Back pain and sciatica
Back pain is one of the most common reasons people visit their doctor. According to the National Institute of Arthritis and Musculoskeletal and Skin Diseases, 25% of adults have at least a day of back pain during a typical 3 month period.
Back pain can be acute, subacute, or chronic.
Back pain can occur in any area of the back, but it most often strikes the lower back, which supports most of the body's weight.
The back is highly complex. Pain may result from damage or injury to any of its various bones, nerves, muscles, ligaments, and other structures. Still, despite sophisticated techniques, which provide detailed anatomical images of the spine and other tissues, the cause of most cases of back pain remains unknown.
Vertebrae. The spine is a column of small bones, or vertebrae, that support the entire upper body. The column is grouped into three sections:
Below the lumbar region is the sacrum, a shield-shaped bony structure that connects with the pelvis at the sacroiliac joints.
At the end of the sacrum are two to four tiny, partially fused vertebrae known as the coccyx, or "tail bone."
Each vertebra is designated by using a letter and number, allowing the doctor to determine where it is in the spine.
The Disks. Vertebrae in the spinal column are separated from each other by small cushions of cartilage known as intervertebral disks. The disks have no blood supply of their own. They rely on nearby blood vessels to keep them nourished.
Each disk is 80% water and contains two structures.
Processes. Each vertebra in the spine has a number of bony projections called processes. The spinous and transverse processes attach to the muscles in the back and act like little levers, allowing the spine to twist or bend. The particular processes form the joints between the vertebrae themselves, meeting together and interlocking at the zygapophysial joints (more commonly known as facet, or z-joints).
Spinal Canal. Each vertebra and its processes surround and protect an arch-shaped central opening. These arches, aligned to run down the spine, form the spinal canal, which encloses the spinal cord.
Spinal Cord. The spinal cord is the central trunk of nerves that connects the brain with the rest of the body. Each nerve root passes from the spinal column to other parts of the body through small openings, bounded on one side by the disk and on the other by the facets. When the spinal cord reaches the lumbar region, it splits into four bundled strands of nerve roots called the cauda equina (meaning horsetail in Latin).
Symptoms and Causes
The origin of the pain is often unknown, and imaging studies may fail to determine its cause. Disk disease, spinal arthritis, and muscle spasms are the most common diagnoses. Other problems can also cause back pain, however.
Muscle and Ligament Injuries/Lumbar Strain
Strain and injury to the muscles and ligaments supporting the back are the major causes of low back pain. The pain is typically more spread out in the muscles next to the spine, and may be associated with spasms in those muscles. The pain may move to the buttocks but rarely any farther down the leg.
The sciatic nerve is a large nerve that starts in the lower back.
Sciatica is not a diagnosis but a description of symptoms. Anything that places pressure on one or more of the lumbar nerve roots can cause pain in parts or all of the sciatic nerve. A herniated disk, spinal stenosis (narrowing of the spinal canal), degenerative disc disease, spondylolisthesis, or other abnormalities of vertebrae can all cause pressure on the sciatic nerve.
Some cases of sciatica pain may occur when a muscle located deep in the buttocks pinches the sciatic nerve. This muscle is called the piriformis. The resulting condition is called piriformis syndrome. Piriformis syndrome usually develops after an injury. It is sometimes difficult to diagnose.
The main nerve traveling down the leg is the sciatic nerve. Pain associated with the sciatic nerve usually originates when nerve roots in the spinal cord become compressed or damaged. Symptoms can include tingling, numbness, or pain that radiates to the buttocks, legs, and feet.
Pain or numbness due to sciatica can vary widely. It may feel like a mild tingling, dull ache, or a burning sensation. In some cases, the pain is severe enough to cause immobility.
The pain most often occurs on one side and may radiate to the buttocks, legs, and feet. Some people have sharp pain in one part of the leg or hip and numbness in other parts. The affected leg may feel weak or cold.
The pain often starts slowly. Sciatica pain may get worse:
Sciatica pain usually goes away within 6 weeks, unless there are serious underlying conditions. Pain that lasts longer than 30 days, or gets worse with sitting, coughing, sneezing, or straining may indicated a longer recovery. Depending on the cause of the sciatica, symptoms may come and go.
A herniated disk, sometimes (incorrectly) called a slipped disk, is a common cause of severe back pain and sciatica. A disk in the lumbar area becomes herniated when it ruptures or thins out, and degenerates to the point that the gel within the disk (the nucleus pulposus) pushes outward. The damaged disk can take on many forms:
Pain in the leg may be worse than the back pain in cases of herniated disks. There is also some debate about how pain develops from a herniated disk and how frequently it causes low back pain. Many people have disks that bulge or protrude and do not suffer back pain. Extrusion (which is less common than the other two conditions) is much more likely to cause back pain, since the gel extends out far enough to press against the nerve root, most often the sciatic nerve. Extrusion is very uncommon, however, while sciatic and lower back pain are very common. But there may be other causes of lower back pain.
