What is Back
Back pain is a
symptom that can arise from many causes. It can range from a dull,
annoying ache to absolute agony. Many cases of back pain are caused by
stresses on the muscles and ligaments that support the spine. Sedentary
jobs and lifestyles may create a vulnerability to this type of stress or
damage. Obesity, which increases both the weight on the spine and the
pressure on the discs, is another factor. Strenuous sports such as
football and gymnastics can also damage the back
What causes back pain?
As people age, bone strength and muscle elasticity and tone tend to
decrease. The discs begin to lose fluid and flexibility, which decreases
their ability to cushion the vertebrae.
Pain can occur when, for example, someone lifts something too heavy or
overstretches, causing a sprain, strain, or spasm in one of the muscles or
ligaments in the back. If the spine becomes overly strained or compressed,
a disc may rupture or bulge outward. This rupture may put pressure on one
of the more than 50 nerves rooted to the spinal cord that control body
movements and transmit signals from the body to the brain. When these
nerve roots become compressed or irritated, back pain results.
Low back pain may reflect nerve or muscle irritation or bone lesions.
Most low back pain follows injury or trauma to the back, but pain may also
be caused by degenerative conditions such as arthritis or disc disease,
osteoporosis or other bone diseases, viral infections, irritation to
joints and discs, or congenital abnormalities in the spine. Obesity,
smoking, weight gain during pregnancy, stress, poor physical condition,
posture inappropriate for the activity being performed, and poor sleeping
position also may contribute to low back pain. Additionally, scar tissue
created when the injured back heals itself does not have the strength or
flexibility of normal tissue. Build up of scar tissue from repeated
injuries eventually weakens the back and can lead to more serious injury.
Occasionally, low back pain may indicate a more serious medical
problem. Pain accompanied by fever or loss of bowel or bladder control,
pain when coughing, and progressive weakness in the legs may indicate a
pinched nerve or other serious condition. People with diabetes may have
severe back pain or pain radiating down the leg related to neuropathy.
People with these symptoms should contact a doctor immediately to help
prevent permanent damage
How is back pain diagnosed?
A thorough medical history and physical exam can usually identify
any dangerous conditions or family history that may be associated with
the pain. The patient describes the onset, site, and severity of the
pain; duration of symptoms and any limitations in movement; and
history of previous episodes or any health conditions that might be
related to the pain. The physician will examine the back and conduct
neurologic tests to determine the cause of pain and appropriate
treatment. Blood tests may also be ordered. Imaging tests may be
necessary to diagnose tumors or other possible sources of the pain.
A variety of diagnostic methods are available to confirm the cause
of low back pain:
X-ray imaging includes conventional and enhanced methods
that can help diagnose the cause and site of back pain. A
conventional x-ray, often the first imaging technique used, looks
for broken bones or an injured vertebra. A technician passes a
concentrated beam of low-dose ionized radiation through the back and
takes pictures that, within minutes, clearly show the bony structure
and any vertebral misalignment or fractures. Tissue masses such as
injured muscles and ligaments or painful conditions such as a bulging
disc are not visible on conventional x-rays. This fast, noninvasive,
painless procedure is usually performed in a doctor’s office or at a
Discography involves the injection of a special contrast dye
into a spinal disc thought to be causing low back pain. The dye
outlines the damaged areas on x-rays taken following the injection.
This procedure is often suggested for patients who are considering
lumbar surgery or whose pain has not responded to conventional
treatments. Myelograms also enhance the diagnostic imaging of
an x-ray. In this procedure, the contrast dye is injected into the
spinal canal, allowing spinal cord and nerve compression caused by
herniated discs or fractures to be seen on an x-ray.
Computerized tomography (CT) is a quick and painless process
used when disc rupture, spinal stenosis, or damage to vertebrae is
suspected as a cause of low back pain. X-rays are passed through the
body at various angles and are detected by a computerized scanner to
produce two-dimensional slices (1 mm each) of internal structures of
the back. This diagnostic exam is generally conducted at an imaging
center or hospital.
