Causes of Back Pain

Sprains and Strains

Most people will experience back pain during their lifetime. Some patients fear the worst, especially when pain is severe. Although back pain can be caused by fracture, disc disorder, or tumor, the most common cause is sprain or strain.Sprains and strains often result from excessive physical demands on the back. Lifting something too heavy, a sudden fall, car crash, or sports injury can cause soft tissues (ligaments, muscles, tendons) to stretch too much.

The spine includes vertebrae (bones), discs (cartilaginous pads or shock absorbers), the spinal cord and nerve roots (neurological wiring system), and blood vessels (nourishment). Ligaments link bones together, and tendons connect muscles to bones and discs. The ligaments, muscles, and tendons work together to handle the external forces the spine encounters during movement, such as bending forward and lifting.

Osteoarthritis

Osteoarthritis, also called degenerative joint disease, is the most common type of arthritis. It is associated with a breakdown of cartilage in joints and can occur in almost any joint in the body. It most commonly occurs in the fingers, hips, knees and spine.

Cartilage is a firm, rubbery material that covers the ends of bones in normal joints. Its main function is to reduce friction in the joints and serve as a "shock absorber." The shock-absorbing quality of normal cartilage comes from its ability to change shape when compressed (flattened or pressed together).Osteoarthritis causes the cartilage in a joint to become stiff and lose its elasticity, making it more susceptible to damage. Over time, the cartilage may wear away in some areas, greatly decreasing its ability to act as a shock absorber. As the cartilage wears away, tendons and ligaments stretch, causing pain. If the condition worsens, the bones could rub against each other.

Degenerative Disc Disease

Degenerative Disc Disease (DDD) is a gradual process that may compromise the spine. Although DDD is relatively common, its effects are usually not severe enough to warrant medical attention. In this discussion we address Degenerative Disc Disease in the lumbar spine.

Degenerative Changes to a Disc

Degenerative changes in the spine are often referred to those that cause the loss of normal structure and/or function. The intervertebral disc is one structure prone to the degenerative changes associated with wear and tear aging, even misuse (e.g. smoking).

Long before Degenerative Disc Disease can be seen radiographically, biochemical and histologic (structural) changes occur. Some of these changes are not unlike those associated with osteoarthritis.

Over time the collagen (protein) structure of the annulus fibrosus weakens and may become structurally unsound. Additionally, water and proteoglycan (PG) content decreases. PGs are molecules that attract water. These changes are linked and may lead to the disc's inability to handle mechanical stress. Understanding the lumbar spine carries a large portion of the body's weight; the stress from motion may result in a disc problem (e.g. herniation).

Non-Operative Treatment: Yesterday vs. Today

DDD is a disorder that may cause low back pain. It is interesting to note that although 80% of adults will experience back pain, only 1-2% will need lumbar spine surgery!

In the past some physicians prescribed long courses of bedrest and/or lumbar traction for their patients with low back pain. However, that is not the attitude today. During the acute phase, bedrest may be recommended for a few days, but beyond that experts advocate stretching, flexion and extension exercises, and no/low impact aerobics. Of course, each patient is different and therefore so is their treatment plan.

Disc Herniation/Bulging

Herniation of the nucleus pulposus (HNP) occurs when the nucleus pulposus (gel-like substance) breaks through the anulus fibrosus (tire-like structure) of an intervertebral disc (spinal shock absorber).

A herniated disc occurs most often in the lumbar region of the spine especially at the L4-L5 and L5-S1 levels (L = Lumbar, S = Sacral). This is because the lumbar spine carries most of the body's weight. People between the ages of 30 and 50 appear to be vulnerable because the elasticity and water content of the nucleus decreases with age.

The progression to an actual HNP varies from slow to sudden onset of symptoms. There are four stages: (1) disc protrusion (2) prolapsed disc (3) disc extrusion (4) sequestered disc. Stages 1 and 2 are referred to as incomplete, where 3 and 4 are complete herniations. Pain resulting from herniation may be combined with a radiculopathy, which means neurological deficit. The deficit may include sensory changes (i.e. tingling, numbness) and/or motor changes (i.e. weakness, reflex loss). These changes are caused by nerve compression created by pressure from interior disc material.