Abnormalities in the Annular Ring. The annular ring, the fibrous band that surrounds and protects the disk, contains a dense nerve network and high levels of peptides that heighten perception of pain. Tears in the annular ring are a frequent finding in patients with degenerative disk disease. Cauda equina syndrome. Cauda equina syndrome is the impingement of the cauda equina (the four strands of nerves leading through the lowest part of the spine). The cause is usually massive extrusion of the disk material. Cauda equina syndrome is an emergency condition that can cause severe complications to bowel or bladder function. It can cause permanent incontinence if not promptly treated with surgery. Symptoms of the cauda equina syndrome include:
Lumbar Degenerative Joint Disease
Osteoarthritis occurs in joints of the spine, usually as a result of aging, but also in response to previous back injuries, excessive wear and tear, previously herniated discs, prior surgeries, and fractures. Cartilage between the joints of the spine is destroyed and extra bone growth or bone spurs develop. Spinal discs dry out and become thinner and more brittle. The rate at which these changes develop varies between people.
The end result of these changes is a gradual loss of mobility of the spine and narrowing of the spaces for spinal nerves and spinal cord, eventually leading to spinal stenosis. Symptoms may be similar to that of a herniated disc or spinal stenosis.
Spinal stenosis is the narrowing of the spinal canal, or narrowing of the openings (called neural foramina) where spinal nerves leave the spinal column. This condition typically develops as a person ages and the disks become drier and start to shrink. At the same time, the bones and ligaments of the spine swell or grow larger due to arthritis and chronic inflammation. However, other problems, including infection and birth defects, can sometimes cause spinal stenosis.
Most patients will report the presence of gradually worsening history of back pain over time. For others, there may be minimal history of back pain, but at some point in this process any disruption, such as a minor injury that results in disk inflammation, can cause impingement on the nerve root and trigger pain.
Patients may experience pain or numbness, which can occur in both legs, or on just one side. Other symptoms include a feeling of weakness or heaviness in the buttocks or legs. Symptoms are usually present or will worsen only when the person is standing or walking upright. Often the symptoms will ease or disappear when sitting down or leaning forward. These positions may create more space in the spinal canal, thus relieving pressure on the spinal cord or the spinal nerves. Patients with spinal stenosis are not usually able to walk for long periods of time, but they may be able to ride a bicycle with little pain.
Spondylolisthesis occurs when one of the lumbar vertebrae slips over another, or over the sacrum.
In children, spondylolisthesis usually occurs between the fifth bone in the lower back (lumbar vertebra) and the first bone in the sacrum area. It is often due to a birth defect in that area of the spine. In adults, the most common cause is degenerative disease (such as arthritis). The slip usually occurs between the fourth and fifth lumbar vertebrae. It is more common in adults over 65 and women.
Other causes of spondylolisthesis include stress fractures (typically seen in gymnasts) and traumatic fractures. Spondylolisthesis may occasionally be associated with bone diseases.
Spondylolisthesis may vary from mild to severe. It can produce increased lordosis (swayback), but in later stages may result in kyphosis (roundback) as the upper spine falls off the lower spine.
Symptoms may include:
Pain generally occurs with activity and is better with rest. Neurological damage (leg weakness or changes in sensation) may result from pressure on nerve roots, and may cause pain radiating down the legs.
Inflammatory Conditions and Arthritis
Inflammatory disorders and arthritis syndromes can produce inflammation in the spine. Rheumatoid arthritis can involve the cervical spine (neck). A group of disorders called seronegative spondyloarthropathies may cause back pain. These include:
There are multiple medical treatments for these potentially disabling diseases, and in most cases surgery is not beneficial.
Osteoporosis and Compression Fractures
Osteoporosis is a disease of the skeleton in which the amount of calcium present in the bones slowly decreases to the point where the bones become fragile and prone to fractures. It usually does not cause pain unless the vertebrae collapse suddenly, in which case the pain is often severe. More than one vertebra may be affected.
In a compression fracture of the vertebrae, the bone tissue of the vertebra collapses. More than one vertebra may collapse as a result. When the fracture is the result of osteoporosis, the vertebrae in the thoracic (chest) and lower spine are usually affected, and symptoms may be worse with walking.
With multiple fractures, kyphosis (a forward hump-like curvature of the spine) may result. In addition, compression fractures are often responsible for loss of height. Pressure on the spinal cord may also occur, producing symptoms of numbness, tingling, or weakness. Symptoms depend upon the area of the back that is affected. However, most fractures are stable and do not produce neurological symptoms.
Back Pain Emergencies
Several serious conditions can also cause back pain. Often, these symptoms develop over a short period of time, become more severe, and may have other findings that go along with them. Some of these conditions include:
Miscellaneous Abnormalities and Diagnoses
Other causes of back pain include:
In most known cases, pain begins with an injury, after lifting a heavy object, or after making a sudden movement. Not all people have back pain after such injuries, however. In the majority of back pain cases, the causes are unknown.
Intervertebral disks begin deteriorating and growing thinner by age 30. One-third of adults over 20 show signs of herniated disks (although only 3% of these disks cause symptoms). As people continue to age and the disks lose moisture and shrink, the risk for spinal stenosis increases. The incidence of low back pain and sciatica increases in women at the time of menopause as they lose bone density. In older adults, osteoporosis and osteoarthritis are also common. However, the risk for low back pain does not mount steadily with increasing age, which suggests that at a certain point, the conditions causing low back pain plateau.
