Back pain
Encyclopedia
Back pain is pain
felt in the back
that usually originates from the muscle
s, nerve
s, bone
s, joint
s or other structures in the spine
.
The pain can often be divided into neck pain
, upper back pain
, lower back pain or tailbone pain. It may have a sudden onset or can be a chronic pain
; it can be constant or intermittent, stay in one place or radiate to other areas. It may be a dull ache, or a sharp or piercing or burning sensation. The pain may radiate into the arm
and hand
), in the upper back, or in the low back, (and might radiate into the leg
or foot
), and may include symptoms other than pain, such as weakness, numbness or tingling.
Back Pain is one of humanity's most frequent complaints. In the U.S., acute low back pain
(also called lumbago) is the fifth most common reason for physician visits. About nine out of ten adults experience back pain at some point in their life, and five out of ten working adults have back pain every year.
The spine is a complex interconnecting network of nerves, joints, muscles, tendons and ligaments, and all are capable of producing pain. Large nerves that originate in the spine and go to the legs and arms can make pain radiate to the extremities.
, upper back pain
, lower back pain or tailbone pain.
By its duration: acute (less than 4 weeks), subacute (4 – 12 weeks), chronic (greater than 12 weeks).
By its cause: musculoskeletal (MSK)
, infectious, cancer, etc.
Back pain is classified according to etiology in mechanical or nonspecific back pain and secondary back pain. Approximately 98% of back pain patients are diagnosed with nonspecific acute back pain which has no serious underlying pathology. However, secondary back pain which is caused by an underlying condition accounts for nearly 2% of the cases. Underlying pathology in these cases may include metastatic cancer, spinal osteomyelitis and epidural abscess which account for 1% of the patients. Also, herniated disc is the most common neurologic impairment which is associated with this condition, from which 95% of disc herniations occur at the lowest two lumbar intervertebral levels.
Back pain does not usually require immediate medical intervention. The vast majority of episodes of back pain are self-limiting and non-progressive. Most back pain syndromes are due to inflammation
, especially in the acute phase, which typically lasts for two weeks to three months.
A few observational studies suggest that two conditions to which back pain is often attributed, lumbar disc herniation and degenerative disc disease
may not be more prevalent among those in pain than among the general population, and that the mechanisms by which these conditions might cause pain are not known. Other studies suggest that for as many as 85% of cases, no physiological cause can be shown.
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.
One potential source of back pain is skeletal muscle
of the back. Potential causes of pain in muscle tissue include muscle strains (pulled muscles)
, muscle spasm
, and muscle imbalances. However, imaging studies do not support the notion of muscle tissue damage in many back pain cases, and the neurophysiology of muscle spasm and muscle imbalances is not well understood.
Another potential source of low back pain is the synovial joints of the spine (e.g. zygapophysial joints/facet joints. These 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. However, the cause of zygapophysial joint pain is not fully understood. Capsule tissue damage has been proposed in people with neck pain following whiplash. In people with spinal pain stemming from zygapophysial joints, one theory is that intra-articular tissue such as invaginations of their synovial membranes and fibro-adipose meniscoids (that usually act as a cushion to help the bones move over each other smoothly) may become displaced, pinched or trapped, and consequently give rise to nociception
(pain).
There are several common other potential sources and causes of back pain: these include spinal disc herniation
and degenerative disc disease
or isthmic spondylolisthesis, osteoarthritis (degenerative joint disease)
and lumbar spinal stenosis, trauma, cancer, infection, fractures, and inflammatory disease.
Radicular pain (sciatica
) is distinguished from 'non-specific' back pain, and may be diagnosed without invasive diagnostic tests.
New attention has been focused on non-discogenic back pain, where patients have normal or near-normal MRI and CT scans. One of the newer investigations looks into the role of the dorsal ramus in patients that have no radiographic abnormalities. See Posterior Rami Syndrome
.
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 back pain patients (most estimates are 1% - 10%) require surgery.
Depending on the particular cause of the condition, posture
training courses and physical exercises might help with relieving the pain.
Minimally invasive surgical procedures are often a solution for many symptoms and causes of back pain. These types of procedures offer many benefits over traditional spine surgery, such as more accurate diagnoses and shorter recovery times.
Surgery is usually the last resort in the treatment of back pain. It is normally recommended only if all other treatment options have been tried or if the situation is an emergency. 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.
