Dr. Tory McJunkin explains the sources of low back pain. Low back pain can come from a variety of sources and cause different types of pain. It is very important to seek proper care for treatment.
Watch Pain Doctor Tory McJunkin Discuss Low Back Pain.
The magnitude of pain in the US is astounding. In effect, pain could be considered an epidemic, with more than 116 million Americans reporting pain that persists for weeks to years, and total financial costs reaching $560 billion to $635 billion annually (Pizzo & Clark, 2012).
Low back pain accounts for a large part of the US pain epidemic. According to research, it is one of the most common reasons for visits to a physician (Berman et al, 2010). In fact, when surveyed about their pain, 27% of respondents of a National Institutes of Health (NIH) Statistics survey indicated that they experienced low back pain more than other types of pain (National Center for Health Statistics
Unfortunately, adults with low back pain are often in poorer physical and mental health than those who do not have low back pain. A report states 28% of adults with chronic low back pain have limited activity, as compared to 10% of adults who do not have low back pain (NCHS, 2006). Also, adults reporting low back pain were three times as likely to be in fair or poor health and more than four times as likely to experience serious psychological distress as people without low back pain (NCHS, 2006).
In general, the back provides a strong musculoskeletal framework that supports the body’s weight, permits movement, carries the head, and maneuvers the upper limbs. The vertebral column, or spine, in most individuals consists of 33 vertebrae that run in a line from the base of the head to the buttocks. The spine is divided into five regions from top to bottom with varying numbers of vertebrae: cervical (seven), thoracic (12), lumbar (five), sacral (five) and coccygeal (three to four). Stress on the vertebral column increases as it runs from the cervical to the lumbar regions, which makes low back problems more common.
A vertebra consists of a vertebral body and an arch. The arches serve as attachments for muscles and ligaments and form joints that serve as sites of articulation with adjacent vertebrae. The arches also align to form a canal, which houses the spinal cord and its protective membranes (meninges), blood vessels, and other tissues. The spinal cord does not extend the full length of the vertebral canal as the vertebral column grows faster than the spinal cord during development.
Spinous processes that can be felt through the skin project from the roof of the vertebral arch. On either side of the arches, transverse processes extend and provide attachment points for muscles and ligaments. The extrinsic muscles of the back are involved with movement of the upper limbs and thoracic wall. The intrinsic muscles of the back support and move the vertebral column and head and participate in movement of the ribs.
A typical vertebra also has six joints with adjacent vertebrae. These include four synovial joints and two symphyses. The latter contain intervertebral discs, which have a tough outer covering (the annulus fibrosus) and a soft inner filling (the nucleus pulposus). The pliable center of an intervertebral disc absorbs impact and compressive forces between vertebrae.
A total of 31 pairs of spinal nerves emerge from the vertebral canal between adjacent vertebrae. Each nerve is attached to the spinal cord by an anterior and posterior root.
Back Pain Conditions
Back pain is either acute or chronic in nature. Acute low back pain occurs suddenly and usually resolves in several weeks, although recurrences are common and low-grade symptoms are often present for years after an initial episode (Carragee, 2005). Approximately 90% of acute episodes resolve within 6 weeks (Carragee, 2005). However, 25% or more of patients have recurrent pain within the next year (Stanton et al, 2008), and chronic back pain, which may persist for longer than several weeks, develops in up to 7% of patients (Speed, 2004).
The chief cause of acute back pain is typically mechanical injury, or damage to myofascial components of the back (e.g., ligaments, discs, joints, nerves, and meninges). Trauma to these tissues can be sustained from exercise, physical accidents, lifting of heavy objects, poor posture, and other causes. When these structures become strained, irritation may occur in local nerves that exit the spine. Mechanical injury accounts for 97% of cases of low back pain (Hoy et al, 2010).
The pathophysiology of chronic low back pain is not completely understood, but is increasingly recognized as complex and multifactorial (Berman et al, 2010). Chronic low back pain is thought to develop over time as a result of age-related degenerative processes or certain health conditions. Structural disorders of the spine itself, such as compression fractures, spinal stenosis, and disc herniation, may account for some 10 to 15% of cases Berman et al, 2010). However, the most common problem (85% of cases) is “nonspecific” or “idiopathic” low back pain, and it is this disorder that is most often associated with chronic or recurrent symptoms (Berman et al, 2010).
More recent investigations into the development of chronic low back pain focus on alterations in the central nervous system (Borsook et al, 2007). Studies using functional MRI have shown alterations in cerebral activation, and anatomical studies have shown changes in regional volume and density in the brain (Berman, 2010). It has been suggested that these alterations may reflect or contribute to changes in central nervous system processing of sensory stimuli (Berman, 2010). However, the specific findings of these studies have not been entirely consistent with one another, and it is not clear whether the observed alterations are a cause or a consequence of chronic low back pain (Berman, 2010).