Jobs that involve lifting, bending, and twisting into awkward positions, as well as those that cause whole-body vibration (such as long-distance truck driving), place workers at particular risk for low back pain. The longer a person continues such work, the higher their risk. Some workers wear back support belts, but evidence strongly suggests that they are useful only for people who currently have low back pain. The belts offer little added support for the back and do not prevent back injuries.
A number of companies are developing programs to protect against back injuries. However, studies have been mixed on the outcome of company interventions. Employers and workers should make every effort to create a safe working environment. Office workers should have chairs, desks, and equipment that support the back or help maintain good posture.
Low back pain accounts for significant losses in workdays and dollars. According to the Bureau of Labor Statistics, back pain was responsible for around 60% of cases of people missing work due to pain involving the upper body.
Osteoporosis is a condition characterized by progressive loss of bone density, thinning of bone tissue, and increased vulnerability to fractures. Osteoporosis may result from disease, dietary or hormonal deficiency, or advanced age. Regular exercise and vitamin and mineral supplements can reduce and even reverse loss of bone density.
Medical Conditions in Children
Persistent low back pain in children is more likely to have a serious cause that requires treatment than back pain in adults.
Stress fractures (spondylolysis) in the spine are a common cause of back pain in young athletes. Sometimes a fracture may not show up for a week or two after an injury. Spondylolysis can cause spondylolisthesis.
Hyperlordosis is an inborn exaggerated inward curve in the lumbar area. Scoliosis, an abnormal curvature of the spine in children, does not usually cause back pain.
Juvenile chronic arthropathy is an inherited form of arthritis. It can cause pain in the sacrum and hip joints of children and young people. Formerly grouped under juvenile rheumatoid arthritis, it is now defined as a separate problem.
Injuries can also cause back pain in children.
Pregnant women are prone to back pain due to a shifting of abdominal organs, the forward redistribution of body weight, and the loosening of ligaments in the pelvic area as the body prepares for delivery. Tall women are at higher risk than short women.
Psychological and Social Factors
Psychological factors are known to play a strong influential role in three phases of low back pain:
Studies also suggest that patients who reported prolonged emotional distress have less favorable outcomes after back surgeries. It should be strongly noted that the presence of psychological factors in no way diminishes the reality of the pain and its disabling effects. Recognizing this presence as a strong player in many cases of low back pain, however, can help determine the full range of treatment options.
Although most episodes of new back pain, as well as exacerbations of chronic back pain, clear up or return to a previous level of discomfort, a medical history and a brief physical examination is always necessary. Depending on the severity of the symptoms, how long they have been present, and any associated medical problems, additional evaluations may be necessary.
The patient should be able to describe the back pain and its history in the following manner:
A patient should report any serious health problems, symptoms, and concerns that may raise a red flag for a more serious condition. These include:
Special state guidelines should be followed for worker's compensation patients.
The main goals of a physical exam are to determine the source of the pain, the limits of movement and to detect signs of a more serious back condition.
Imaging tests used to evaluate back pain range from a simple x-ray to a CT scan or MRI of the spine. Depending on medical diagnoses that are identified by the history, the patient may need such tests as a Dual energy X-ray absorptiometry (DEXA) scan for osteoporosis or a nuclear scan for suspected arthritis, cancer, or infection.
Because most patients with new back pain are on the mend or completely recover within 6 weeks, imaging techniques such as x-rays or scans are rarely recommended early in the course of back pain. Doing so does not improve outcomes, unless a serious underlying condition is suspected.
Patients who have the following symptoms or experience certain events may need more sophisticated imaging studies:
Even when symptoms last longer, unless a potentially serious diagnosis is suspected, MRI or CT scans can often be delayed until the time when surgery or epidural steroid injections come into consideration as treatment options.
X-Rays. Many patients with acute and uncomplicated low back pain believe that plain x-rays of the spinal column are important in a diagnosis. However, they are not very helpful in most patients with nonspecific back pain.
Magnetic Resonance Imaging (MRI). Magnetic resonance imaging (MRI) can provide very well-defined images of soft tissue and bone. The test is not painful or dangerous, but some people may feel claustrophobic in scanners where they are fully enclosed. MRIs can detect tears in the disks, disk herniation, or disk fragments. It can also detect spinal stenosis and non-spinal causes of back pain, including infection and cancer.
MRI scans often detect spine abnormalities that are not causing symptoms in the patient. Almost half of all adults have bulging or protruding vertebral disks, and most have no back pain. Also, the degree of disk abnormalities revealed by MRIs often has very little to do with the severity of the pain or the need for surgery. Disk abnormalities in people who have back pain may simply be a coincidence rather than an indication for treatment.
Patients are also more likely to think of themselves as having a serious back problem if abnormalities are identified on MRI scans, even if the scans do not result in treatment changes. This perception may sometimes slow down their recovery.
CT stands for computerized tomography. In this procedure, a thin x-ray beam is rotated around the area of the body to be visualized. Using very complicated mathematical processes called algorithms the computer is able to generate a 3-D image of a section through the body. CT scans are very detailed and provide excellent information for the doctor.
