Back pain

Back pain is a common reason for absence from work and for seeking medical treatment. It can be uncomfortable and debilitating.

It can result from injury, activity and some medical conditions. Back pain can affect people of any age, for different reasons. As people get older, the chance of developing lower back pain increases, due to factors such as previous occupation and degenerative disk disease.

Lower back pain may be linked to the bony lumbar spine, discs between the vertebrae, ligaments around the spine and discs, spinal cord and nerves, lower back muscles, abdominal and pelvic internal organs, and the skin around the lumbar area.

Pain in the upper back may be due to disorders of the aorta, tumors in the chest, and spine inflammation.

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There are many causes of back pain, including blood vessels, internal organs, infections, mechanical, and autoimmune causes. The spinal cord, nerve roots, vertebral column, and muscles around the spine can all be sources of back pain. The anterior ligaments of the intervertebral disc are extremely sensitive, and even the slightest injury can cause significant pain.In osteoporosis, the bones become weaker and can develop small cracks, or fractures, in the bones, resulting in pain. Arthritis in the joints of the back can also result in discomfort. The synovial joints of the spine (e.g. zygapophysial joints/facet joints) have been identified as the primary source of the pain in approximately one third of people with chronic low back pain, and in most people with neck pain following whiplash.

Approximately 98 percent of people with back pain are diagnosed with nonspecific acute back pain in which there is no serious underlying pathology. Less than 2 percent are attributed to secondary factors, with metastatic cancers and serious infections, such as spinal osteomyelitis and epidural abscesses, accounting for around 1 percent.

Back pain can be divided into non-radicular pain and radiculopathy. Radiculopathy occurs when there is irritation in the nerve root, causing neurologic symptoms, such as numbness and tingling. Disk herniation and foraminal stenosis are the most common causes of radiculopathy. Non-radicular back pain is most commonly caused by injury to the spinal muscles or ligaments, degenerative spinal disease, or a herniated disk. Spondylosis, or spinal degeneration, occurs when the intervertebral disc undergoes degenerative changes, causing the disc to fail at cushioning the vertebrae. There is an association between intervertebral disc space narrowing and lumbar spine pain. The space between the vertebrae becomes more narrow, resulting in compression and irritation of the nerves. There is a weak association between low back pain and facet osteoarthritis, which has been considered as a primary reason for compression of spine nerve roots as they exit the intervertebral foramen.

Back pain can also be due to referred pain from another source. Referred pain occurs when pain is felt at a location different from the source of the pain. An abdominal aortic aneurysm and ureteral colic can both result in pain felt in the back.

Another possible cause of chronic back pain in people with otherwise normal scans is central sensitization, where an initial injury or infection causes a longer-lasting state of heightened sensitivity to pain. This persistent state maintains pain even after the initial injury has healed. Treatment of sensitization typically involves low doses of anti-depressants.

Other causes

Some medical conditions can lead to back pain.

  • Cauda equina syndrome: The cauda equine is a bundle of spinal nerve roots that arise from the lower end of the spinal cord. Symptoms include a dull pain in the lower back and upper buttocks, as well as numbness in the buttocks, genitalia, and thighs. There are sometimes bowel and bladder function disturbances.
  • Cancer of the spine: A tumor on the spine may press against a nerve, resulting in back pain.
  • Infection of the spine: A fever and a tender, warm area on the back could be due to an infection of the spine.
  • Other infections: Pelvic inflammatory disease, bladder, or kidney infections may also lead to back pain.
  • Sleep disorders: Individuals with sleep disorders are more likely to experience back pain, compared with others.
  • Shingles: An infection that can affect the nerves may lead to back pain. This depends on which nerves are affected.

Obesity, sedentary lifestyle, and lack of exercise can increase a person's risk of back pain. People who smoke are more likely to experience back pain than others. Poor posture and weight gain in pregnancy are also risk factors for back pain. In general, fatigue can worsen pain.

A few studies suggest that psychosocial factors such as on-the-job stress and dysfunctional family relationships may correlate more closely with back pain than structural abnormalities revealed in X-rays and other medical imaging scans.

The following factors are linked to a higher risk of developing low back pain:

  • occupational activities
  • pregnancy
  • a sedentary lifestyle
  • poor physical fitness
  • older age
  • obesity and excess weight
  • smoking
  • strenuous physical exercise or work, especially if done incorrectly
  • genetic factors
  • medical conditions, such as arthritis and cancer

Lower back pain also tends to be more common in women than in men, possibly due to hormonal factors. Stress, anxiety, and mood disorders have also been linked to back pain.

The main symptom of back pain is an ache or pain anywhere in the back, and sometimes all the way down to the buttocks and legs.

Some back issues can cause pain in other parts of the body, depending on the nerves affected.

