Back pain

We have selected the following expert medical opinion based on its clarity, reliability and accuracy. Credits: Sourced from the Cleveland Clinc, Ohio. Please refer to your own medical practitioner for a final perspective, assessment or evaluation.

Overview

Who is affected by back pain?

In the United States 85 to 90% of people experience back pain at some time during their lives. Back pain is the second most common reason people visit their family doctors (just after upper respiratory infections).

On any given day, almost 2% of the entire US work force is disabled by back pain. In people under 40 years of age, back pain is the most common reason for the inability to perform daily tasks. It also is the direct cause of enormous healthcare expenses, with estimates as high as $60 billion annually.

Pain that primarily affects the back is different from a spinal condition that results in mostly leg pain, a condition commonly called sciatica. Typically, sciatica is the result of a "pinched nerve" in the spinal column.

In most cases the cause of the sciatica is clear — for example, a disc problem or arthritis. The cause of an episode of back pain, on the other hand, often is more difficult to pinpoint and may be related to the discs, joints, or soft tissue supports (muscles, ligaments, and tendons).

What is acute back pain?

Acute back pain refers to a brief episode of pain that comes on suddenly. Most people recover from acute back pain within two weeks with minimal treatment. Using over-the-counter pain relievers — such as acetaminophen / paracetamol or ibuprofen — and getting back to normal activities as the pain permits are simple and effective treatments for most people with acute back pain.

What is chronic, persistent back pain?

Most back pain is relieved within a few days to a couple of weeks with simple treatment. When back pain persists beyond 2 to 4 weeks — which is chronic, persistent back pain — further medical evaluation is required. This evaluation focuses on a careful assessment of the patient's medical history and a thorough physical examination to identify, if possible, a precise cause of the pain. In rare cases, cancer or an infection is found. More commonly, the pain is related to the spinal joints, discs, or supporting muscles of the back.

Causes

What causes back pain?

Back strain is the leading cause (85% of cases) of back pain in the US.

Other causes of back pain include:

• Disc herniation: A herniated disc is a rupture or tear of the cartilage that surrounds the vertebral discs. Pressure from the vertebrae above and below the affected disc squeezes the cushioning substance (nucleus pulposus) out of the disc. The nucleus pulposus can press against spinal nerve roots. This can cause severe leg pain and may cause nerve damage if not treated properly.
• Osteoarthritis/spinal stenosis: The constriction or narrowing of the vertebral canal, the space that surrounds the spinal column.
• Ankylosing spondylitis: A chronic inflammatory disease that first affects the spine and nearby structures. As the disease progresses, vertebrae will fuse together. This disease has a strong hereditary (runs in the family) tendency and primarily affects men under 30 years of age.
• Spondylolisthesis: Spondylolisthesis is the partial forward movement (dislocation) of one vertebra over the one below it. Usually, the fifth lumbar (low back) vertebra is dislocated over the first sacral (tail bone) vertebra.
• Infection (less than 1% of cases).
• Cancer (less than 1% of cases).
• Fracture.
  
• Trauma: An injury due to an accident or fall may cause a fracture or muscle strain.
• Non-spinal causes: Non-spinal causes of low back pain include abdominal aortic aneurysms, kidney stones, infection, or perforating stomach ulcer.

Diagnosis

How is back pain diagnosed?

Evaluating the patient's medical history often is the doctor's most powerful diagnostic tool. The doctor asks a series of questions to help identify possible causes of the back pain.

The questions may focus on:

• Lifestyle factors, such as where you live, what type of work you do, and what activities or hobbies you enjoy
• When your pain began
• Where your pain is located and what effect it has had on your daily activities
• Whether your pain has responded to any treatment
• Your medical, surgical, family, and social history
  
  
  

Extensive testing — including X-rays, MRI/CT scans, EMGs (electromyography, to test electrical activity of skeletal muscles), and lab tests — are necessary in only a small number of cases.

For example, the MRI (magnetic resonance imaging) gives little information about the condition of the ligaments, muscles, and tendons. However, it may show common degenerative, or "wear and tear," changes in the discs or joints in the spine.

One or more of these diagnostic tests may be done immediately if the pain is caused by trauma or a neurological change, persistent fever, weight loss, numbness, weakness, or loss of bowel or bladder control.

Treatment

How is back pain treated?

Most back pain can be successfully treated with conservative (non-surgical) measures. 

Conservative treatment includes:

• As much activity (standing, walking, working) as can be tolerated
• Acetaminophen (non-aspirin over-the-counter pain reliever) and/or an anti-inflammatory medication
• Cold packs to diminish swelling and pain
  
  
  

Usually, the pain will subside within 4 to 7 days. If there is no improvement after 4 to 7 days, contact your doctor.

When back pain is chronic, persistent and disabling, a complete treatment approach addressing all aspects of the problem, including psychological as well as physical, offers the best hope for rehabilitation and recovery. 

A multi-disciplinary treatment team — consisting of a medical physician, physiotherapist, psychologist or psychiatrist, and pain management specialist — offers the best hope for return to an active, productive life.

Medication

The role of medication in the management of back pain is to relieve symptoms and facilitate an active, exercise-oriented rehabilitation program. An array of new medications is now available to assist in achieving this goal.

The newer anti-inflammatory pain relievers, such as celecoxib, are less likely to cause gastrointestinal side effects, such as nausea or diarrhoea.

Some older medications also have been found to help in the treatment of back pain. For example, disruption of sleep by chronic back pain is common. Poor sleep may, in fact, magnify pain. Low doses of traditional anti-depressant medicines may reduce pain and improve the quality of sleep.

Anti-convulsants, such as gabapentin, often are helpful for nerve irritation symptoms, such as burning or numbness.

In rare instances, careful use of long-acting opioid pain relievers may improve function and quality of life.

Exercise

Active, exercise-oriented physiotherapy is the cornerstone of treatment for people with chronic back pain. Heat, ice, massage, and ultrasound may provide temporary relief, but rarely provide long-term benefits.

Exercise programs should be individualized by a spine-oriented physical therapist. Typically, the exercise program can be performed at home without special equipment. Follow-up visits with the therapist are necessary to "fine tune" the program. Returning to work in any capacity is strongly recommended.

Living with back pain

When should I go back to my healthcare provider?

See your healthcare provider if:

• You have a fever
• The pain worsens
• The pain progressively moves from your back into your leg(s)
• Pain is unrelieved at rest or disturbs sleep
  
  

These are warning signs or "red flags" that require prompt, urgent medical attention.

REFERENCES

1. National Institute of Neurological Disorders and Stroke. Back Pain Information Page Accessed 12/28/2016.
2. National Institute of Neurological Disorders and Stroke. Low Back Pain Fact Sheet Accessed 12/28/2016.
3. National Institute of Arthritis and Musculoskeletal and Skin Diseases. What is Back Pain? Accessed 12/28/2016.
4. American Academy of Orthopaedic Surgeons. Low Back Pain

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