WHY DO I HAVE BACK PAIN?
Back pain is a ubiquitous human experience which spans the globe and in all
age ranges. Most of the time lower back pain is a benign consequence of tissue
fatigue for a microscopic injury with short-lived stiffness, pain and even
muscle spasm. There are other more significant underlying conditions which may
be contributory discussed further below.
I. SEVERE LUMBAR SPRAIN/STRAINS
These can occur in all age groups when muscle ligament or tendon insertions
begin to fail, tear or rip under unusual loads or forces. The symptoms include
local pain which can then radiate toward the tailbone, the buttocks, the hips
but usually not below the knees. Treatment includes rest, ice, use of
over-the-counter analgesics such as Tylenol or NSAIDS as well as potential
treatment from a physical therapist if the symptoms become more protracted or
our chiropractic professionals. These problems are usually self-limiting.
Caution is advised in older patients with osteoporosis who may have an
underlying compression fracture and in that situation may warrant a visit to
their family doctor for purposes of x-ray examination if the symptoms last for
more than three days.
II. DEGENERATIVE DISC DISEASE AND HERNIATED LUMBAR DISCS
The human disc is a complex hydrostatic support mechanism meant to absorb and
disperse stresses ongoing in the spine under a variety of conditions and
postures. Young, healthy discs are succulent because of healthy cells
maintaining a matrix which imbibes water, and this protects the outer edges of
the disc, the annulus which is a more dense collagen ligamentous-type tissue.
Sometimes under certain loads and stresses the retaining disc annulus wall will
thin, and nuclear material will begin to occupy the space and push outward. When
this occurs in the direction of the nerves, it can cause intense back pain
especially with prolonged sitting, bending and stooping. Mediators of
inflammation can irritate the nerves and cause radiating leg pain, typically
burning or lancinating, and there is frequent numbness or tingling and even
weakness in certain leg muscle groups. This is a symptomatic disc herniation.
Disc herniations can become larger or extruded where the nuclear contents freely
spit out from the disc space and cause more intense nerve compression and
irritation resulting in severe and even incapacitating nerve-type sciatic leg
pain. This process is frequently self-limiting but not always. Patients who are
beginning to manifest these types of symptoms should consult their family
doctor. They may benefit from certain exercises that can reduce the forces
across the disc and alleviate symptoms. Rest, avoidance of repetitive bending
and stooping, avoidance of heavy lifting and prolonged sitting in conjunction
with the use of analgesic medications such as Tylenol and NSAIDS are
appropriate. When symptoms become more severe or protracted especially when
accompanied by leg numbness and weakness, an MRI is recommendable and
consideration for more aggressive treatment such as lumbar epidural steroid
injections. Patients who fail to respond or manifest progressive numbness or
weakness in the legs or begin to manifest loss of bladder or bowel function
require surgical evaluation by a spinal surgical specialist. Degenerative disc
disease is ubiquitous in society and is not always symptomatic. Sometimes small
fissures will present in the back or sides of the disc which can cause local
pain for which analgesic medications, muscle relaxers and physical therapy are
typically very helpful. In some individuals with more incapacitating attacks of
back pain, there may be a place for epidural steroid injections or even spinal
operative treatment.
III. SPONDYLOLISTHESIS
This is a condition which can present in young patients and old. About 8% of
the population have a bony defect, a spondylolysis which in time can result in a
shift of the whole vertebral body, a spondylolisthesis. Some people know this is
as a “slipped disc”. Treatment is usually non-operative with supportive
medication as stated above and back strengthening exercise. With some
individuals with more severe or incapacitating pain or functional limitations
requiring injection therapies such as epidural steroid injections. When the
condition results in concomitant nerve pain, sciatica with or without leg
numbness or weakness, the condition is frequently treated by operative
intervention by a spinal surgical specialist.
IV. OSTEOPOROSIS AND COMPRESSION/FRAGILITY FRACTURES
The spine bones may fracture after severe high-energy trauma such as from
falls from heights, motor vehicle accidents or other types of direct or indirect
trauma. However, some elderly individuals and even some younger individuals with
metabolic disease or who are taking corticosteroids for chronic illness can
develop vertebral body compression fractures under low trauma conditions or even
with virtually no trauma at all. There should be a high index of suspicion in
patients who already have been diagnosed with osteoporosis. The diagnosis is
typically by x-ray examination in condition with a structural study such as an
MRI. Treatment for this condition has become much more effective/satisfactory
with vertebral augmentation procedures such as kyphoplasty which is typically
offered
V. SPINAL STENOSIS
Spinal stenosis is a condition where the space available in the spinal canal
behind the vertebral bodies is gradually encroached upon from local anatomic
structures whether they be a bulging disc, enlarged arthritic facet joints,
thickened ligamentum flavum or lamina and especially if there is a vertebral
shift (spondylolisthesis or retrolisthesis). The patients typically will
complain of increasing back pain and leg weakness and fatigue with standing and
walking. They typically do better leaning forward, for instance, while walking
behind a shopping cart. The treatment is initially with therapeutic exercise.
Epidural steroid injections can favorably impact on this problem. Some
individuals have stenosis so severe that they require operative management.
Options available for such management include the new X-STOP implant as well as
more traditional and frequently necessary lumbar laminectomy (decompressive)
spinal surgical procedures. X-rays and lumbar spine MRI examinations are
frequently required to make the diagnosis.
VI. NON-MECHANICAL PAIN
Some individuals unfortunately have back pain for reasons which are not
benign. There are a variety of structures or conditions which can cause this.
One such condition is a tumor of one of the bones of the spine or one of the
nerve structures. Some tumors themselves are benign but most frequently tumors
of the spine are the result of metastases from breast cancer, prostatic cancer
alike. Individuals who are likely undergoing such treatment should have a high
index of suspicion if they are experiencing pain, severe in nature, even at
rest. Infections can also cause such intractable severe pain at rest, such as
spondylodiscitis; frequently the result of urinary tract infections and other
types of skin infections in individuals who have compromised immune status or
have chronic corticosteroid therapies. Other conditions which can potentially
cause non-mechanical back pain include kidney-related conditions such as kidney
stones, pancreatic conditions such as pancreatitis and pancreatic cancers and
even some vascular conditions such as a dissecting aortic aneurysm. These are
all very serious problems which require urgent workup and appropriate and
aggressive medical intervention.
