Oh, My Aching Back!
By Vijaya Polovaram, MD
If you've ever groaned, “Oh, my aching back!”, you are not alone. Back pain is one of the most common medical problems, affecting eight out of ten people at some point during their lives. Back pain can range from a dull, constant ache to a sudden, sharp pain. Acute back pain comes on suddenly and usually lasts from a few days to a few weeks. Back pain is considered chronic if it lasts for more than three months.
Most back pain goes away on its own, though it may take awhile. Taking over-the-counter pain relievers and resting can help. However, staying in bed for more than one or two days can make it worse.
If your back pain is severe or doesn't improve after three days, you should call your health care provider. You should also get medical attention if you have back pain following an injury.
THE PAIN
Americans spend at least $50 billion each year on low back pain, the most common cause of job-related disability and a leading contributor to missed work. Back pain is the second most common neurological ailment in the United States – only headache is more common.
 Acute or short-term low back pain generally lasts from a few days to a few weeks. Most acute back pain is mechanical in nature – the result of trauma to the lower back or a disorder such as arthritis. Pain from trauma may be caused by a sports injury, work around the house or in the garden, or a sudden jolt such as a car accident or other stress on spinal bones and tissues. Symptoms may range from muscle ache to shooting or stabbing pain, limited flexibility and/or range of motion, or an inability to stand straight. Occasionally, pain felt in one part of the body may “radiate” from a disorder or injury elsewhere in the body. Some acute pain syndromes can become more serious if left untreated.
Chronic back pain is measured by duration – pain that persists for more than three months is considered chronic. It is often progressive and the cause can be difficult to determine. The lumbar region of the back is where most back pain is felt since this region of the back transmits the weight of upper body to the lower extremities.
CAUSES OF BACK PAIN
As people age, bone strength and muscle elasticity and tone tend to decrease. The discs begin to lose fluid and flexibility, which decreases their ability to cushion the vertebrae.
Pain can occur when, for example, someone lifts something too heavy or overstretches, causing a sprain, strain, or spasm in one of the muscles or ligaments in the back. If the spine becomes overly strained or compressed, a disc may rupture or bulge outward. This rupture may put pressure on one of the more than 50 nerves rooted to the spinal cord that control body movements and transmit signals from the body to the brain. When these nerve roots become compressed or irritated, back pain results.
- Low back pain may reflect nerve or muscle irritation or bone lesions.
- Most low back pain follows injury or trauma to the back, but pain may also be caused by degenerative conditions such as arthritis or disc disease, osteoporosis or other bone diseases, viral infections, irritation to joints and discs, or congenital abnormalities in the spine.
- Obesity, smoking, weight gain during pregnancy, stress, poor physical condition, posture inappropriate for the activity being performed, and poor sleeping position also may contribute to low back pain.
- Additionally, scar tissue created when the injured back heals itself does not have the strength or flexibility of normal tissue.
- Buildup of scar tissue from repeated injuries eventually weakens the back and can lead to more serious injury.
- Occasionally, low back pain may indicate a more serious medical problem. Pain accompanied by fever or loss of bowel or bladder control, pain when coughing, and progressive weakness in the legs may indicate a pinched nerve or other serious condition.
People with diabetes may have severe back pain or pain radiating down the leg related to neuropathy. People with these symptoms should contact a doctor immediately to help prevent permanent damage
WHO IS MOST LIKELY TO DEVELOP LOW BACK PAIN?
Nearly everyone has low back pain sometime. Men and women are equally affected. It occurs most often between ages 30 and 50, due in part to the aging process but also as a result of sedentary life styles with too little exercise. The risk of experiencing low back pain from disc disease or spinal degeneration increases with age.
Low back pain unrelated to injury or other known cause is unusual in pre-teen children. However, a backpack overloaded with schoolbooks and supplies can quickly strain the back and cause muscle fatigue. The U.S. Consumer Product Safety Commission estimates that more than 13,260 injuries related to backpacks were treated at doctors’ offices, clinics, and emergency rooms in the year 2000. To avoid back strain, children carrying backpacks should bend both knees when lifting heavy packs, visit their locker or desk between classes to lighten loads or replace books, or purchase a backpack or airline tote on wheels.
WHAT CONDITIONS ARE ASSOCIATED WITH LOW BACK PAIN?
Here are some conditions that may cause low back pain and require treatment by a physician or other health specialist.
 Bulging disc (also called protruding, herniated, or ruptured disc). The intervertebral discs are under constant pressure. As discs degenerate and weaken, cartilage can bulge or be pushed into the space containing the spinal cord or a nerve root which causes pain. The most herniated discs occur in the lower, lumbar portion of the spinal column.
A much more serious complication of a ruptured disc is cauda equina syndrome, which occurs when disc material is pushed into the spinal canal and compresses the bundle of lumbar and sacral nerve roots. Permanent neurological damage may result if this syndrome is left untreated.
Sciatica is a condition in which a herniated or ruptured disc presses on the sciatic nerve, the large nerve that carries nerve connections to the leg. This compression causes shock-like or burning low back pain combined with pain through the buttocks and down one leg to below the knee, occasionally reaching the foot.
