Back pain or lower back (lumbalgia) it's the leading reason for disability for people under the age of 45, it will strike 90% of all American adults, it's the second-leading surgical procedure, and it's only getting worse.
- Up to 85% of the US Population will have Back Pain at some time in their life.
- On any given day 6.5 million people are in bed because of back pain.
- 5.4 million Americans are disabled annually due to back pain.
- An estimated 93 million workdays are lost each year due to back pain.
- 90% of all back pain resolves in 6-12 weeks
- 5-10% of low back pain becomes chronic.
- Lesser than 20% of all back surgeries are successful after 2 years
- The total number of spine surgeries in the U.S. approaches 500,000 per year.
Causes of lower back painLow back pain and lower extremity pain often get put into one category, but the causes, and therefore the treatments, can be different. Lower extremity pain, when it radiates from the low back, is usually the result of pressure on a nerve due to discogenic compression to the nerve root. The pain is often in the distribution which the nerve supplies. Low back pain is often related to the mechanics of the spine. Muscle strain and sprain, arthritis, trauma, osteoporosis, and fracture are often contributed to the causes. Other disease processes which cause lower extremity pain can also cause low back pain, and vice versa.
Back pain can be caused by many different diseases and conditions. Some of these conditions can be very serious but fortunately they are for the most part uncommon. These serious conditions include cancer, tumors, neoplasm, inflammatory arthritis and infection.
Several common conditions that can cause back pain are listed below.
Fractures and Dislocations
Fractures and dislocations can occur anywhere in the body. The vertebral bodies which help support the weight of the upper body can break resulting in a compression fracture. These types of fractures can be very painful and even disabling.
It is important for the physician to determine the nature of these fractures. Some fractures can be caused by dangerous or serious conditions such as cancers, malignancies, or advanced osteoporosis. These are called pathological fractures. Other types of fractures may occur through traumatic events.
A dislocation is a term used to describe a condition where a joint has been disrupted and has separated to the point where the two adjacent bones are no longer aligned or touching. When a joint is dislocated the spine becomes unstable and is unable to protect the spinal cord or nerves.
Degenerative Disc Disease
Degenerative Disc Disease (DDD) is a natural condition of the body that causes deterioration of the intervertebral discs. This is a gradual process that may compromise the spine. Although DDD is relatively common, its effects are usually not severe enough to warrant significant medical intervention. The intervertebral disc is one structure prone to degenerative changes associated with aging. Long before Degenerative Disc Disease can be seen radiographically, biochemical and histologic (structural) changes occur. Over time the collagen (protein) structure of the annulus fibrosis weakens and may become structurally unstable. Additionally, water and proteoglycans(PG) content decreases. PGs are molecules that attract water. These changes are linked and may lead to the disc's inability to handle mechanical stress.
Herniation of the nucleus pulposus (HNP) occurs when the nucleus (gel-like substance) breaks through the annulus fibrosis (tire-like structure) of an intervertebral disc (spinal shock absorber). Injury to the disc may result in pain, numbness, tingling or loss of muscle strength. Disc injuries in the neck region may affect the arms or hands while disc injuries in the low back may affect the legs or feet. People between the ages of 30 and 50 appear to be vulnerable because the elasticity of the disc and water content of the nucleus decreases with age.
Facet syndrome is a common spinal disorder affecting the posterior joints that results in pain, stiffness and inflammation. Increased stress at the facets results in stretching of the ligamentous capsule, deterioration of the smooth cartilaginous surfaces and increased friction at the joint. In facet syndrome, the symptoms of pain, discomfort and weakness frequently localize to the spine, nonetheless a small percentage may be felt in the extremities or other body areas.
The spinal nerves pass through openings on the side of the spine called intervertebral foramen. Foraminal stenosis occurs when these openings are smaller than normal. This condition can be the result of injury, degenerative change or congenital anomaly. The smaller opening may result in compression of the nerve. This irritation often causes symptoms of numbness, weakness, burning or tingling in the involved extremity. Long standing or severe stenosis may result in a functional loss.
Spinal stenosis is a condition where the size of the spinal canal is reduced. This may lead to compression of the spinal cord. Symptoms often include pain, numbness, tingling and weakness. Severe cases may actually cause loss of function and may even lead to disability. Spinal stenosis is more common in patients over fifty years of age. Many factors can cause stenosis including injury and degenerative change.
Fibromyalgia is a chronic disorder associated with widespread soft tissue pain, tenderness and fatigue. A person with fibromyalgia will experience pain when up to 18 specific areas called tender points are pressed. Pushing carefully on these specific points during an examination causes discomfort or pain. The pain of fibromyalgia is more than normal muscle aches common after physical exertion. Fibromyalgia often can be severe enough to disrupt a person's daily work and activities. The cause of fibromyalgia is not known.
Osteoporosis is commonly called the "fragile bone disease." It is due to loss of bone density caused by a deficiency in such bone-building nutrients as calcium, vitamin D and other vitamins and minerals. The most common complication of osteoporosis is compression fracture. In people with advanced osteoporosis, compression fractures can occur as the result of simple daily activities such as bending, carrying heavy loads, or a minor fall.