There are different types of surgical procedures that are used in treating various conditions causing back pain. All of them can be classified into nerve decompression, fusion of body segments and deformity correction surgeries. The first type of surgery is primarily performed in older patients who suffer from conditions causing nerve irritation or nerve damage
. Fusion of bony segments is also referred to as a spinal fusion
, and it is a procedure used to fuse together two or more bony fragments with the help of metalwork. The latter type of surgery is normally performed to correct congenital deformities or those that were caused by a traumatic fracture. In some cases, correction of deformities involves removing bony fragments or providing stability provision for the spine.
The main procedures used in back pain surgery are discetomies, spinal fusions, laminectomies, removal of tumors, and vertebroplasties.
A discetomy is performed when the intervertebral disc have 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
. The disc material which is putting pressure on the nerve is removed through a small incision that is made over that particular disc. This is one of the most popular types of back surgeries and which also has a high rate of success. The recovery
period after this procedure does not last longer than 6 weeks. The type of procedure in which the bony fragments are removed through an endoscope is called percutaneous disc removal.
Microdiscetomies may be performed as a variation of standard discetomies in which a magnifier
is used to provide the advantage of a smaller incision, thus a shorter recovery process.
Spinal fusions are performed in cases in which the patient has had the entire disc removed or when another condition has caused the vertebrae to become unstable. The procedure consists in uniting two or more vertebrae by using bone grafts and metalwork to provide more strength for the healing bone. Recovery after spinal fusion may take up to one year, depending greatly on the age of the patient, the reason why surgery has been performed and how many bony segments needed to be fused.
In cases of spinal stenosis or disc herniation, laminectomies can be performed to relieve the pressure on the nerves. During such a procedure, the surgeon enlarges the spinal canal by removing or trimming away excessive lamina which will provide more space for the nerves. The severity of the condition as well as the general health status of the patient are key factors in establishing the recovery time, which may be range from 8 weeks to 6 months.
Back surgery can be performed to prevent the growth of benign and malignant tumors. In the first case, surgery has the goal of relieving the pressure from the nerves which is caused by a benign growth, whereas in the latter the procedure is aimed to prevent the spread of cancer to other areas of the body. Recovery depends on the type of tumor that is being removed, the health status of the patient and the size of the tumor.
Back pain in pregnancy may be severe enough to cause significant pain and disability and pre-dispose patients to back pain in a following pregnancy. No significant increased risk of back pain with pregnancy has been found with respect to maternal weight gain, exercise, work satisfaction, or pregnancy outcome factors such as birth weight, birth length, and Apgar scores.
Biomechanical factors of pregnancy that are shown to be associated with low back pain of pregnancy include abdominal sagittal and transverse diameter and the depth of lumbar lordosis. Typical factors aggravating the back pain of pregnancy include standing, sitting, forward bending, lifting, and walking. Back pain in pregnancy may also be characterized by pain radiating into the thigh and buttocks, night-time pain severe enough to wake the patient, pain that is increased during the night-time, or pain that is increased during the day-time.
The avoidance of high impact, weight-bearing activities and especially those that asymmetrically load the involved structures such as: extensive twisting with lifting, single-leg stance postures, stair climbing, and repetitive motions at or near the end-ranges of back or hip motion can ease the pain.
Direct bending to the ground without bending the knee causes severe impact on the lower back in pregnancy and in normal individuals, which leads to strain, especially in the lumbo-saccral region that in turn strains the multifidus.
, through loss of workers on sick leave
. Some national governments, notably Australia
and the United Kingdom
, have launched campaigns of public health awareness to help combat the problem, for example the Health and Safety Executive
's Better Backs campaign.
In the United States
lower back pain’s economic impact reveals that it is the number one reason for individuals under the age of 45 to limit their activity, second highest complaint seen in physician’s offices, fifth most common requirement for hospitalization, and the third leading cause for surgery.
Pain
Pain is an unpleasant sensation often caused by intense or damaging stimuli such as stubbing a toe, burning a finger, putting iodine on a cut, and bumping the "funny bone."...
felt in the back
Human back
The human back is the large posterior area of the human body, rising from the top of the buttocks to the back of the neck and the shoulders. It is the surface opposite to the chest, its height being defined by the vertebral column and its breadth being supported by the ribcage and shoulders...
that usually originates from the muscle
Muscle
Muscle is a contractile tissue of animals and is derived from the mesodermal layer of embryonic germ cells. Muscle cells contain contractile filaments that move past each other and change the size of the cell. They are classified as skeletal, cardiac, or smooth muscles. Their function is to...
s, nerve
Nerve
A peripheral nerve, or simply nerve, is an enclosed, cable-like bundle of peripheral axons . A nerve provides a common pathway for the electrochemical nerve impulses that are transmitted along each of the axons. Nerves are found only in the peripheral nervous system...
