Lower Back Pain

For a condition as common as back pain (one survey found that almost twenty percent of Americans suffer a month-long bout of back pain each year) it's remarkably hard to find the actual cause in individual patients. According to the American Pain Society and the American College of Physicians, it's impossible to say precisely why a person's back hurts in more than 85 percent of cases. A cure, not surprisingly, can also be elusive.

Low back pain is extremely common. Almost every person will have at least one episode of low back pain at some time in his or her life. The pain can vary from severe and long term to mild and short lived. It will resolve within a few weeks for most people.

There are 24 vertebrae in three segments of the spinal column. These three segments create three natural curves of the back: the curves of the neck area (cervical), chest area (thoracic), and lower back (lumbar). In addition, the spine also includes two additional segments located at the lower end of the spine which are called the sacrum and coccyx. These are made up of a series of vertebrae that are fused together.

The lower back is a complex area that connects the upper body (including the chest and arms) to the lower body (including the pelvis and legs). The lower back is composed of several vertebrae, disks of soft cartilage, muscles, joints, ligaments, and nerve tissue. Disks act as shock absorbers between the vertebrae, and allow for spine movement. The spinal cord and nerves are essentially the "electrical cables," which travel through a central canal in the lumbar vertebrae, connecting the brain to the leg muscles. The small joints between the vertebrae allow movement and provide stability. Muscles and ligaments provide strength and power, as well as support and stability.

The lower back provides the body with power and mobility, allowing such movements as turning, twisting or bending, as well as the strength to stand, walk, and lift. Proper functioning of the lower back is needed for almost all activities of daily living.

Most low back pain is triggered by some combination of overuse, muscle strain, and injury to the muscles, ligaments, and discs that support the spine. Many experts believe that over time muscle strain can lead to an overall imbalance in the spinal structure. This leads to a constant tension on the muscles, ligaments, bones, and discs, making the back more prone to injury or reinjury. But in a structure as complex as the back, disks between your vertebrae can also bulge, rupture, or wear out. As a result of wear and tear on the spine, ligaments, and disks, a disk may begin to protrude or collapse and put pressure on the nerve root leading to a leg or foot, causing pain in those areas (sciatica). The problem can be aggravated by associated conditions, such as narrowing (stenosis) of the canal or shifting of the vertebra (spondylolisthesis), one upon the other. The facet joints that hold the spine in alignment can become inflamed due to arthritis or injury. Other causes can include something as simple as poor posture. Occasionally, it happens with no cause.

The causes of pain in the low back, or lumbosacral region, tend to add on to one another. For example, after straining muscles, you are likely to walk or move in different ways to avoid pain or to use muscles that aren't sore. That can cause you to strain other muscles that don't usually move that way. Doctors do not know why some people with acute back pain go on to suffer from long term (chronic) low back pain. They also don't know why some people go on to feel quite well between episodes of severe pain.

The symptoms of low back pain vary in some ways and are similar in others. Most people find that reclining or lying down will improve their pain and after their initial severe episode, many will be able to rest at night without severe pain. Most people experience more severe pain when they bend over to pick something up. Some get relief from arching backward (extending the back). Leg pain also can be part of the problem. The pain is most common in the back or outer side of the thigh, and can go all the way to the foot. Pain that goes to the foot is called sciatica because it is pain that follows the course of the sciatic nerve. Sciatica is often made worse by coughing or sneezing.

With an acute episode, back pain can be very severe for a few days or a week and then will often improve. By 2 weeks to 4 weeks, most people are much better. The length of time between episodes varies greatly from person to person, as does the length of each episode, the intensity of each episode, and how well each individual copes with the pain.

Treatments for low back pain are multiple and varied. At times, counseling and education about the problem to ease a person's anxiety is enough to make it tolerable until the episode resolves. A few days of rest can often calm the pain down as well. Prolonged bed rest (more than 2 days to 3 days) is no longer generally recommended for people with low back pain. Medications such as nonsteroidal anti inflammatory drugs (NSAIDS) or acetaminophen can be helpful. Occasionally, stronger medications such as muscle relaxants and narcotics are used for a short period. Although there is minimal scientific evidence of their effectiveness in treating low back pain, back braces are commonly used. Most common is a corset type brace that can be wrapped around the back and abdomen. People who use corset type braces sometimes report feeling better supported and more comfortable.

Passive modalities include the application of heat or cold, massage, ultrasound, electrical stimulation, traction, acupuncture and spinal manipulation. Exercising to restore motion and strength to a painful lumbar spine can be very helpful in relieving pain. Although there is controversy as to which are the most effective spine exercises, it is generally agreed that exercise should be both aerobic (aimed at improving heart and lung function) and specific to the spine. Aerobic exercises include walking, jogging, swimming, and bicycling. Instruction in lifting techniques can be helpful as well. Improperly bending over to lift can cause a large increase in strain on the low back. Proper lifting keeps the back straight while you bend with the knees.

Surgery for low back pain should only be performed when nonsurgical treatment options have been tried and have failed. For example, surgery should not be done if an exercise program is effective but the person does not want to do it. Another consideration that can influence a successful surgical outcome is stress. Low back pain, like many other pain problems, can be worse during times of stress. It may not be a good idea to commit to an operation like this when there are major stressful events happening in one's life. Occasionally, the back problem can become more tolerable once the stress is reduced. Finally, the patient must decide whether he or she is having enough of a problem to undergo an invasive procedure that is not guaranteed to work.