Bone Scintigraphy and SPECT Imaging. In rare cases, doctors may use bone scintigraphy (bone scanning) to determine abnormalities in the bones. The technique may be useful for early detection of spinal fractures, cancer that has spread to the bone, or certain inflammatory arthritic conditions. During this exam, a small amount of radioactive material is injected into a vein. It circulates through the body, and is absorbed by the bones. The bones can then be seen using x-rays or single photon emission computed tomography (SPECT).
An x-ray myelogram is an x-ray of the spine that requires a spinal injection of a special dye and the need to lie still for several hours to avoid a very painful headache. It has value only for select patients with pain on moving and standing. It has largely been replaced by CT and MRI scans.
Tests that analyze the electric waveforms of nerves and muscles may be useful for detecting nerve abnormalities that may be causing back pain, and identifying possible injuries. They are also useful to determine if any abnormal structural findings on an MRI or other imaging tests have real significance as a cause of back pain. It should be noted that any nerve injuries that affect these tests may not be present for 2 - 4 weeks after symptoms begin.
Nerve conduction studies and electromyography are the electrodiagnostic tests most commonly performed. These tests are not used often in the evaluation and management of patients with low back pain.
Diskography: Since many people have evidence of disk degeneration on their MRI scans, it is not always easy to tell if the finding on this MRI scan explains pain the patient may be experiencing. Diskography is a test that is used to help determine whether an abnormal disk seen on MRI explains someone's pain. It is generally reserved for patients who did not experience relief from other therapies, including surgery. This procedure requires injections into disks suspected of being the source of pain and disks nearby. It can be painful. There is controversy among physicians who take care of the spine regarding the usefulness of diskography for making decisions about care, particularly surgery. The American Pain Society is against the use of provocative diskography for patients with chronic nonradicular (pain that does not radiate) low back pain.
Blood and urine samples may be used to test for infections, arthritis, or other conditions.
Injecting a drug that blocks pain into the nerves in the back helps locate the level in the spine where problems occur.
A procedure called a facet block is also useful in locating areas of specific damage.
A conservative home care program is often the first therapy regimen for new back pain (unless the doctor suspects a serious underlying condition). The goals are to reduce any swelling and improve function. The regimen often includes period of rest and movement, the application of ice or heat, nonsteroidal anti-inflammatory drugs (NSAIDs) and gentle exercises. A work ergonomics assessment may also be beneficial.
Home Care Tips for Relieving Pain
Smokers are at higher risk for back problems, perhaps because smoking decreases blood circulation or because smokers tend to have an unhealthy lifestyle in general. The association is stronger in adolescents compared to adults. A British study found that young adults who were long-term smokers were nearly twice as likely to develop low back pain as nonsmokers were.
Exercise and Obesity
Sedentary Lifestyle. People who do not exercise regularly face an increased risk for low back pain, especially when they perform sudden, stressful activities such as shoveling, digging, or moving heavy items. Although no definitive studies have been done to prove the relationship between lack of exercise and low back pain, some doctors believe that an inactive lifestyle may be to blame in some cases. Lack of exercise leads to the following conditions that may threaten the back:
Improper or Intense Exercise. Improper or excessive exercise may also increase one's chances for back pain.
Tips for Daily Movement and Inactivity
The way a person moves, stands, or sleeps plays a major role in back pain.
Tips for Lifting and Bending
Anyone who engages in heavy lifting should take precautions when lifting and bending.
There are four natural curves in the spinal column: the cervical, thoracic, lumbar, and sacral curvature. The curves, along with the intervertebral disks, help to absorb and distribute stresses that occur from everyday activities such as walking or from more intense activities such as running and jumping.
Acetaminophen (Tylenol) is a safe and effective pain reliever for mild-to-moderate acute back pain. It is also used to reduce fever. The benefits are usually felt 30 - 60 minutes after ingestion, and it can be taken every 4 - 6 hours. Side effects can include skin rashes or inflammation, and in rare cases, damage to the liver or kidneys.
The most commonly prescribed medications for the treatment of back pain are nonsteroidal anti-inflammatory drugs (NSAIDs). Short-term use of NSAIDs may help some patients with acute back pain. The benefits of NSAIDs for chronic back pain are less certain.
There are dozens of available NSAIDs:
While widely available and generally safe for most patients when used on a short-term basis, long-term use of these drugs carries several side effects. The Food and Drug Administration (FDA) has issued "black box" warnings, the FDA's strongest, around risks for heart disease, ulcers, and gastrointestinal bleeding:
Those at highest risk for bleeding include people over age 60, anyone with a history of ulcers or gastrointestinal bleeding, patients with serious heart conditions, people who abuse alcohol, and those who take medications such as anticoagulants (blood thinners) and corticosteroids.
Proton-pump inhibitor (PPI) drugs may help prevent and heal ulcers caused by NSAIDs. PPIs include omeprazole (Prilosec), esomeprazole (Nexium), and lansoprazole (Prevacid).
To reduce the risks associated with NSAIDs, take the lowest dose possible for pain relief. Always talk with your health care provider before using any of these drugs on a regular basis.
Other possible side effects of NSAIDs may include:
An ulcer is a crater-like lesion on the skin or mucous membrane that is caused by an inflammatory, infectious, or cancerous condition. To avoid irritating an ulcer, stop smoking and try to eliminate certain substances from your diet, including caffeine and alcohol. Prescription medicines are available to suppress the acid in the stomach that causes erosion of the stomach lining. Endoscopic therapy can be used to stop ulcer-related bleeding.
