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Back Pain

back pain


The lower back is made up from muscles that attach to, and surround, the spine. The spine is made up of many bones called vertebrae. The vertebrae are roughly circular and between each vertebra is a disc. The discs between the vertebrae are a combination of a strong fibrous outer layer and a softer, gel like centre. The discs act as shock absorbers and allow the spine to be flexible. Strong ligaments also attach to adjacent vertebrae to give extra support and strength to the spine. The various muscles that are attached to the spine enable the spine to bend and move in various ways.

The spinal cord, which contains the nerve pathways to and from the brain, is protected by the spine.

The types of low back pain

Non-specific low back pain
This is the most common type of back pain. This is the type of back pain that most people will have at some point. It is called non-specific because it is usually not clear what is actually causing the pain.
Nerve root pain - often called sciatica
Nerve root pain means that a nerve coming out from the spinal cord is irritated or pressed on. You feel pain along the course of the nerve. Therefore, you typically feel pain down a leg, sometimes as far as to the calf or foot. The pain in the leg or foot is often worse than the pain in the back. The irritation or pressure on the nerve may also cause pins and needles, numbness or weakness in part of a buttock, leg or foot.

This is mostly due to a prolapsed disc - also called a slipped disc. The prolapsed part of the disc can press on a nerve nearby.

Cauda equina syndrome

A particularly serious type of nerve root problem. This is a rare disorder where the nerves at the very bottom of the spinal cord are pressed on. This syndrome can cause low back pain plus: problems with bowel and bladder function (usually unable to pass urine), numbness in the saddle area (around the anus), and weakness in one or both legs. This syndrome needs urgent treatment to preserve the nerves to the bladder and bowel from becoming permanently damaged. This is a medical emergency.

Less common causes

  • Osteoarthritis is the common form or arthritis and usually occurs in older people.
  • Ankylosing spondylitis is another form of arthritis that can occur in young adults and causes pain and stiffness in the lower back.
  • Rheumatoid arthritis may affect the spine, but you are likely to have other joints affected too.
  • Various uncommon bone disorders, tumors, infections, and pressure from structures near to the spine occasionally cause low back pain.

What is the cause of non-specific low back pain?

It is thought that in some cases the cause may be a sprain of a ligament or muscle. In other cases the cause may be a minor problem with a disc between two vertebrae, or a minor problem with a small facet joint between two vertebrae.

What are the symptoms of non-specific low back pain?

Usually a pain may develop immediately after you lift something heavy, or after an awkward twisting movement. Occasionally it can develop for no apparent reason. You just wake up one day with low back pain.

The severity of the pain can range from mild to severe. Typically, the pain is in one area of the lower back, but sometimes it spreads to one or both buttocks or thighs. The pain is usually eased by lying down flat. It is often made worse if you move your back, cough, or sneeze.

Most people with a bout of non-specific low back pain improve quickly, usually within a week or so, sometimes a bit longer. However, once the pain has eased or gone it is common to have further bouts of pain from time to time in the future.  Occasionally this may deteriorate chronic low backache.

How is it diagnosed?

A doctor will usually want to ask questions about your symptoms, and examine you. Basically, the symptoms are usually as described above, with no other worrying symptoms to suggest anything serious or another cause of back pain. The examination by a doctor will not detect anything to suggest a more serious cause of back pain.

Be warned if any of the following symptoms occur:

  • Pain that develops gradually and slowly gets worse and worse over days or weeks.
  • Constant back pain that is not eased by lying down or resting.
  • Pain that travels to the chest, or is higher in the back behind the chest.
  • Weakness of any muscles in a leg or foot.
  • Numbness (lack of feeling) in any part of your bottom or leg.
  • If you have taken steroid tablets for more than a few months.

Symptoms that may indicate an inflammatory (arthritis) cause such as ankylosing spondylitis:

  • Pain which is worse in the second half of the night or after waking.
  • Stiffness, in addition to pain, of the back muscles in the morning after getting up from bed that lasts more than 30 minutes.
  • The pain is eased  by activity.

