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Low Back Pain-OrthoInfo - AAOS

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Copyright 2013 American Academy of Orthopaedic Surgeons

Low Back Pain

This article is also available in Spanish: Lumbalgia (Low Back

Pain)Lumbalgia (Low Back Pain) (topic.cfm?topic=A00498).

Almost everyone will experience low back pain at some point in

their lives. This pain can vary from mild to severe. It can be short-
lived or long-lasting. However it happens, low back pain can make
many everyday activities difficult to do.

Your spine is made up of small bones, called vertebrae, which are

stacked on top of one another. Muscles, ligaments, nerves, and
intervertebral disks are additional parts of your spine.

Understanding your spine and how it works can help you better
understand low back pain. Learn more about spine anatomy: Spine
BasicsSpine Basics (topic.cfm?topic=A00575)

Back pain is different from one person to the next. The pain can
have a slow onset or come on suddenly. The pain may be
intermittent or constant. In most cases, back pain resolves on its
own within a few weeks.

There are many causes of low back pain. It sometimes occurs after
a specific movement such as lifting or bending. Just getting older

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also plays a role in many back conditions.

As we age, our spines age with us. Aging causes degenerative

changes in the spine. These changes can start in our 30s or
even younger and can make us prone to back pain, especially if
we overdo our activities.

These aging changes, however, do not keep most people from

leading productive, and generally, pain-free lives. We have all seen
the 70-year-old marathon runner who, without a doubt, has
degenerative changes in her back!

Over-activity

One of the more common causes of low back pain is muscle

soreness from over-activity. Muscles and ligament fibers can be
overstretched or injured.

This is often brought about by that first softball or golf game of the
season, or too much yard work or snow shoveling in one day. We
are all familiar with this "stiffness" and soreness in the low back
and other areas of the body that usually goes away within a few
days.

Disk Injury

Some people develop low back pain that does not go away within
days. This may mean there is an injury to a disk.

Disk tear. Small tears to the outer part of the disk (annulus)
sometimes occur with aging. Some people with disk tears have no
pain at all. Others can have pain that lasts for weeks, months, or
even longer. A small number of people may develop constant pain

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that lasts for years and is quite disabling. Why some people have
pain and others do not is not well understood.

Disk herniation. Another common type of disk injury is a "slipped"

or herniated disc.

Herniated disk.

A disk herniates when its jelly-like center (nucleus) pushes against

its outer ring (annulus). If the disk is very worn or injured, the
nucleus may squeeze all the way through. When the herniated disk
bulges out toward the spinal canal, it puts pressure on the sensitive
spinal nerves, causing pain.

Because a herniated disk in the low back often puts pressure on

the nerve root leading to the leg and foot, pain often occurs in the
buttock and down the leg. This is sciatica.

A herniated disk often occurs with lifting, pulling, bending, or

twisting movements.

Disk Degeneration

With age, intevertebral disks begin to wear away and shrink. In

some cases, they may collapse completely and cause the facet
joints in the vertebrae to rub against one another. Pain and stiffness
result.

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Disk degeneration.

This "wear and tear" on the facet joints is referred to as

osteoarthritis. It can lead to further back problems, including spinal
stenosis.

Degenerative Spondylolisthesis

(Spon-dee-low-lis-THEE-sis). Changes from aging and general

wear and tear make it hard for your joints and ligaments to keep
your spine in the proper position. The vertebrae move more than
they should, and one vertebra can slide forward on top of another. If
too much slippage occurs, the bones may begin to press on the
spinal nerves.

Spondylolisthesis.

Spinal Stenosis

Spinal stenosis occurs when the space around the spinal cord
narrows and puts pressure on the cord and spinal nerves.

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When intervertebral disks collapse and osteoarthritis develops, your

body may respond by growing new bone in your facet joints to help
support the vertebrae. Over time, this bone overgrowth (called
spurs) can lead to a narrowing of the spinal canal. Osteoarthritis
can also cause the ligaments that connect vertebrae to thicken,
which can narrow the spinal canal.

Spinal stenosis.

Animation courtesy Visual Health Solutions, Inc.

Scoliosis

This is an abnormal curve of the spine that may develop in children,

most often during their teenage years. It also may develop in older
patients who have arthritis. This spinal deformity may cause back
pain and possibly leg symptoms, if pressure on the nerves is
involved.

Additional Causes

There are other causes of back pain, some of which can be

serious. If you have vascular or arterial disease, a history of cancer,
or pain that is always there despite your activity level or position,
you should consult your primary care doctor.

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Back pain varies. It may be sharp or stabbing. It can be dull, achy,

or feel like a "charley horse" type cramp. The type of pain you have
will depend on the underlying cause of your back pain.

Most people find that reclining or lying down will improve low back
pain, no matter the underlying cause.

People with low back pain may experience some of the following:

Back pain may be worse with bending and lifting.

Sitting may worsen pain.

Standing and walking may worsen pain

Back pain comes and goes, and often follows an up and down
course with good days and bad days.

Pain may extend from the back into the buttock or outer hip area,
but not down the leg.

Sciatica is common with a herniated disk. This includes buttock and

leg pain, and even numbness, tingling or weakness that goes down
to the foot. It is possible to have sciatica without back pain.

Regardless of your age or symptoms, if your back pain does not get
better within a few weeks, or is associated with fever, chills, or
unexpected weight loss, you should call your doctor.

Medical History and Physical Examination

After discussing your symptoms and medical history, your doctor

will examine your back. This will include looking at your back and
pushing on different areas to see if it hurts. Your doctor may have
you bend forward, backward, and side to side to look for limitations
or pain.

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Your doctor may measure the nerve function in your legs. This
includes checking your reflexes at your knees and ankles, as well
as strength testing and sensation testing. This might tell your doctor
if the nerves are seriously affected.