Tramadol (Ultram) is a pain reliever that has been used as an alternative to opioids. While the drug has opioid-like properties, it is not as addictive. (Dependence and abuse have been reported, however.) Tramadol can cause nausea, but it does not cause the severe gastrointestinal problems that NSAIDs can. Some patients who take tramadol experience severe itching. A combination of tramadol and acetaminophen (Ultracet) is available. It provides more rapid pain relief than tramadol alone.
Opioid Pain Relievers
Narcotics are pain-relievers that act on the central nervous system. They are the most powerful medications available for the management of pain.
There are two types of narcotics:
Opioids are effective for short-term relief of back pain. Using them for longer than 16 weeks to treat low back pain has not been well studied and may increase the risk of abuse, if a health care provider does not manage usage well.
Newer ways to deliver pain medicine have been developed. A skin patch containing an opioid called transdermal fentanyl (Duragesic) may relieve chronic back pain more effectively than oral opioids.
Common side effects of opioids include anxiety, constipation, nausea, vomiting, dizziness, drowsiness, paranoia, urinary retention, restlessness, and labored or slow breathing. Addiction is a risk, although less than is commonly believed when these medications are used for pain relief. In fact, when prescribed properly, use of opioids for chronic pain can be safer in some cases than on-going use of NSAIDs. Unfortunately, opioid abuse among young people is a major concern. Unless the pain is very severe, experts advise against routinely prescribing opioids.
Epidural Steroid Injections
Injections of corticosteroids (commonly called steroids) are sometimes used to treat low back pain caused by nerve impingement. The injection is placed into the epidural space, just inside the outer membrane covering the spine.
The injection is directed as close to the location of the affected nerve as possible. Corticosteroids reduce inflammation.
Studies that measure the benefits of steroid injections on sciatica or low back pain are conflicting. A recent review of the research showed that there is no strong evidence to support injection therapy in subacute and chronic low back pain patients. More research is necessary to determine if certain patients will respond favorably.
No high quality studies have shown that these injections provide long-term benefit for most patients, compared to more conservative treatments. However, reasonable evidence shows that patients receive short-term pain relief, generally over a 1 - 2 month period, from these injections.
The American Pain Society’s guidelines on injection therapy stress shared decision making between doctor and patient. It concludes that corticosteroid injection, prolotherapy (a sugar water injection that causes temporary inflammation and increased blood flow) and intradiscal corticosteroid injections should not be performed on patients with nonradicular (non-radiating) low back pain. The society recommends a thorough discussion of the risks, possible short term benefits and lack of evidence for patients with radiculopathy (nerve root damage) due to herniated disc.
Serious and painful side effects, including meningitis and inflammation, are possible. However, such risks are very low.
Epidural steroid injections for spinal stenosis may provide short-term relief of pain but generally do not improve the patient's daily functioning, nor do they help patients avoid surgery.
Antidepressants may lessen the severity of pain in certain patients with chronic back pain, but they should not be used routinely. More information is necessary to determine which patients would benefit from antidepressant medication for low back pain.
Antidepressants called tricyclics may be effective in non-depressed people with chronic back pain. Such antidepressants include amitriptyline (Elavil, Endep), desipramine (Norpramin), doxepin (Sinequan), imipramine (Tofranil), amoxapine (Asendin), nortriptyline (Pamelor, Aventyl), and maprotiline (Ludiomil). Tricyclics can have bothersome and rarely dangerous side effects.
Another antidepressant medication, duloxetine hydrochloride (Cymbalta), has been approved for the treatment of lower back pain. Side effects may include nausea, dry mouth, insomnia, drowsiness, constipation, fatigue, and dizziness. More serious side effects are rare.
Combining antidepressant medications with a pain self-management program or some type of cognitive behavioral therapy often adds to the benefit in back pain patients who are also depressed. A combined therapy approach, including antidepressant therapy and pain self-management, has been shown to improve depression symptoms and reduce the severity of pain and disability.
A combination of nonsteroidal anti-inflammatory drugs and muscle relaxants -- such as cyclobenzaprine (Flexeril), diazepam (Valium), carisoprodol (Soma), or methocarbamol (Robaxin) -- are sometimes used for patients with acute low back pain. Evidence has shown that they can help relieve non-specific low back pain, but some experts warn that these drugs should be used cautiously, since they target the brain, not the muscles. Patients who take muscle relaxants may experience a number of central nervous system side effects, such as drowsiness. The muscle relaxant Soma can be addictive and does little more than induce sleep.
Herbs and Supplements
Generally, manufacturers of herbal remedies and dietary supplements do not need FDA approval to sell their products. Just like a drug, herbs and supplements can affect the body's chemistry, and therefore have the potential to produce side effects that may be harmful. There have been a number of reported cases of serious and even lethal side effects from herbal products. Always check with your doctor before using any herbal remedies or dietary supplements.
Most herbal remedies used for back pain, such as those listed here, claim to have both pain-relieving and anti-inflammatory effects. A few have been found to have some benefit when compared to placebo or sugar pill. However, none of these have been compared to other standard medical treatments.
Caution is warranted. White willow bark, bromelain, and Boswellia have blood-thinning properties and can interfere with anticoagulant medications, such as warfarin (Coumadin).
