The Basics of Back Pain

Pain that primarily affects the back should be distinguished from a spinal condition that results in mostly leg pain, a condition 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; for example, a disc problem or arthritis. The cause of an episode of back pain, on the other hand, often is more difficult to pinpoint, and may be related to the discs, joints, or soft tissue supports (muscles, ligaments and tendons).

What is acute back pain?

Acute back pain refers to a brief episode of pain that comes on suddenly. Most people recover from acute back pain within two weeks with minimal treatment. Using over-the-counter pain relievers - such as acetaminophen or ibuprofen - and getting back to normal activities as the pain permits are simple and effective treatments for most people with acute back pain.

What is chronic, persistent back pain?

Most back pain is relieved within a few days to a couple of weeks with simple treatment. When back pain persists beyond two to four weeks - which is chronic, persistent back pain - further medical evaluation is required. This evaluation focuses on a careful assessment of the patient's medical history and a thorough physical examination to identify, if possible, a precise cause of the pain. In rare cases, cancer or an infection is found. More commonly, the pain is related to the spinal joints, discs, or supporting muscles of the back.

What causes back pain?

Other causes of back pain include:

• Disc herniation - A herniated disc is a rupture or tear of the cartilage that surrounds the vertebral discs. Pressure from the vertebrae above and below the affected disc squeezes the cushioning substance (nucleus pulposus) out of the disc. The nucleus pulposus can press against spinal nerve roots. This can cause severe leg pain and may cause nerve damage if not treated properly.
• Osteoarthritis/spinal stenosis - This is characterized by the constriction or narrowing of the vertebral canal, the space that surrounds the spinal column.
• Ankylosing spondylitis - Ankylosing spondylitis is a chronic inflammatory disease that first affects the spine and adjacent structures. As the disease progresses, vertebrae will fuse together. This disease has a strong hereditary tendency and primarily affects men under 30 years of age.
• Spondylolisthesis - Spondylolisthesis is the partial forward movement (dislocation) of one vertebra over the one below it. Usually, the fifth lumbar vertebra is dislocated over the first sacral vertebra.
• Infection (less than 1 percent of cases).
• Cancer (less than 1 percent of cases).
• Fracture.
• Trauma - An injury due to an accident or fall may cause a fracture or muscle strain.
• Non-spinal causes - Non-spinal causes of low back pain include abdominal aortic aneurysms, kidney stones, infection, or perforating stomach ulcer.

How is back pain diagnosed?

Evaluating the patient's medical history often is the doctor's most powerful diagnostic tool. The doctor asks a series of questions to help identify possible causes of the back pain. The questions may focus on lifestyle factors, such as where you live, what type of work you do, and what activities or hobbies you enjoy; when your pain began; where your pain is located and what effect it has had on your daily activities; and whether your pain has responded to any treatment. The doctor also will ask about your medical, surgical, family, and social history.

Extensive testing - including X-rays, MRI/CT scans, EMGs, and lab tests - are necessary in only a small number of cases. For example, the MRI provides little information about the condition of the ligaments, muscles and tendons. However, it may demonstrate common degenerative, or wear and tear, changes in the discs or joints in the spine. If the pain is caused by trauma or a neurological change, or if the patient has a persistent fever, is losing weight, has numbness or weakness or loss of bowel or bladder control, one or more of these diagnostic tests may be done immediately.

How is back pain treated?

Most back pain can be successfully treated with conservative (non-surgical) measures. Conservative treatment includes activity (standing, walking, working) as tolerated, acetaminophen (non-aspirin over-the-counter pain reliever), and/or an anti-inflammatory medication, and cold packs to diminish swelling and pain. Usually, the pain will subside within four to seven days. If there is no improvement after four to seven days, contact your doctor.

When back pain is chronic, persistent and disabling, a comprehensive treatment approach addressing all aspects of the problem, including psychological as well as physical, offers the best hope for rehabilitation and recovery. A multi-disciplinary treatment team - consisting of a medical physician, physical therapist, psychologist or psychiatrist, and pain management specialist - offers the best hope for return to an active, productive lifestyle.

Medication

The role of medication in the management of back pain is 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. The newer anti-inflammatory pain relievers, such as celecoxib, are less likely to cause gastrointestinal side effects, such as nausea or diarrhea. Some older medications also have been found to help in the treatment of back pain. For example, disruption of sleep by chronic back pain is common. Poor sleep may, in fact, magnify pain. Low doses of traditional anti-depressant medicines, such as doxepin, may reduce pain and improve the quality of sleep. Anti-convulsants, such as gabapentin, often are 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.

Exercise

Active, exercise-oriented physical therapy is the cornerstone of treatment for people with chronic back pain. Heat, ice, massage and ultrasound may provide temporary relief, but rarely provide long-term benefits. 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. Returning to work in any capacity is strongly recommended.

When should I call my healthcare provider?

See your health care provider if you have a fever, if the pain worsens, if the pain progressively moves from your back into your leg(s), or if your pain is unrelieved at rest or disturbs sleep. These are warning signs or red flags that require prompt, urgent medical attention.