Lower Back Pain

Back pain affects approximately 90% of Americans at some point in their lifetime. Fifty percent (50%) of those that suffer from a primary episode of low back pain will have a recurrent episode. It is estimated that approximately 85% of people with low back pain, no specific reason can be identified for the pain.

America spends approximately $85 billion a year on the treatment of lower back pain. 1 Back pain is the sixth most costly medical condition in the United States. The biggest surge in spending was for drugs. In 2005, Americans spent an estimated $20 billion on drug treatments for back and neck problems, an increase of 171 percent from 1997. The biggest jump was for narcotic pain relievers, such as OxyContin and other drugs, which increased more than 400 percent. 2 It could be that rising obesity rates are taking an added toll on the spine, researchers suggested. Or it could be that excessive treatment of back problems is leading to more problems. 3 The treatment of back pain is in line with annual expenditures for major conditions, including cancer, arthritis, and diabetes. Yet during the same period, patients reported more disability from back and neck pain, including more depression and physical limitations.

Outpatient treatment for back and neck problems increased 74 percent to about $31 billion during the 1997 to 2005 time period, while spending related to emergency room visits grew by 46 percent to $2.6 billion. Spending for surgical procedures and other inpatient costs grew by 25 percent to about $24 billion. 4

Headaches are the most common disorders of the nervous system followed by lower back pain. The common cold is the leading cause of lost work days, trailed by low back pain. Back pain is the leading reason for ER department visits and physician visits.

Low back pain is a symptom that may occur from a variety of different reasons. For most people the symptoms and pain from low back pain will go away on its own within two months regardless of the type of treatment or no treatment.

Symptoms of Low Back Pain

Pain in the lower part of the back (lumbosacral area) is the primary symptom of low back pain.

  • The pain may radiate down the front, side, or back of your leg, or it may be limited to the lower back.
  • The pain may become worse with activity.
  • Occasionally, the pain may be worse at night or with extended periods of sitting.
  • Numbness or weakness in the part of the leg that from a compressed nerve. This can cause an inability to stand on your toes, bring your foot downward, or raise your big toe upward.
What Causes Lower Back Pain?

America spends approximately $85 billion a year on the treatment of lower back pain. 1Because of the possible causes of low back pain, it is important to have a complete medical exam so that your medical team can make clinically sound decisions on the correct diagnostic tests that may be needed.

The most common causes of low back pain are overuse or injury of muscles, ligaments, and joints, or pressure on one of the spinal nerve roots. Nerve roots are the beginning of one of the thirty-one pairs leaving the central nervous system from the spinal cord. Irritation of nerve roots is called nerve root syndrome.

Nerve root syndromes are often due to a herniation/bulging of the disc between the vertebrae of the spine. Sciatica is an example. With nerve root pain the pain tends to be sharp, affecting a specific area, and accompanying with numbness in the area of the leg that the affected nerve supplies.

  • One third (1/3) of herniated discs are found in adults 20 years old and older. Only 3% of these, however, produce symptoms or the related pain of nerve impingement.
  • Herniated discs develop as the spinal discs degenerate or grow thinner. The jellylike central portion of the disc bulges out of the central cavity and pushes against a nerve root. Intervertebral discs begin to degenerate by the third decade of life.
  • The diagnosis and treatment of painful degenerative disc disease remains one of the most controversial topics in spine literature. There are few objective criteria for making a clear diagnosis. For 80% of back pain patients there is no clear diagnosis linking symptoms with pathological changes.
  • There have been many epidemiological studies over the past 30 years on what causes lower back pain. They have revealed heavy physical work, truck-driving and smoking as risk factors for back problems, based on an ‘injury’ paradigm. This model implies that overloading results in structural damage which leads to disc degeneration causing symptomatic conditions.
  • Discs degenerate far earlier than do other musculoskeletal tissues; the first unequivocal findings of degeneration in the lumbar discs are seen between ages 11-16 years 5. About 20% of people in their teens have discs with mild signs of degeneration; degeneration increases steeply with age, particularly in males, so that around 10% of 50-year-old have discs and 60% of 70-year-old spinal discs are severely degenerate.6

    Spondylosis is a term referring to degenerative osteoarthritis that happens as vertebra discs lose moisture and volume with age, which decreases the disc height. Even minor strain under these circumstances can cause inflammation and nerve root impingement, which can produce classic sciatica without suffering a ruptured disc.

    Spondylosis is a noninfectious inflammation of the spine that can cause stiffness and pain in the spine that is particularly worse in the morning. Ankylosing spondylitis typically begins in adolescents and young adults.

