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Causes of Lower Back Pain

Lower Back Pain Symptoms, Diagnosis, and Treatment

Causes of Lower Back Pain

Lower back pain is a common cause for visits to the doctor.

Lower back pain is very common. It can result from a strain (injury) to muscles or tendons in the back. Other causes include arthritis, structural problems and disk injuries. Pain often gets better with rest, physical therapy and medication. Reduce your risk of low back pain by keeping at a healthy weight and staying active.

According to the National Institute of Neurological Disorders and Stroke (NINDS), low back pain is the most common cause of job-related disability. At least 80 percent of Americans will experience low back pain in their lifetime.

Nearly everyone will experience some form of back pain in his or her lifetime. The low back is the area behind the belly from the rib cage to the pelvis and is also called the lumbar region. Back pain is a major cause of missed work. Low back pain usually resolves on its own and is commonly the result of a strain injury. There are many treatments for low back pain.

There are many possible causes of lower back pain, with the majority being mechanical in nature. Lower back pain is often linked to spondylosis, the degeneration of the spine’s intervertebral discs due to everyday wear and tear. Additionally, some health conditions have the potential to cause lower back pain.

The vast majority of low back pain is mechanical in nature. In many cases, low back pain is associated with spondylosis, a term that refers to the general degeneration of the spine associated with normal wear and tear that occurs in the joints, discs, and bones of the spine as people get older.

Most commonly, mechanical issues and soft-tissue injuries are the cause of low back pain. These injuries can include damage to the intervertebral discs, compression of nerve roots, and improper movement of the spinal joints.

What Exactly Is the Lower Back

Your lower back is known as the lumbar region of the spine. It has a lot of heavy lifting to do: The lumbar spine carries the weight of your entire upper body, plus biomechanical stresses that occur with movement.

The lumbar spine has five vertebrae—backbones. Each vertebra has a large disc – cushiony gel wrapped in a tough membrane – on its front side that acts as a shock absorber. Each vertebra also has two cartilage-lined facet joints on its back side. Working together, discs and facet joints allow the spine to safely bend and twist.

Your lower back also includes ligaments, tendons, and muscles. Ligaments are strong bands that hold the vertebrae and discs together. Tendons attach muscles to the vertebrae. These structures help limit excessive movement that could harm the spinal cord.

What Is Lower Back Pain?

Low back pain can result from many different injuries, conditions or diseases — most often, an injury to muscles or tendons in the back.

Pain can range from mild to severe. In some cases, pain can make it difficult or impossible to walk, sleep, work or do everyday activities.

Usually, lower back pain gets better with rest, pain relievers and physical therapy (PT). Cortisone injections and hands-on treatments (like osteopathic or chiropractic manipulation) can relieve pain and help the healing process. Some back injuries and conditions require surgical repair.

Common Symptoms of Lower Back Problems

Specifically identifying and describing symptoms can help lead to a more accurate diagnosis and effective treatment plan.

Low back pain is typically characterized by a combination of the following symptoms:

Dull, aching pain
Pain that remains within the low back (axial pain) is usually described as dull and aching rather than burning, stinging, or sharp. This kind of pain can be accompanied by mild or severe muscle spasms, limited mobility, and aches in the hips and pelvis.

Pain that travels to the buttocks, legs, and feet
Sometimes low back pain includes a sharp, stinging, tingling or numb sensation that moves down the thighs and into the low legs and feet, also called sciatica. Sciatica is caused by irritation of the sciatic nerve, and is usually only felt on one side of the body.

Pain that is worse after prolonged sitting
Sitting puts pressure on the discs, causing low back pain to worsen after sitting for long periods of time. Walking and stretching can alleviate low back pain quickly, but returning to a sitting position may cause symptoms to return.

Pain that feels better when changing positions
Depending on the underlying cause of pain, some positions will be more comfortable than others. For example, with spinal stenosis walking normally may be difficult and painful, but leaning forward onto something, such as a shopping cart, may reduce pain. How symptoms change with shifting positions can help identify the source of pain.

Pain that is worse after waking up and better after moving around
Many who experience low back pain report symptoms that are worse first thing in the morning. After getting up and moving around, however, symptoms are relieved. Pain in the morning is due to stiffness caused by long periods of rest, decreased blood flow with sleep, and possibly the quality of mattress and pillows used.