s, bone
Bone
Bones are rigid organs that constitute part of the endoskeleton of vertebrates. They support, and protect the various organs of the body, produce red and white blood cells and store minerals. Bone tissue is a type of dense connective tissue...
s, joint
Joint
A joint is the location at which two or more bones make contact. They are constructed to allow movement and provide mechanical support, and are classified structurally and functionally.-Classification:...
s or other structures in the spine
Vertebral column
In human anatomy, the vertebral column is a column usually consisting of 24 articulating vertebrae, and 9 fused vertebrae in the sacrum and the coccyx. It is situated in the dorsal aspect of the torso, separated by intervertebral discs...
.
The pain can often be divided into neck pain
Neck pain
Neck pain is a common problem, with two-thirds of the population having neck pain at some point in their lives.Neck pain, although felt in the neck, can be caused by numerous other spinal problems. Neck pain may arise due to muscular tightness in both the neck and upper back, or pinching of the...
, upper back pain
Upper back pain
Upper back pain, also called middle back pain or thoracic pain, is pain that is felt between the bottom of the neck and top of the lumbar spine...
, lower back pain or tailbone pain. It may have a sudden onset or can be a chronic pain
Chronic pain
Chronic pain has several different meanings in medicine. Traditionally, the distinction between acute and chronic pain has relied upon an arbitrary interval of time from onset; the two most commonly used markers being 3 months and 6 months since the initiation of pain, though some theorists and...
; it can be constant or intermittent, stay in one place or radiate to other areas. It may be a dull ache, or a sharp or piercing or burning sensation. The pain may radiate into the arm
Arm
In human anatomy, the arm is the part of the upper limb between the shoulder and the elbow joints. In other animals, the term arm can also be used for analogous structures, such as one of the paired forelimbs of a four-legged animal or the arms of cephalopods...
and hand
Hand
A hand is a prehensile, multi-fingered extremity located at the end of an arm or forelimb of primates such as humans, chimpanzees, monkeys, and lemurs...
), in the upper back, or in the low back, (and might radiate into the leg
Human leg
The human leg is the entire lower extremity or limb of the human body, including the foot, thigh and even the hip or gluteal region; however, the precise definition in human anatomy refers only to the section of the lower limb extending from the knee to the ankle.Legs are used for standing,...
or foot
Foot
The foot is an anatomical structure found in many vertebrates. It is the terminal portion of a limb which bears weight and allows locomotion. In many animals with feet, the foot is a separate organ at the terminal part of the leg made up of one or more segments or bones, generally including claws...
), and may include symptoms other than pain, such as weakness, numbness or tingling.
Back Pain is one of humanity's most frequent complaints. In the U.S., acute low back pain
Low back pain
Low back pain or lumbago is a common musculoskeletal disorder affecting 80% of people at some point in their lives. In the United States it is the most common cause of job-related disability, a leading contributor to missed work, and the second most common neurological ailment — only headache is...
(also called lumbago) is the fifth most common reason for physician visits. About nine out of ten adults experience back pain at some point in their life, and five out of ten working adults have back pain every year.
The spine is a complex interconnecting network of nerves, joints, muscles, tendons and ligaments, and all are capable of producing pain. Large nerves that originate in the spine and go to the legs and arms can make pain radiate to the extremities.
Classification
Back pain can be divided anatomically: neck painNeck pain
Neck pain is a common problem, with two-thirds of the population having neck pain at some point in their lives.Neck pain, although felt in the neck, can be caused by numerous other spinal problems. Neck pain may arise due to muscular tightness in both the neck and upper back, or pinching of the...
, upper back pain
Upper back pain
Upper back pain, also called middle back pain or thoracic pain, is pain that is felt between the bottom of the neck and top of the lumbar spine...
, lower back pain or tailbone pain.
By its duration: acute (less than 4 weeks), subacute (4 – 12 weeks), chronic (greater than 12 weeks).
By its cause: musculoskeletal (MSK)
Musculoskeletal causes of back pain
Most cases of back pain are related to issues in human musculoskeletal system and are not related to severe diseases. Musculoskeletal problems also called mechanical because many of them linked to vertebrae physical motions...
, infectious, cancer, etc.
