LOW BACK PAIN

Low back pain (LBP) is a common and frequent complaint. Pain may be either acute or chronic and can be due to injury, trauma, overuse, or from lifting heavy objects. If the inflammation or irritation results in significant damage to the back structures, the pain result in a chronic pain disorder. Structural damage to the lower back (lumbar spine) may include injury to the vertebrae, facet joints, vertebral discs, vertebral ligaments, lower back muscles, spinal cord and peripheral nerves, as well as internal organs in the pelvis (spleen, kidney, pancreas, and liver). Most of the time, LBP is acute and resolves within four weeks, however, depending on the pain cause. LBP can be a recurring condition and is very common among the American population.

Though unlikely, there are serious conditions that cause back pain as well. Seek medical attention if your back pain is severe and is accompanied by a high fever.

Back Anatomy

Bony Structures

The bony structures of the back, the vertebrae, connect together. At the top and bottom of each vertebra are facet joints, connection points, for the vertebrae to attach to one another. The five lumbar spine vertebrae provide a flexible, movable support structure, which also protects the spinal cord.

Spinal bone conditions that can cause chronic LBP include:

Facet Joint Osteoarthritis
Spinal Stenosis(narrowing of the spinal canal)
Vertebral Body Fractures
Osteoporosis
Spondylolisthesis
Neoplasms (Primary vs. metastatic lesions)
Infections

Disc Conditions that can produce chronic LBP include:

Degenerative Disc Disease
Disc Protrusion
Disc Herniation
Disc Extrusion
Facet Joint Osteoarthritis
Spinal Stenosis(narrowing of the spinal canal)
Sciatica(Nerve Root Irritation or Compression)
Disc Infection.

Spinal Ligaments and Muscles

There are three major spinal ligaments that attach, support and protect each vertebra. The many muscles, also, provide the same support and are responsible for movement. The spine has a complex spinal nerve system. Each nerve has two roots attached to the spinal cord. They exit the spine to innervate the skin, muscles, and surrounding structures of the back and lower extremities (legs and feet).

Spinal ligaments and muscles have a tendency to become strained from excessive lifting, exercise, or improper body mechanics. This can cause local nerve irritation, resulting in LBP, and myofascial (muscle and connective tissue) and ligament injury account for the majority of this kind of back pain.

Conditions that can produce chronic pain from ligaments and musculature include:

Myofascial Pain Syndrome
Muscular Strain
Torn Muscle
Ligamentous Strain
Ligamentous Tear

Referred pain

Referred pain is any pain that has its source in one area but is felt in a completely different location in the body. Organs in the abdomen and pelvis can cause referred back pain. Specifically, the kidney, pancreas, spleen, and liver are known to cause LBP due to: enlargement, infection, inflammation, obstruction, decreased blood supply and sometimes cancer. All the nerves in the body connect to the spine and may travel into the spinal cord at the same level as other structures in the lower back. This can cause pain perception in the back, instead of the organs.

Pathology

Common causes of LBP include: Herniated Discs, Spinal Stenosis, Strained Muscles Sciatica, Arthritis (auto-immune vs. non-auto-immune), Fibromyalgia, Vertebral Body Fractures, and Osteoporosis. Far less common causes are infections, Ankylosing Spondylitis, Psychological causes and Metastatic Cancer. There are several different risk factors for malignancy (cancer), but some are: an age greater than 50, pain not improved by lying down, symptoms worsen at night, and pain for longer than four weeks.

Acute Lower-Back Pain

Acute LBP comes on quickly, and occurs either during or after, a specific activity. This kind of injury is often caused by overuse, excessive exercise, heavy lifting, sports injuries, motor vehicle accidents, or any trauma to the lower back. Acute pain of this kind is usually the result of inflammation from strain or sprain to muscles and surrounding ligaments. Acute pain from ligament and muscle irritation responds well to anti-inflammatory drugs (Ibuprofen).

Vertebral body fractures, ruptured discs, and spinal cord compressions can also cause acute pain. This is, especially, true if there are pre-existing conditions, like osteoporosis, cancer, or spinal stenosis.

Acute back pain should be evaluated by a physician to rule out other causes like: kidney stones, kidney infection, and acute pancreatitis. In some cases of acute back pain, a specialist and proper imaging is required for immediate evaluation.

These causes and symptoms might include:

Acute Vertebral Compression Fractures
Acute Disc Herniation
Fever/Chills
Weakness or Paralysis
Loss of Bowel or Bladder Control
Spinal Cord Compression

Chronic Lower Back Pain

Chronic LBP is any persistent pain that lasts, at least, three months. Usually this kind of pain manifests gradually and worsens over time. A person with chronic LBP may experience additional pain down either leg. This is called sciatica.