  • Spinal stenosis is where there is spinal disc degeneration together with disease in joints of the low back can lead to spinal-canal narrowing. These changes in the disc and the joints produce symptoms and can be seen on an x-rays. Those who suffer with spinal stenosis may have pain radiating down both legs while standing for a long time or walking even short distances.
  • Direct compression of the spinal cord is called Cauda equine syndrome. Disc material expands into the spinal canal, which compresses the nerves. A person will experience pain, potentially loss of sensation in their legs, and bowel or bladder dysfunction. This could include result in incontinence or the inability to begin urination.
  • Referred pain is another common cause of lower back pain; referred pain can originate from the appendicitis, aneurysms, kidney diseases, kidney infection, bladder infections, pelvic infections, and ovarian disorders, among others, can cause pain referred to the back. Pregnancy can cause back pain in many as a result of stretching ligaments within the pelvis, irritating nerves, and straining the low back.
  • Myofascial pain syndrome (MPS), also known as chronic myofascial pain (CMP), is a syndrome characterized by chronic pain caused by multiple trigger points and fascial constrictions. Musculoskeletal pain syndromes that produce low back pain include myofascial pain syndromes and fibromyalgia.
    • Fascial is a form of connective tissue that surrounds muscles, groups of muscles, blood vessels, and nerves that holds these structures together. Like ligaments and tendons, fasciae are connective tissues. Myofascial pain is characterized by pain and tenderness over localized areas (trigger points), loss of range of motion in the involved muscle groups, and pain radiating in a characteristic distribution but restricted to a peripheral nerve. Relief of pain is often reported when the involved muscle group is stretched.
    • Fibromyalgia results in widespread pain and tenderness throughout the body. Generalized stiffness, fatigue, and muscle aches are reported. (Read more about fibromyalgia).
  • The herpes zoster virus that causes shingles can lead to inflammation of the nerves from the spine. This can occur in the chest area and cause upper back pain or in the abdominal area to cause low back pain.
  • Tumors (cancerous or not) can be a source of skeletal pain.
When Should I seek Medical Care for Low Back Pain?

Back pain is the leading reason for ER department visits and physician visits. The Agency for Healthcare Research and Quality (AHRQ) has identified 11 symptoms of potential larger causes of pain that medical doctors need to look for when assessing a person with back pain. The focus of these symptoms is to detect fractures, infections, or tumors of the spine. Presence of any of the following symptoms associated with low back pain should prompt a visit to your doctor as soon as possible for complete medical exam.

  • Recent significant shock from a fall from a height, motor vehicle accident, or similar.
  • A fall down a few steps or slipping and landing on the buttocks may be considered or other mild trauma in those 50 or older.
  • Those with asthma, COPD, or other rheumatic disorders that have been prescribed long term steroid medications.
  • A history of osteoporosis or brittle bones.
  • Anyone 70 and over; due to age the increased incidence of cancer, infections, abdominal aortic aneurysms maybe causes of the pain.
  • Prior history of cancer
  • Recent infection
  • Temperature over 100 F
  • IV drug users due to the increase risk of an undiagnosed infection
  • Pain that is more painful at rest; this may be the result of an infection, or an undiagnosed tumor or ankylosing spondylitis (AS) a form of arthritis.
  • Any unexplained weight loss

With any of the above symptoms, if your personal health care provider is unable to see you within 24 hours, AHRQ recommends that one be seen in an emergency room. The inability to walk or inability to raise or lower your foot at the ankle, the inability to raise the big toe upward or walk on your heels or stand on your toes a visit to a hospital ER is also strongly recommended. These may be symptoms of an acute nerve injury or nerve compression. These may be an acute surgical emergency. Loss of bowel or bladder control maybe a sign of an acute emergency and requires urgent evaluation in an ER.

Self-Care

Clinical data strongly suggest that bed rest is associated with a longer recovery period. Those confined to bed rest are more likely to develop depression, blood clots in the leg(s), and a loss of muscle tone. Very few experts recommend more than a 48-hour period of decreased activity or bed rest. In other words, get up and get moving to the extent you can.

Stretching or activities that place added strain on the back is discouraged. General recommendations are to resume normal, or near normal, activity as soon as possible.

Exercise may be useful for people with chronic back pain to help them return to normal activities and work.

Application of local cold therapy from an Arctic Ease pad alternated with a heating pad set on low may provide relief for some people and should be tried. (Do not use a heating pad on “high”.)

Nonprescription OTC medications may provide relief from pain. Ibuprofen (Advil, Nuprin, Motrin), available are medications that may be used for short-term treatment of low back pain. Because of the risk of ulcers and gastrointestinal bleeding, talk with your doctor about using this medication for a long time. Acetaminophen (Tylenol) has been shown to be as effective as ibuprofen in relieving pain.

Topical agents such as deep-heating rubs have not been shown to be effective.

Many studies have called into question the usefulness of our present treatment of back pain. For any given person, it is not known if a particular therapy will provide benefit until it is tried. Your doctor may try treatments known to be helpful in the past.

1 This total represents only the more readily identifiable costs for medical care, workers compensation payments and time lost from work. It does not include costs associated with lost personal income due to acquired physical limitation resulting from a back problem and lost employer productivity due to employee medical absence. In Project Briefs: Back Pain Patient Outcomes Assessment Team (BOAT). In MEDTEP Update, Vol. 1 Issue 1, Agency for Health Care Policy and Research, Rockville,
2 Brook M, Deyo R, Mirza S, Turner J, Comstock B, Hollingworth W, Sullivan S Expenditures and Health Status Among Adults With Back and Neck Problems. JAMA 2008;299(6):656-664. doi: 10.1001/jama.299.6.656
3 Ibid
4 Ibid
5 Boos N, Weissbach S, Rohrbach H, Weiler C, Spratt KF, Nerlich AG. Classification of age-related changes in lumbar intervertebral discs: 2002 Volvo Award in basic science. Spine. 2002;27:2631-2644. [PubMed]
6 Miller J, Schmatz C, Schultz A. Lumbar disc degeneration: Correlation with Age, Sex, and Spine Level in 600 Autopsy Specimens. Spine. 1988;13:173-178. [PubMed]