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| Patient Education -- Low Back
Pain |
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Low Back Pain
If you are experiencing low back pain, you are not alone.
More than 65 million Americans suffer from low back pain
every year. Back aches are the most common reason for
doctor visits, after cold and flu symptoms. Fifty percent
of all patients who suffer from an episode of low back
pain will have another occurrence within one year.
In the vast majority of cases back pain is caused by the
irritation of a nerve root near the spine, not by problems
with the muscles, ligament or bone. A nerve that travels
from the spinal cord through the openings between the
bones of the spine gets pinched or irritated, the surrounding
muscles tense up and the patient experiences low back
pain.
Low back pain is widespread in our society, but the good
news is that in most instances the pain ends within a
few days. More serious cases of back pain are treated
with anti-inflammatory medication, physical therapy and
muscle relaxants. Surgery, a common treatment a generation
ago, is now considered necessary for only a very small
percentage of back pain patients.
How Low Back Pain Occurs
A basic understanding of the spine is needed to understand
back pain. The spine or spinal column is the body''s backbone,
a column of cylindrical bones known as vertebrae. The
spine protects the spinal cord, which begins in the brain
and runs most of the way down the back. The spinal cord
controls every movement and function of the body. Motor
nerves leading out of the spinal cord are responsible
for controlling movement in the body, while sensory nerves
entering into the spinal cord are responsible for communicating
messages from the body back to the brain. Together, the
motor and sensory nerves form more than 50 nerve roots,
which run through holes (foramina or windows) between
the bones of the spine. Irritation of these nerve roots
causes back pain.
Low Back Pain Conditions
Herniated Disc (Slipped Disc)
A herniated or slipped disc is a frequent cause of mild
or moderate low back or leg pain. Soft flexible discs
separate the bones in the spine. The discs, which have
a rigid outside rim and a soft, gel-like center, act as
shock absorbers and protect the spinal cord. Activity,
stress, or a mechanical problem in the spine can cause
a disc to bulge and become misshapen. The damaged or bulging
disc may pinch or irritate a nerve root, causing pain.
Disc degeneration (osteoarthritis in the spine)
Another common disorder of the lower spine is disc degeneration,
or osteoarthritis in the spine. As the body ages, the
discs in the spine dehydrate or dry out, and lose their
ability to act as shock absorbers. The bones and ligaments
that make up the spine also become less flexible and thicken.
Degeneration in the discs is normal and is not in itself
a problem. But pain occurs when these discs or bone spurs
begin to pinch and put pressure on the nearby nerve roots
or spinal cord.
Sciatica
The sciatic nerve, composed of several lumbar nerve roots,
is one of the nerves most likely to become irritated,
usually by a herniated disc. Each of the major branches
of sciatic nerve travels through the pelvis and deep in
the buttocks, then down the hip and along the back of
the thigh to the foot. The pain of sciatica ranges from
a mild tingling to a sharp ache severe enough to cause
immobility.
Lumbar spinal stenosis
Degeneration of the spine also can result in lumbar spinal
stenosis (LSS). This disease involves a narrowing of the
canal that houses the spinal cord and nerve roots. A narrowed
spinal canal may compress nerve roots in the lower back,
resulting in pain and weakness in the legs and a dull
pain in the lower back. Patients often find relief by
sitting or standing in a hunched over position, as if
leaning on a shopping cart. Symptoms of LSS usually do
not occur until after the age of 50.
Spondylolisthesis
Degeneration in the spine also can lead to spondylolistheses,
a condition characterized by the slippage of a vertebra
in the spine. One vertebra slips forward over another,
stretching or pinching the sciatic nerve and causing pain.
Causes of Back Pain
The causes of more than 80 percent of back pain cases
are unknown. Some people have damaged or bulging discs
but feel fine. Researchers do know that back pain often
begins with an injury, after lifting a heavy object or
moving suddenly. People who do not exercise regularly
face an increased risk for back pain, as do obese people.
Sciatica can be caused by blood clots, tumors and abscesses.
Arthritic back pain can be the result of infections such
as Lyme disease and viral arthritis. Atherosclerosis (hardening
of the arteries) can cause back pain when arteries in
the legs are clogged.
Wait and See
If low back pain occurs with a fever or occurs after a
recent injury, such as a car accident, a fall or sports
injury, patients should call their primary care physician
immediately or visit the emergency room. A doctor needs
to determine if a spinal fracture, infection, tumor or
other serious condition is present. Patients suffering
from low back pain without a fever or without recent trauma
can wait to see if the pain improves for a few days before
calling a physician. Patients should restrict strenuous
activities, take anti-inflammatory medications such as
ibuprofen (not aspirin or acetaminophen), take hot showers
and try massage. Because a nerve root is often being irritated,
relief comes when pressure on the nerve is relieved. Usually,
a patient can find a comfortable position that relieves
the pain.
If the low back pain gets worse or does not improve after
two or three days of home treatment, contact a primary
care physician.
Diagnosing Low Back Pain
Physicians evaluate low back pain through a medical history,
a physical exam and diagnostic tests. The physical exam
includes an assessment of sensation, strength and reflexes
in various parts of the body to help pinpoint which nerves
or parts of the spinal cord are affected. Patients are
asked to sit, stand and walk on their toes, heels and
flat-footed. They also are asked to bend forward, backward
and sideways and to lift their legs while lying down.