Of course, there are other ways people experience low back pain. Low back pain varies on an individual level, and many factors influence the pain experience, including mental and emotional health, financial stress, or exercise and activity level.

What Are The Causes Of Low Back Pain?

Strains

The muscles and ligaments in the back can stretch or tear due to excess activity. Symptoms include pain and stiffness in the lower back, as well as muscle spasms. Rest and physical therapy are remedies for these symptoms.

A lumbar strain is a stretch injury to the ligaments, tendons, and/or muscles of the low back. The stretching incident results in microscopic tears of varying degrees in these tissues. Lumbar strain is considered one of the most common causes of low back pain. The injury can occur because of overuse, improper use, or trauma. Soft-tissue injury is commonly classified as “acute” if it has been present for days to weeks. If the strain lasts longer than three months, it is referred to as “chronic.”

Lumbar strain most often occurs in people in their 40s, but it can happen at any age. The condition is characterized by localized discomfort in the low back area with onset after an event that mechanically stressed the lumbar tissues. The severity of the injury ranges from mild to severe, depending on the degree of strain and resulting spasm of the muscles of the low back. The diagnosis of lumbar strain is based on the history of injury, the location of the pain, and exclusion of nervous system injury. Usually, X-ray testing is only helpful to exclude bone abnormalities.

The treatment of lumbar strain consists of resting the back (to avoid reinjury), medications to relieve pain and muscle spasm, local heat applications, massage, and eventual (after the acute episode resolves) reconditioning exercises to strengthen the low back and abdominal muscles. Initial treatment at home might include heat application, acetaminophen (Tylenol) or ibuprofen (Advil, Motrin), and avoiding reinjury and heavy lifting.

Prescription medications that are sometimes used for acute low back pain include non-steroidal anti-inflammatory medications, such as sulindac (Clinoril), naproxen (Naprosyn), and ketorolac (Toradol) by injection or by mouth, muscle relaxants, such as carisoprodol (Soma), cyclobenzaprine (Flexeril), methocarbamol (Robaxin), and metaxalone (Skelaxin), as well as analgesics, such as tramadol (Ultram).

Disc Injury

The discs in the back are prone to injury. This risk increases with age. The outside of the disc can tear or herniate.

A herniated disc, which is also known as a slipped or ruptured disc, occurs when the cartilage surrounding the disc pushes against the spinal cord or nerve roots. The cushion that sits between the spinal vertebrae extends outside its normal position.

This can result in compression of the nerve root as it exits from the spinal cord and through the vertebral bones. Disc injury usually occurs suddenly after lifting something or twisting the back. Unlike a back strain, pain from a disc injury usually lasts for more than 72 hours.

Degeneration Of The Spine And Intervertebral Disc

As people age, it is normal for the spine’s rubbery intervertebral discs to lose integrity through a process known as spondylosis. These discs are usually responsible for cushioning the spine’s individual bones as they move on each other during bending and flexing. In elderly individuals, the intervertebral discs cannot provide this type of support to the lower back area, which can result in lower back pain.

When the intervertebral discs become weakened, any significant degree of compression can lead to a change in positioning, making them bulge outwards. This is known as herniation. Lower back pain can also result from this.

Spinal stenosis is another condition that causes back pain. It involves the narrowing of the spinal column in one area at least. This can lead to an increase in pressure on the surrounding nerves. Spondylolisthesis is another condition in which there is a spinal vertebra displacement due to it slipping out of place. This can also press against the nerves and cause lower back pain.

Sciatica

Sciatica can occur with a herniated disc if the disc presses on the sciatic nerve. The sciatic nerve connects the spine to the legs. As a result, sciatica can cause pain in the legs and feet. This pain usually feels like burning, or pins and needles.

Cauda Equina Syndrome

Cauda equina syndrome is a rare condition that develops when something compresses or damages the cauda equina, which is a bundle of nerves in the lower part of the spinal cord.

This condition typically results from a herniated disc, but other causes include spinal stenosis and fractures, infections, and tumors that affect the spine. It can sometimes also occur as a complication of spinal surgery.

Symptoms of cauda equina syndrome can include:

  • severe lower back pain
  • bowel and bladder problems
  • numbness, weakness, or loss of sensation in one or both legs
  • difficulty walking

Spondylolisthesis

A vertebra slides forward out of position, disrupting your spine’s alignment and sometimes compressing nerve roots. It is most common in the lumbar region, but can happen anywhere along the spine. This slippage is often caused by either disc degeneration or a fractured vertebra (spondylolysis).

