Back pain can occur at any point along the spine, but the most common site is the lower back or lumbar region.
Factors such as a sedentary lifestyle and poor posture can increase the risk for back pain.
The most common causes of back pain are sprains, strains and minor injuries.
Treatment for back pain may include a combination of medication, physical therapy and exercise. Surgery is only necessary in a minority of cases (2% of cases).
You can help prevent back problems by getting regular aerobic exercise, maintaining a healthy weight, and using proper body mechanics.
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What is back pain?
Back pain can occur anywhere along the spine, but the most common site is the lower back or lumbar region. The lower part of the back bears the weight of the upper body plus any weight you are carrying, and it also twists and bends more than the upper back.
Back pain may be acute or chronic. Most cases of back pain are acute i.e. the pain starts suddenly and intensely, and usually lasts a short time (less than a month). Acute back pain is not usually caused by a serious medical condition, and most cases resolve within a few days without treatment. Recurrence is common, however. Repeated episodes may eventually lead to chronic back pain.
Chronic back pain persists beyond three months, and even slight movements can trigger it. Chronic pain is usually more intractable than acute pain, and often requires specialist advice.
Structure of the back
The back's system of bones, muscles, ligaments, tendons and nerves work together to bear the weight of your body and the loads you carry. The structure of the back provides considerable strength and flexibility, but because the spine is so central to the body's movements, even small amounts of damage can often cause pain.
The spine consists of 33 bony segments, the vertebrae. Between these lie the discs: tough, spongy "cushions" that act as shock absorbers for the vertebrae and give the spine flexibility. Strong elastic ligaments hold the vertebrae and discs firmly together in a column. Muscles attach to the vertebrae by fibrous connections called tendons. The complex layers of back muscle contract to move your back and upper body.
The spine also protects the spinal cord, which runs down through a canal formed by the vertebrae. Nerves from the spinal cord branch out and leave the spine through spaces between the vertebrae at the levels of the discs.
Who gets back pain and who is at risk?
Back pain is second only to headaches as the most common location of pain. Four out of five adults will experience at least one bout of back pain in their lives.
The following factors can increase your risk for back problems:
Ageing. Discs begin gradual deterioration by age 30. With age, the discs lose moisture and shrink. This puts more stress on the facet joints which become arthritic with resultant back pain.
Sedentary lifestyle. Being unfit increases your risk for back pain, especially if you attempt an unaccustomed activity. Lack of exercise leads to the following conditions, which may threaten your back:
Muscle inflexibility: restricts the back's ability to bend and rotate.
Weak back muscles: increases load on the spine and the risk of disc compression.
Weak stomach muscles: increases strain on the back and causes the pelvis to tilt abnormally.
Obesity: increases weight on the spine and pressure on the vertebrae and discs. A large belly pulls the spine forward and out of alignment, increasing the risk of back strain.
Poor posture and spending long periods in one position e.g. working at a computer, slouching in front of TV.
Obesity. The increased weight causes wear and tear of the disks and facet joints.
Genetic factors. Some people are genetically susceptibility to back pain, usually from inheriting spinal structural abnormalities. Mutation of the COL9A2 gene may be linked to about 10% of sciatica cases. This gene plays a role in producing collagen, an important protein component of the discs. The defective gene may cause disc deterioration, leading to sciatica.
Work that stresses the back: risky activities include lifting, forceful movements, bending and twisting into awkward positions, repetitive movements and vibration (as occurs with long-distance truck driving).
Improper body mechanics during sporting activities can damage the back e.g. a jerky golf swing or incorrect use of exercise equipment. Cyclists often experience low back pain, which is often resolved by adjusting the angle of the bicycle seat. Some research suggests that, over time, high-impact exercise such as rugby or aerobics may increase the risk for degenerative disc disease.
Pregnancy makes women prone to back pain due to shifting of abdominal organs, forward redistribution of body weight, and loosening of ligaments in the pelvic area prior to delivery.
Smoking, possibly because it decreases blood circulation to the tissues of the back. The association may also be due to a generally unhealthy lifestyle.
Psychological factors. Research indicates that in many people, pre-existing depression and feelings of helplessness may contribute negatively to the perception of pain and the ability to cope with back problems. People in depression are also more likely to have vague physical symptoms, including back pain.
What causes back pain?
In about 85% of acute back pain cases, the exact cause cannot be identified. There are many different possible causes; the following are some of the more common causes:
Sprains, strains and minor injuries, usually after lifting a heavy object or making an abrupt movement, are what causes back pain in most cases, rather than serious damage or disease. This is often called "simple" back pain.