Magnetic resonance imaging (MRI) is used to evaluate the
lumbar region for bone degeneration or injury or disease in tissues
and nerves, muscles, ligaments, and blood vessels. MRI scanning
equipment creates a magnetic field around the body strong enough to
temporarily realign water molecules in the tissues. Radio waves are
then passed through the body to detect the “relaxation” of the
molecules back to a random alignment and trigger a resonance signal at
different angles within the body. A computer processes this resonance
into either a three-dimensional picture or a two-dimensional “slice”
of the tissue being scanned, and differentiates between bone, soft
tissues and fluid-filled spaces by their water content and structural
properties. This noninvasive procedure is often used to identify a
condition requiring prompt surgical treatment.
Electrodiagnostic procedures include electromyography (EMG),
nerve conduction studies, and evoked potential (EP) studies. EMG
assesses the electrical activity in a nerve and can detect if muscle
weakness results from injury or a problem with the nerves that control
the muscles. Very fine needles are inserted in muscles to measure
electrical activity transmitted from the brain or spinal cord to a
particular area of the body. With nerve conduction studies the doctor
uses two sets of electrodes (similar to those used during an
electrocardiogram) that are placed on the skin over the muscles. The
first set gives the patient a mild shock to stimulate the nerve that
runs to a particular muscle. The second set of electrodes is used to
make a recording of the nerve’s electrical signals, and from this
information the doctor can determine if there is nerve damage. EP
tests also involve two sets of electrodes — one set to stimulate a
sensory nerve and the other set on the scalp to record the speed of
nerve signal transmissions to the brain.
Bone scans are used to diagnose and monitor infection,
fracture, or disorders in the bone. A small amount of radioactive
material is injected into the bloodstream and will collect in the
bones, particularly in areas with some abnormality. Scanner-generated
images are sent to a computer to identify specific areas of irregular
bone metabolism or abnormal blood flow, as well as to measure levels
of joint disease.
Thermography involves the use of infrared sensing devices to
measure small temperature changes between the two sides of the body or
the temperature of a specific organ. Thermography may be used to
detect the presence or absence of nerve root compression.
Ultrasound imaging, also called ultrasound scanning or
sonography, uses high-frequency sound waves to obtain images inside
the body. The sound wave echoes are recorded and displayed as a
real-time visual image. Ultrasound imaging can show tears in
ligaments, muscles, tendons, and other soft tissue masses in the back.
How is back pain treated?
Most back pain can be treated without surgery. Treatment involves
using analgesics, reducing inflammation, restoring proper function and
strength to the back, and preventing recurrence of the injury. Most
patients with back pain recover without residual functional loss.
Although ice and heat (the use of cold and hot compresses)
have never been scientifically proven to quickly resolve low back
injury, compresses may help reduce pain and inflammation and allow
greater mobility for some individuals. As soon as possible following
trauma, patients should apply a cold pack or a cold compress (such as
a bag of ice or bag of frozen vegetables wrapped in a towel) to the
tender spot several times a day for up to 20 minutes. After 2 to 3
days of cold treatment, they should then apply heat (such as a heating
lamp or hot pad) for brief periods to relax muscles and increase blood
flow. Warm baths may also help relax muscles. Patients should avoid
sleeping on a heating pad, which can cause burns and lead to
additional tissue damage.
Magnet therapy: The application of high
strength rare earth magnets at the point of pain. The magnets should be
applied continuously over a period of at least 3 weeks.
Magnets can be applied in the form of back belts and straps,
wraps, insoles, jewellery, pillows, mattress
Bed rest: 1–2 days at most. A 1996 Finnish study found that
persons who continued their activities without bed rest following
onset of low back pain appeared to have better back flexibility than
those who rested in bed for a week. Other studies suggest that bed
rest alone may make back pain worse and can lead to secondary
complications such as depression, decreased muscle tone, and blood
clots in the legs. Patients should resume activities as soon as
possible. At night or during rest, patients should lie on one side,
with a pillow between the knees (some doctors suggest resting on the
back and putting a pillow beneath the knees).
