Back pain affects more than 30 million Americans at any given time, ultimately 80% of the population will suffer, at some point. Anywhere from 2% to 10% of individuals who experience back pain develop what is considered chronic back pain, defined as recurring pain lasting more than three months. By taking some time to better understand back pain, patients can develop a full understanding of what may be causing their pain, the treatments available and how to minimize or prevent back pain.
Causes of Back Pain
The exact cause of back pain isn’t always easy to pinpoint, especially for discomfort that’s initially diagnosed as “lower back pain”. There is usually no specific cause able to be determined, meaning that the pain could be the result of anything from pulled muscles and strained ligaments to misaligned discs and swollen joints. Most causes of back pain are treatable, to some extent, with recovery rates depending on factors such as a patient’s overall health and age. According to the American Chiropractic Association, degenerated discs and herniated discs rank as the leading causes of back pain, affecting any one of the spongy material (discs) sitting between the 30 individual vertebra making up the spine. When discs wear out or become damaged, the bones of the spine come in contact with each other, often involving nearby nerves as they emerge from the spinal column.
Anatomical causes of back pain are divided into three main classifications: axial pain (the most common type of back discomfort often caused by muscle strain), referred pain (pain that moves around and various in intensity, often radiating beyond the back area) and radicular pain (more intense pain frequently causing related numbness in extremities that is often associated with spinal stenosis and sciatica). Even if there is no apparent physical cause, back pain can still be very real. Psychological factors, such as prolonged depression, can also contribute to recurring back issues. Additional sources of back pain can include:
- Sports injuries
- Spondylolisthesis (normal wear and tear of joints and ligaments supporting the spine causing vertebrae to move excessively, resulting in pressure on nerves)
- Scoliosis (abnormal curvature of the spine)
- Arthritis (affecting joints supporting the back)
- Bone loss (weakens the spine itself)
- Psychological stress
- Kidney stones
- Poor posture
- Spinal stenosis (narrowing of space around the spinal cord caused by calcification in the vertebrae)
- Osteoporosis (brittle bones susceptible to injury)
Diagnosing Back Pain
Diagnostic tests can confirm an abnormality or disease that may be contributing to spine-related pain or discomfort. However, unless back pain is the result of an obvious cause (tumours, sudden trauma, injury to the spine), diagnosis can be difficult. It is not unusual for different spine specialists to have varying opinions on the source of back pain. The attempt to accurately diagnosis back pain starts with ruling out other conditions that may be causing or contributing to the pain. Diagnostic tests, such as CT scans, x-rays, MRIs, electromyography, facet blocks and selective nerve root blocks, alone do not always clearly identify a specific source of back pain. Consequently, diagnostic testing is often combined with findings from physical examination and patient history to achieve what is termed a “clinical diagnosis” based on several factors used to determine the most likely source of back pain.
Treating Back Pain
The general approach to back pain treatment is to start with conservative treatments before progressing to surgical options. Studies suggest that so-called “common sense treatments” like bed rest, learning proper lifting techniques and modifying routines to avoid situations likely to cause back pain tend to be effective for most instances of temporary back pain caused by muscle strain or overexertion, although successful relief from back pain tends to involve a combination of treatments. Escalation of treatment is usually dependent on how well patients are responding and whether or not the pain is at a point where it can be managed without diminishing a patient’s overall quality of life.
Physical Therapy (PT)
Physical therapy for back pain can be either passive or active. Passive PT includes the application of heat and cold, iontophoresis (the application of steroids through the skin in conjunction with an electrical current to facilitate delivery to the affected area to reduce inflammation), transcutaneous electrical nerve stimulator (TENS) and ultrasound (often used for acute episodes of pain). Active PT includes any type of therapy involving movement to strengthen muscles, tendons and ligaments supporting the spine such as low-impact aerobics, water-based exercises, weight training, strength training and range of motion exercises.
Chiropractic Manipulation and Acupuncture
Chiropractic manipulation involves adjustments that stimulate certain muscles supporting the spine to relieve tension that may be aggravating pain. The Agency for Health Care Policy refers to chiropractic manipulation as the safest drug-free treatment for lower back pain suffers. Acupuncture, the careful insertion of sterilized needles into specific points within the body, also provides relief for some patients. As with chiropractic manipulation, there is not a lot of scientific research or evidence base available on the effectiveness of acupuncture. However, such treatments rarely cause any serious detrimental side effects.
