Low back pain

Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]

Low back pain is a common musculoskeletal disorder which affects the lumbar segment of the spine. It can be either acute, subacute or chronic in its clinical presentation. Typically, the symptoms of low back pain do show significant improvement within two to three months from its onset. In a significant number of individuals, low back pain tends to be recurrent in nature with a waxing and waning quality to it. In a small proportion of sufferers this condition can become chronic. Population studies show that back pain affects most adults at some stage in their life and accounts for more sick leave and disability than any other single medical condition.

An acute lower back injury may be caused by a traumatic event, like a car accident or a fall. It occurs suddenly and its victims will usually be able to pinpoint exactly when it happened. In acute cases, the structures damaged will more than likely be soft tissue like muscles, ligaments and tendons. These tissues can account for chronic low back pain as well. With a serious accident, or when osteoporosis or other causes of weakened vertebral bones is present, vertebral fractures in the lumbar spine may also occur. At the lowest end of the spine, some patients may have tailbone pain (also called coccyx pain or coccydynia). Others may have pain from their sacroiliac joint at the bottom of the lumbar spine, called sacroiliac joint dysfunction.

Chronic lower back pain usually has a more insidious onset, occurring over a long period of time. Physical causes may include soft tissue injury or pathology as previously described, nerve root irritation radiculopathy, osteoarthritis, rheumatoid arthritis, degeneration of the discs between the vertebrae, spinal disc herniation, vertebral fracture (such as from osteoporosis), or rarely, a tumor (including cancer) or infection. Psychological or emotional issues can also have a profound impact upon low back pain.

Many people will feel better within 1 week after the start of acute low back pain. After another 4-6 weeks, the back pain will likely be completely gone.

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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]

The back is an intricate structure of bones, muscles, and other tissues that form the posterior part of the body’s trunk, from the neck to the pelvis. The centerpiece is the spinal column, which not only supports the upper body’s weight but houses and protects the spinal cord — the delicate nervous system structure that carries signals that control the body’s movements and convey its sensations. Stacked on top of one another are more than 30 bones — the vertebrae — that form the spinal column, also known as the spine. Each of these bones contains a roundish hole that, when stacked in register with all the others, creates a channel that surrounds the spinal cord. The spinal cord descends from the base of the brain and extends in the adult to just below the rib cage. Small nerves (“roots”) enter and emerge from the spinal cord through spaces between the vertebrae. Because the bones of the spinal column continue growing long after the spinal cord reaches its full length in early childhood, the nerve roots to the lower back and legs extend many inches down the spinal column before exiting. This large bundle of nerve roots was dubbed by early anatomists as the cauda equina, or horse’s tail. The spaces between the vertebrae are maintained by round, spongy pads of cartilage called intervertebral discs that allow for flexibility in the lower back and act much like shock absorbers throughout the spinal column to cushion the bones as the body moves. Bands of tissue known as ligaments and tendons hold the vertebrae in place and attach the muscles to the spinal column.

Starting at the top, the spine has four regions:

• the seven cervical or neck vertebrae (labeled C1–C7),
• the 12 thoracic or upper back vertebrae (labeled T1–T12),
• the five lumbar vertebrae (labeled L1–L5), which we know as the lower back, and
• the sacrum and coccyx, a group of bones fused together at the base of the spine.

The lumbar region of the back, where most back pain is felt, supports the weight of the upper body. 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 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. Any one of these structures can back and leg pain. When the posterior branch of a nerve root become compressed or irritated, back pain results. When the anterior branch of the nerve root becomes irritated back and leg pain results.

Low back pain may reflect nerve irritation, muscle or ligament injury 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. Buildup 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 pain radiating down the leg related to neuropathy. People with any of these symptoms should contact a doctor immediately to help prevent permanent damage.