In addition, psychological and behavioral factors, including fear of movement, appear to play an important role in patients with chronic low back pain (Berman, 2010) Such patients have been shown to have altered brain-activation patterns at subcortical and cortical sites associated with emotion and postural control (Berman, 2010).
Degenerative disc disease is thought to be a normal process that occurs with aging. As a person ages, discs in the vertebral column can flatten, deform and lose their suppleness, inhibiting smooth movement and causing pain. The resulting reduction in space between vertebral bodies can also create excessive friction between vertebrae, particularly in the delicate facet joints, and crowding which results in compressed spinal nerves and crumbling spinal bones.
As spinal discs gradually degenerate, pressure within the spinal column increases, often causing bulging and herniation of discs. A bulging disc, or protuberance of the disc out of place, can produce local nerve irritation and compression of the spinal cord. In disc herniation, a tear or softening in the outer fibrous layer of an intervertebral disc permits the pliable inner material to prolapse through the weakened part of the disc. Although disc herniation is associated with age-related degenerative changes, it can occur in younger people, generally by trauma or heavy lifting. Like bulging discs, herniated discs cause local nerve irritation and compression of the spinal cord, which produce pain.
In other cases, the vertebral bones are responsible for low back pain. Reasons for this include vertebral fractures, and bone degeneration from osteoarthritis.
Vertebral fractures of the thoracic and lumbar spine account for an estimated 700,000 of the 1.5 million osteoporotic fractures occurring annually in the United States (Riggs & Melton, 1995). Vertebral fractures typically occur as a manifestation of the low bone mineral density characteristic of osteoporosis (Ensrud & Schousboe, 2011), and are usually identified clinically when a patient presents with back pain, and a spinal radiograph is interpreted as showing a fracture of a vertebral body (Cooper et al, 1992).
The prevalence and incidence of radiographic vertebral fractures increase with age, with the prevalence among white women rising from 5% to 10% between the ages of 50 and 59 years and to 30% or more at 80 years of age or older (Melton et al, 1993). Reported prevalence rates are lower among black women (Cauley et al, 2008), Asian women (Ling et al, 2000) and men (O’Neill et al, 2000).
Osteoarthritis involves degeneration of the smooth cartilage covering joint surfaces within the vertebrae, and lowered production of synovial fluid, the specialized fluid produced to lubricate joints. Painful swelling and irritation of joint linings, the synovial membranes, may also occur. As the spinal joints begin to rub against each other, the result is pain, inflammation, and formation of bone spurs.
When spinal nerve roots are compressed from disc problems, osteoarthritis, or other reasons, a form of pain called radiculitis may occur. Radiculitis is pain that radiates or shoots down the length of the nerve, travelling from the spine outward, often down an arm or leg. In the low back, radiculitis within the large sciatic nerve that extends through the buttocks down the back of the leg causes the common ailment sciatica.
When radiculitis goes untreated, complications such as muscle atrophy, reflex changes and sensory loss may occur over time. In addition, a patient may begin to favor the unaffected side, causing overdevelopment of unaffected muscles. This more severe nerve root condition is known as radiculopathy and highlights the importance of seeking early treatment.
Spinal stenosis is another long-term condition that can be responsible for low back pain. In spinal stenosis, harmful narrowing of the spinal canal puts painful pressure on the central region of the spinal canal directly surrounding the spinal cord and cauda equina, or the bundle of nerve fibers at the bottom of the spinal cord. In some cases, the narrowing can affect spinal nerves where they exit through the openings in the vertebrae. Spinal stenosis may result from a variety of causes including osteoarthritis of the spine, herniated discs, congenital defects (abnormalities present at birth) and Paget’s disease, a bone disorder involving abnormal breakdown and regrowth of bone tissue.
Rarer mechanisms of low back pain include cancer and infection. In the case of cancer, tumors or metastases to the spine weaken or expand bone in the vertebral column, often leading to fracture, nerve compression, or spinal instability. And any source of infection (e.g., dental abscess, pneumonia) can seed the spine; urinary tract infection is the most common (Siemienow et al, 2008). Another rarer cause of low back pain is referred pain. Although this type of pain originates from structures located in the same region as the spine, it is interpreted by the brain as pain felt in the back. For example, problems with reproductive organs can be perceived as low back pain. In cases of referred pain, treating the underlying cause helps eradicate discomfort felt in the low back.