Over-the-counter (OTC) non-steroidal anti-inflammatory drugs (NSAIDs) like Tylenol (acetaminophen), Aleve (naproxen) and Motrin (ibuprofen) are typically the first medications most people take for relief from back pain. If OTC medications fail to provide meaningful relief, the next step up is prescription NSAIDs like Voltaren (diclofenac), Celebrex (celecoxib) and Relafen (nabumetone). NSAIDs, while generally safe, can produce potentially serious side effects in larger doses, including kidney and liver damage, ulcers and gastrointestinal issues. Anti-inflammatory medications are also available in topical forms that can be applied directly to the affected area of the back. There is less risk with topical medications like capsaicin, eucalyptus oil, menthol and camphor than anything consumed orally. Additional medications that may be prescribed or recommended for back pain relief include:
- Muscle relaxants (to relieve muscle spasms)
- Opioids (for long-lasting relief of chronic back pain, often recommended following spine surgery)
- Corticosteroids (to relieve inflammation, available in both injectable and oral form)
Some antidepressants like Cymbalta and anti-seizure medications like Lyrica are prescribed to relieve nerve symptoms associated with back pain. Drowsiness is the most common side effect associated with muscle relaxants. However, there is a risk of dependence associated with opioids (narcotic medications). Some patients may have allergic reactions to such drugs. Side effects associated with corticosteroids may include weight gain, bone loss and issues with blood sugar levels. Patients are encouraged to maintain an open dialogue with their doctors to minimize risks associated with both OTC and prescription medications, especially when it comes to potential interactions with medications being taken for other conditions not related to back pain.
Except for spinal cord injuries and certain diseases that are clearly affecting nerves, surgery is rarely the first option for back pain relief. It is comforting for patients to know that spine surgery has come a long way since its infancy. New technology used in spinal fusions, the most common type of back-related surgery, allowing surgeons to get a better view of the spine to ensure the proper placement of screws and related hardware.
During fusion surgery, bones of the spine are “fused” together to prevent mobility in the affected area of the spine to reduce pain associated with movement. Since part of the spine is fused together, patients often have some degree of limited mobility. However, physical therapy can restore enough mobility to allow patients to lead a normal or near normal life.
Artificial disc replacement is an alternative to traditional fusion surgery, involving the insertion of an artificial disc in the space left from the removal of the damaged disc This technique preserves motion of the affected area of the spine. The technique has been approved for use among the general population by the U.S. Food and Drug Administration.
Additional surgical options for back pain include:
- Laminectomy (removal of bone spurs, part of a vertebra, or certain ligaments supporting the spine to relieve pressure on nerves)
- Foraminotomy (cutting away of bone along the sides of vertebrae to allow for more space where nerve roots leave the spine)
- Discectomy (removal of all or part of a “bulging” or herniated disc, sometimes combined with other surgeries to correct multiple issues affecting the spine)
- Inter-laminar implant (an alternative to fusion surgery involving the insertion of a U-shaped device between vertebrae to relieve pressure on spinal nerves)
Risks associated with back surgery include infection, bleeding at the surgical site, blood clots, nerve damage, possibly leading to increased weakness, sexual dysfunction or damage to adjacent parts of the spine. Patients with pre-existing conditions may be at risk of heart attack or stroke. Severe complications are rare, especially if patients are properly evaluated before proceeding with back surgery.
Potential benefits of successful back surgery can include an improved mood, increasing movement without pain and less dependence on medications that may have side effects associated with long-term use. Even non-surgical options like bracing are only meant for short-term use. Patients should know that exploratory surgery prior to spine surgery is rare due to improved techniques for viewing the spine and its related parts. It is vitally important for patients to adhere to follow-up instructions to increase the odds of experiencing a successful recovery.
Preventing Back Pain
While back pain can affect anybody at anytime, there are certain steps that can be taken to minimize the risk of developing back issues. Bed rest is only recommended for short-term relief of back pain since prolonged bed rest can weaken muscles supporting the spine and, inadvertently, make back pain worse. Remaining active, under doctor’s supervision, can also prevent back pain from recurring. Back issues can also be avoided, or at least minimized, by taking any of the following steps:
- Maintaining a healthy diet (and a proper weight range)
- Warming up before exercising or working out
- Wearing comfortable shoes (low-heeled)
- Maintaining a proper posture
- Avoiding uncomfortable (or unnatural) sleeping positions
- Sleeping on a medium-firm mattress (to minimize curvature of the spine)
- Limiting alcohol intake and quitting smoking
Despite the fact that it’s a common complaint for one out of every four Americans, back pain is highly individualized. Treatments that work for one person may have little or no effect on someone else with the same type of pain. For this reason, it is important for patients to be as involved with their diagnosis and treatment as much as possible by asking questions, seeking multiple opinions and gathering information so well-informed decisions can be made when it comes to finding a treatments most likely to provide meaningful relief.