Progression of Herniated Disc

The extremities affected are dependent upon the vertebral level at which the HNP occurred. Consider the following examples:

• Cervical - Pain in the neck, shoulders, and arms
• Thoracic - Pain radiates into the chest
• Lumbar - Pain extends into the buttocks, thighs, legs

Cauda Equina Syndrome occurs from a central disc herniation and is serious requiring immediate surgical intervention. The symptoms include bilateral leg pain, loss of perianal sensation (anus), paralysis of the bladder, and weakness of the anal sphincter.

Diagnosis of a Herniated Disc

The spine is examined with the patient laying down and standing. Due to muscle spasm, a loss of normal spinal curvature may be noted. Radicular pain (inflammation of a spinal nerve) may increase when pressure is applied to the affected spinal level.

A Lasegue test, also known as Straight-leg Raising Test, is performed. The patient lies down, the knee is extended, and the hip is flexed. If pain is aggravated or produced, it is an indication the lower lumbosacral nerve roots are inflamed.

Other neurological tests are performed to determine loss of sensation and/or motor function. Abnormal reflexes are noted as these changes may indicate the location of the herniation.

Radiographs are helpful, but Computed Axial Tomography (CAT) or Magnetic Resonance Imaging (MRI) provides more detail. The MRI is the best method enabling the physician to see the soft spinal tissues unseen in a conventional x-ray.

Radiculopathy

Lumbar radiculopathy, which refers to pain in the lower extremities in a dermatomal pattern. A dermatome is a specific area in the lower extremity innervated by a specific lumbar nerve. This pain is caused by compression of the roots of the spinal nerves in the lumbar region of the spine. Diagnosing leg and back pain begins with a detailed patient history and examination.

Facet Syndrome

Is a common cause of pain related to the spine. The facet joints are the articulations or connections between the vertebraes in the spine. They are like any other joint in the body like the knee or elbow that enable the bending or twisting movements of the spine. The facet joints can get inflamed secondary to injury or arthritis and cause pain and stiffness. When the facet joints are affected in the neck or cervical spine it typically causes pain in this area as well headaches and difficulty rotating the head.

People who suffer from this problem usually complain that they have to turn their entire body to look over to the right or left. Pain can be felt in other areas such as the shoulders or midback area. Low back pain is commonly caused by Facet Joint Syndrome. Pain is felt in the lower back and sometimes it can be felt in the buttock as well in the thighs usually not going below the knee.

Sciatica

This is a condition which causes pain down the back of one or both thighs. Inflammation of the sciatic nerve (which is the largest nerve in the body-about the diameter of your little finger) can be either constant or intermittent. Success in solving this problem is directly correlated to the diagnosis. Sciatica can be caused by a pinched nerve as it exits the low back spine or it can be caused by prostatic cancer. Odds are usually that the cause is some structural imbalance, but there are so many potential causes, some serious and some benign, it is better to at least know that there may be a grave cause to the symptoms.

This doesn't mean that you shouldn't immediately incorporate a strategy to eliminate any structural imbalances. In most cases, this will resolve the problem. If the problem doesn't respond to these basic efforts, then professional assistance may be needed. The first effort in relieving sciatic symptoms should be to review Hip Pain.

Trigger points can accumulate in the piriformis muscle forcing a contraction and strangulation of the sciatic nerve. The tennis ball exercise should be incorporated to help to relax the piriformis muscle. Stretching may be beneficial, but that is more of a "try an see" exercise. If there are no improvements with this approach, refer to Low Back Pain to better understand the relationship between the sciatic nerve and the low back spine. Seeking help from a chiropractor or orthopedist may be indicated if the solution can't be found at home.

Foraminal Stenosis

This disease is associated with spinal stenosis, but it differs because it primary affects one or more vertebral foramen. Normally, nerve roots have enough room to easily slip through the foramen. However, with age and disease, the neuroforamen may become clogged with debris. The nerves can become trapped and compressed.