Spinal degeneration from disc wear and tear can lead to a narrowing of the spinal canal. A person with spinal degeneration may experience stiffness in the back upon awakening or may feel pain after walking or standing for a long time.
Spinal stenosis related to congenital narrowing of the bony canal predisposes some people to pain related to disc disease.
Osteoporosis is a bone disease where fractures of porous bones in the spinal vertebral body occur due to decreases in bone density and cause chronic back pain.
Skeletal irregularities produce strain on the vertebrae and supporting muscles, tendons, ligaments, and tissues supported by spinal column. These irregularities include scoliosis, a curving of the spine to the side; kyphosis, in which the normal curve of the upper back is severely rounded; lordosis, an abnormally accentuated arch in the lower back; back extension, a bending backward of the spine; and back flexion, in which the spine bends forward.
Fibromyalgia is a chronic disorder characterized by widespread musculoskeletal pain, fatigue, and multiple “tender points,” particularly in the neck, spine,
shoulders, and hips.
Spondylitis refers to chronic back pain and stiffness caused by a severe infection to or inflammation of the spinal joints. Other painful inflammations in the lower back include osteomyelitis (infection in the bones of the spine) and sacroiliitis (inflammation in the sacroiliac joints).
HOW IS LOW BACK PAIN DIAGNOSED?
The physician will examine the back and conduct neurologic tests to determine the cause of pain and appropriate treatment. A variety of diagnostic methods may be ordered by your doctor to confirm the cause of low back pain such as x-ray, discography, CT scans, MRI, electrodiagnostic procedures, electromyography (EMG), nerve conduction studies, and evoked potential (EP) studies, vertebra thermography and ultrasound imaging of spine.
HOW IS BACK PAIN TREATED?
First Aid: Although ice and heat (the use of cold and hot compresses) have never been scientifically proven to quickly resolve low back injury, compresses may help reduce pain and inflammation and allow greater mobility for some individuals. As soon as possible following trauma, patients should apply a cold pack or a cold compress to the tender spot several times a day for up to 20 minutes. After two to three days of cold treatment, heat should be applied for brief periods to relax muscles and increase blood flow. Warm baths may also help relax muscles. Patients should avoid sleeping on a heating pad, which can cause burns and lead to additional tissue damage.
 Be active – No bed rest: Exercise may be the most effective way to speed recovery from low back pain and help strengthen back and abdominal muscles. Maintaining and building muscle strength is particularly important for persons with skeletal irregularities. Doctors and physical therapists can provide a list of gentle exercises that help keep muscles moving and speed the recovery process. A routine of back-healthy activities may include stretching exercises, swimming, walking, and movement therapy to improve coordination and develop proper posture and muscle balance. Yoga is another way to gently stretch muscles and ease pain. Any mild discomfort felt at the start of these exercises should disappear as muscles become stronger. But if pain is more than mild and lasts more than 15 minutes during exercise, patients should stop exercising and contact a doctor. Patients who are treated for acute back pain with bed rest have more pain and slower recovery than ambulatory patients. Activity modification should generally be minimal, with patients returning to activities of daily living as soon as possible.
Medications are often used to treat acute and chronic low back pain. Effective pain relief may involve a combination of prescription drugs and over-the-counter remedies. Patients should always check with a doctor before taking drugs for pain relief. Certain medicines, even those sold over the counter, may conflict with other medications and may cause side effects such as drowsiness, or may lead to liver damage.
Over-the-counter analgesics, including nonsteroidal anti-inflammatory drugs (aspirin, naproxen, and ibuprofen) may help. Some of the prescription drugs are anticonvulsants. Some antidepressants, particularly tricyclic antidepressants such as amitriptyline and desipramine, have been shown to relieve pain. Opioids such as codeine, oxycodone, hydrocodone, and morphine are often prescribed to manage severe acute and chronic back pain but should be used only for a short period of time and under a physician’s supervision. Side effects can include drowsiness, decreased reaction time, impaired judgment, and potential for addiction. Many specialists are convinced that chronic use of these drugs is detrimental to the back pain patient, adding to depression and even increasing pain.
OTHER METHODS OF TREATMENT
When back pain does not respond to more conventional approaches, patients may consider the following non-invasive treatment options:
Spinal manipulation is literally a “hands-on” approach in which professionally licensed specialists use leverage and a series of exercises to adjust spinal structures and restore back mobility. Other treatments are acupuncture, biofeedback, traction, transcutaneous electrical nerve stimulation (TENS) and Ultrasound.
Minimally invasive outpatient treatments to seal fractures of the vertebrae caused by osteoporosis include vertebroplasty and kyphoplasty. Vertebroplasty uses three-dimensional imaging to help a doctor guide a fine needle into the vertebral body. A glue-like epoxy is injected, which quickly hardens to stabilize and strengthen the bone and provide immediate pain relief. Discectomy is one of the more common ways to remove pressure on a nerve root from a bulging disc or bone spur. During this procedure, the surgeon takes out a small piece of the lamina (the arched bony roof of the spinal canal) to remove the obstruction below.
Dr. Polavaram specializes in internal medicine and is the owner of Capital Primary Care with offices in Cary and Raleigh.
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