Conditions that may cause low back pain and require treatment by a physician or other health specialist include:

• Bulging disc (also called protruding, herniated, or ruptured disc). The intervertebral discs are under constant pressure. As discs degenerate and weaken, cartilage can bulge or be pushed into the space containing the spinal cord or a nerve root, causing pain. Studies have shown that most herniated discs occur in the lower, lumbar portion of the spinal column.
• A much more serious complication of a ruptured disc is cauda equina syndrome, which occurs when disc material is pushed into the spinal canal and compresses the bundle of lumbar and sacral nerve roots. Permanent neurological damage may result if this syndrome is left untreated.
• Sciatica is a condition in which a herniated or ruptured disc presses on the sciatic nerve, the large nerve that extends down the spinal column to its exit point in the pelvis and carries nerve fibers to the leg. This compression causes shock-like or burning low back pain combined with pain through the buttocks and down one leg to below the knee, occasionally reaching the foot. In the most extreme cases, when the nerve is pinched between the disc and an adjacent bone, the symptoms involve not pain but numbness and some loss of motor control over the leg due to interruption of nerve signaling. The condition may also be caused by a tumor, cyst, metastatic disease, or degeneration of the sciatic nerve root.
• Spinal degeneration from disc wear and tear can lead to a narrowing of the spinal canal. A person with spinal degeneration may experience stiffness in the back upon awakening or may feel pain after walking or standing for a long time.
• Spinal stenosis related to congenital narrowing of the bony canal predisposes some people to pain related to disc disease.
• Osteoporosis is a metabolic bone disease marked by progressive decrease in bone density and strength. Fracture of brittle, porous bones in the spine and hips results when the body fails to produce new bone and/or absorbs too much existing bone. Women are four times more likely than men to develop osteoporosis. Caucasian women of northern European heritage are at the highest risk of developing the condition.
• Skeletal irregularities produce strain on the vertebrae and supporting muscles, tendons, ligaments, and tissues supported by spinal column. These irregularities include scoliosis, a curving of the spine to the side; kyphosis, in which the normal curve of the upper back is severely rounded; lordosis, an abnormally accentuated arch in the lower back; back extension, a bending backward of the spine; and back flexion, in which the spine bends forward.
• Fibromyalgia is a chronic disorder characterized by widespread musculoskeletal pain, fatigue, and multiple “tender points,” particularly in the neck, spine, shoulders, and hips. Additional symptoms may include sleep disturbances, morning stiffness, and anxiety.
• Spondylitis refers to chronic back pain and stiffness caused by a severe infection to or inflammation of the spinal joints. Other painful inflammations in the lower back include osteomyelitis (infection in the bones of the spine) and sacroiliitis (inflammation in the sacroiliac joints).

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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]

Radiographic abnormalities of the low back may occur in patients without pain.^[1][2]

Possible causes of low back pain: ^{[3] [4]}

• Mechanical:
  • Apophyseal osteoarthritis
  • Facet arthropathy
  • Diffuse idiopathic skeletal hyperostosis
  • Degenerative Discs
  • Scheuermann’s kyphosis
  • Spinal disc herniation (slipped disc)
  • Spinal stenosis
  • Spondylolisthesis and other congenital abnormalities
  • Fractures
  • Non-specific muscular or ligamentous strains or sprains
  • Leg length difference
  • Restricted hip motion
  • Misaligned pelvis- pelvic obliquity, anteversion or retroversion
• Inflammatory:
  • Seronegative spondylarthritides (e.g. ankylosing spondylitis)
  • Rheumatoid arthritis
  • Infection – epidural abscess or osteomyelitis
• Neoplastic:
  • Bone tumors (primary or metastatic)
  • Intradural spinal tumors
• Metabolic:
  • Osteoporotic fractures
  • Osteomalacia
  • Ochronosis
  • Chondrocalcinosis
• Paget’s disease
• Referred pain:
  • Pelvic/ abdominal disease
  • Posture
• Soft Tissue:
  • Ligament strain
  • Muscle spasm
  • Nerve root irritation, radiculopathy
  • Posterior rami syndrome
  • Sympathetic pain syndromes RSD,CRPS
• Depression
• Oxygen deprivation