Spinal Stenosis

Spinal stenosis is when the spinal column narrows, putting pressure on the spinal cord and spinal nerves.

Spinal stenosis is most commonly due to degeneration of the discs between the vertebrae. The result is compression of the nerve roots or spinal cord by bony spurs or soft tissues, such as discs.

Pressure on the spinal nerves causes symptoms such as:

  • numbness
  • cramping
  • weakness

You might feel these symptoms anywhere in the body. Many people with spinal stenosis notice their symptoms worsen when standing or walking.

Osteoarthritis

This condition results from wear and tear of the disc and facet joints. It causes pain, inflammation, instability, and stenosis to a variable degree, and can occur at a single level or multiple levels of the lower spine. Spinal osteoarthritis is associated with aging and is slowly progressive. It is also referred to as spondylosis or degenerative joint disease.

Deformity

Curvature of the spine can include scoliosis or kyphosis. The deformity may be associated with lower back pain if it leads to the breakdown of the discs, facet joints, sacroiliac joints or stenosis.

Trauma

Acute fractures or dislocations of the spine can lead to pain. Lower back pain that develops after a trauma, such as a motor vehicle accident or a fall, should be medically evaluated.

Spinal stenosis

A narrowing of the inside spaces of your spine, most often from a herniated disc but sometimes from bone spurs caused by spinal osteoarthritis. This can result in painful pressure on your spinal nerves. Spinal stenosis can occur in both the upper (cervical) spine and the lumbar spine, but lumbar spinal stenosis is more common.

Radiculopathy

If a spinal nerve root is compressed, inflamed, or otherwise injured, the pressure on the nerve can lead to pain, numbness, or other sensations such as tingling in various areas of the body, depending on the nerve that was affected. Radiculopathy is the term for this condition, and it is commonly associated with herniated discs that damage a spinal nerve root.

Sciatica is a type of radiculopathy that involves compression of the sciatic nerve, the main nerve to the leg. This is responsible for transmitting sensation and motor activity to and from the buttocks and down the back of the legs. Sciatica can cause sharp, burning pain in the lower back, buttocks, and (usually) one leg. It can also lead to numbness and weakness of the affected muscles in severe cases.

Scoliosis

Scoliosis is a sideways curvature of the spine that can cause uneven shoulders and hips. The condition tends to affect children ages 11–12, often just before they have a growth spurt. However, scoliosis can develop at any age.

Children with scoliosis are more likely to develop lower back pain as an adult.

How Is Low Back Pain Diagnosed?

A complete medical history and physical exam can usually identify any serious conditions that may be causing the pain. Neurologic tests can help determine the cause of pain and appropriate treatment. Imaging tests are not needed in most cases but may be ordered to rule out specific causes of pain, including tumors and spinal stenosis. Occasionally the cause of chronic lower back pain is difficult to determine even after a thorough examination.

Tests include:

Blood tests are not routinely used to diagnose the cause of back pain but might be ordered to look for signs of inflammation, infection, cancer, and/or arthritis.

Bone scans can detect and monitor an infection, fracture, or bone disorder. A small amount of radioactive material is injected into the bloodstream and collects in the bones, particularly in areas with some abnormality. Scanner-generated images can identify specific areas of irregular bone metabolism or abnormal blood flow, as well as to measure levels of joint disease.

Discography involves injecting a contrast dye into a spinal disc thought to be causing low back pain. The fluid’s pressure in the disc will reproduce the person’s symptoms if the disc is the cause. The dye helps to show the damaged areas on CT scans taken following the injection.

Electrodiagnostics can identify problems related to the nerves in the back and legs. The procedures include:

  • electromyography (EMG) assesses the electrical activity in a muscle and can detect if muscle weakness results from a problem with the nerves that control the muscles. Very fine needles are inserted in muscles to measure electrical activity transmitted from the brain or spinal cord to a particular area of the body.
  • evoked potential studies involve two sets of electrodes—one set to stimulate a sensory nerve, and the other placed on the scalp to record the speed of nerve signal transmissions to the brain.
  • nerve conduction studies (NCS) also use two sets of electrodes to stimulate the nerve that runs to a particular muscle and record the nerve’s electrical signals to detect any nerve damage.