Symptoms that may indicate cauda equina syndrome:

  • Numbness around the anus(saddle anesthesia).
  • Bladder symptoms such as loss of bladder sensation; loss of bladder control, incontinence, loss of sensation when passing urine.
  • Incontinence of feces.

Symptoms that may indicate a fracture in the spine:

  • Back pain following major trauma such as a road accident or fall from a height.
  • Back pain following minor trauma in people with osteoporosis.

Symptoms that may indicate infection or spread of cancer affecting the spine:

  • Onset of pain in a person over 50 years, or under 20 years, of age.
  • Pain that remains when lying down; aching night-time pain disturbing sleep.

Tests such as X-rays or scans may be advised in certain situations. This is mainly if there are symptoms, or signs during a doctor’s examination, to suggest that there may be a serious underlying cause for the back pain.

What are the treatments for a bout of non-specific low back pain?

Exercise and keep going

Continue with normal activities as much as possible. This may not be possible at first if the pain is very bad. However, move around as soon as you are able, and get back into normal activities as soon as you can. As a rule, don't do anything that causes a lot of pain.

Also, sleep in the most naturally comfortable position on whatever is the most comfortable surface.

If you have a job, aim to get back to work as soon as possible. There is no need to wait for complete freedom from pain before returning to work. You are less likely to develop chronic back pain if you keep active when you have back pain rather than rest a lot.

Medication

  • If you need painkillers, it is best to take them regularly. This is better than taking them now and again just when the pain is very bad.
  • Paracetamol is often sufficient if you take it regularly at full strength. For an adult, this is 1000 mg (usually two 500 mg tablets), four times a day.
  • Anti-inflammatory painkillers. They include ibuprofen which you can buy at pharmacies or get on prescription. Other types such as diclofenac or naproxen need a prescription.
  • A muscle relaxant such as diazepam is occasionally prescribed for a few days if the back muscles become very tense and make the pain worse.

Other treatments

Heat such as a hot bath may help to ease pain. Guarded physiotherapy and yoga may be helpful in a few cases.

What is the prognosis?

Most non-specific back pains ease and go quickly, usually within a week or so. Some may last longer from four weeks to six weeks. However, once the pain has eased or gone it is common to have recurrences from time to time in the future. In a small number of cases the pain persists for several months or longer. This is called chronic back pain.

Chronic non-specific low back pain

Non-specific low back pain is classed as chronic (persistent) if it lasts longer than six weeks. In some people it lasts for months, or even years.

What is the treatment for chronic non-specific low back pain?

Initial treatment is similar to acute attacks. That is, aim to keep as active as possible. In addition to the painkillers listed above, your doctor may advise a course of an antidepressant medicine in the tricyclic group, for example, amitriptyline.

In addition the following will help:

Structured exercise programme. This means a programme of exercise supervised by a professional such as a physiotherapist. It typically consists of up to eight supervised sessions over 8-12 weeks with encouragement to keep on doing the exercises at home between sessions.

Manual therapy. Typically this includes several sessions of massage, spinal mobilization and/or spinal manipulation.  In spinal mobilization the therapist moves the joints of the spine around in their normal movement range. In spinal manipulation, the therapist moves joints beyond the usual range of movement.

A course of acupuncture. It is not clear how this may work.

Cognitive behaviour therapy (CBT) may also be recommended as a treatment option. There is good evidence from research trials that it can help. CBT aims to help you to change the way that you think, feel and behave. It is used as a treatment for various health problems including various types of chronic pain.

Rarely, a surgical operation called spinal fusion is considered when all other treatment options have not helped and pain remains constant and severe.

Can back pain be prevented?

Evidence suggests that the best way to prevent bouts of low back pain is simply to keep active, and to exercise regularly. This means general fitness exercise such as walking, running, swimming.


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