Causes of chronic LBP are numerous and include:

Arthritis, Facet Joint
Sacroiliac Joint Disease
Spinal Stenosis (narrowing of the spinal canal)
Fibromyalgia
Degenerative Disc Disease
Disc Protrusion
Disc Herniation
Disc Extrusion
Facet Joint Osteoarthritis
Nerve Root Irritation or Compression (Sciatica)
Central Sensitization
Excessive Breast Size
Poor Posture
Psychological and Emotional Factors
Vertebral Body Fractures
Osteoporosis
Spondylolisthesis
Ankylosing Spondylitis
Neoplasms
Infections

Central Sensitization is common with any chronic pain syndrome and involves, both, the peripheral nervous system (PNS) and the central nervous system (CNS). Tissue injury and inflammation activate the PNS, which sends pain signals through the spinal cord to the brain.

Central sensitization is when neuron over-activity occurs within the CNS, (brain and spinal cord). Normal responses from the PNS begin to produce abnormally high responses, so that a sensory reaction that once normally produced a harmless normal sensation, now produces significant pain. This is often seen in patients suffering from chronic LBP.

Sacroiliac Joint (SIJ) Disease

SIJ is another chronic pain cause that is centered in the sacroiliac joint disease. Many strong ligaments and muscles support these joints, which are located on both sides of the lower back. The main function of these joints is for weight support and weight transfer, which makes them susceptible to injury.

The SIJ is innervated by multiple nerves and spinal nerve roots, and inflammation in this joint causes severe pain. SIJ pain can worsen with prolonged sitting, twisting motions, or other sudden movements. The pain often starts spontaneously; or as the result of specific injury or trauma.

Conservative treatment options, such as anti-inflammatory drugs and physical therapy, are often effective. A 2007 report found that the effectiveness of a lidocaine injection into the SIJ resulted in a 96% pain improvement in patients with SIJ (2007 Murakami).

Diagnosis

Making a LBP diagnosis can be difficult, because so many different conditions can cause similar symptoms. After a physical exam and detailed history, he or she will most likely order one or more visual tests, like, an X-ray, Computerized tomography (CT) scan, Magnetic resonance imaging (MRI) or Bone scan. All of these depend on clinical suspicions and findings during the exam.

Treatment Options

Spinal bone conditions

A 2007 report stated that lumbar facet joint nerve blocks, with local anesthetics, may be effective for treating chronic lower back pain, especially, of facet joint origin. Physical therapy, cognitive behavioral therapy, biofeedback, diet and exercise have also proven to be effective (Manchikanti 2007).

Procedures like, facet injections/denervation, vertebroplasty, SI joint injection/denervation, lysis of adhesions, spinal cord stimulation, intrathecal pumps and other treatments may provide pain relief for many spinal bone conditions.

Disc treatments

Facet injections, epidural steroid injections, lysis of adhesions, epidural infusions, spinal cord stimulation, intrathecal pumps and other treatments can be a beneficial pain management option for many disc injuries and conditions.

Spinal Ligaments and Muscles treatments

Trigger point injections have proven successful for pain relief for musculoskeletal pain. Prolotherapy is an alternative therapy that specifically targets ligaments. This sort of therapy, also called Regenerative Injection Therapy, is beneficial for many sufferers of chronic pain. Physical therapy, acupuncture, massage, yoga, diet, and exercise, and other alternative therapies, can beneficial pain management options for myofascial pain and other ligament and muscle pain.

Individuals with LBP pain lasting longer than four weeks or who are experiencing uncontrollable pain should see a pain specialist for treatment options.

Recent research shows that early treatment lowers the risk of developing a chronic pain syndrome. Contrary to some belief, bed rest generally doesn’t help LBP. Staying active and physical therapy are suggested instead. There are many pain relief options for those with severe LBP.

Pain Relief Option Overview

Pharmacotherapy – NSAIDs (Ibuprofen like drugs), Acetaminophen (Tylenol), muscle relaxants, and membrane stabilizing medications can offer significant relief from LBP.

Minimally-Invasive Procedures

Epidural Steroidal Injections are commonly used for chronic back pain syndromes, like degenerative disc disease. Medications are injected into the epidural space (area outside the spinal cord) and in the area where the pain originates. ESI’s are used to alleviate symptoms for a range of back-pain conditions. The medications spread to other areas and portions of the spine to reduce inflammation and irritation.

Medial Branch Blocks (MBBs) are often used to treat neck and back pain related to arthritis. Medial branches are spinal nerves that branch out from the vertebra and connect to the facet joints. The procedure is an injection of medications that reduce inflammation and irritation of the facet joint.