A physician may order diagnostic studies. These studies
may include:
X-rays: An x-ray will show the bones of the spine
and determine if there is significant wear and tear or
disease of the bone. It will also show whether the bones
are lined up properly.
Computed Tomography (CT): A CT (also known as a
CAT scan) uses an x-ray and a computer to generate images
of the spine in slices. The CT shows the anatomy of the
spine in great detail. It also clarifies the relationship
of the disc or bone spurs to the spinal cord and nerves.
Magnetic Resonance Imaging (MRI): The MRI uses
a powerful magnetic field rather than x-rays to produce
a detailed anatomical picture of the spine and the structures
within. It is probably the best test to see herniated
discs since they are soft tissue that are invisible to
x-rays.
Myelogram: A myelogram is an x-ray picture taken
with a special dye injected into the spinal sac to highlight
the spinal cord and nerves. The dye is usually injected
into the spine with a needle and then the x-rays are obtained.
Myelograms have largely been replaced by CT and MRI scans.
Electromyogram and Nerve Conduction Studies (EMG/NCS):
Unlike the other tests, which help reveal anatomy and
structure, these tests primarily study how the nerve and
muscles are actually working together. They test for the
impulse coming from the brain and/or spinal cord. If the
impulse is blocked somewhere, it may be delayed or diminished
enroute to its final destination (i.e., muscle, skin,
toe, finger-tips). This information can assist in determining
which nerves or muscles are functioning abnormally.
Discography: This is a special x-ray test that
may help identify which discs are damaged and if they
are a source of pain. It uses a contrast dye injected
into the disc space to image the disc.
Treatment Options
Conservative treatment is the most likely course of action
for back pain. Although back pain can be debilitating,
the pain improves without surgery in most cases. Physicians
usually recommend 6 to 12 weeks of conservative therapy
before considering surgery.
Treatment usually involves relieving the inflammation
around the nerve. Mild cases of back pain often respond
well to rest or anti-inflammatory medication such as ibuprofen.
Other conservative treatments include physical therapy,
steroid injections, traction, ultrasound, electrical stimulation,
acupuncture, heat/ice, massage and whirlpool.
Patients often are advised to change their lifestyle.
They should lose weight, walk 30 minutes a day and do
stomach-strengthening exercises such as sit-ups. Smokers
need to quit. Smoking damages the structure of the spine.
Patients also need to be alert as to how they stand, sit
and sleep. They should maintain good posture, avoid standing
for long periods, use chairs with straight backs or low
back support and sleep on a firm mattress.
If these treatment options do not provide relief within
two to three months, then surgery may be needed.
When Surgery is Necessary
Surgery may be the correct course of action if conservative
treatment does not work. Signs that indicate the possible
need for surgery:
• Leg or back pain limits normal activity, resulting
in an unacceptable quality of life.
• Weakness or numbness in the legs.
• Difficulty walking or standing.
• Medication and physical therapy are ineffective.
If a patient is in reasonably good health, neurosurgeons
have a variety of surgical options available to help relieve
pressure on the nerve. The most common procedure is a
discectomy, which involves removing the soft gel-like
material in the disc. This procedure returns the disc
to a more normal shape, thereby relieving pressure on
the nerve.
Neurosurgeons will sometimes remove a small piece of bone
near the disc and irritated nerve to gain access to the
disc or to give the area more space to expand and swell.
If the nerve is being pinched as it goes through the opening
between the bones on the way to or from the spinal cord,
the neurosurgeon can also perform a foraminotomy, a procedure
designed to expand the opening through which the nerve
travels.
If several nerves and discs are causing the pain or the
spinal column is unstable or degenerating, the neurosurgeon
may opt to fuse the bones together with bone grafts and
stabilize the vertebra with instrumentation, including
metal plates, screws, rods or cages. Fusion will usually
prevent the disc from bulging or herniating again.
Recovery After Surgery
A patient is usually released from a hospital two to five
days after surgery and can resume physical activities
such as walking almost immediately. Normal postsurgical
pain will occur for a few weeks. Physical therapy may
be recommended to help strengthen the muscles of the lower
back and abdomen. Total recovery takes anywhere from six
weeks to six months, depending on how advanced the condition
was at the time of surgery and the patient''s preoperative
neurological condition. Healthier patients tend to heal
faster. Physical therapy may be recommended to speed healing.
The Role of Neurosurgeons
Neurosurgeons are the only physicians who routinely treat
the entire spine. They can deal with problems of the spinal
cord itself, nerve roots and the supporting structures
of the spine. Neurosurgeons undergo six to eight years
of specialized training following medical school, one
of the longest training periods of any medical specialties.
Because neurosurgeons spend about 70 percent of their
time treating spine problems and have been extensively
trained on diseases of the spine, they are familiar with
all of the treatment options and can determine which option
is likely to be the most effective for each patient. Surgery
is one of many possible solutions the neurosurgeon may
identify. A neurosurgeon will diagnose what is wrong and
work with the patient to develop the optimal treatment
plan.
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