Exercise: may be the most effective way to speed recovery
from low back pain and help strengthen back and abdominal muscles.
Maintaining and building muscle strength is particularly important for
persons with skeletal irregularities. Doctors and physical therapists
can provide a list of gentle exercises that help keep muscles moving
and speed the recovery process. A routine of back-healthy activities
may include stretching exercises, swimming, walking, and movement
therapy to improve coordination and develop proper posture and muscle
balance. Yoga is another way to gently stretch muscles and ease pain.
Any mild discomfort felt at the start of these exercises should
disappear as muscles become stronger. But if pain is more than mild
and lasts more than 15 minutes during exercise, patients should stop
exercising and contact a doctor.
Medications: are often used to treat acute and chronic low
back pain. Effective pain relief may involve a combination of
prescription drugs and over-the-counter remedies. Patients should
always check with a doctor before taking drugs for pain relief.
Certain medicines, even those sold over the counter, are unsafe during
pregnancy, may conflict with other medications, may cause side effects
including drowsiness, or may lead to liver damage.
- Over-the-counter analgesics, including nonsteroidal
anti-inflammatory drugs (aspirin, naproxen, and ibuprofen), are
taken orally to reduce stiffness, swelling, and inflammation and to
ease mild to moderate low back pain. Counter-irritants
applied topically to the skin as a cream or spray stimulate the
nerve endings in the skin to provide feelings of warmth or cold and
dull the sense of pain. Topical analgesics can also reduce
inflammation and stimulate blood flow. Many of these compounds
contain salicylates, the same ingredient found in oral pain
medications containing aspirin.
- Anticonvulsants — drugs primarily used to treat seizures
— may be useful in treating certain types of nerve pain and may also
be prescribed with analgesics.
- Some antidepressants, particularly tricyclic
antidepressants such as amitriptyline and desipramine, have been
shown to relieve pain (independent of their effect on depression)
and assist with sleep. Antidepressants alter levels of brain
chemicals to elevate mood and dull pain signals. Many of the new
antidepressants, such as the selective serotonin reuptake
inhibitors, are being studied for their effectiveness in pain
- Opioids such as codeine, oxycodone, hydrocodone, and
morphine are often prescribed to manage severe acute and chronic
back pain but should be used only for a short period of time and
under a physician’s supervision. Side effects can include
drowsiness, decreased reaction time, impaired judgment, and
potential for addiction. Many specialists are convinced that chronic
use of these drugs is detrimental to the back pain patient, adding
to depression and even increasing pain.
Spinal manipulation is literally a “hands-on” approach in
which trained specialists (such as chiropractors, osteopaths, and
massage therapists) use leverage and a series of exercises to adjust
spinal structures and restore back mobility. These specialists do not
prescribe drugs or use surgery in their treatment of low back pain.
When back pain does not respond to more conventional approaches,
patients may consider the following options:
Acupuncture involves the insertion of needles the width of a
human hair along precise points throughout the body. Practitioners
believe this process triggers the release of naturally occurring
painkilling molecules called peptides and keeps the body’s normal flow
of energy unblocked. Clinical studies are measuring the effectiveness
of acupuncture in comparison to more conventional procedures in the
treatment of acute low back pain.
Biofeedback is used to treat many acute pain problems, most
notably back pain and headache. Using a special electronic machine,
the patient is trained to become aware of, to follow, and to gain
control over certain bodily functions, including muscle tension, heart
rate, and skin temperature (by controlling local blood flow patterns).
The patient can then learn to effect a change in his or her response
to pain, for example, by using relaxation techniques. Biofeedback is
often used in combination with other treatment methods, generally
without side effects.
Interventional therapy can ease chronic pain by blocking
nerve conduction between specific areas of the body and the brain.
Approaches range from injections of local anesthetics, steroids, or
narcotics into affected soft tissues, joints, or nerve roots to more
complex nerve blocks and spinal cord stimulation. When extreme pain is
involved, low doses of drugs may be administered by catheter directly
into the spinal cord. Chronic use of steroid injections may lead to
increased functional impairment.