Lysis of adhesions is a type of ESI that removes excessive scar tissue from the epidural space. It’s typically performed when other more conservative treatments have failed to provide adequate pain relief.

Infusions Techniques involves inserting a small catheter into the epidural space or next to the affected nerves. A local anesthetic, and other medications, are administered through the catheter. The continuous infusion of medicines and anesthetic has the potential to result in long-lasting pain relief.

Spinal cord stimulation is typically used for individuals with chronic and severe LBP. A small electrical pulse generator is implanted under the skin, decreasing pain to the spinal cord and brain pain processing centers. An initial trial period is done to see if it will help with longer-term pain relief. If the trial period offers pain relief, than a permanent SCS device is implanted.

Peripheral Nerve Stimulation is typically used for individuals with chronic and severe LBP. Tiny electrodes are placed close to the affected nerves, and low-level electrical impulses block pain perception originating from the nerve. An initial trial period is done to see if it will help with longer-term pain relief. It may offer significant pain relief from chronic LBP as well.

Kyphoplasty and vertebroplasty are two procedures that treat compression fractures, which are often related to osteoporosis. Acrylic bone cement is injected into compressed or fractured vertebrae, strengthening the vertebrae, restoring vertebral height, and reversing spinal deformities.

Intrathecal pump implants allow delivery of pain medications (opiates, local anesthetics, and/or muscle relaxants) to affected area. Sixty-six percent of cancer patients, who use intrathecal pumps, experience pain reduction (Becker 2000).

Percutaneous discectomy, is a procedure for herniated or bulging discs, where a needle is inserted through the skin into the bulging disc. The extra material is suctioned out of the disc, relieving pressure on the disc and on other nearby structures.

Disc denervation uses heat to deaden or dull a nerve. Needles are placed along the vertebral bodies, close to the discs, and when the appropriate nerve placement is located, the nerves are anesthetized and destroyed using heat, generated from radio frequency.

Cryotherapy utilizes freezing temperatures to deaden or dull a nerve. A probe is placed through a needle, near the irritated and painful nerves, and electrical stimulation is used to pinpoint the proper location, and nerves are anesthetized. Several freezing cycles are initiated over the painful nerves.

Peripheral nerve blocks and ablation is a nerve block that uses injected medications on, or near, irritated nerves. Peripheral nerves are often are sources of LBP. Once the painful sensations are blocked with a local anesthetic, then ablation or destruction of the nerves can be performed.

Trigger points are specific muscle areas that cause pain, and trigger point injections involve injecting a local anesthetic and steroid, onto a “Trigger Point.” Often this procedure can offer significant pain relief from muscle spasms.

The use of Botox for LBP is a relatively new and innovative treatment option. In 2005 “Botulinum toxin Type A” (BtA) became the first line therapy for the treatment for cervical dystonia. Although a single injection of BtA is effective, multiple injections often work better for patients (Costa 2005). Along with pain reductions, many patients have had an improved range of motion ((Juan 2004). Not everyone can receive Botox injections, so it is important to speak with your doctor about all your medical conditions before proceeding.

Transcutaneous Electrical Nerve Stimulation (TENS) – TENs uses a small, battery-operated device that delivers low-voltage electrical current through the skin via electrode patches. The electric impulses interfere with pain sensations and replace pain perceptions with different stimuli.

Alternative/Complimentary Treatment Options

Always consult a physician before beginning any alternative or complimentary therapy. There are many different alternative therapies that are very helpful in relieving LBP including, acupuncture, biofeedback, physical therapy, exercise, nutrition, therapeutic massage, chiropractic manipulations, nutrition, and prolotherapy.

Surgical Options

Surgical procedures are typically performed conservative pain management options have failed, or when the spinal cord nerves are severely compressed. Serious compressions are characterized by bladder and/or bowel incontinence, lower extremity weakness, spasticity, and/or loss of sensation.

Invasive Surgical Procedures Include:

Discectomy
Laminectomy
Spinal Fusion
Spinal Instrumentation

For long-term pain relief, surgical fusion or discectomy may not be successful. In addition, these procedures have greater risks for serious complications, including: bleeding, nerve damage, epidural scarring, and prolonged recovery times.

Surgery is generally the last resort, when pain specialists have exhausted other avenues of treatments; or when life-threatening complications have developed, or neurological symptoms like weakness, bowel or bladder changes, and/or loss of sensation are experienced. Surgical fusion or surgery for the chronic pain treatment is not usually routine.

For more information about lower back pain causes, conditions, procedures, treatments or other items mentioned, please consult your pain physician.