Back Pain

Causes of Back Pain

What Causes Back Pain?

The causes of back pain can be complex. Some causes of back pain include accidents, muscle strains, and sports injuries.

How Is Back Pain Diagnosed?

In addition to performing a complete history and physical exam for your back pain, your doctor may suggest one of the following diagnostic studies:

• X-rays, which can be used to provide detail of the bone structures in the spine and to check for instability (such as spondylolisthesis, see below), tumors, and fractures.
• CT scans, which can identify specific conditions, such as a herniated disc or spinal stenosis.
• MRI scans, which can provide details about the backs' discs and nerve roots. MRI scans are most commonly used for pre-surgical planning.
• CT scans, which can identify specific conditions, such as a herniated disc or spinal stenosis.

A number of other imaging and electrical studies may also be used to identify back problems, and some injections are used for diagnostic purposes as well as for pain relief.

Types of Back Injury

Two main types of back injury include:

• Spondylolisthesis: This is a slipping of vertebra that occurs, in most cases, at the base of the spine. Spondylolysis, which is a defect or fracture of one or both wing-shaped parts of a vertebra, can result in vertebrae slipping backward, forward, or over a bone below.
• Cervical Radiculopathy: Cervical radiculopathy is the damage or disturbance of nerve function that results if one of the nerve roots near the cervical vertebrae is compressed. Damage to nerve roots in the cervical area can cause pain and the loss of sensation in various upper extremities, depending on where the damaged roots are located.

Causes of Spondylolithesis

There are many causes for spondylolithesis. A vertebra might be defective from the time a person is born, or a vertebra may be broken by trauma or a stress fracture. In addition, vertebrae can be broken down by infection or disease. Most commonly, this disorder occurs in children and adolescents who are active in sports.

Management of Back Pain

There can be many causes of back pain including accidents, strains, and injuries. Two types of back injury are spondylolisthesis and cervical radiculopathy. Both have their own set of symptoms, causes, and treatments.

The spine, or backbone, is made up of a column of 33 bones and tissue extending from the skull to the pelvis. These bones, or vertebrae, enclose and protect a cylinder of nerve tissues known as the spinal cord. Between each one of the vertebra is an intervertebral disk, or band of cartilage serving as a shock absorber between the vertebrae. The types of vertebrae are:

• Cervical vertebrae: the seven vertebrae forming the upper part of the spine
• Thoracic vertebrae: the 12 bones between the neck and the lower back
• Lumbar vertebrae: the five largest and strongest vertebrae located in the lower back between the chest and hips
• The sacrum and coccyx are the bones at the base of the spine. The sacrum is made up of five vertebrae fused together, while the coccyx (tailbone) is formed from four fused vertebrae.

Symptoms of Spondylolithesis

Symptoms of spondylolithesis include:

• Lower back pain
• Muscle tightness and stiffness
• Pain in the buttocks
• Pain radiating down the legs (due to pressure on nerve roots)

Spondylolithesis Treatments

Spondylolisthesis is treated with the strengthening of supportive abdominal and back muscles through physical therapy. For patients who continue to have severe pain and disability after physical therapy, there is the option of surgical fusion (arthrodesis) of the vertebra to the bone below.

Causes of Cervical Radiculopathy

In cervical radiculopathy, damage can occur as a result of pressure from material from a ruptured disc, degenerative changes in bones, arthritis, or other injuries that put pressure on the nerve roots. In older people, normal degenerative changes in the discs can cause pressure on nerve roots. In younger people, cervical radiculopathy tends to be the result of a ruptured disc. This disc material then compresses the nerve root, causing pain.

Symptoms of Cervical Radiculopathy

The main symptom of cervical radiculopathy is pain that spreads into the arm, neck, chest, and/or shoulders. A person with radiculopathy may experience muscle weakness and/or numbness or tingling in fingers or hands. Other symptoms may include lack of coordination, especially in the hands.

Cervical Radiculopathy Treatment

Cervical radiculopathy may be treated with a combination of pain medications such as corticosteroids (powerful anti-inflammatory drugs) or non-steroidal pain medication (Motrin or Aleve) and physical therapy. Steroids may be prescribed either orally or injected epidurally (into the dura, which is the membrane that surrounds the spinal cord).
Physical therapy might include gentle cervical traction and mobilization, exercises, and other modalities to reduce pain.
If significant compression on the nerve exists to the extent that motor weakness results, surgery may be necessary to relieve the pressure.

It is important to understand that back pain is a symptom of a medical condition, not a diagnosis itself. Medical problems that can cause back pain include the following:

Mechanical problems: A mechanical problem is due to the way your spine moves or the way you feel when you move your spine in certain ways. Perhaps the most common mechanical cause of back pain is a condition called intervertebral disc degeneration, which simply means that the discs located between the vertebrae of the spine are breaking down with age. As they deteriorate, they lose their cushioning ability. This problem can lead to pain if the back is stressed. Another cause of back pain is the wearing down of the facet joints, which are the large joints that connect each vertebrae to another. Other mechanical causes of back pain include spasms, muscle tension, and ruptured discs, which are also called herniated discs.