Exercise and Physical Therapy
The Role of Physical Therapy
Physical therapy with a trained professional may be useful if pain has not improved after 3 - 4 weeks. It is important for any person who has chronic low back pain to have an exercise program. Professionals who understand the limitations and special needs of people with back pain, and can address individual health conditions, should guide this program. One study indicated that patients who planned their own exercise program did worse than those in physical therapy or doctor-directed programs.
Physical therapy typically includes the following:
Incorrect movements or long-term high-impact exercise is often a cause of back pain in the first place. People vulnerable to back pain should avoid activities that put undue stress on the lower back or require sudden twisting movements, such as football, golf, ballet, and weight lifting.
Exercises performed after a simple diskectomy do not seem to provide much added benefit over time.
Specific and regular exercise under the guidance of a trained professional is important for reducing pain and improving function, although patients often find it difficult to maintain therapy.
Exercise and Acute or Subacute Back Pain
Exercise does not help acute back pain. In fact, overexertion may cause further harm. Beginning after 4 - 8 weeks of pain, however, a rehabilitation program may benefit the patient.
An incremental aerobic exercise program (such as walking, stationary biking, and swimming) may begin within 2 weeks of symptoms. Jogging is usually not recommended, at least not until the pain is gone and muscles are stronger.
Patients should avoid exercises that put the lower back under pressure until the back muscles are well toned. Such exercises include leg lifts done in a facedown position, straight leg sit-ups, and leg curls using exercise equipment.
In all cases, patients should never force themselves to exercise if, by doing so, the pain increases.
Exercise and Chronic Back Pain
Exercise can help reduce chronic back pain. Repetition is the key to increasing flexibility, building endurance, and strengthening the specific muscles needed to support the spine. Exercise should be considered as part of a broader program to return to normal home, work, and social activities. In this way, the positive benefits of exercise not only affect strength and flexibility but also alter and improve patients' attitudes toward their disability and pain. Exercise may also be effective when combined with a psychological and motivational program, such as cognitive-behavioral therapy.
There are different types of back exercises. Stretching exercises work best for reducing pain, while strengthening exercises are best for improving function. Graded exercise programs, including daily walks and home and workplace interventions may improve pain and function for 12 months or longer in patients with chronic low back pain.
Weekly yoga and stretching classes can be effective methods to improve function and reduce symptoms.
Exercises for back pain include:
Specific Exercises for Low Back Strength
Perform the following exercises at least three times a week:
Partial Sit-ups. Partial sit-ups or crunches strengthen the abdominal muscles.
Pelvic Tilt. The pelvic tilt alleviates tight or fatigued lower back muscles.
Over time increase this exercise until it is held for 5 seconds. Then, extend your legs a little more so that your feet are further away from your body and try it again.
Stretching Lower-Back Muscles. The following are three exercises for stretching the lower back:
Note: No one with low back pain should perform exercises that require bending over right after getting up in the morning. At that time, the disks are more fluid-filled and more vulnerable to pressure from this movement.
People use many complementary and alternative treatments to relieve back pain. Complementary means something that is used together with conventional medicine. Alternative means something that is done in place of conventional medicine.
Acupuncture is now a common alternative treatment for certain kinds of pain. It involves inserting small needles or exerting pressure on certain "energy" points in the body. When the pins have been placed successfully, the patient is supposed to experience a sensation that brings a feeling of fullness, numbness, tingling, and warmth with some soreness around the acupuncture point. Unfortunately, rigorous studies of acupuncture are difficult to perform, and most evidence on its benefits is weak. Debate continues on whether the placebo affect is a major factor in acupuncture. In any case, it may be helpful for certain patients with back pain, such as pregnant women, who must avoid medications. Anyone who undergoes acupuncture should be sure it is performed in a reputable facility by experienced practitioners who use sterilized equipment. Cost per session can vary from $65 to $125, but many insurance companies now provide some type of coverage.
Acupuncture has not shown any benefits for acute low back pain in most patients, but it may provide some help for patients with chronic low back pain. Organizations such as the American College of Physicians, American Pain Society, North American Spine Society and UK National Institute of Health and Clinical Excellence have included acupuncture among possible treatment options for low back pain, particularly for patients with chronic low back pain who do not respond well to self-care treatments.
Massage therapy can help some patients with chronic or acute back pain, especially when combined with exercise and patient education.
A course of cognitive-behavioral therapy can help reduce chronic back pain, or at least enhance the patient's ability to deal with it. The primary goal of this form of therapy in such cases is to change the distorted perceptions that patients have of themselves, and change their approach to pain. Patients use specific tasks and self-observations to help them change their thinking. They gradually shift their perception of helplessness against the pain that dominates their lives into the perception that pain is only one negative among many positives and, to a degree, a manageable experience.
Behavioral therapy has been shown to be more effective than usual care for chronic low back pain in the short term. However, it has shown similar benefits to group exercise programs in the intermediate and long term.
Chiropractors typically perform spinal manipulations, but so do osteopathic doctors.
Spinal Manipulation for Uncomplicated Low Back Pain.