Diagnostic imaging tests allow specialists to see into the body without having to perform exploratory surgery. Imaging includes:

  • Computerized tomography (CT) can show soft tissue structures that cannot be seen on conventional x-rays, such as disc rupture, spinal stenosis, or tumors.
  • Magnetic resonance imaging (MRI) creates a computer-generated image of bony structures and soft tissues such as muscles, ligaments, tendons, and blood vessels. An MRI may be ordered if a problem such as infection, tumor, inflammation, disc herniation or rupture, or pressure on a nerve is suspected
  • X-ray imaging can show broken bones or an injured or misaligned vertebra.
  • Myelograms enhance the diagnostic imaging of x-rays and CT scans. In this procedure, a contrast dye is injected into the spinal canal, allowing spinal cord and nerve compression caused by herniated discs or fractures to be seen on an x-ray or CT scans.

What Are The Treatment Options For Low Back Pain?

Home Care

Self-care methods are helpful for the first 72 hours after the pain begins. If the pain doesn’t improve after 72 hours of home treatment, you should call your doctor.

Stop your normal physical activities for a couple of days and apply ice to your lower back. Doctors generally recommend using ice for the first 48 to 72 hours, then switching to heat.

Alternate ice and heat to relax muscles. The RICE protocol — rest, ice, compression, and elevation — is recommended within the first 48 hours.

Take over-the-counter pain medication, such as ibuprofen (Advil, Motrin IB), or acetaminophen (Tylenol), to relieve pain.

Sometimes lying on your back causes more discomfort. If so, try lying on your side with your knees bent and a pillow between your legs. If you can lie comfortably on your back, place a pillow or rolled-up towel beneath your thighs to reduce the pressure on the lower back.

A warm bath or a massage can often relax stiff and knotted muscles in the back.

Medical Treatment

Low back pain can occur with a number of different conditions, including:

  • muscle strain and weakness
  • pinched nerves
  • spinal cord misalignment

There are a number of possible medical treatments including:

  • medications
  • medical appliances
  • physical therapy

Your doctor will determine the appropriate dosage and application of drugs and medications based on your symptoms.

Some medications your doctor may prescribe include:

  • muscle relaxants
  • nonsteroidal anti-inflammatory drugs (NSAIDs)
  • narcotic drugs such as codeine for pain relief
  • steroids to reduce inflammation
  • corticosteroid injections

Your doctor may also prescribe physical therapy, including:

  • massage
  • stretching
  • strengthening exercises
  • back and spinal manipulation

Surgery

For severe cases, surgery may be necessary. Surgery is usually only an option when all other treatments fail. However, if there’s loss of bowel or bladder control, or a progressive neurological loss, surgery becomes an emergency option.

A discectomy relieves pressure from a nerve root pressed on by a bulging disc or bone spur. The surgeon will remove a small piece of the lamina, a bony part of the spinal canal.

A foraminotomy is a surgical procedure that opens up the foramen, the bony hole in the spinal canal where the nerve root exits.

Intradiscal electrothermal therapy (IDET) involves inserting a needle through a catheter into the disc and heating it up for 20 minutes. This makes the disc wall thicker and cuts down on the inner disc’s bulging and irritation of the nerve.

A nucleoplasty uses a wand-like device inserted through a needle into the disc. It can then remove inner disc material. The device then uses radio waves to heat and shrink the tissue.

Radiofrequency lesioning or ablation is a way to use radio waves to interrupt the way the nerves communicate with each other. A surgeon inserts a special needle into the nerves and heats it, which destroys the nerves.

Spinal fusion makes the spine stronger and cuts down on painful motion. The procedure removes discs between two or more of the vertebrae. The surgeon then fuses the vertebrae next to each other with bone grafts or special metal screws.

A spinal laminectomy, also known as spinal decompression, removes the lamina to make the size of the spinal canal bigger. This relieves pressure on the spinal cord and nerves.

Yoga: Stretching for Back Pain

If back pain doesn’t go away in three months, there’s evidence that yoga can help. In one recent study, people who took 12 weeks of yoga classes had fewer symptoms of low back pain than people who were given a book about care for back pain. The benefits lasted several months after the classes were finished. The study suggests conventional stretching also works just as well. Make sure your instructor is experienced at teaching people with back pain and will modify postures for you as needed.

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