Injuries: Spine injuries such as sprains and fractures can cause either short-lived or chronic back pain. Sprains are tears in the ligaments that support the spine, and they can occur from twisting or lifting improperly. Fractured vertebrae are often the result of osteoporosis, a condition that causes weak, porous bones. Less commonly, back pain may be caused by more severe injuries that result from accidents and falls.

Acquired conditions and diseases: Many medical problems can cause or contribute to back pain. They include scoliosis, which causes curvature of the spine and does not usually cause pain until mid-life; spondylolisthesis; various forms of arthritis, including osteoarthritis, rheumatoid arthritis, and ankylosing spondylitis; and spinal stenosis, a narrowing of the spinal column that puts pressure on the spinal cord and nerves. While osteoporosis itself is not painful, it can lead to painful fractures of the vertebrae. Other causes of back pain include pregnancy; kidney stones or infections; endometriosis, which is the buildup of uterine tissue in places outside the uterus; and fibromyalgia, which causes fatigue and widespread muscle pain.

Infections and tumors: Although they are not common causes of back pain, infections can cause pain when they involve the vertebrae, a condition called osteomyelitis, or when they involve the discs that cushion the vertebrae, which is called discitis. Tumors, too, are relatively rare causes of back pain. Occasionally, tumors begin in the back, but more often they appear in the back as a result of cancer that has spread from elsewhere in the body.

Although the causes of back pain are usually physical, it is important to know that emotional stress can play a role in how severe pain is and how long it lasts. Stress can affect the body in many ways, including causing back muscles to become tense and painful. Untreated depression and anxiety can make back pain feel much worse. Likewise, insomnia, or the lack of sleep, can also contribute to back pain.

Understanding Back Pain -- Symptoms

What Are the Symptoms of Back Pain?

Most people have experienced back pain sometime in their life. The causes of back pain are numerous; some are self-inflicted due to a lifetime of bad habits. Other back pain causes include accidents, muscle strains, and sports injuries. Although the causes may be different, most often they share the same symptoms.
The symptoms for back pain are:

• Persistent aching or stiffness anywhere along your spine, from the base of the neck to the hips.
• Sharp, localized pain in the neck, upper back, or lower back -- especially after lifting heavy objects or engaging in other strenuous activity.
• Chronic ache in the middle or lower back, especially after sitting or standing for extended periods.
• Back pain that radiates from the low back to the buttock, down the back of the thigh, and into the calf and toes.
• Inability to stand straight without having severe muscle spasms in the low back.

Call Your Doctor About Back Pain If:

• You feel numbness, tingling, or loss of control in your arms or legs. This may signal damage to the spinal cord.
• The pain in your back extends downward along the back of the leg. You may be suffering from sciatica.
• The pain increases when you cough or bend forward at the waist. This can be the sign of a herniated disc.
• The pain is accompanied by fever, burning during urination, or strong-smelling urine. You may have a bacterial urinary tract infection.
• You have urine or fecal incontinence.
• You have dull pain in one area of your spine when lying in or getting out of bed. If you are over 50 you may be suffering from osteoarthritis.

Understanding Back Pain -- Diagnosis and Treatment

How Is Back Pain Diagnosed?

Before a doctor can begin treating back pain, he or she may do tests to diagnose what is causing the patient's problem. Unless you are totally immobilized from a back injury, your doctor probably will test your range of motion and nerve function and touch your body to locate the area of discomfort.
Blood and urine tests will make sure the pain is not due to an infection or other systemic problem if that's something your doctor suspects. X-rays are useful in pinpointing broken bones or other skeletal defects. They can sometimes help locate problems in connective tissue. To analyze soft-tissue damage, magnetic resonance imaging (MRI) scans may be needed. A CT scan can be done instead for those who cannot have an MRI. X-rays and imaging studies are not usually indicated for first time back pain due to an overuse type injury, and are generally used only for checking out direct trauma to the back, back pain with fever, or nerve problems such as weakness or numbness in the arms or legs. To determine possible nerve or muscle damage, an electromyogram (EMG) can be useful.

What Are the Treatments for Back Pain?

