Who Has Low Back Pain?

Low back pain is a common problem for almost everyone. Four out of five people will experience low back pain at some point during their lifetime.

After the common cold, problems with the low back are the most frequent cause of lost work time in adults under the age of 45 years.

The cost of low back pain (lost wages and medical costs) has been estimated to total $50 billion annually. It is a common and costly ailment for Americans.

What Causes Low Back Pain?

1. The Aging Process: It is hard to keep living without getting older! The aging process for the spine starts at a very young age (25-30 years). The changes that occur with aging may "weaken" the spine's ability to withstand everyday activities (e.g., bending, lifting, sitting). How well you age and how fast you age relates a lot to your genetics-your parents and their parents! Some of us get gray hair early. Some of us develop back pain earlier than others. Most citizens will eventually end up with a sore back or neck.

2. Mechanical Problems: Along with aging, mechanical problems contribute significantly to back problems. Poor posture, poor physical fitness, poor work habits, obesity, and smoking may not only lead to low back pain, but may also prolong recovery when you do develop back pain.

3. Injury: About 50% of patients will have a specific injury as a cause of low back pain. Injuries caused by lifting heavy objects, falling, motor vehicle accidents and sports activities are common causes of low back pain. Lifting injuries are the most avoidable. Bending the knees while lifting objects can prevent many injuries.

Specific Causes of Low Back and Leg Pain

1. Lumbar Disc Degeneration: Most patients with low back pain will have disc degeneration (wear and tear), disc herniation or spinal stenosis (narrowing of the spinal canal) as the reason for their low back pain.

2. Slipped Vertebra: Less frequently, and usually in the younger patients, back and leg pain may be caused by spondylolisthesis, a condition in which one spine bone (vertebra) slips forward on the bone below. This condition affects as much as 2-3% of the population. Spondylolisthesis may be due to the bones not forming properly, or due to injury. This allows one spine bone (vertebra) to slip in relation to another.

3. Arthritis: Often patients are told they have "arthritis" in their spine. This can be greeted with panic by patients who might be concerned that this means they will end up in a wheelchair (highly unlikely). We prefer not to use the term "arthritis." As we get older, our hair becomes gray, our skin wrinkles, and our discs wear out. Over time, everyone will show signs of this aging process on lumbar spine x-rays. This isn't ARTHRITIS-this is simply "gray hair" of the back. Crippling arthritis of the spine is a rare entity.

4. Metabolic Conditions: With aging, especially in women, the bones of the body may weaken or "soften." This is called osteoporosis. Problems caused by osteoporosis will sometimes cause back pain, and you will need the care of a medical specialist that treats osteoporosis. The best treatment for osteoporosis is prevention (a good diet with vitamins and calcium, hormones if you are post-menopausal, bone building medicine, regular exercise and NO SMOKING).

Less Common Causes of Back Pain

1. Infection: Infection involving the bones of the spine (vertebrae) or the discs between them may occasionally cause severe back pain. These infections are treated with antibiotics, and sometimes surgery. They can cause damage to the vertebrae that my require a long recovery period.

2. Tumors: Malignant tumors from other parts of the body may spread to the spine and cause pain-a rare situation. Bone tumors can begin in the spine, but they are much less common than tumors that spread to the spine. Pain that keeps you awake at night and a lot of weight loss are the two things that may suggest this problem. If you are concerned about this possibility-ask! This diagnosis is rarely made, so it may not be mentioned to you and may leave you with concerns.

3. Low Back Pain and Stress: While not a direct cause of low back pain, emotional problems or stress-related tensions can increase back pain. A person with low back pain who is emotionally upset or stressed with often be very tense. Tension can increase muscle spasms in the back. These spasms lead to more pain, which also causes the muscles to "tighten" or become tense.

Why Does the Pain Occur?