The symptoms of foraminal stenosis may include numbness, weakness, burning sensations, tingling, and pins and needles in the involved extremity, such as the leg. Not every stenosis is critical, but if spinal stenosis is ignored, nerves may die, which could result in a loss of function. The functional loss could involve the ability to feel (sensory) and/or move (motor).

If conservative forms of treatment are unsuccessful, surgery is an option. The procedure is termed a foraminotomy.

Scoliosis

Scoliosis is defined as a side-to-side deviation from the normal frontal axis of the body (Fig. 2a&b).Although traditional, this definition is limited since the deformity occurs in varying degrees in all three planes: back-front; side-to-side; top-to-bottom. Scoliosis is a descriptive term and not a diagnosis. As such, a search is made for the cause. In more than 80% of the cases, a specific cause is not found and such cases are termed idiopathic, i.e., of undetermined cause. This is particularly so among the type of scoliosis seen in adolescent girls. Conditions known to cause spinal deformity are congenital spinal column abnormalities, neurological disorders, genetic conditions and a multitude of other causes.

Scoliosis does not come from carrying heavy things, athletic involvement, sleeping/standing postures, or minor lower limb length inequality. In managing AIS, the judgment of the surgeon and the participation of informed patients and families are as important in determining treatment outcome as surgical techniques. Decision-making in the management of AIS remains complex despite the availability of data on natural history, prognosis of different curve patterns, brace treatment factors, and surgical innovations. The management of AIS includes several steps and treatment options:

• screening and early detection of deformity,
• observation of changes in deformity over time with informed judgment regarding prognosis, orthotic and non-operative interventions,
• surgical planning and operating

Fibromyalgia

Fibromyalgia syndrome (or fibromyalgia) is a chronic disorder associated with widespread muscle and soft tissue pain, tenderness, and fatigue. A person with fibromyalgia will experience pain when up to 18 specific areas called tender points are pressed. Pushing carefully on these specific trigger points during an examination causes discomfort or sharp pain.

The cause of fibromyalgia is not known. Fibromyalgia has been recognized as a medical disorder only since the 1980s, although there is evidence it may have existed for centuries.1

The pain of fibromyalgia is more than normal muscle aches common after physical exertion. Fibromyalgia often can be severe enough to disrupt a person's daily work and activities.

Other symptoms that commonly occur with fibromyalgia include:

• Unrestful sleep.
• Fatigue.
• Morning stiffness.

Less common symptoms or conditions that can accompany fibromyalgia include:

• Headache.
• Raynaud's syndrome.
• Irritable bowel syndrome (present in about one-half of those with fibromyalgia).2
• Depression.

Fibromyalgia can be difficult to diagnose because its symptoms are similar to many other disorders and diseases. There are no lab tests to diagnose fibromyalgia. It is often diagnosed after other conditions have been ruled out. Fibromyalgia is diagnosed when:3

A person has had widespread pain for at least 3 months. To be considered "widespread," the pain must be both above and below the waist and on both sides of the body.

At least 11 of 18 specific tender points are painful when pressed. (Because symptoms vary widely from person to person, some people with fibromyalgia may have fewer painful tender points.)

Fibromyalgia is not a psychological condition, although it has some psychological components. As with many conditions that cause chronic pain, anxiety and depression are common in people with fibromyalgia and may make symptoms worse.

While there is no specific cure for fibromyalgia, symptoms of this syndrome can be treated. If you have fibromyalgia, taking an active role in your treatment is very important to managing your condition.

Treatment may be different for each individual. It can include:

• Medications to help you sleep better and to relieve pain.
• Exercise therapy to help with muscle aches and stiffness.
• Counseling to help you manage chronic pain.

Research is ongoing to understand the cause of fibromyalgia and its cure.