• Acute intermittent porphyria
• Adrenal hemorrhage
• Alkaptonuria
• Ankylosing spondylitis
• Aortic aneurysm, abdominal
• Autoimmune oophoritis
• Axial osteosclerosis
• Back strain
• Bone metastases
• Breakdance back syndrome
• Breast cancer
• Cauda equina syndrome
• Chlamydia infection
• Chondrocalcinosis
• Chordoma
• Cholesterol embolism
• Chronic interstitial nephritis
• Chronic pancreatitis
• Clinical depression
• Cobb syndrome
• Coccydynia
• Colorectal polyps
• Colorectal cancer
• Copper toxicity
• Danubian endemic familial nephropathy
• Degenerative disc disease
• Diffuse idiopathic skeletal hyperostosis
• Disc disorder
• Discitis
• Dysmenorrhoea
• Ehlers-Danlos syndrome
• Enteropathic arthritis
• Epidural abscess
• Excessive lifting
• Facet arthropathy
• Familial renal cell carcinoma
• Fractures
• Functional disorders
• Intervertebral disc herniation
• Intradural spinal tumors
• Juvenile osteochondrosis of spine
• Juvenile osteoporosis
• Leukemia, mast-cell
• Ligament strain
• Malignancy
• Marchiafava-Micheli disease
• Metastatic neoplasm
• Misaligned pelvis- pelvic obliquity, anteversion or retroversion
• Multifocal fibrosclerosis
• Muscle spasm
• Myeloma
• Ochronosis
• Osteomalacia
• Osteomyelitis
• Osteoporosis
• Paget disease of bone
• Pancreatic cancer
• Pelvic abscess
• Pelvic inflammatory disease
• Polycystic kidney disease, adult (autosomal dominant)
• Polymyalgia rheumatica
• Pompe’s disease
• Posterior Rami Syndrome
• Posture
• Pregnancy
• Premenstrual syndrome
• Prostate cancer
• Prostatitis
• Psoriatic arthritis
• Pyelonephritis, acute
• Reiter’s syndrome
• Retroperitoneal fibrosis
• Retroperitoneal haemorrhage
• Scheuermann’s disease
• Seronegative spondylarthritides
• Spastic pelvic floor syndrome
• Spinal cord injury, acute
• Spondylolisthesis
• Spondylolysis
• Spondylosis
• Sympathetic pain syndromes
• Tethered cord syndrome
• Transverse myelitis
• Tuberculosis
• Uterine fibroids
• UTI
• Vertebral dysfunction
• Vertebral fracture
• Viral prostatitis
• Whiplash Injuries

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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1];Associate Editor(s)-in-Chief: Hadeel Maksoud M.D.[2]

Diagnosing the cause of back pain can be difficult, because many diseases can cause this symptom. Most frequently the cause is benign and/or self-limiting, but more serious causes may require urgent intervention. Acute back pain is a severe, persistent back pain of sudden onset that is likely to require surgical intervention to treat its cause. The following table summarizes differential diagnosis for back pain.

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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]

Nearly everyone has low back pain sometime. Men and women are equally affected. It occurs most often between ages 30 and 50, due in part to the aging process but also as a result of sedentary life styles with too little (sometimes punctuated by too much) exercise. While the risk of experiencing low back pain from disc disease or spinal degeneration increases with age after age 50 degenerative disc disease is less likely to be the cause. It is important not to assume that low back pain is due to disk disease simply because it is present on X ray or MRI as these findings are quite common in those without back pain as well.

Low back pain unrelated to injury or other known cause is unusual in pre- teen children. However, a backpack overloaded with schoolbooks and supplies can quickly strain the back and cause muscle fatigue. The U.S. Consumer Product Safety Commission estimates that more than 13,260 injuries related to backpacks were treated at doctors’ offices, clinics, and emergency rooms in the year 2000. To avoid back strain, children carrying backpacks should bend both knees when lifting heavy packs, visit their locker or desk between classes to lighten loads or replace books, or purchase a backpack or airline tote on wheels.

One is also at risk for low back pain in case of:

• Pregnancy
• Stress or depression
• Arthritis or osteoporosis
• Smoking
• Overweight
• Job that requires heavy lifting, a lot of bending and twisting, or whole body vibration (such as truck driving or using a sandblaster)

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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]

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Many people will feel better within 1 week after the start of acute low back pain. After another 4-6 weeks, the back pain will likely be completely gone.

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