A strain or tear to the muscles, tendons or ligaments can in turn produce painful muscle tension and spasm. The pain usually only lasts for a few days.
Although this pain often begins suddenly, and one particular movement can trigger it, the underlying cause may have been developing for some time. Inactivity and improper movements are usually at the root of simple back pain. (See risk factors).
Herniated disc. Wear and tear or strain may cause a spinal disc to bulge or rupture (herniate). The disc's gelatinous filling protrudes and presses against sensitive nerves from the spinal cord. This is commonly referred to as a "slipped disc".
Facet joint problems and osteoarthritis. This is the usual cause of chronic low back pain. Spinal movement is made possible by joints between the vertebrae that consist of two flat faces or "facets". If these degenerate, the two halves of the joint grate painfully against each other.
Firstly, the disc herniates or wears down and secondly, this puts more stress on the facet joints behind it. These joints become inflamed and later wear out (osteoarthritis). The inflamed joints cause backache. Later the arthritic joints become big and swollen (like an old lady’s arthritic finger joints) and these enlarged joints protrude into the spinal canal and cause narrowing of the spinal canal (spinal stenosis). This causes pinching of the nerves running down the buttocks and legs with nerve pain and weakness down the legs (sciatica).
Other causes
Back pain can also be due to abscesses, blood clots and tumours, and can result from problems in other organs, usually near the spine. These conditions include ulcers, kidney problems, pancreatitis, infections, inflammatory bowel disease, pregnancy, menstruation and other gynaecological problems such as ovarian cysts. In older people, low back pain may be a sign of Paget's disease or Parkinson's disease.
How is back pain diagnosed?
>Physical examination and medical history
Your doctor will take a medical history, and will likely ask about the frequency, duration and nature of the pain (whether it is piercing, throbbing, burning, etc); when it began; whether it was triggered by an event, such as lifting something heavy; what worsens the pain (e.g. coughing, walking) and what relieves it (e.g. lying down, exercise). Tell your doctor about any previous back pain episodes and injuries involving your back, neck or hips.
Your doctor will then give you a full physical examination.
Most cases of back pain will not require complex tests for initial assessment and treatment. However, if pain is severe and not responding to treatment, or if you have significant leg pain, some imaging tests may be necessary. These may include the following:
X-rays can help show bone alignment, and the presence of degenerative joint disease, tumours, infection or injury in some cases. Plain X-rays will not show soft tissues such as the lumbar discs or nerves.
Magnetic resonance imaging (MRI) or computerised tomography (CT) scans generate images that help reveal conditions involving the soft tissues e.g. herniated discs. MRIs can also help detect non-spinal causes of back pain, including infection and cancer.
Bone scan: a radioactive substance (tracer) is injected into a vein to help detect bone tumours or compression fractures caused by osteoporosis.
Discography: discs suspected of being the source of pain are injected with dye and X-rayed. This technique is generally used to identify the location of the injured disc in patients undergoing back surgery.
Myelography: a dye injected into the spinal canal shows up herniated discs or other lesions on X-rays. This has largely been replaced by CT and MRI scans.
Electrodiagnostic studies: electrical tests, such as EMG (electromyography) are used to study nerve conduction pathways, and can confirm nerve compression caused by conditions such as herniated discs or stenosis.
Other tests
Blood and urine samples may be used to test for conditions such as infections or arthritis.
How is back pain treated?
Because most back problems aren't serious, doctors often recommend home treatment first. Eighty to 90 percent of back pain resolves by itself within six weeks.
Home treatment
The following therapies may be useful for home treatment of back pain:
Over-the-counter pain medications such as paracetamol may help control pain, and mild nonsteroidal anti-inflammatory drugs (NSAIDs) such as aspirin and ibuprofen can reduce muscle and joint inflammation. Consult your doctor about long-term use of even non-prescription medications, especially NSAIDs, as these can have significant side-effects.
Alternating heat and cold application can help relieve sore and inflamed back muscles. Immediately after back pain starts up, try applying ice compresses several times a day, up to 20 minutes each time. After spasms and acute pain subside, apply heat for up to 20 minutes to help loosen tight muscles.
Back braces, corsets and belts can relieve strain and support your back temporarily. Prolonged use may result in weakened muscles, so limit use of these aids to short periods (less than 1 week) or during back-straining activities. Braces and corsets are available over-the-counter at pharmacies and medical supply stores. Your doctor may prescribe a customised brace.
