A large number of people experience an episode of back pain during their lifetime. Back pain is one of the top most common reasons people visit healthcare providers. In the West, for example, back pain is the second of two common reasons why people visit their family doctor (just behind upper respiratory infections). Back pain also disables a substantial percentage of the workforce on any given day. In people under 40 years of age, back pain is the most common reason for inability to perform daily activities.
Pain that affects primarily the back should be distinguished from spinal conditions that result in predominant leg pain, commonly called sciatica. Typically, sciatica is the result of a “pinched nerve” in the spinal column. In most cases, the cause of the sciatica is clearly defined - such as disc or arthritic spur. The cause of an episode of back pain, on the other hand, is often more difficult to pinpoint and may be related to the spinal discs, joints, vertebrae, or soft tissue supports (muscles, ligaments, tendons).
Acute back pain
Most people recover from an episode of acute back pain within two weeks with minimal medical intervention. Appropriate use of over-the-counter pain relievers, such as acetaminophen or ibuprofen, and early resumption of normal activities as permitted by pain, for most are simple and effective treatments. X-rays or scans (MRI, CT scan) are rarely required.
Warning signs or “red flags” that should prompt urgent medical evaluation include the presence of fever, worsening pain, progressive movement of the pain from the back into the leg, and pain that is unrelieved at rest or disturbs sleep.
Chronic persistent back pain
Most back pain resolves within a few days with simple treatment. When back pain persists beyond 2 - 4 weeks, further careful medical evaluation is required. This evaluation focuses on a careful medical history and physical examination to identify, if possible, a precise cause of the pain. Rarely, malignancy or infection is found. More commonly, the source of the pain is discovered to be related to the spinal joints, discs, or supporting musculature.
In many people with back pain, an MRI is not helpful in defining the cause. For example, the MRI provides little information as to the condition of the ligaments, muscles, and tendons. It may demonstrate common degenerative, or “wear and tear” changes in the discs or joints in the spine. However, these changes are common in people who have no symptoms. It is often difficult to know whether or not to “blame” back symptoms on a finding seen on the MRI scan.
Treatment of back pain: an "aggressive, conservative" approach
Most chronic, persistent back pain can be successfully treated without surgery. Following a careful medical evaluation for rare, serious causes, and, in some cases, x-ray or MRI imaging, treatment focuses on symptom relief and active, exercise-oriented rehabilitation of the back. Excessive bed rest or restricted activity promotes muscular stiffness, deconditioning, and delays recovery.
The role of medication in the management of back pain is primarily to relieve symptoms and facilitate an active, exercise-oriented rehabilitation program. An array of new medications is now available to assist in achieving this goal.
New roles for some older medications have been found in the treatment of back pain. For example, disruption of sleep by chronic back pain is common. Poor sleep may, in fact, magnify pain. Improving the quality of sleep with low doses of traditional anti-depressant medicine such as doxepin may reduce pain. Anti-convulsants such as gabapentin are often helpful for nerve irritation symptoms such as burning or numbness. In rare instances, careful use of long-acting opioid pain relievers may improve function and quality of life.
Active, exercise-oriented physical therapy is the cornerstone of treatment for people with chronic back pain. Treatments methods such as heat, ice, massage, and ultrasound may provide temporary relief, but rarely provide long-term benefit. Exercise programs should be individualized by a spine-oriented physical therapist. Typically, the exercise program can be performed at home without special equipment. Follow-up visits with the therapist are necessary to “fine-tune” the program.
When back pain is chronic, persistent and disabling, a comprehensive treatment approach addressing all aspects of the problem, including physical as well as psychological issues, offers the best hope for rehabilitation and recovery. A multi-disciplinary treatment team consisting of a doctor, physical therapist, psychologist or psychiatrist, and pain management specialist offers the best hope for return to an active, productive lifestyle.