Imaging Tests

Other tests which may help your doctor confirm your diagnosis
include:

X-rays. Although they only visualize bones, simple X-rays can help
determine if you have the most obvious causes of back pain. It will
show broken bones, aging changes, curves, or deformities. X-rays
do not show disks, muscles, or nerves.

Magnetic resonance imaging (MRI). This study can create better

images of soft tissues, such as muscles, nerves, and spinal disks.
Conditions such as a herniated disk or an infection are more visible
in an MRI scan.

Computerized axial tomography (CAT) scans. If your doctor

suspects a bone problem, he or she may suggest a CAT scan. This
study is like a three-dimensional X-ray and focuses on the bones.

Bone scan. A bone scan may be suggested if your doctor needs

more information to evaluate your pain and to make sure that the
pain is not from a rare problem like cancer or infection.

Bone density test. If osteoporosis is a concern, your doctor may

order a bone density test. Osteoporosis weakens bone and makes
it more likely to break. Osteoporosis by itself should not cause back
pain, but spinal fractures due to osteoporosis can.

In general, treatment for low back pain falls into one of three

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categories: medications, physical medicine, and surgery.

Nonsurgical Treatment

Medications. Several medications may be used to help relieve

your pain.

Aspirin or acetaminophen can relieve pain with few side effects.

Non-steroidal anti-inflammatory medicines like ibuprofen and

naproxen reduce pain and swelling.

Narcotic pain medications, such as codeine or morphine, may help.

Steroids, taken either orally or injected into your spine, deliver a

high dose of anti-inflammatory medicine.

Physical medicine. Low back pain can be disabling. Medications

and therapeutic treatments combined often relieve pain enough for
you to do all the things you want to do.

Physical therapy can include passive modalities such as heat, ice,

massage, ultrasound, and electrical stimulation. Active therapy
consists of stretching, weight lifting, and cardiovascular exercises.
Exercising to restore motion and strength to your lower back can be
very helpful in relieving pain.

Braces are often used. The most common brace is a corset-type

that can be wrapped around the back and stomach. Braces are not
always helpful, but some people report feeling more comfortable
and stable while wearing them.

Chiropractic or manipulation therapy is provided in many

different forms. Some patients have relief from low back pain with
these treatments.

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Traction is often used, but without scientific evidence for

effectiveness.

Other exercise-based programs, such as Pilates or yoga are

helpful for some patients.

Surgical Treatment

Surgery for low back pain should only be considered when

nonsurgical treatment options have been tried and have failed. It is
best to try nonsurgical options for 6 months to a year before
considering surgery.

In addition, surgery should only be considered if you doctor can

pinpoint the source of your pain.

Surgery is not a last resort treatment option "when all else fails."
Some patients are not candidates for surgery, even though they
have significant pain and other treatments have not worked. Some
types of chronic low back pain simply cannot be treated with
surgery.

Spinal Fusion. Spinal fusion is essentially a "welding" process.

The basic idea is to fuse together the painful vertebrae so that they
heal into a single, solid bone.

Spinal fusion eliminates motion between vertebral segments. It is

an option when motion is the source of pain. For example, your
doctor may recommend spinal fusion if you have spinal instability, a
curvature (scoliosis), or severe degeneration of one or more of your
disks. The theory is that if the painful spine segments do not move,
they should not hurt.

Fusion of the vertebrae in the lower back has been performed for

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decades. A variety of surgical techniques have evolved. In most

cases, a bone graft is used to fuse the vertebrae. Screws, rods, or
a "cage" are used to keep your spine stable while the bone graft
heals.

The surgery can be done through your abdomen, your side, your
back, or a combination of these. There is even a procedure that is
done through a small opening next to your tailbone. No one
procedure has been proven better than another.

The results of spinal fusion for low back pain vary. It can be very
effective at eliminating pain, not work at all, and everything in
between. Full recovery can take more than a year.

Disk Replacement. This procedure involves removing the disk and

replacing it with artificial parts, similar to replacements of the hip or
knee.

The goal of disk replacement is to allow the spinal segment to keep

some flexibility and maintain more normal motion.

The surgery is done through your abdomen, usually on the lower

two disks of the spine.

Although no longer considered a new technology, the results of

artificial disk replacement compared to fusion are controversial.

It may not be possible to prevent low back pain. We cannot avoid

the normal wear and tear on our spines that goes along with aging.
But there are things we can do to lessen the impact of low back
problems. Having a healthy lifestyle is a good start.

Exercise

Combine aerobic exercise, like walking or swimming, with specific

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exercises to keep the muscles in your back and abdomen strong

and flexible.

Proper Lifting

Be sure to lift heavy items with your legs, not your back. Do not
bend over to pick something up. Keep your back straight and bend
at your knees.

Weight

Maintain a healthy weight. Being overweight puts added stress on

your lower back.

Avoid Smoking

Both the smoke and the nicotine cause your spine to age faster
than normal.

Proper Posture

Good posture is important for avoiding future problems. A therapist

can teach you how to safely stand, sit, and lift.

Last reviewed: December 2013

AAOS does not endorse any treatments, procedures, products, or

physicians referenced herein. This information is provided as an
educational service and is not intended to serve as medical advice.
Anyone seeking specific orthopaedic advice or assistance should
consult his or her orthopaedic surgeon, or locate one in your area
through the AAOS "Find an Orthopaedist" program on this website.

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Copyright 2013 American Academy of Orthopaedic Surgeons

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Related Resources

Video: Herniated Disk ()

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Wellness: Spine Exercise Conditioning Program (/PDFs

/Rehab_Spine_5.pdf)

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OrthoInfo
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Rosemont, IL 60018
Phone: 847.823.7186
Email: [email protected]

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