Low Back Pain

Almost everyone will experience low back pain at some point in their lives. This pain can vary from mild to severe. It can be short lived or long lasting. However it happens, low back pain can make many everyday activities difficult to do.

Anatomy

Your spine is made up of small bones, called vertebrae, which are stacked on top of one another. Muscles, ligaments, nerves, and intervertebral disks are additional parts of your spine. Understanding your spine and how it works can help you better understand low back pain.

Description

Back pain is different from one person to the next. The pain can have a slow onset or come on suddenly. The pain may be intermittent or constant. In most cases, back pain resolves on its own within a few weeks.

Cause

There are many causes of low back pain. It sometimes occurs after a specific movement such as lifting or bending. Just getting older also plays a role in many back conditions. As we age, our spines age with us. Aging causes degenerative changes in the spine. These changes can start in our 30s — or even younger - and can make us prone to back pain, especially if we overdo our activities. These aging changes, however, do not keep most people from leading productive, and generally, pain free lives. We have all seen the 70 year old marathon runner who, without a doubt, has degenerative changes in her back! Over -activity One of the more common causes of low back pain is muscle soreness from over activity. Muscles and ligament fibers can be overstretched or injured. This is often brought about by that first softball or golf game of the season, or too much yard work or snow shoveling in one day. We are all familiar with this "stiffness" and soreness in the low back — and other areas of the body — that usually goes away within a few days.

Risk Factors/Prevention

• In children and young adults, disks have high water content. As people age, the water content in the disks decreases and the disks become less flexible. The disks begin to shrink and the spaces between the vertebrae get narrower. Conditions that can weaken the disk include:
• Improper lifting
• Smoking
• Excessive body weight that places added stress on the disks (in the lower back)
• Sudden pressure (which may be slight)
• Repetitive strenuous activities

Symptoms

Back pain varies. It may be sharp or stabbing. It can be dull, achy, or feel like a "charley horse" type cramp. The type of pain you have will depend on the underlying cause of your back pain. Most people find that reclining or lying down will improve low back pain, no matter the underlying cause. People with low back pain may experience some of the following:

• Back pain may be worse with bending and lifting.
• Sitting may worsen pain.
• Standing and walking may worsen pain
• Back pain comes and goes, and often follows an up and down course with good days and bad days.
• Pain may extend from the back into the buttock or outer hip area, but not down the leg.
• Sciatica is common with a herniated disk. This includes buttock and leg pain, and even numbness, tingling or weakness that goes down to the foot. It is possible to have sciatica without back pain.

Regardless of your age or symptoms, if your back pain does not get better within a few weeks, or is associated with fever, chills, or unexpected weight loss, you should call your doctor.

Diagnosis

Medical History and Physical Examination

After discussing your symptoms and medical history, your doctor will exam- ine your back. This will include looking at your back and pushing on different areas to see if it hurts. Your doctor may have you bend forward, backward, and side to side to look for limitations or pain. Your doctor may measure the nerve function in your legs. This includes checking your reflexes at your knees and ankles, as well as strength testing and sensation testing. This might tell your doctor if the nerves are seriously affected.

Imaging Tests

Tests which may help your doctor confirm your diagnosis include:

• X-rays: Although they only visualize bones, X-rays can help determine if you have spinal stenosis. X-rays will show aging changes, like loss of disk height or bone spurs. X-rays taken while you lean forward and backward can show "instability" in your joints. X-rays can also show too much mobility. This is called spondylolisthesis.
• Magnetic resonance imaging (MRI): This study can create better images of soft tissues, such as muscles, disks, nerves, and the spinal cord. Conditions such as a herniated disk or an infection are more visible in an MRI scan.
• Computerized axial tomography (CAT) scans: If your doctor suspects a bone problem, he or she may suggest a CAT scan. This study is like a three dimensional X-ray and focuses on the bones.  CAT scans can create cross section images of your spine.

Additional tests:

• Myelogram: Your doctor may also order a myelogram. In this procedure, dye is injected into the spine to make the nerves show up more clearly. It can help your doctor determine whether the nerves are being com- pressed. bones, aging changes, curves, or deformities. X-rays do not show disks, muscles, or nerves.
• Bone scan: A bone scan may be suggested if your doctor needs more information to evaluate your pain and to make sure that the pain is not from a rare problem like cancer or infection.
• Bone density test: If osteoporosis is a concern, your doctor may order a bone density test. Osteoporosis weakens bone and makes it more likely to break. Osteoporosis by itself should not cause back pain, but spinal fractures due to osteoporosis can.

Treatment

In general, treatment for low back pain falls into one of three categories: medications, physical medicine, and surgery.

Nonsurgical Treatment

• Aspirin or acetaminophen can relieve pain with few side effects.
• Non -steroidal anti-inflammatory medicines like ibuprofen and naproxen reduce pain and swelling.
• Narcotic pain medications, such as codeine or morphine, may help.
• Steroids, taken either orally or injected into your spine, deliver a high dose of anti-inflammatory medicine. Physical medicine. Low back pain can be disabling. Medications and therapeutic treatments combined often relieve pain enough for you to do all the things you want to do
• Braces are often used. The most common brace is a corset type that can be wrapped around the back and stomach. Braces are not always helpful, but some people report feeling more comfortable and stable while wearing them.
• Chiropractic or manipulation therapy is provided in many different forms. Some patients have relief from low back pain with these treatments.
• Traction is often used, but without scientific evidence for effectiveness.
• Other exercise based programs, such as pilates or yoga are helpful for some patients.

Surgical Treatment

Surgery for low back pain should only be considered when nonsurgical treatment options have been tried and have failed. It is best to try nonsurgical options for 6 months to a year before considering surgery.

In addition, surgery should only be considered if you doctor can pinpoint the source of your pain.

Surgery is not a last resort treatment option "when all else fails." Some patients are not candidates for surgery, even though they have significant pain and other treatments have not worked. Some types of chronic low back pain simply cannot be treated with surgery.

Laminectomy: This procedure involves removing the bone, bone spurs, and ligaments that are compressing the nerves. This procedure may also be called a "decompression." Laminectomy can be performed as open surgery, in which your doctor uses a single, larger incision to access your spine. The procedure can also be done using a minimally invasive method, where several smaller incisions are made. Your doctor will discuss the right option for you.

Spinal Fusion: Spinal fusion is essentially a "welding" process. The basic idea is to fuse together the painful vertebrae so that they heal into a single, solid bone.

Spinal fusion eliminates motion between vertebral segments. It is an option when motion is the source of pain. For example, your doctor may recommend spinal fusion if you have spinal instability, a curvature (scoliosis), or severe degeneration of one or more of your disks. The theory is that if the painful spine segments do not move, they should not hurt.

Fusion of the vertebrae in the lower back has been performed for decades. A variety of surgical techniques have evolved. In most cases, a bone graft is used to fuse the vertebrae. Screws, rods, or a "cage" are used to keep your spine stable while the bone graft heals.

The surgery can be done through your abdomen, your side, your back, or a combination of these. There is even a procedure that is done through a small opening next to your tailbone. No one procedure has been proven better than another.

The results of spinal fusion for low back pain vary. It can be very effective at eliminating pain, not work at all, and everything in between. Full recovery can take more than a year.

Disk Replacement: This procedure involves removing the disk and replacing it with artificial parts, similar to replacements of the hip or knee.

The goal of disk replacement is to allow the spinal segment to keep some flexibility and maintain more normal motion.

The surgery is done through your back, usually on the lower two disks of the spine.