Chronic low back pain from any long-term condition like osteoporosis, facet arthritis, radiculitis, and spinal stenosis may lead to central sensitization. In central sensitization, chronic injury and inflammation in peripheral tissues eventually prompt pain receptors in the central nervous system to overreact to normal physical sensations. Low-threshold sensory fibers activated by light touch of the skin trigger neurons in the spinal cord that normally respond only to painful stimuli, and painful stimuli can be felt as more painful than necessary. Early treatment can help impede the gradual evolution of factors that lead to central sensitization.
Back Pain Treatments
In order to determine the etiology as well as the optimal treatment approaches, a history and physical examination are the first steps in addressing a patient’s back pain. These steps are useful for detecting signs of serious underlying diseases and identifying risk factors for delayed recovery (Carragee, 2005). In some cases, imaging studies (e.g., MRI, CT scan, X-ray) will be ordered to help visualize structures that may be causing the pain.
Nerve blocks (e.g., medial branch blocks) are a minimally invasive non-surgical procedure that may be ordered for diagnostic evaluation of low back pain. Nerve blocks are used to test whether certain suspect nerves are causing pain and whether they will respond to more permanent interruption by denervation procedures such as radio-frequency ablation. Nerve blocks also have a therapeutic effect in that they reduce inflammation and irritation in painful areas of the spine.
One test used by some clinicians to direct invasive therapy is provocative discography, which involves injection of dye into an intervertebral disc in order to obtain a detailed image (Carragee, 2005). Discography is intended to provide detailed information on the pain potential of the affected area, and is commonly used for surgical planning prior to a lumbar fusion. In addition, proponents of the test suggest that if injection into a disc reproduces a patient’s typical low back pain, then that disc must be the cause of the patient’s pain.
A wide variety of treatments are available for the treatment of low back pain, with different treatments specifically designed to target different etiologies (Chien & Bajwa, 2008). A balanced approach to treatment, which takes into account patient psychosocial factors and incorporates multidisciplinary care, increases the likelihood of success from back pain interventions (Chien & Bajwa, 2008). In fact, multidisciplinary treatment has been shown to ameliorate pain, increase functional restoration, and improve quality of life with medium to high effect sizes even for patients with a long history of chronic back pain (Moraidi et al, 2012).
Treatment plans often begin with gentle pharmacological therapy and rest. Medications prescribed for low back pain usually include analgesics, anti-inflammatory drugs, and muscle relaxants. Non-steroidal anti-inflammatory drugs (NSAIDs, or Ibuprofen-like drugs), Acetaminophen (Tylenol), muscle relaxants, and membrane stabilizing medications are particularly effective in treating low back pain. Regarding NSAIDs, evidence from 65 trials included in a review suggests these drugs are effective for short-term symptomatic relief in patients with acute and chronic low-back pain without sciatica (Roelofs et al, 2008). Also, antidepressant drugs of the tricyclic and tetracyclic variety have also demonstrated small but reliable benefits in pain reduction (e.g., a 20 to 40 percent greater reduction in pain than with placebo, during a period of four to eight weeks) in randomized trials in patients with chronic low back pain without clinical depression (Staiger et al, 2003).
Most healthcare providers agree that opioids should be avoided as a therapy for low back pain, if possible, due to their strong and potentially fatal side effects. Opioids are associated with sedation, dizziness, nausea, vomiting, constipation, physical dependence, tolerance, and respiratory depression, delayed gastric emptying, hyperalgesia, immunologic and hormonal dysfunction, muscle rigidity, and myoclonus (Benyamin et al, 2008). Regarding the fatal potential of these drugs, a review on opioids published in the New England Journal of Medicine noted an increase in deaths by poisoning propelled by increased opioid use, which has caused overdose deaths to surpass motor vehicle crashes as the commonest cause of accidental death in the United States (Okie, 2010). The increase, which caused 11,499 of the deaths in 2007, represents more deaths than from heroin and cocaine combined (Okie, 2010). Further, visits to emergency departments for opioid abuse more than doubled between 2004 and 2008, and admissions to substance-abuse treatment programs increased by 400% between 1998 and 2008, with prescription painkillers being the second most prevalent type of abused drug after marijuana (Okie, 2010).
Beyond pharmaceuticals, a variety of extremely safe, efficacious and non-invasive therapies are available for treatment of low back pain.
One such proven therapy is exercise, which seems to increase the rate of return to normal activities in patients with persistent low back pain (Carragee, 2005). A Cochrane review of randomized trials of various exercises for persistent low back pain, which involved strengthening, general stretching, the McKenzie method of passive end-range stretching exercises, and conventional physical therapy, showed that these strategies appeared equivalent and seemed to be more effective than the usual care by a general practitioner (Van Tulder et al, 2000).