There is limited evidence of benefit for spinal manipulation treatment of subacute pain and exacerbations of chronic pain. It has not been shown to offer additional benefit over usual care in acute back pain patients. Ongoing or maintenance spinal manipulation has not been proven to alter the course of chronic back pain.
Mild and temporary side effects from spinal manipulation are common. The potential for serious adverse effects from low back manipulation is low.
X-rays, particularly those of the full spine, are not generally needed and expose patients to radiation. Patients should also be aware that some other alternative treatments provided by chiropractors have not been proven or rigorously studied.
Percutaneous Neuromodulation Therapy. A technique called percutaneous neuromodulation therapy (PNT) uses a small device that delivers electrical stimulation to deep tissues and nerve pathways near the spine through the skin.
Electrical Nerve Stimulation. Transcutaneous electrical nerve stimulation (TENS) uses low-level electrical pulses to suppress back pain. A variant of this procedure, percutaneous electrical nerve stimulation (PENS), applies these pulses through a small needle to acupuncture points. Both of these apply the stimulation through the skin.
When tested in high-quality studies, these electrical nerve stimulation techniques have not been found to provide much help for chronic low back pain.
Spinal cord stimulation. A more invasive technique involves delivering the electrical impulse through electrodes implanted on or next to the spinal column. It is only considered for patients with chronic radicular pain that is still present after surgery and other drug and non-invasive treatments have failed to help. The risks and benefits and high rate of complications of this type of stimulation should be discussed thoroughly with the surgeon.
Radiofrequency Neurotomy. An interventional procedure that involves the use of heat applied to the nerves that carry pain signals. Preliminary research has shown benefits in treating patients with back pain in the facet joints on either side of the spine. It may provide benefits in the sacroiliac joints in the lowest part of the spine as well.
Surgery and Invasive Procedures
The health care provider should give patients complete information on the expected course of their low back pain and self-care options before discussing surgery. Patients should ask their health care provider about evidence favoring surgery or other (nonsurgical) treatments in their particular case. They should also ask about the long-term outcome of the recommended treatment. Would the improvements last and, if so, for how long? Another consideration when surgery is an option is the overall safety of the recommended procedure, weighed against its potential short-term benefits and its benefits in the long run.
Patients should generally try all possible non-surgical treatments before opting for surgery. The vast majority of back pain patients will not need aggressive medical or surgical treatments.
The most common reasons for surgery for low back pain are disk herniation and spinal stenosis. In general, surgery has been found to provide better short term and possibly quicker relief for selected patients when compared to non-surgical treatment. However, over time, nonsurgical treatments are as effective.
Many approaches and procedures are available or being investigated. However, there have been few well-conducted studies to determine if any type of back pain surgery works better than others, or if a single procedure is better than no surgery at all.
It should be noted that surgery does not always improve outcome and, in some cases, can even make it worse. Surgery can be an extremely effective approach, however, for certain patients whose severe back pain does not respond to conservative measures.
Diskectomy is the surgical removal of the diseased disk. The procedure relieves pressure on the spine. It has been performed for 40 years, and less invasive techniques have been developed over time. However, few studies have been conducted to determine the procedure's real effectiveness. In appropriate candidates it provides faster relief than medical treatment, but long-term benefits (over 5 years) are uncertain.
Diskectomy is recommended when a herniated disk causes one or more of the following:
Most other people with low back or neck pain, numbness, or even mild weakness are often first treated without surgery. Often, many of the symptoms of low back pain caused by a herniated disc get better or disappear over time, without surgery.
When the soft, gelatinous central portion of an intervertebral disk is forced through a weakened part of a disk, it is called a slipped disk. Most slipped disks (herniated disks) take place in the lumbar area of the spine. Slipped disks are one of the most common causes of lower back pain. The mainstay of treatment is an initial period of rest with pain and anti-inflammatory medications followed by physical therapy. If pain and symptoms persist, surgery to remove the herniated portion of the intervertebral disk may be needed.
Microdiskectomy. Microdiskectomy is the current standard procedure. It is performed through a small incision (1 to 1-1/2 inch). The back muscles are lifted and moved away from the spine. After identifying and moving the nerve root, the surgeon removes the injured disk tissue under it. The procedure does not change any of the structural supports of the spine, including joints, ligaments, and muscles.
Other, less invasive procedures are available, including endoscopic diskectomy, percutaneous diskectomy (PAD), and laser diskectomy. The long-term benefits of these procedures are unknown, however. There is no evidence that any of these less-invasive procedures are as effective as the standard microdiskectomy.
Complications and Outlook. Most people achieve pain relief and can move better after microdiskectomy. Numbness and tingling should get better or disappear. Your pain, numbness, or weakness may NOT get better or go away if the disk damaged your nerve before surgery.
Scar tissue is a potential problem, since it can cause persistent low back pain afterward. Other complications of spinal surgery can include nerve and muscle damage, infection, and the need for another operation.
Patients are usually up and walking soon after disk surgery. It may take 4 - 6 weeks for full recovery, however. Gentle exercise may be recommended at first. Starting intensive exercise 4 - 6 weeks after a first-time disk surgery appears to be very helpful for speeding up recovery. Little or no physical therapy is usually needed.
Laminectomy is surgery to remove either the lamina, two small bones that make up a vertebra, or bone spurs in your back. Laminectomy opens up your spinal canal so your spinal nerves or spinal cord have more room. It is often done along with a diskectomy, foraminotomy, and spinal fusion.