Osteoarthritis, also called degenerative joint disease (DJD), is the most common type of arthritis. OA can occur in almost any joint of the body but most commonly occurs in the fingers, hips, knees and spine. Over time changes occur within the smooth cartilaginous surfaces of the joint. These changes lead to a loss of elasticity and the cartilage becomes stiff or brittle making it susceptible to injury. This will lead to stiffness, pain and crepitation at the joint. Advanced cases may actually result in significant damage to the bone itself.
Spondylolisthesis occurs when one vertebrae slips forward (translation) in relation to the adjacent vertebrae. Stability is inversely proportional to the degree of translation. The ability of a vertebrae to "slip" in relation to its neighbor can be caused by many factors, including facet or disc degeneration, trauma or a defect in a region of the vertebrae called the pars interarticularis. Severe cases may result in spinal cord or nerve compression and can require surgical intervention.
Sprains and strains are two of the most common causes of back pain. They can be caused by trauma, overuse, lack of conditioning, and improper body mechanics. The term sprain is used when this injury occurs in a ligament. Conversely, strain is used when the affected tissue is muscle or tendon. Typically, patients will complain of increased pain with activity and relief at rest. Treatment will often include a period of rest followed by a therapeutic exercise program to increase flexibility and strength.
Compression fractures can occur in any vertebra (spinal bones) and is described as a collapse of the vertebra.
Symptoms - The first symptom of a compression fracture may be sudden and severe back pain that remains in one local area. Some persons may experience numbness/tingling, or weakness in the arms or legs if the spinal cord or nerves leading away from the fracture have been compressed. If multiple fractures occur in an area of the back, the person will develop a forward hump-like curvature to the back.
Causes - There are many possible causes of compression fractures. Car accidents, falls, and weakening of the bone due to pathology (i.e. cancer), or Osteoporosis are common.
Diagnosis - The diagnosis is based on observation of the aforementioned symptoms and x-rays of the spine. Additional tests (i.e. bone scan, blood tests) may be needed to diagnose the actual cause of the compression fracture.
Discitis, or disc space infection, is an inflammatory lesion of the intervertebral disc that occurs in adults but more commonly in children. Its cause has been the subject of debate, although most authors believe it to be infectious. The infection probably begins in one of the continguous end plates, and the disc is infected secondarily. Severe back pain that begins insidiously is characteristic of the disease.
Kyphosis is the abnormal forward bending of the spine. In kyphosis, the curve of the spine is abnormal, forming a hump.
What is going on in the body?
The normal spine rounds slightly in the chest area, with arching in the lower back and neck regions. Excessive kyphosis can occur mainly in the chest area of the spine, causing the roundness of the back to appear exaggerated.
What are the signs and symptoms of the condition?
Symptoms are usually minimal, unless the deformity is severe. In that case, the back may ache or, rarely, nerve problems may arise. The hamstrings, or muscles at the back of the thigh, may also be tight.
What are the causes and risks of the condition?
Kyphosis is generally caused by an abnormal posture. Other possible causes include:
- a significant fracture of the vertebra, which can cause the back to angle forward
- spinal surgery
- Scheuermann's disease, which results in wedging of the vertebrae. This disease is usually seen in teenage boys, and its cause is unknown. Pott's disease, which refers to kyphosis due to collapse of the vertebra when tuberculosis infects the spine
- osteoporosis in elderly women, which causes a type of kyphosis known as dowager's hump
- spinal tumors, or surgery to remove them
- nerve disorders
Ligaments run up and down the spinal column. Hypertrophy of the ligaments in the vertebral canal (the posterior longitudinal ligament -- runs up and down along the back side of the vertebral bodies, and the ligamentum flavum -- runs up and down under the posterior bone ring made up of the lamina and spinous process) can increase their mass enough that they narrow the canal (stenosis) sometimes to the point that the spinal cord and/or nerve roots running through the canal are compressed. When the posterior longitudinal ligament in front and ligamentum flavum behind the spinal cord hypertrophy the cord is almost "circumferentially" surrounded and compressed).
Hypertrophy of the ligamentum flavum laterally near the facet joint can also contribute to foraminal narrowing (stenosis) with potential nerve compression (pinching).
According to the American Obesity Association (AOA) 64.5 percent of adult Americans (about 127 million) are categorized as being overweight or obese (1). The unfortunate truth is that obesity is becoming a global epidemic affecting adults and children.
Connection to Back Pain
Most people know that obesity contributes to the development of coronary heart disease, diabetes, high blood pressure, and colon cancer. However, did you know that obesity is a contributing factor to back pain? It is true. Being overweight or obese can significantly contribute to symptoms associated with osteoporosis, osteoarthritis (OA), rheumatoid arthritis (RA), degenerative disc disease (DDD), spinal stenosis, and spondylolisthesis.
The spine is designed to carry the body's weight and distribute the loads encountered during rest and activity. When excess weight is carried, the spine is forced to assimilate the burden, which may lead to structural compromise and damage (e.g. injury, sciatica).