The pain often goes away without treatment, but if it occurs with any of the following people should see their doctor:

  • weight loss
  • fever
  • inflammation or swelling on the back
  • persistent back pain, where lying down or resting does not help
  • pain down the legs
  • pain that reaches below the knees
  • a recent injury, blow or trauma to the back
  • urinary incontinence
  • difficulty urinating
  • fecal incontinence, or loss of control over bowel movements
  • numbness around the genitals
  • numbness around the anus
  • numbness around the buttocks

In most cases of low back pain, medical consensus advises not seeking an exact diagnosis but instead beginning to treat the pain. This assumes that there is no reason to expect that the person has an underlying problem. In most cases, the pain goes away naturally after a few weeks.Typically, people who do seek diagnosis through imaging are not likely to have a better outcome than those who wait for the condition to resolve.

Laboratory testing may include white blood cell (WBC) count, erythrocyte sedimentation rate (ESR), and C-reactive protein (CRP).

  • Elevated ESR could indicate infection, malignancy, chronic disease, inflammation, trauma, or tissue ischemia.
  • Elevated CRP levels are associated with infection

An imaging scan and other tests may be required if:

  • back pain appears to result from an injury
  • there may be underlying cause that needs treatment
  • the pain persists over a long period
  • An X-ray, MRI, or CT scan can give information about the state of the soft tissues in the back.
  • X-rays can show the alignment of the bones and detect signs of arthritis or broken bones, but they may not reveal damage in the muscles, spinal cord, nerves, or disks.
  • MRI or CT scans can reveal herniated disks or problems with tissue, tendons, nerves, ligaments, blood vessels, muscles, and bones.
  • Bone scans can detect bone tumors or compression fractures caused by osteoporosis. A radioactive substance or tracer is injected into a vein. The tracer collects in the bones and helps the doctor detect bone problems with the aid of a special camera.
  • Electromyography or EMG measures the electrical impulses produced by nerves in response to muscles. This can confirm nerve compression, which may occur with a herniated disk or spinal stenosis.
  • The doctor may also order a blood test if infection is suspected.

Other types of diagnosis

  • A chiropractor manipulates and adjusts the back of a patient.

  • A chiropractor will diagnose through touch, or palpation, and a visual examination. Chiropractic is known as a direct approach, with a strong focus on adjusting the spinal joints. A chiropractor may also want to see the results of imaging scans and any blood and urine tests.
  • An osteopath also diagnoses through palpation and visual inspection. Osteopathy involves slow and rhythmic stretching, known as mobilization, pressure or indirect techniques, and manipulation of joints and muscles.
  • A physical therapist focuses on diagnosing problems in the joints and soft tissues of the body.

The management goals when treating back pain are to achieve maximal reduction in pain intensity as rapidly as possible, to restore the individual's ability to function in everyday activities, to help the patient cope with residual pain, to assess for side-effects of therapy, and to facilitate the patient's passage through the legal and socioeconomic impediments to recovery. For many, the goal is to keep the pain to a manageable level to progress with rehabilitation, which then can lead to long-term pain relief. Also, for some people the goal is to use non-surgical therapies to manage the pain and avoid major surgery, while for others surgery may be the quickest way to feel better

Not all treatments work for all conditions or for all individuals with the same condition, and many find that they need to try several treatment options to determine what works best for them. The present stage of the condition (acute or chronic) is also a determining factor in the choice of treatment. Only a minority of people with back pain (most estimates are 1% - 10%) require surgery.

Non medical

Back pain is generally treated with non-pharmacological therapy first, as it typically resolves without the use of medication. Superficial heat and massage, acupuncture, and spinal manipulation therapy may be recommended.

  • Heat therapy is useful for back spasms or other conditions. A review concluded that heat therapy can reduce symptoms of acute and sub-acute low-back pain.
  • Regular activity and gentle stretching exercises is encouraged in uncomplicated back pain, and is associated with better long-term outcomes. Physical therapy to strengthen the muscles in the abdomen and around the spine may also be recommended.  These exercises are associated with better patient satisfaction, although it has not been shown to provide functional improvement. However, one study found that exercise is effective for chronic back pain, but not for acute pain. If used, they should be performed under supervision of a licensed health professional.
  • Massage therapy may give short-term pain relief, but not functional improvement, for those with acute lower back pain. It may also give short-term pain relief and functional improvement for those with long-term (chronic) and sub-acute lower pack pain, but this benefit does not appear to be sustained after 6 months of treatment. There does not appear to be any serious adverse effects associated with massage.
  • Acupuncture may provide some relief for back pain. However, further research with stronger evidence needs to be done.
  • Spinal manipulation is a widely-used method of treating back pain, although there is no evidence of long-term benefits.
  • "Back school" is an intervention that consists of both education and physical exercises. A 2016 Cochrane review found the evidence concerning back school to be very low quality and was not able to make generalizations as to whether back school is effective or not.

Medication

If non-pharmacological measures are not effective, medications may be tried.