The structures of the low back have nerve endings that can become a source of pain (see "Spine Basics"). In low back injuries, the pain may arise from damaged muscles, ligaments, or discs (jelly-like cushions between the vertebrae). Disc injuries come in many varieties, from minor damage to the outer ring of the disc (annulus) to more severe disc damage called a "rupture" (see "Understanding the Spinal Disc").

In a ruptured disc, the annulus is torn and the soft center of the disc is pushed out. A ruptured disc is also called a "herniated," "prolapsed" or "slipped disc." Pressure on a spinal nerve by a damaged disc or other structure can cause pain that radiates down the leg into the buttock, thigh, calf or foot. This pain is known as "sciatica."

Bone damage from infection, tumor, or fracture can affect the spinal nerves, causing low back pain. Other body organs such as the kidneys, blood vessels, and uterus can be a source of pain in the low back and must be distinguished from other causes of low back pain.

How Can Low Back Pain Be Diagnosed?

In a Physician's Office
Most types of low back pain can be diagnosed and treated effectively in the physician's office after a history and physical examination. The patient will be asked questions regarding the history of the back problem such as:

• How did the pain start?
• How long has it been present?
• Where is your pain?
• Are there activities which increase or decrease the pain?
• Does your family have a history of back problems?
• Do you have any important information concerning other types of past or present illness?

The physician will observe the patient standing, bending, and walking. The spine and legs will be examined and reflexes will be tested.

Laboratory Studies and Scans
Laboratory studies such as blood and urine tests may be necessary. X-rays of the lumbar spine (low back) may also be required. These x-rays show only bones. A ruptured disc cannot be seen on a regular x-ray, but a narrowed disc space, which can be seen, may be an indication of trouble in that area of the spine.

CT Scan
Depending upon the results of the initial studies, further tests may be necessary. A bone scan detects abnormal bone activity. Computerized tomography (CT scan) gives a cross-section view of the spine and can show a bulging or ruptured disc. Myelography is an outpatient procedure, done at the hospital. It involves placing dye into the spinal fluid. The spinal cord and nerves are outlined by the dye. Usually a CT scan will be done in addition to myelography to obtain more information about the problem.

MRI
Magnetic Resonance Imaging (MRI) is used widely in the diagnosis of spinal conditions. MRI is especially beneficial for the study of soft-tissue problems such as disc degeneration, protrusion, and rupture. It is usually the test ordered before all the others listed above. The main reason for ordering an MRI is to plan surgery for patients who have failed to respond to other forms of treatment.

How is Low Back Pain Treated?

Once the physician has made a diagnosis, treatment may begin with a period of rest in bed to allow inflamed or injured tissues to heal.

At times, a corset or back brace may be prescribed to provide support for the spine while you are up and moving around.

Many patients need to begin a program of special low back exercises prescribed by the physician. The patient may be sent to a physical therapist to learn and practice the exercises.

Various types of medication may be prescribed to relieve pain, relax muscles and reduce inflammation. These medications should be used only as prescribed and should not be taken for extended periods of time. Addictive medication should be used with caution.

Treatment may involve weight loss as well as general body conditioning, using exercises such as walking, bicycling or swimming.

For the patient with a prolonged pain problem, referral to a specialized pain clinic may be advisable.

Patient education plays an important role in the treatment of your low back pain. Some communities have organized programs to treat patients with chronic back disorders. Sometimes referred to as "back schools," these programs provide education for persons with low back pain.

Fewer than one in ten patients who have low back pain will require surgery. Surgical treatment may be advisable for conditions that do not respond to other methods of treatment.

Several forms of surgical treatment are available and are outlined in other brochures that will be provided to patients who are considering surgery.

Summary
Almost all cases of low back pain will respond to non-surgical care.

Surgery is necessary or advisable only in a small number of cases. It should be preceded by an honest and thorough discussion between the patient and the physician.

All treatments involve both risks and benefits and these should be clearly known before treatment begins.

It is important to stay in good physical condition and to avoid injuries caused by lifting a heavy object or lifting in an awkward position.

Prevention of low back pain is the best treatment.