Spinal Stenosis

This refers to a narrowing of the spinal canal. Certain individuals may have a narrow canal from birth, but the majority of individuals develop narrowing with age. With age, wear and tear arthritic spurs build up on the facet joints in the posterior part of the spine. These arthritic spurs then encroach on the spinal canal and pinch the lumbar nerve roots. This condition can be worsened as well by narrowing and degeneration of the disc at that level as the space for exit of the nerve root (called the foramen) is narrowed further by a degenerated disc. Spinal stenosis is most common in the last three levels of the lumbar spine namely L3-4, L4-5 and L5-S1. It is diagnosed and confirmed by an MRI or CAT scan/myelogram. There are various signs and symptoms of spinal stenosis. A common one is referred to as spinal claudication. This refers to pain in the legs, the calves or the buttocks. This pain is associated with activity. The pain is often relieved by sitting and resting. It will then often times start up again with activity.

A common complaint is that an individual will be able to walk several blocks then develops leg pain, is able to get rid of the leg pain by sitting and resting for five to ten minutes and then, upon trying to walk another several blocks the pain will return. The pain may be a radiating pain like a sciatica or it may be a cramping pain. At times though, the stenosis may be severe enough that the leg pain is constant and unremitting. It may at times be indistinguishable from the kind of pain that occurs with a herniated disc. Spinal stenosis is uncommon in younger people. It usually occurs at age 50 or older. Leg pains from spinal pathology are more common from herniated discs in people under 50. Over 50 it is more common that spinal stenosis will be the problem. In addition to developmental degenerative spinal stenosis, entrapped nerve roots may be caused as well by spondylolisthesis and scotiosis. There is really no conservative treatment for a spinal stenosis. It will rarely cause paralyis.

The condition will tend to gradually worsen with time and cause increasing pain however. Patients with congenital spinal stenosis (such as achondroplastic dwarfs) may develop symptomatic stenosis as early as age 15 or 20.

Kyphosis

Kyphosis is the abnormal forward bending of the spine. In kyphosis, the curve of the spine is abnormal, forming a hump.

What is going on in the body?

The normal spine rounds slightly in the chest area, with arching in the lower back and neck regions. Excessive kyphosis can occur mainly in the chest area of the spine, causing the roundness of the back to appear exaggerated.

What are the signs and symptoms of the condition?

Symptoms are usually minimal, unless the deformity is severe. In that case, the back may ache or, rarely, nerve problems may arise. The hamstrings, or muscles at the back of the thigh, may also be tight.

What are the causes and risks of the condition?

Kyphosis is generally caused by an abnormal posture. Other possible causes include: · a significant fracture of the vertebra, which can cause the back to angle forward · spinal surgery · Scheuermann's disease, which results in wedging of the vertebrae. This disease is usually seen in teenage boys, and its cause is unknown. · Pott's disease, which refers to kyphosis due to collapse of the vertebra when tuberculosis infects the spine · osteoporosis in elderly women, which causes a type of kyphosis known as dowager's hump · spinal tumors, or surgery to remove them · nerve disorders

Spondylolithesis

Spondylolisthesis occurs when one lumbar vertebra slips forward in relationship to the adjacent vertebra. In the Greek language, the term spondylolisthesis means slipped vertebra. The neural arch (lamina) and the paired facet joints are anatomical structures that prevent vertebrae from slipping (Fig 1). A vertebra may slip following the development of a stress fracture through the neural arch. The defect in the lamina separates the back part of the vertebra from the remaining part; the vertebral body and disc. The stabilizing role of the paired facet joints is lost and the vertebral body slips forward. The laminar stress fracture (in Greek called spondylolysis) occurs in a specific region of the lamina called the pars interarticularis or isthmus. Hence the condition is called isthmic spondylolisthesis.

Lordosis

Lordosis is a disorder defined by an excessive inward curve of the spine. It differs from the spine's normal curves at the cervical, thoracic, and lumbar regions, which are, to a degree, either kyphotic or lordotic. The spine's natural curves position the head over the pelvis and work as shock absorbers to distribute mechanical stress during movement.

Lordosis can be found in all age groups. It primarily affects the lumbar spine, but does occur in the neck (cervical). When found in the lumbar spine, the patient may appear swayback, the buttocks more prominent, and in general an exaggerated posture. A lumbar lordosis can be painful sometimes affecting movement.

Certain disease processes can adversely affect the structural integrity of the spine and contribute to lordosis. Some common causes include achondroplasia, discitis, kyphosis, obesity, osteoporosis, and spondylolisthesis.