Back Pain / Lumbago / Low Back Pain / Backache

CAUSES — SYMPTOMS — DIAGNOSIS — TREATMENT

Low back pain is a very common problem. The lifetime prevalence (prevalence refers to the number of people in a particular population who have complaints over a given period of time) of patients with back pain in the United States is about 90 percent. Low back pain is the second most common cause of visits to the doctor's office after cold and flu. Low back pain is also a common reason for trips to the emergency room. It has been estimated that between 30 and 60 percent of the U.S. population will experience some form of low back pain in any given year. Of course, not all of these people will seek medical attention. Low back pain is usually divided into acute (less than three months) and chronic (more than three months) types. The lifetime prevalence of chronic low back pain in the US is estimated to be between 10 and 20 percent of the population.

Low back pain also has a significant effect on the work force. Two percent of the work force will have a work-related compensible injury each year. The estimated number of workdays lost each year in the United States is 175 million. The cost including both direct cost (relating to medical care) and indirect cost (relating to loss of productivity) is upwards of 100 billion dollars each year. Low back pain is the most common cause of activity limitation in people younger than 45 years old.

The number of operations performed for low back problems each year is about 350,000 and that number is increasing. Each year, newer techniques are being discovered for the surgical treatment of back problems.

The good news is that only 7 percent of patients with low back pain will have symptoms lasting longer than 2 weeks. The vast majority of patients with back problems will improve without the need for surgery or prolonged treatment.

Back Pain / Lumbago / Low Back Pain / Backache Causes

Injuries are a common cause of back pain. The most common types of injury that result in back pain are strains (injury caused by overuse or misuse) and sprains (injury to a ligament caused by excessive movement of a joint). These types of injury usually result in back pain without leg pain. Another type of injury that can cause back pain is damage to the intervertebral discs. This can be from trauma or degenerative changes from aging and work. This can cause back pain with or without associated leg pain. A third type of back injury is a fracture. Spine fractures have many causes such as falls, car accidents and direct blows. Lumbar spondylosis is a term that refers to degenerative changes of the bones in the lumbar spine. This can be due to aging or possibly from jobs that put significant stress on the spine (heavy labor, long haul trucking). Osteoporosis can also causes spine fractures. There are a number of medical problems that can cause back pain but that do not directly affect the spine.

Back Pain / Lumbago / Low Back Pain / Backache Symptoms

The most common symptom of low back pain is pain! Usually located in the middle of the lower portion of the back, the pain can be sharp, stabbing, dull, throbbing or aching. Some people experience associated pain in the buttock and or leg. This pain can be located on one side or more rarely on both sides. This is often called sciatica and is a different problem than standard low back pain. The pain can increase with movement such as bending, twisting, lifting and even walking. Frequently patients feel better when lying down and worse when standing or sitting. Certain symptoms such as urinary problems, leg or foot weakness, loss of sensation, pain lasting more than a month, sudden severe pain not related to an injury and fever or weight loss associated with back pain are reasons to seek medical treatment urgently.

Back Pain / Lumbago / Low Back Pain / Backache Diagnosis

As always, a careful history and physical examination are the first steps in diagnosis. Most patients do not require x-rays, CT scans or MRI scans at the onset of low back pain. Depending on the facts of the individual case, imaging studies might be ordered. Rarely, this might consist of x-rays. It can be helpful to include flexion and extension views when obtaining x-rays of the low back in order to evaluate possible abnormal movements. Not infrequently, the first imaging study will be an MRI scan. Generally, intravenous contrast enhancement is not necessary.

Other tests include electromyography and nerve conduction velocity testing (EMG/NCV) which looks for irritation of the nerves or muscles. In the past, myelogram and post-myelogram CT scanning (injection of dye into the spinal fluid) were frequently performed to examine the back. Now, these tests are performed much less frequently because the MRI scan usually gives better information. Another possible test is a discogram. This involves injecting dye into the disc itself. The test consists of two parts, the symptomatic part, during which the doctor asks the patient about pain during the dye injection and the radiographic part, this consists of a CT scan performed after the dye injection.

A different type of testing is that performed by physiatrists and pain specialists. This includes injection of local anesthetic into various parts of the spine. These tests look for pain relief after the injection. This helps to localize and define the cause of the pain.

Back Pain / Lumbago / Low Back Pain / Backache Treatment

In general, the first steps in the treatment of uncomplicated low back pain include a few days of rest and anti-inflammatory medications. In the past patients would be placed at prolonged bed rest. Now, this seems not to be effective and may even be harmful. The generally accepted number of days recommended is two to four. The best position is the most comfortable for the patient. Usually this is either on the side with the knees bent or on the back with the knees bent, perhaps using a pillow for support. An ice or cold pack applied to the back for 20 minutes three to four times a day may be helpful. Medication in the form of an anti-inflammatory such as aspirin, ibuprofen, naproxen, celebrex or vioxx may be taken. As these medications have side effects, patients should carefully read the package material or consult their doctor if taking any medications for longer than a few days. Braces or corsets are of little value and in the long term may cause a loss of muscle tone. If symptoms improve then a gradual resumption of normal activity follows.

Other recommended treatments might include a short course of oral steroid medication, stronger pain medication, muscle relaxant medication, possibly steroids injected into the epidural (outside the covering of the nervous system) space, the use of a transcutaneous electrical nerve stimulator (TENS unit), a referral for a short course of chiropractic treatment or acupuncture. Depending on the particular situation, a short (three to four week) course of physical therapy may be prescribed.

Since there is very little good research data on the treatment of low back pain, a single best treatment has yet to be determined. Most episodes of low back pain will resolve with little need for long term treatment. This brings us to the case where so-called conservative (non-surgical) treatment does not work.

Surgery as treatment for low back pain is a somewhat controversial subject. In the relatively recent past it was thought that surgery, while quite effective for the treatment of sciatica (from disc herniation) and leg pain (from spinal stenosis), was less effective for treating back pain. Lately, newer spine surgical hardware has made fusion surgery safer and more effective. The difficulty is choosing the right patient for the right surgery. CINN is currently conducting a number of studies looking at various aspects of surgical treatment of low back pain.