Another category of conservative treatment for low back pain is manual therapy, such as physical therapy, massage and chiropractic manipulation. Available data suggest that a combination of therapies including physical therapy or manipulation may be moderately more effective in reducing pain and self-rated disability than is a single method of treatment (Carragee, 2005).
Functional restoration programs may incorporate physical therapy and medical treatment strategies with cognitive behavioral therapy (CBR), an approach that focuses on achieving specific functional goals (Carragee, 2005). CBR seeks to help patients redefine perceptions and opinions about illness, and teaches symptom reduction skills, which may help alter behavioral response to pain. Such programs may also include biofeedback, a treatment method that teaches a patient to become aware and gain some degree of conscious control of processes normally thought to be involuntary inside of the body (e.g., blood pressure, temperature, heart rate). The goal of biofeedback is to influence and improve level of pain.
When more conservative measures fail to bring relief, percutaneous treatments including injections and neuroablation procedures are frequently considered for the treatment of low back pain.
Epidural Steroid Injections (ESIs) into the neck are commonly used for back pain arising from conditions such as degenerative disc disease. The treatment involves injection of a corticosteroid and local anesthetic (e.g., lidocaine) into the epidural space of the spinal cord, where the medication travels throughout the spine, soothing irritated nerve roots and lowering inflammation. In a randomized, double-blind trial, researchers administered up to three epidural injections of corticosteroids or placebo (isotonic saline) to 158 patients with sciatica due to a herniated nucleus pulposus (Carette et al, 1997). At three weeks, there was significantly greater pain relief as measured by Oswestry disability index (ODI) in the group receiving corticosteroid injections compared to the placebo group.
When nerve blocks demonstrate relief, a patient becomes eligible for radiofrequency ablation, or heat-activated destruction of persistently painful nerves causing neck pain. Destruction of these irritated nerves can bring permanent relief to individuals with stubborn back pain. Another method of denervation is cryotherapy, which employs cold temperatures to destroy problematic nerve tissues.
Spinal cord stimulation is another percutaneous intervention for chronic low back pain. In this procedure, small electrodes are implanted within the epidural space close to the spinal cord. The electrodes release a mild electrical current that replaces the feelings of pain with a pleasant buzzing sensation.
A therapy that uses principles similar to spinal cord stimulation to interrupt the transmission of pain signals is transcutaneous electrical nerve stimulation (TENS). Like spinal cord stimulation, TENS uses mild electric impulses to alter sensations that were previously painful. However, unlike spinal cord stimulation, TENS is not an implanted therapy. The unit is placed on the skin over the painful area and can be easily removed. The efficacy of TENS is well-known; for example, a recent study examining the impact of long-term TENS therapy in patients with degenerative disc disease found the treatment contributed to pain relief and improvement of function and mobility of the lumbosacral spine (Pop et al, 2010). In addition, 100% of patients given the treatment reported pain relief as well as improved spinal function and mobility.
Kyphoplasty and vertebroplasty are newer, minimally invasive procedures designed to treat vertebral body collapse and pain. Crushed vertebrae are stabilized by injecting bone cement (e.g., methyl macrylate) into weakened or damaged bone. These procedures are most frequently performed to treat osteoporotic wedge fractures, which represent a substantial cause of morbidity and pain in older patients.
Kyphoplasty and vertebroplasty, which are performed under sedation or light general anesthesia, involve insertion of a metal cannula into the pedicle(s) of the target vertebral body, and injection of liquid bone cement, which hardens quickly. Whereas kyphoplasty incorporates use of a specialized balloon to expand the target area prior to injection, vertebroplasty uses no balloon. The goals of both procedures are to reinforce the strength of crumbling vertebral bodies and restore vertebral height. Studies have shown no clear advantage of one methodology over the other in terms of efficacy and safety (Han et al, 2011; Goz et al, 2011)
Most healthcare providers recommend a calcium intake of 1,000 to 1,200 mg per day and a vitamin D intake of 600 to 800 IU per day (through diet, supplements, or both) to help reduce the risk of subsequent vertebral fractures (Ensrud & Schousboe, 2011). The relatively safe and low-cost drug alendronate is also recommended for reducing incident fractures, including hip fracture) (Ensrud & Schousboe, 2011).
Percutaneous discectomy, or disc decompression, may also bring relief to patients with low back pain. This procedure involves removal of material from the inner disc to relieve pressure on nearby nerve roots. The procedure is typically used for patients with sciatica or leg pain caused by a herniated or bulging disc. The procedure is minimally invasive, performed through small incisions and sometimes endoscopes.
