Low Back Pain

Definition

Low back pain, as with any pain in the back, can be a dull, constant ache or a sudden, sharp pain. When it is sudden and sharp, the pain often makes it difficult to move with normal motions. Low back pain can last only for a short period (be intermittent) or be long lasting (constant). In either case, low back pain can make everyday activities difficult to perform. For most people with low back pain, the pain will go away on its own within several days or a few weeks.

Description

The purpose of the spine, which runs the length of the back, is to hold up the head, shoulders, and upper body. The spine also gives the human body support, allowing it to stand up straight. The back protects the spine from damage as a person bends, twists, and performs many daily movements throughout the day. The spine consists of small bones called vertebrae, which are stacked one upon the other. Also within the spine are intervertebral disks, ligaments, muscles, and nerves. The spine is divided into three sections: cervical (highest third of the back), thoracic (middle part), and lumbar (lowest third). Low back pain occurs in the region called the lumbar. When low back pain occurs, it is because strain has been placed on one or more parts of this lowest third of the back.

Low back pain differs significantly from individual to individual and, for any particular individual, from event to event. Pain may appear slowly and gradually grow to its most severe level, or it may have a sudden onset as, for example, when a person strains her back attempting to lift a heavy object. Low back pain may last for a very short period, or it may continue for days, weeks, or months at a time. Low back pain is often characterized as acute if it lasts less than about 4 weeks, subacute if it lasts four to 12 weeks, and chronic if it persists for more than 12 weeks.

Demographics

Low back pain is one of the most common of all medical complaints. According to the U.S. National Institute of Neurological Disorders and Stroke (NINDS) about 80% of all individuals experience at least one bout of low back pain during their lifetimes. The NINDS reports that a study ranked the worst conditions in terms of mortality or poor health, as considered by its participants. In 1990, low back pain was ranked as the sixth worst condition whereas, in 2010, low back pain had risen to third.

TheGoodBody.com , an organization promoting good health and fitness, reported that, in 2013, 29% of people 18 years of age and older had experienced low back pain in the last three months (as per its survey). Of those 65 years and older, the statistic was 33.7%. The organization also stated that less than one-third (30.2%) of female adults suffer from low back pain, whereas slightly more than one-fourth (26.4%) of males experience the same pain.

Of all those who experience back pain, the American Physical Therapy Association (APTA) found that 37% of them do not seek professional help in relieving their pain. Nearly three-fourths (72%) of those with low back pain, both those who seek professional help and those who do not, use pain medication to relieve their symptoms. More than half (55%) said that they use heat and cold packs for relief. These statistics are the result of an APTA survey in which 2,600 people aged 18 years and older completed questionnaires on low back pain. In a similar study conducted by The-GoodBody.com , the treatments most likely used by US adults are prescription medicines (58%), chiropractic treatment (54%), and physical therapy (48%).

Further, the National Institute of Arthritis and Musculoskeletal and Skin Diseases, part of the U.S. National Institutes of Health, determined that low back pain becomes more common the older one gets. Low back pain is likely to first appear when individuals are in their 30s or 40s.

Except for incidents resulting from an accident, low back pain is relatively uncommon among young people. Recent research suggests, however, that certain types of behavior can increase a young person's tendency to experience low back pain. The Consumer Products Safety Commission (CPSC), for example, has determined that in 2000 more than 13,260 emergency room (ER) visits by children resulted from low back pain caused by carrying back packs that were too heavy for them. This problem lessened considerably over the next 13 years, at least with regards toER visits. In 2013, CPSC reported that approximately 5,000 children were in emergency rooms suffering from backpack- related injuries. In addition, more than 14,000 children were treated outside the ER in that year.

Dr. Mary Ann Wilmarth, an APTA spokesperson, stated that, “Most people experience low back pain at some point in their lives, but many people don't realize they can prevent or treat the condition with the help of a physical therapist. For Americans living with low back pain, everyday tasks can be a challenge, and this survey revealed just how much this condition can affect someone's quality of life.”

Causes and symptoms

Like most of the rest of the body, the back consists of a complex network of nerves, muscles, and other tissues. Any event that causes the tissues to stretch, strain, sprain, or tear can result in low back pain. One of the most common causes of low back pain is simply aging. As the body grows older, tissues tend to break down, such that damage and the resulting pain become more likely. Any type of sudden stretching, twisting, or compression pressure on the back can also result in damage to muscles and nerves, causing low back pain. Some of the specific proximate causes of low back pain are the following:

Low back pain can occur for a number of other reasons. Many of these include bacterial infections, tumors that develop in the spinal region, urinary disorders, pelvic inflammatory disease, pancreatitis, gallbladder disorders, prostate disease, a number of genetic disorders in which the spine fails to develop properly, and other anatomical abnormalities that develop over time and that cause misalignment of the spine.