Because back pain stems from a variety of causes, treatment goals are pain relief and restored movement. The basic treatment for relieving back pain from strain or minor injury is rest. An ice pack can be helpful, as can aspirin or another nonsteroidal anti-inflammatory drug (NSAID) to reduce pain and inflammation. After the inflammation subsides, applying heat can soothe muscles and connective tissue.
Long-term bed rest, which is considered greater than 72 hours, is not only no longer considered necessary for most cases of back pain, it is actually potentially harmful, making recovery slower and potentially causing new problems. In most cases, you will be expected to start normal, nonstrenuous activity (such as walking) within 24 to 72 hours. After that you should begin controlled exercise or physical therapy. Physical therapy treatments may employ massage, ultrasound, whirlpool baths, controlled application of heat, and individually tailored exercise programs to help you regain full use of the back. Strengthening both the abdominal and back muscles helps stabilize the spine. You can prevent further back injury by learning -- and doing -- gentle stretching exercises and proper lifting techniques, and maintaining good posture.
If back pain keeps you from normal daily activities, your doctor can help by recommending or prescribing pain medications. Over-the-counter painkillers such as Tylenol, aspirin, or ibuprofen can be helpful. Your doctor may prescribe prescription strength anti-inflammatories/pain medicines or may prefer to prescribe combination opioid/acetaminophen medications such as Vicodin or Percocet. Some doctors also prescribe muscle relaxants. But beware, these medications have their main effect on the brain, not the muscles, and often cause drowsiness and dependence. Other medicines such as antidepressants and anticonvulsants are sometimes prescribed to help with pain related to irritated nerves.

What Are the Treatments for Back Pain? continued...

The antidepressant Cymbalta (duloxetine) has been approved for chronic back pain as well. It's a serotonin-norepinephrine reuptake inhibitor, or SNRI, that was first approved by the FDA in 2004.
If your primary doctor isn't able to help you control back pain, he or she may refer you to a back specialist or a pain specialist. Sometimes these doctors will use injections of steroids or anesthetics to help control the pain. In cases where there is a herniated disc or pinching of the nerve from the spinal cord, surgery may be indicated.
For those patients with long-standing back pain and nerve damage, some newer treatments have been developed recently to help with the treatment of pain. One of these is radiofrequency ablation, a process of delivering electrical stimulation to specific nerves to make them less sensitive to pain, or by delivering enough electricity to actually destroy the nerve to prevent further pain. These procedures are not favored by some doctors who find them ineffective.
Knowing the cause of the pain and fixing the problem if possible should be primary in the course of your treatment, however.
Some physicians advocate using a transcutaneous electrical nerve stimulator (TENS), although whether TENS is clearly helpful for back pain has not been resolved. Electrodes taped to the body carry a mild electric current that helps relieve pain.TENS is not painful and may be effective therapy to mask pain such as diabetic neuropathy. However, TENS for chronic low back pain is not effective and cannot be recommended, according to the American Academy of Neurology (AAN).
Surgery for nonspecific back pain is a last resort. In cases of persistent pain from extreme nerve damage, rhizotomy -- surgically severing a nerve -- may be necessary to stop transmission of pain to the brain. Rhizotomy can correct the symptoms caused by friction between the surfaces in a spinal joint, but it doesn't address other problems, such as herniated discs.
Chiropractors have a role in the treatment of back pain. The U.S. Agency for Healthcare Research and Quality recognizes spinal manipulation by chiropractors and osteopaths as effective for acute low-back pain. Its effectiveness for treating chronic back pain is less well established. Some researchers suggest that early chiropractic adjustments for acute back pain may prevent chronic problems from developing. Other doctors warn against some chiropractic manipulations, particularly those that involve rapid twisting of the neck.
Osteopathic treatment is likely to combine drug therapy with spinal manipulation or traction, followed by physical therapy and exercise.
Acupuncture may bring moderate to complete back pain relief for many sufferers. It can be used alone or as part of a comprehensive treatment plan that includes medications and other bodywork. Clinical achievements, along with positive research results, prompted the National Institutes of Health (NIH) to declare acupuncture a reasonable treatment option for those suffering low back pain.

What Are the Treatments for Back Pain? continued...

If you consult a psychotherapist for cognitive behavioral therapy (CBT), your treatment may include stress management, behavioral adaptation, education, and relaxation techniques. CBT can lessen the intensity of back pain, change perceptions about levels of pain and disability, and even lift depression. The NIH considers CBT useful for relieving low back pain, citing studies that show CBT to be superior to routine care and placebo. Other comprehensive behavioral programs have shown similar success, with participants able to lessen the amount of medication they needed while improving their outlook and pain-related behavior.
If lower back pain is related to muscle tension or spasm, biofeedback can be effective for lessening pain intensity, decreasing drug use, and improving quality of life. Biofeedback may help you train your muscles to respond better to stress or movement.
The Alexander Technique, Pilates, and the Feldendkrais Method are all specialized forms of body work that help you learn to move in a more coordinated, flexible, and graceful manner. They may help reduce pain and can relieve stress. Some of the postures of yoga may help diminish low back pain, improve flexibility, strength, and sense of balance. Yoga is good for stress reduction and can help with the psychological aspects of pain.
Aquatic therapy and exercise can also improve flexibility and decrease pain for those with chronic low back problems. The unique properties of water make it an especially safe environment for exercising a sore back; it provides gentle resistance, comfort, and relaxation.