Laminectomy is frequently done to treat spinal stenosis. You and your doctor can decide when you need to have surgery for your condition. Spinal stenosis symptoms often become worse over time, but this may happen very slowly. Surgery may help when your symptoms become more severe and interfere with your daily life or job.
Laminectomy for spinal stenosis will often provide full or partial relief of symptoms for many patients, but it is not always successful.
Future spine problems are possible for all patients after spine surgery. If you had spinal fusion and laminectomy, the spinal column above and below the fusion are more likely to have problems in the future. If you needed more than one kind of back surgery (such as laminectomy and spinal fusion), you may have more of a chance of future problems.
Some recurrence of back pain and sciatica occurs in half to two-thirds of postoperative patients. Minimally invasive variations are under investigation. For spinal stenosis, the traditional approach is a laminectomy and partial removal of the facet joint. There is controversy whether performing a fusion procedure along with these procedures is needed. Only a few randomized trials have compared this procedure with nonoperative treatment. Their results suggest that surgical treatment is better, at least over the first 2 years after surgery.
Spinal fusion is surgery to fuse spine bones (vertebrae) that cause you to have back problems. Fusing means two bones are permanently placed together so there is no longer movement between them.
Spinal fusion is usually done along with other surgical procedures of the spine, such as a diskectomy, laminectomy, or a foraminotomy. It is done to prevent any movement in a certain area of the spine.
Conditions fusion may be done for include:
The surgeon will use a graft (such as bone) to hold (or fuse) the bones together permanently. There are several different ways of fusing vertebrae together:
The surgeon may get the graft from different places:
The vertebrae are often also fixed together with screws, plates, or cages. These are used to keep the vertebrae from moving until the bone grafts fully heal.
Future spine problems are possible for all patients after spine surgery. After spinal fusion, the area that was fused together can no longer move. Therefore, the spinal column above and below the fusion is more likely to be stressed when the spine moves, and develop problems later on. Also, if you needed more than one kind of back surgery (such as laminectomy and spinal fusion), you may have more of a chance of future back problems.
There are many video-assisted fusion techniques. These new techniques are less invasive than standard "open" surgical approaches, which use wide incisions. To date, however, the newer procedures have higher complication rates than the open approaches, and some medical centers have abandoned them.
Other Surgical Procedures
Percutaneous Vertebroplasty. Percutaneous vertebroplasty involves the injection of a cement-like bone substitute into vertebrae with compression fractures. It is done under endoscopic and x-ray guidance.
Warning: The Food and Drug Administration (FDA) has warned consumers that polymethylmethacrylate bone cement, used during vertebroplasty, could leak. Such leakage could cause damage to soft tissues and nerves. It is extremely important that the patient is sure that the health care provider has had significant experience performing the vertebroplasty procedure. A major trial reported little benefit from vertebroplasty. More research is needed.
Percutaneous kyphoplasty. The health care provider injects bone cement into the space surrounding a fractured vertebra. (Vertebroplasty injects the cement directly into the vertebra.) Kyphoplasty is used to stabilize the spine and return spinal height to as normal as possible. Kyphoplasty should only be done if bed rest, medicines, and physical therapy do not relieve back pain. Those with severe fractures or spinal infections should not have kyphoplasty. More research on kyphoplasty is needed.
Artificial Disk Replacement. Total disk replacement is an investigative procedure for some patients with severely damaged disks. It is done instead of spinal fusion surgery, but it has not yet been shown to be superior to it. The technique implants artificial disks (such as ProDisc, Link, and SB Charite) consisting of two metal plates and a soft core. The surgery can be performed using a minimally invasive laparoscopic procedure. It is done through tiny cuts using miniature tools and viewing devices. An artificial cushioning device called the prosthetic disk nucleus (PDN) replaces only the inner gel-like core (nucleus pulposus) within the intervertebral space, rather than the entire disk. A possible benefit of these artificial disks is that they would allow more movement of the spine, and therefore prevent disk degeneration below and above the site of surgery (a frequent complication of spinal fusion). This benefit has not yet been proven in large and long-term studies.
In its updated recommendations, the American Pain Society is against vertebral disc replacement in patients with non radicular (non-radiating or not involving a nerve) low back pain, degenerative spinal changes, and persistent and disabling symptoms.
Intradiscal Electrothermal Treatment (IDET). Intradiscal electrothermal treatment (IDET) uses electricity to heat a painful disk. Heat is applied for about 15 minutes. Pain may temporarily feel worse, but after healing, the disk shrinks and becomes desensitized to pain. However, healing takes several weeks. While some studies have reported benefit, many consider the evidence to support the use of this procedure weak.
Most people with acute low back pain are back at work within a month and fully recover within a few months. According to one study, about a third of patients with uncomplicated low back pain significantly improved after a week; two-thirds recovered by 7 weeks.
However, studies now suggest that up to 75% of patients suffer at least one recurrence of back pain over the course of a year. After 4 years, fewer than half of patients may be symptom-free. Some doctors are approaching the problem as one that is not necessarily curable and that needs a consistent on-going approach.
Specific conditions can determine the rate of improvement. For example:
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