillow will be placed under the knees.
Exercises may be the fastest way to restore after lower back pain. They will help strengthen the back and abdominal muscles. Maintaining and enhancing muscle strength is especially important for people with skeletal deformities. Doctor or physiotherapist can give you a list of exercises that will help in this regard. Ordinary activities which help maintain a healthy back are curative exercises, swimming, walking and physical therapy to improve coordination and develop proper posture. Any mild discomfort felt at the beginning of this activity will disappear as soon as the muscles strengthen. But if the pain is more severe and lasts for more than 15 minutes during exercise, patients should stop exercising and consult a doctor.
Drug treatment often used in acute or chronic lower back pain. An effective treatment of lower back pain may involve a combination of prescription and OTC drugs. In all cases, patients should consult their doctor before taking the medication for the treatment of pain. Some medicines, even those sold without prescription, can have a number of adverse effects, may be contraindicated during pregnancy, can interact with other drugs and can lead to liver damage.
- OTC painkillers (without prescription), including NSAID (aspirin, naproxen, ibuprofen) are administered orally to reduce the stiffness, swelling and inflammation and relieve moderate pain. Local irritants applied as a cream or a spray, stimulate nerve endings in the skin and produce a sensation of heat or cold, thereby masking the pain. Topical analgesics can also reduce inflammation and stimulate local blood flow.
- Anticonvulsants - medication used mainly for the treatment of epilepsy - may be useful in treating certain types of pain and can be prescribed along with pain-killers.
- It was proved that some antidepressants , especially tricyclics, such as amitriptyline, can reduce pain, independently of their anti-depressant effect. At the moment the latest generation antidepressants (selective serotonin reuptake inhibitors) are investigated in terms of their impact on pain.
- Opioids, such as codeine, oxycodone, hydrocodone, morphine, are often prescribed for the treatment of severe acute and chronic pain, but should be taken only for a short period of time and only under the supervision of a physician. Side effects may include drowsiness, decreased reaction rate, thought disorder and addiction. Many experts believe that chronic use of these drugs is harmful to patients with lower back pain, accentuating the depression or even the pain.
Manual therapy is a technique used by chiropractors, osteopaths, manualists for the treatment of acute or chronic lower back pain. It includes actions on joints and bone structure (backbone). Clinical studies have shown that for people who suffer from lower back pain for more than 4 weeks, manual therapy is as effective as conventional treatment (analgesics, rest, exercise). The optimum amount of manipulation is unknown. Most clinical studies have used two sessions per week for 2-3 weeks.
When the pain does not respond to treatment with conventional methods, one can apply the following:
- Acupuncturecomprises insertion of small diameter needles (hair diameter) at certain points of the body. Proponents believe that acupuncture helps to release certain chemicals that reduce pain (endorphins, endogenous opioids). In general, acupuncture was more effective in patients with chronic low lower back pain.
- Biofeedback is a technique used to solve many problems referring to acute pain, especially lower back pain and headache. Using a special electronic device, the patient learns to recognize, to track and to take control of certain bodily functions, including muscle tone, heart rate and body temperature (by controlling local blood flow). Thereafter, the patient can learn to make changes in the pain response using relaxation methods. Typically biofeedback is used in combination with other treatments, without any side effects.
- Local blockades can relieve lower back pain associated with sciatica, blocking nerve conduction in certain nerves or nerve roots. Methods may differ from injections of local anesthetics, corticosteroids, opiates in the soft tissue surrounding a nerve or joint capsules, to more complex nerve blocks and spinal cord stimulation. Epidural corticosteroids may somehow reduce the pain after 2 - 6 weeks after injection, but the effect disappears at 3, 6 or 12 months after the procedure. In case of severe intractable lower back pain one can use intramedullary pumps that continuously injects drugs into the spinal canal. No clinical data exists that proves that the blockade may be useful in patients with low back pain without sciatica.
- Traction is associated with the use of weights for the "extension" of skeletal structures and their subsequent proper alignment. Clinical studies have shown no benefit from traction in the first weeks of back pain
- Choosing the right mattress - The advantage of rigid mattress in treating or preventing lower back pain had not been clinically proven. In one study, it was established that the mattress of medium hardness is more effective in relieving chronic lower back pain than more rigid one.
- Transdermal electrical stimulation (TENS) is performed with a device that sends electrical signals through the nerves thereby blocking pain impulses. Small electrodes placed on the skin over or near the source of pain generate electrical currents which block the propagation of pain signals from the periphery. TENS may be useful by stimulating the production of endorphins in the brain (endogenous substances with analgesic effect).