One region of the spine that is most vulnerable to the effects of obesity is the low back; the lumbar spine. Lack of exercise and bodily conditioning leads to poor flexibility and weak muscles in the back, pelvis, and thighs. This can increase the curve of the lower back causing the pelvis to tilt too far forward. Further, this is detrimental to proper posture and as posture weakens, other regions of the spine (neck) may become painful.
You may try to dismiss the cause of some of these spinal disorders to the process of normal aging. It is true that with age body tissues can cause changes to spinal anatomy (2). However, if you are overweight or obese, chances are you have, or will have, back pain.
Trauma to the spine refers to injury that has occurred to bony elements, soft tissues and/or neurological structures. The two things that surgeons are most concerned about, in the case of spinal trauma, are instability of the vertebral column and actual or potential neurological injury.
Stability to the spinal column can be compromised when bony elements are injured or there is disruption to soft tissues such as ligaments. Instability causes the back to become unable to successfully carry normal loads, which can lead to permanent deformity, severe pain and in some cases catastrophic neurological injuries. Most often the instability comes from a fracture in one of the bony parts of the vertebra, specifically the vertebral body, the lamina or the pedicles.
In the case of trauma, dislocations and fractures happen simultaneously and can result in a very unstable spinal column. They can occur in any region of the spine and are associated with a degree of neurological injury. A surgeon needs to restore the mechanical stability of the spine to try and prevent more neurologic injury, progressive deformity or prolonged incapacitation pain.
Back pain in pregnancy
Introduction to back pain during pregnancy
For pregnant women, back pain during pregnancy is not a trivial matter. If not addressed, it can have a negative impact on your daily lifestyle, cause missed time from work, and make your delivery more difficult. Back pain in the course of your pregnancy can also create problems that will continue for an extended period after delivery.
Addressing back pain during pregnancy
While it is fairly common, back pain during pregnancy should definitely not be accepted as just part of the process. To help make your pregnancy as pleasant as possible and facilitate an easier delivery, back pain should be always be addressed as quickly as possible and managed throughout your pregnancy.
Low back pain of long duration (several weeks or months) during pregnancy is a predictor for post partum back pain (pain after birth). For this reason, pregnant women are encouraged to seek appropriate treatment for back pain during pregnancy.
Likewise, any post partum pain that lasts longer than six to eight weeks should be treated in order to avoid chronic or recurring back problems.
Lumbar radiculopathy, which refers to pain in the lower extremities in a dermatomal pattern. A dermatome is a specific area in the lower extremity innervated by a specific lumbar nerve. This pain is caused by compression of the roots of the spinal nerves in the lumbar region of the spine. Diagnosing leg and back pain begins with a detailed patient history and examination.
Scoliosis is defined as a side-to-side deviation from the normal frontal axis of the body. Although traditional, this definition is limited since the deformity occurs in varying degrees in all three planes: back-front; side-to-side; top-to-bottom. Scoliosis is a descriptive term and not a diagnosis. As such, a search is made for the cause. In more than 80% of the cases, a specific cause is not found and such cases are termed idiopathic, i.e., of undetermined cause. This is particularly so among the type of scoliosis seen in adolescent girls. Conditions known to cause spinal deformity are congenital spinal column abnormalities, neurological disorders, genetic conditions and a multitude of other causes. Scoliosis does not come from carrying heavy things, athletic involvement, sleeping/standing postures, or minor lower limb length inequality.
In managing AIS, the judgment of the surgeon and the participation of informed patients and families are as important in determining treatment outcome as surgical techniques. Decision-making in the management of AIS remains complex despite the availability of data on natural history, prognosis of different curve patterns, brace treatment factors, and surgical innovations.
The management of AIS includes several steps and treatment options:
- screening and early detection of deformity,
- observation of changes in deformity over time with informed judgment regarding prognosis, orthotic and non-operative interventions,
- surgical planning and operating.
This is a condition which causes pain down the back of one or both thighs. Inflammation of the sciatic nerve (which is the largest nerve in the body-about the diameter of your little finger) can be either constant or intermittent. Success in solving this problem is directly correlated to the diagnosis. Sciatica can be caused by a pinched nerve as it exits the low back spine or it can be caused by prostatic cancer. Odds are usually that the cause is some structural imbalance, but there are so many potential causes, some serious and some benign, it is better to at least know that there may be a grave cause to the symptoms.
This doesn't mean that you shouldn't immediately incorporate a strategy to eliminate any structural imbalances. In most cases, this will resolve the problem. If the problem doesn't respond to these basic efforts, then professional assistance may be needed. The first effort in relieving sciatic symptoms should be to review Hip Pain.
Trigger points can accumulate in the piriformis muscle forcing a contraction and strangulation of the sciatic nerve. The tennis ball exercise should be incorporated to help to relax the piriformis muscle. Stretching may be beneficial, but that is more of a "try an see" exercise. If there are no improvements with this approach, refer to Low Back Pain to better understand the relationship between the sciatic nerve and the low back spine. Seeking help from a chiropractor or orthopedist may be indicated if the solution can't be found at home.