Diagnosis

The first step in diagnosing low back pain is almost always a patient history and general physical examination. The patient is asked to describe the circumstances under which pain began and any events that might have been related to its occurrence, such as being hit in a football game or jumping to retrieve an out-of-bounds basketball.

The healthcare provider then follows up to look for specific anatomical changes that may be associated with the pain, using technologies such as x-rays, CT (computed tomography) and MRI (magnetic resonance imaging) scans; bone scans; bone density tests; myelograms (injection of a dye into the spinal canal); discograms (injection of a dye into a disc); nerve conduction studies; and ultrasound imaging.

Two-dimensional x-rays are usually the first imaging technique used to diagnosis low back pain. These scans allow the physician to see the bony structure of the spine, specifically, any problems within the spine such as a misalignment or fracture. When more detail is needed, a three-dimensional CT scan is used. Because it uses cross-sectional images of the spine using individual x-ray scans, it can view disc herniation and rupture, stenosis, and tumors, as well as other back problems.

Myelograms, which involve a procedure called myelography, help to enhance images provided by x-rays and CT scans. They provide more detail to parts of the spine, especially the spinal osseous elements. Discograms, using a process called discography, generally are not used to evaluate an initial diagnosis of low back pain. They are, however, often used in association with other types of scans, primarily MRI scans, that have not produced a specific cause for low back pain, or if the patient has not responded to rehabilitation.

MRI scans use a magnetic force (a large magnet and radio waves, another type of electromagnetic radiation), instead of x-ray radiation, to create a computer-generated image of the spine. Bone scans are used to find infection in the bones of the spine, along with fractures and other disorders. Bone tests are routinely used to determine symptoms that accompany low back pain such as arthritis, infection, and inflammation.

KEY TERMS
Annulus—
The outer portion of a spinal disc.
Disc (also intervertebral disk)—
Bony structures that lie between adjacent vertebrae in the spine.
Lumbago—
Another name for low back pain.
Osteoarthritis—
A progressive, degenerative disease of the joints.
Scoliosis—
Abnormal form of the spine caused by a twisting of the spinal column.
Spinal fusion—
A surgical procedure in which adjacent discs are welded to each other.
Spinal stenosis—
A narrowing of the openings through which the spinal cord runs in vertebrae and discs.
Spondylolisthesis—
A condition in which two adjacent vertebrae slide forward or backward in relation to each other, causing low back pain.
Spondylolysis—
A fracture in one of the lower vertebrae.

A nerve conduction study (NCS), sometimes also called a nerve conduction velocity (NCV) test, produces the speed at which an electrical impulse flows through a nerve. It helps to determine nerve damage and destruction. Ultrasound imaging uses ultrasound (sound or other vibrations at a frequency above the limit of human hearing) to visualize tendons, muscles, joints, and other body structures. It is also called diagnostic sonography and ultrasonography.

Treatment

A variety of treatments are available for most instances of acute and chronic low back pain. Under the most favorable of conditions, many cases of low back pain resolve on their own within a matter of few days or a few weeks with even modest therapeutic efforts. An early step is to treat the affected area with cold compresses on a regular basis for the first few days after injury, followed by warm compresses for several days.

Patients should attempt to continue mild exercises that will not aggravate an injury, but that will keep tissues in the region healthy and supple. Physical therapy, acupuncture, and spinal manipulation by a qualified medical professional may help hasten healing.

Some instances of chronic low back pain are resistant to these treatments and require more aggressive treatment, usually surgical interventions. The most common forms of surgery are the following:

Prognosis

Many studies have been conducted to determine how readily low back pain is likely to be resolved with and without various types of treatment regimes. The results of these studies are somewhat mixed, partly because of differing methodologies, but some generalizations seem possible. First, about 60% of all individuals presenting with low back pain experience relief within a month of injury, no matter what treatment they have received. More than 80% of those with low back pain return to work in less than a month after the problem develops.

Conversely, as many as 30% of those with low back pain continue to have symptoms for at least a year after the problem is initially diagnosed. More than 90% of those individuals, who are then classified as having chronic low back pain, do not report any long-term relief from the problem. The occurrence of low back pain suggests, therefore, that, even with non-surgical treatment, a significant fraction of individuals may expect to have reoccurrences of the problem in both the short and long term.