- Other treatments include ultrasound, interferential therapy, shortwave diathermy, laser therapy, all related to the application of stimuli to the skin. The effectiveness of any of these methods has not been demonstrated, especially in the first 4-6 weeks after the onset of pain in the back.
Only a small percentage of patients with lower back pain require surgical intervention. Surgical treatment is necessary in the following situations:
- Cauda equina syndrome
- Another serious problem such a tumor or infection
- Severe or progressive muscle weakness due to spinal canal stenosis or pinched spinal spine.
If drug therapy is not working and there are indications for surgical treatment, one can perform the following operations:
- Discectomy is one of the most commonly performed operations in the case of a herniated disc. During the procedure one removes a part of a herniated disc protruded in the spinal canal or intervertebral foramen. Usually, discectomy is combined with laminectomy, which means removal of a portion of bone arch that connects the spinous processes of the vertebral body and forms the upper wall of the intervertebral foramen - vertebral lamina. In recent years, microdiscectomy is increasingly practiced, which is performed through a smaller incision and has less postoperative complications.
- Foraminotomy is an intervention that "cleans" or enlarges the hole between the vertebrae through which the spinal roots exit - the intervertebral foramen. Bulging disc or hypertrophic intervertebral joints can lead to a narrowing of the intervertebral foramen, causing compression of the roots and subsequent pain, numbness and weakness in one arm or leg. Removal of a small fragment of bone expands the bone canal and relieve pinched roots.
- IntraDiscal Electrothermal Therapy (IDET) uses heat to reduce the volume of a herniated disc. A special needle is inserted into the intervertebral disc, and heated at high temperature for 20 minutes. Heat shrink the gel core and reduces intradiscal pressure which will reduce the load on the spinal spine and will reduce pain.
- Percutaneous nucleoplasty involves removing of the contents of the disk using a special catheter and percutaneous decreasing of intradiscal pressure.
- Spinal or vertebral fusion (spondylodesis) is an operation aimed at merging two or more vertebrae together. All fusion techniques involves the placement of a bone graft (auto- or allograft) between the vertebrae. Spinal fusion alters the normal biomechanical processes and is associated with an increase in degenerative changes in the adjacent spinal segments, so it will be used in the last turn, only after all other treatments will be proven ineffective.
Other operations for the relieve of severe lower back pain include rhisotomy , i.e. cutting the sensory nerve roots in the immediate vicinity of where they enter the spinal cord, to interrupt the spread of pain signals (and all other signals) from the region where the pain is felt; chordotomy that includes incision of sensory nerve fibers that connect the anterior and posterior roots and that innervate the intervertebral foramen; DREZ operation (dorsal root entry zone) during which the dorsal horn neurons of the spinal cord that are responsible for transmission of pain to the brain are destroyed.
How can you prevent lower back pain?
There are many opportunities to prevent recurrence of pain. Perhaps the most important recommendation is practicing the curative exercises and maintaining an active lifestyle. It is also important to avoid those activities that are associated with bending forward and rotation in the lumbar segment of the spine and to avoid excessive physical exertion.
Using lumbar support (orthopedic corset) to prevent lower back pain even today remains a controversial topic. In general, we recommend to combine corsets and exercises to maintain the mobility and strength of lumbar muscles.
Properly bend and lift - People with lower back pain need to learn how to bend and lift weights. For example, weights lifting should always be done with the knees bent and with abdominal muscles contracted to prevent overloading of the back muscles.
Take a break - People whose work is associated with a prolonged stay in a standing or sitting position, must often change position and use a chair with good back support. Office chair should be adjusted several times during the day to prevent sitting long in the same position. You should make short but frequent breaks to walk around, they also contribute to the prevention of pain associated with long-term presence in the same position.
Tips for a healthy back
- Every time you start a physical activity do some exercises to warm up.
- Do not sit or stand hunchbacked. The spine more easily supports the weight of the body when it is straight.
- At work or at home, make sure that the workplace is at a convenient height
- Use a chair with a good back support. Keep your shoulders straight. Change your body position frequently and regularly rise stand up and walk around the office.
- Wear comfortable shoes with low heels or without heels.
- Sleep on your side, to reduce any curvature of the back. Always sleep on a hard surface.
- Always call for help when you make a physical effort (for example, lifting the patient in bed).
- Do not try to pick up items too heavy for you. Lift with bent knees, tighten your abdominal muscles and keep your back straight. Keep objects close to the body. Do not spin your back, when you lift something heavy.
- Follow a healthy diet and a diet to reduce and prevent the accumulation of excessive weight. A diet rich in calcium, phosphorus and vitamin D will contribute to the consolidation of bone and will increase bone strength and hardness.
- If you smoke, stop smoking. It has been shown in clinical studies that smoking is associated with an increased risk of developing degenerative changes of the spine.