Lie down in a comfortable position at the onset of back pain. However, bed rest for longer than a few days is not recommended, as this can reduce your muscle strength and lead to further disability. When the pain lessens:
try to get moving again as soon as possible, but increase your activity levels gradually
try not to stay in one position or do any activity for more than 30 minutes at a time
avoid lifting, bending or twisting until you have been pain-free for a few days
avoid the activity which caused the pain for a couple of weeks
Healthy sleep is important in recovery. It is often difficult to sleep when suffering from back pain, particularly when pain intensifies at night. Try lying in a fetal position with a pillow between your knees, or lying on your back with a pillow under your knees. Avoid caffeine, try having a warm bath before bedtime, and practise relaxation techniques. Medication may be necessary to help manage night-time pain and sleeplessness.
Contact your doctor if pain does not improve after about a week with home treatment.
Other
You may need professional treatment that could include some of the following therapies:
Medications. Your doctor may prescribe nonsteroidal anti-inflammatory drugs (NSAIDs) and muscle relaxants to relieve mild to moderate back pain and muscle spasm. Corticosteroid injections may be prescribed for more severe back pain.
Physical therapy may include:
Heat and cold applications
Massage performed by a physical therapist
Hydrotherapy: exercises done in a special swimming pool. Warm water helps support damaged tissues, and provides resistance for exercises.
Exercise. Once the pain subsides, your doctor or physical therapist can design an exercise programme to improve muscle strength, flexibility and posture.
Relaxation can loosen tense muscles and ease pain, and help you learn to cope better with chronic pain.
Electrical stimulation: Transcutaneous electrical nerve stimulation (TENS) acts by interfering with transmission of pain signals. Electrodes are placed on your skin near the painful area, and a mild electric current is passed through them. TENS may relieve sciatica pain, but usually provides little relief from chronic back pain.
Surgery is unnecessary in most cases of back pain. Only 2% of back pain investigation results in a back operation. Certain conditions that do not respond to other treatments may benefit from surgery: these include unrelenting pain or progressive muscle weakness caused by nerve compression, or incontinence (which can indicate spinal cord irritation).
Laminectomy and fusion are among the most commonly performed back surgeries. Laminectomy aims to relieve sciatica by removing bone spurs or disc fragments that protrude into the spinal canal or press on nerve roots. Fusion involves joining two vertebrae with a metal implant and bone graft to eliminate painful movement.
Before deciding on back surgery, consider getting a second opinion. Surgery to remove a herniated disc, for example, is a frequently performed procedure with usually good results. However, long-term outcomes are often similar following less-invasive treatments.
Spinal manipulation is use of the hands to apply force to the back. Manipulation should only be carried out by an appropriately trained doctor, physiotherapist, osteopath or chiropractor and must be done in consultation with an orthopaedic specialist.
Can back pain be prevented?
You can help prevent back problems with the following common-sense measures:
Get regular aerobic exercise (e.g. walking or swimming). Exercise increases back and abdominal muscle strength and flexibility, which helps support and align your back, and minimises the frequency and severity of back injuries. Flexibility in the hips and upper legs allows for correct pelvic bone alignment.
Choose an exercise level suited to your fitness level, and do gentle warm-up stretches before and after exercising. If you've had back problems, consult your doctor or physiotherapist before starting a new exercise regime.
Use proper body mechanics:
Standing. Maintain a neutral pelvic position, and avoid rounding your back. Avoid hunching your shoulders and tensing your neck when stressed. Wear comfortable, low-heeled shoes - high heels put pressure on your lower back.
Sitting. Use a seat with good lower back support. Keep your knees and hips level.
Lifting. Hold the load close to your body, keep your back straight and bend at the knees. Let your legs take most of the strain. Avoid lifting and twisting simultaneously.
Lose weight. If you are more than 10 percent over your ideal body weight, lose weight through healthy diet and aerobic exercise, on your doctor's advice.
When to call the doctor
Contact your doctor promptly if back pain results from a fall or blow to the back. Otherwise, contact your doctor if pain does not improve after about a week.
Infrequently, back pain can signal a serious medical problem. Consult your doctor if you have back pain and:
Bladder or bowel control problems, or difficulty passing urine
Numbness in the groin or anal region
Weakness, numbness or "pins and needles" in the legs
Fever
Rapid weight loss
A history of cancer
Abdominal pain
Pain running down one or both legs
You feel unsteady on your feet
The pain is increased by lying down
The pain is unrelated to movement
A history of corticosteroid use
A history of intravenous drug use
A history of urinary tract infection
In children, any severe back pain that persists for more than three days
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