  • Non-steroidal anti-inflammatory drugs (NSAIDs) are typically tried first. NSAIDs have been shown to be more effective than placebo, and are usually more effective than paracetamol (acetaminophen).
  • Long-term use of opioids has not been tested in order to determine if it is effective or safe for treating chronic lower back pain. For severe back pain not relieved by NSAIDs or acetaminophen, opioids may be used. Opioids may not be better than NSAIDs or antidepressants for chronic back pain with regards to pain relief and gain of function.
  • Skeletal muscle relaxers may also be used. Their short term use has been shown to be effective in the relief of acute back pain. However, the evidence of this effect has been disputed, and these medications do have negative side-effects.
  • In people with nerve root pain and acute radiculopathy, there is evidence that a single dose of steroids, such as dexamethasone, may provide pain relief.
  • Epidural corticosteroid injection (ESI) is a procedure in which steroid medications are injected into the epidural space. The steroid medications reduce inflammation and thus decrease pain and improve function. ESI has long been used to both diagnose and treat back pain, although recent studies have shown a lack of efficacy in treating low back pain.

Surgery

Surgery for back pain is typically used as a last resort, when serious neurological deficit is evident. A 2009 systematic review of back surgery studies found that, for certain diagnoses, surgery is moderately better than other common treatments, but the benefits of surgery often decline in the long term.

Surgery may sometimes be appropriate for people with severe myelopathy or cauda equina syndrome. Causes of neurological deficits can include spinal disc herniation, spinal stenosis, degenerative disc disease, tumor, infection, and spinal hematomas, all of which can impinge on the nerve roots around the spinal cord. There are multiple surgical options to treat back pain, and these options vary depending on the cause of the pain.

When a herniated disc is compressing the nerve roots, hemi- or partial- laminectomy or discectomy may be performed, in which the material compressing on the nerve is removed. A mutli-level laminectomy can be done to widen the spinal canal in the case of spinal stenosis. A foraminotomy or foraminectomy may also be necessary, if the vertebrae are causing significant nerve root compression. A discectomy is performed when the intervertebral disc has herniated or torn. It involves removing the protruding disc, either a portion of it or all of it, that is placing pressure on the nerve root. Total disc replacement can also be performed, in which the source of the pain (the damaged disc) is removed and replaced, while maintaining spinal mobility. When an entire disc is removed (as in discectomy), or when the vertebrae are unstable, spinal fusion surgery may be performed. Spinal fusion is a procedure in which bone grafts and metal hardware is used to fix together two or more vertebrae, thus preventing the bones of the spinal column from compressing on the spinal cord or nerve roots.

If infection, such as a spinal epidural abscess, is the source of the back pain, surgery may be indicated when a trial of antibiotics is ineffective. Surgical evacuation of spinal hematoma can also be attempted, if the blood products fail to break down on their own.

Steps to lower the risk of developing back pain consist mainly of addressing some of the risk factors.

Exercise: Regular exercise helps build strength and control body weight. Guided, low-impact aerobic activities can boost heart health without straining or jerking the back. Before starting any exercise program, talk to a health care professional.

There are two main types of exercise that people can do to reduce the risk of back pain:

  • Core-strengthening exercises work the abdominal and back muscles, helping to strengthen muscles that protect the back.
  • Flexibility training aims at improving core flexibility, including the spine, hips, and upper legs.

Diet: Make sure your diet includes enough calcium and vitamin D, as these are needed for bone health. A healthful diet also helps control body weight.

Smoking: A significantly higher percentage of smokers have back pain incidences compared to non-smokers of the same age, height, and weight.

Body weight: The weight people carry and where they carry it affects the risk of developing back pain. The difference in back pain risk between obese and normal-weight individuals is considerable. People who carry their weight in the abdominal area versus the buttocks and hip area are also at greater risk.

Posture when standing: Make sure you have a neutral pelvic position. Stand upright, head facing forward, back straight, and balance your weight evenly on both feet. Keep your legs straight and your head in line with your spine.

If you regularly use a computer, it is important to ensure that you have a chair with good back support and adopt a good posture and head position.

Posture when sitting: A good seat for working should have good back support, arm rests and a swivel base. When sitting, try to keep your knees and hips level and keep your feet flat on the floor, or use a footstool. You should ideally be able to sit upright with support in the small of your back. If you are using a keyboard, make sure your elbows are at right-angles and that your forearms are horizontal.

LiftingWhen lifting things, use your legs to do the lifting, rather than your back.

Keep your back as straight as you can, keeping your feet apart with one leg slightly forward so you can maintain balance. Bend only at the knees, hold the weight close to your body, and straighten the legs while changing the position of your back as little as possible.

Bending your back initially is unavoidable, but when you bend your back try not to stoop, and be sure to tighten your stomach muscles so that your pelvis is pulled in. Most important, do not straighten your legs before lifting, or you will be using your back for most of the work.

Do not lift and twist at the same time: If something is particularly heavy, see if you can lift it with someone else. While you are lifting keep looking straight ahead, not up or down, so that the back of your neck is like a continuous straight line from your spine.

Moving things: It is better for your back to push things across the floor, using your leg strength, rather than pulling them.

Shoes: Flat shoes place less of a strain on the back.

Driving: It is important to have proper support for your back. Make sure the wing mirrors are properly positioned so you do not need to twist. The pedals should be squarely in front of your feet. If you are on a long journey, have plenty of breaks. Get out of the car and walk around.

Bed: You should have a mattress that keeps your spine straight, while at the same time supporting the weight of your shoulders and buttocks. Use a pillow, but not one that forces your neck into a steep angle.

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