QUESTIONS TO ASK YOUR DOCTOR

Prevention

Given how common low back pain is, experts warn that it is probably impossible to completely avoid having one or more episodes of the condition. However, a number of steps can be taken to reduce the risk of having accidents that lead to low back pain. One should, in the first place, attempt to eliminate conditions that place one at greater risk for low back pain, such as being overweight; smoking, which increases the risk of osteoporosis); and poor sitting and walking positions.

Experts suggest that a person should sleep on his or her side to reduce curvature of the spine and use comfortable, well-fitting shoes to prevent unnecessary stress on the spinal column. A nutritious diet is likely to improve one's overall health and reduce the risk of medical problems, such as those that lead to low back pain.

Exercises that strengthen back muscles, such as aerobic and strength training, are also likely to help prevent low back pain. Athletes should include conditioning and training exercises recommended for their sport, helping to build a strong and flexible body that can adjust to the particular stresses placed on it by the sport.

Resources

BOOKS

Borenstein, David G. Fast Facts: Low Back Pain. 2nd. ed. Abingdon: Health Press Limited, 2012.

Dagenais, Simon, and Scott Halderman, eds. Evidence-Based Management of Low Back Pain. St. Louis: Elsevier Mosby, 2012.

McGill, Stuart. Low Back Disorders: Evidence-Based Prevention and Rehabilitation, 3rd. ed. Champaign: Human Kinetics, 2016.

McGill, Stuart. Ultimate Back Fitness and Performance. Waterloo: Backfitpro, 2014.

Szpalski, Marek, et al., eds. Surgery for Low Back Pain. Heidelberg: Springer, 2010.

WEBSITES

American Academy of Orthopaedic Surgeons. Low Back Pain. AAOS.org . http://orthoinfo.aaos.org/topic.cfm?topic=a00311 (accessed March 3, 2017).

American Academy of Orthopaedic Surgeons. Spine Basics. AAOS.org . http://orthoinfo.aaos.org/topic.cfm?topic=A00575 (accessed March 3, 2017).

American Physical Therapy Association. Most Americans Live with Low Back Pain—and Don't Seek Treatment. APTA.org . http://www.apta.org/Media/Releases/Consumer/2012/4/4/ (accessed March 3, 2017).

The Good Body. 30 of the Most Surprising (And Alarming) Back Pain Statistics. TheGoodBody.com . http://www.thegoodbody.com/back-pain-statistics (accessed March 3, 2017).

Malanga, Gerard. Myelography, Discography, and Selective Neural Blockage. SpineUniverse.com . https://www.spineuniverse.com/exams-tests/myelographydiscography-selective-neural-blockade (accessed March 3, 2017).

National Institute of Arthritis and Musculoskeletal and Skin Diseases. What is Back Pain? Fast Facts: An Easy-to-Read Series of Publications for the Public. National Institutes of Health. https://www.niams.nih.gov/health_info/back_pain/back_pain_ff.asp (accessed March 3, 2017).

National Institute of Neurological Disorders and Stroke. Low Back Pain Fact Sheet. National Institutes of Health. http://www.ninds.nih.gov/disorders/backpain/detail_backpain.htm (accessed March 3, 2017).

Staples, Gracie Bonds. Beware of Backpacks: 14,000 Children Treated Yearly for Injuries. The Atlanta Journal Constitution. http://archive.jsonline.com/news/health/beware-of-backpacks-14000-children-treated-yearlyfor-injuries-b9984635z1-222888831.html (accessed March 3, 2017).

ORGANIZATIONS

American Academy of Orthopaedic Surgeons, 9400 W. Higgins Rd., Rosemont, IL, 60018, (847) 823-7186, Fax: (847) 823-8125, http://www.aaos.org/ .

American Association of Neurological Surgeons, 5550 Meadowbrook Dr., Rolling Meadows, IL, 60008-3852, (847) 378-0500, Fax: (847) 378-0600, (888) 566-2267, info@aans.org, http://www.aans.org/ .

American Chronic Pain Association, PO Box 850, Rocklin, CA, 95677, Fax: (916) 652-8190, (800) 533-3231, ACPA@theacpa.org, https://www.theacpa.org/ .

David E. Newton, AB, MA, EdD
Revised by William A. Atkins, BB, BS, MBA

  This information is not a tool for self-diagnosis or a substitute for professional care.