A study observed the effects of percutaneous discectomy in six patients with recurrent herniation who had failed conservative treatment for at least 6 weeks and lumbar surgery for at least 6 months (Eloqayli & Al-Omari, 2012). Based on the positive results, the authors of the study concluded that although the study was small and a short follow up duration, it can be postulated that percutaneous discectomy is effective enough to be considered a fist line treatment for recurrent disc herniation with predominantly leg pain. The authors noted this could be especially helpful in patients with high risk for anesthesia.
Back Pain Alternative Treatments
Another relatively conservative solution for low back pain is acupuncture, a therapeutic intervention characterized by the insertion of fine, solid metallic needles into or through the skin at specific sites (Berman, 2010). The technique is believed to have originated in China, where it has remained a fundamental component of a system of medical theory and practice (Berman, 2010).
Traditional Chinese medicine espouses an ancient physiological system (not based on Western scientific empiricism) in which health is seen as the result of harmony among bodily functions and between body and nature (Berman, 2010). Internal disharmony is believed to cause blockage of the body’s vital energy, known as qi, which flows along 12 primary and 8 secondary meridians (Berman, 2010). Blockage of qi is thought to be manifested as tenderness on palpation (Berman, 2010). The insertion of acupuncture needles at specific points along the meridians is supposed to restore the proper flow of qi (Berman, 2010).
Acupuncture has been shown to induce the release of endogenous opioids in brain-stem, subcortical, and limbic structures (Berman, 2010). According to rat studies, electroacupuncture may induce secretion of adrenocorticotropic hormone and cortisol by the pituitary gland, leading to systemic anti-inflammatory effects (Li et al, 2010). Functional MRI studies in humans have shown immediate effects of prolonged acupuncture stimulation in limbic and basal forebrain areas related to somatosensory and affective functions that are known to be involved in pain processing (Dhond et al, 2010), and results captured by positron-emission tomography have shown that acupuncture increases μ-opioid–binding potential for several days in some of the same brain areas (Harris et al, 2009). Acupuncture also has effects on local tissues, including mechanical stimulation of connective tissue (Langevin et al, 2007), release of adenosine at the site of needle stimulation (Goldman et al, 2010), and increases in local blood flow (Sandberg et al, 2003).
Needle insertion sites are typically determined based upon history and physical examination of the patient by the acupuncturist (Berman, 2010). Needles are usually left in place for 15 to 30 minutes and may be stimulated manually by the practitioner or enhanced with an electrical current (electroacupuncture), moxibustion (burning the herb artemisia vulgaris at the end of the acupuncture needle), or heat (Berman, 2010). Major adverse effects of acupuncture appear to be rare. Two prospective surveys, covering a total of more than 60,000 acupuncture sessions, did not report any major adverse events (MacPherson et al, 2001; White et al, 2001).
Back Pain Conclusion
The role for the surgical treatment of persistent disabling low back pain remains controversial (Carragee, 2005). The chief reason that surgery is avoided unless absolutely necessary is risk of complications such as infection or poor healing. Surgical procedures such as spinal fusion, discectomy, laminectomy and spinal instrumentation are reserved for cases where conservative treatments have been unsuccessful in reducing low back pain or when the spinal cord or exiting nerves are being severely compressed, causing neurological compromise (e.g., bladder and bowel incontinence, lower extremity weakness, spasticity, loss of sensation).
The guidelines of the North American Spine Society suggest that surgery be considered only after a two-to-four-month trial of non-operative measures and only when there are objective findings of structural defects, although the guidelines do not specify whether common degenerative findings constitute sufficient defects (Carragee, 2005). Guidelines of the Washington State Medical Association, which are frequently used, recommend consideration of fusion only for demonstrable instability, deformity, or neurologic injury (Carragee, 2005).
A small randomized trial of 64 patients compared spinal fusion surgery with an aggressive rehabilitation program that used a cognitive behavioral approach among patients with chronic back pain and degenerative changes on imaging found no differences between groups at one year in back pain, function, use of medication, work status, or general satisfaction. After one year, 22 percent of patients in the fusion group returned to work, as compared with 33 percent of those in the rehabilitation group (Ivar Brox et al, 2003).
Low back pain has an enormous impact on individuals, families, communities, governments and businesses throughout the world (Hoy et al, 2010). Since diagnosis of low back pain can be challenging even for seasoned practitioners, consultation with a pain specialist can be invaluable. Pain specialists have received extra training in examination and diagnostics of low pain and other painful conditions. Consultation with a pain specialist can lead to development of an individualized, multimodal treatment plan for low back pain.
- Low Back Pain – PainDoctor.com
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