Traction involves the use of weights to apply constant or
intermittent force to gradually “pull” the skeletal structure into
better alignment. Traction is not recommended for treating acute low
Transcutaneous electrical nerve stimulation (TENS) is
administered by a battery-powered device that sends mild electric
pulses along nerve fibers to block pain signals to the brain. Small
electrodes placed on the skin at or near the site of pain generate
nerve impulses that block incoming pain signals from the peripheral
nerves. TENS may also help stimulate the brain’s production of
endorphins (chemicals that have pain-relieving properties).
Ultrasound is a noninvasive therapy used to warm the body’s
internal tissues, which causes muscles to relax. Sound waves pass
through the skin and into the injured muscles and other soft tissues.
Minimally invasive outpatient treatments to seal fractures of the
vertebrae caused by osteoporosis include vertebroplasty and
kyphoplasty. Vertebroplasty uses three-dimensional imaging to help
a doctor guide a fine needle into the vertebral body. A glue-like
epoxy is injected, which quickly hardens to stabilize and strengthen
the bone and provide immediate pain relief. In kyphoplasty, prior to
injecting the epoxy, a special balloon is inserted and gently inflated
to restore height to the bone and reduce spinal deformity.
In the most serious cases, when the condition does not respond to
other therapies, surgery may relieve pain caused by back problems or
serious musculoskeletal injuries. Some surgical procedures may be
performed in a doctor’s office under local anesthesia, while others
require hospitalization. It may be months following surgery before the
patient is fully healed, and he or she may suffer permanent loss of
flexibility. Since invasive back surgery is not always successful, it
should be performed only in patients with progressive neurologic
disease or damage to the peripheral nerves.
- Discectomy is one of the more common ways to remove
pressure on a nerve root from a bulging disc or bone spur. During
the procedure the surgeon takes out a small piece of the lamina (the
arched bony roof of the spinal canal) to remove the obstruction
- Foraminotomy is an operation that “cleans out” or
enlarges the bony hole (foramen) where a nerve root exits the
spinal canal. Bulging discs or joints thickened with age can cause
narrowing of the space through which the spinal nerve exits and can
press on the nerve, resulting in pain, numbness, and weakness in an
arm or leg. Small pieces of bone over the nerve are removed through
a small slit, allowing the surgeon to cut away the blockage and
relieve the pressure on the nerve.
- IntraDiscal Electrothermal Therapy (IDET) uses thermal
energy to treat pain resulting from a cracked or bulging spinal
disc. A special needle is inserted via a catheter into the disc and
heated to a high temperature for up to 20 minutes. The heat thickens
and seals the disc wall and reduces inner disc bulge and irritation
of the spinal nerve.
- Nucleoplasty uses radiofrequency energy to treat patients
with low back pain from contained, or mildly herniated, discs.
Guided by x-ray imaging, a wand-like instrument is inserted through
a needle into the disc to create a channel that allows inner disc
material to be removed. The wand then heats and shrinks the tissue,
sealing the disc wall. Several channels are made depending on how
much disc material needs to be removed.
- Radiofrequency lesioning is a procedure using electrical
impulses to interrupt nerve conduction (including the conduction of
pain signals) for 6 to12 months. Using x-ray guidance, a special
needle is inserted into nerve tissue in the affected area. Tissue
surrounding the needle tip is heated for 90-120 seconds, resulting
in localized destruction of the nerves.
- Spinal fusion is used to strengthen the spine and prevent
painful movements. The spinal disc(s) between two or more vertebrae
is removed and the adjacent vertebrae are “fused” by bone grafts
and/or metal devices secured by screws. Spinal fusion may result in
some loss of flexibility in the spine and requires a long recovery
period to allow the bone grafts to grow and fuse the vertebrae
- Spinal laminectomy (also known as spinal decompression)
involves the removal of the lamina (usually both sides) to increase
the size of the spinal canal and relieve pressure on the spinal cord
and nerve roots.
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