Back pain is classified according to etiology in mechanical or nonspecific back pain and secondary back pain. Approximately 98% of back pain patients are diagnosed with nonspecific acute back pain which has no serious underlying pathology. However, secondary back pain which is caused by an underlying condition accounts for nearly 2% of the cases. Underlying pathology in these cases may include metastatic cancer, spinal osteomyelitis and epidural abscess which account for 1% of the patients. Also, herniated disc is the most common neurologic impairment which is associated with this condition, from which 95% of disc herniations occur at the lowest two lumbar intervertebral levels.
Associated conditions
Back pain can be a sign of a serious medical problem, although this is not most frequently the underlying cause:- Typical warning signs of a potentially life-threatening problem are bowelIntestineIn human anatomy, the intestine is the segment of the alimentary canal extending from the pyloric sphincter of the stomach to the anus and, in humans and other mammals, consists of two segments, the small intestine and the large intestine...
and/or bladderUrinary bladderThe urinary bladder is the organ that collects urine excreted by the kidneys before disposal by urination. A hollow muscular, and distensible organ, the bladder sits on the pelvic floor...
incontinenceUrinary incontinenceUrinary incontinence is any involuntary leakage of urine. It is a common and distressing problem, which may have a profound impact on quality of life. Urinary incontinence almost always results from an underlying treatable medical condition but is under-reported to medical practitioners...
or progressive weakness in the legs. - Severe back pain (such as pain that is bad enough to interrupt sleepSleepSleep is a naturally recurring state characterized by reduced or absent consciousness, relatively suspended sensory activity, and inactivity of nearly all voluntary muscles. It is distinguished from quiet wakefulness by a decreased ability to react to stimuli, and is more easily reversible than...
) that occurs with other signs of severe illness (e.g. feverFeverFever is a common medical sign characterized by an elevation of temperature above the normal range of due to an increase in the body temperature regulatory set-point. This increase in set-point triggers increased muscle tone and shivering.As a person's temperature increases, there is, in...
, unexplained weight lossWeight lossWeight loss, in the context of medicine, health or physical fitness, is a reduction of the total body mass, due to a mean loss of fluid, body fat or adipose tissue and/or lean mass, namely bone mineral deposits, muscle, tendon and other connective tissue...
) may also indicate a serious underlying medical condition. - Back pain that occurs after a trauma, such as a car accident or fall, may indicate a bone fractureBone fractureA bone fracture is a medical condition in which there is a break in the continuity of the bone...
or other injury. - Back pain in individuals with medical conditions that put them at high risk for a spinal fracture, such as osteoporosisOsteoporosisOsteoporosis is a disease of bones that leads to an increased risk of fracture. In osteoporosis the bone mineral density is reduced, bone microarchitecture is deteriorating, and the amount and variety of proteins in bone is altered...
or multiple myelomaMultiple myelomaMultiple myeloma , also known as plasma cell myeloma or Kahler's disease , is a cancer of plasma cells, a type of white blood cell normally responsible for the production of antibodies...
, also warrants prompt medical attention. - Back pain in individuals with a history of cancer (especially cancers known to spread to the spine like breast, lung and prostate cancer) should be evaluated to rule out metastatic disease of the spine.
Back pain does not usually require immediate medical intervention. The vast majority of episodes of back pain are self-limiting and non-progressive. Most back pain syndromes are due to inflammation
Inflammation
Inflammation is part of the complex biological response of vascular tissues to harmful stimuli, such as pathogens, damaged cells, or irritants. Inflammation is a protective attempt by the organism to remove the injurious stimuli and to initiate the healing process...
, especially in the acute phase, which typically lasts for two weeks to three months.
A few observational studies suggest that two conditions to which back pain is often attributed, lumbar disc herniation and degenerative disc disease
Degenerative disc disease
Degeneration of the intervertebral disc, often called "degenerative disc disease" of the spine, is a condition that can be painful and can greatly affect the quality of one's life...
may not be more prevalent among those in pain than among the general population, and that the mechanisms by which these conditions might cause pain are not known. Other studies suggest that for as many as 85% of cases, no physiological cause can be shown.
A few studies suggest that psychosocial
Psychosocial
For a concept to be psychosocial means it relates to one's psychological development in, and interaction with, a social environment. The individual needs not be fully aware of this relationship with his or her environment. It was first commonly used by psychologist Erik Erikson in his stages of...
factors such as on-the-job stress and dysfunctional family relationships
Dysfunctional family
A dysfunctional family is a family in which conflict, misbehavior, and often abuse on the part of individual members occur continually and regularly, leading other members to accommodate such actions. Children sometimes grow up in such families with the understanding that such an arrangement is...
may correlate more closely with back pain than structural abnormalities revealed in x-rays and other medical imaging scans.
Differential diagnosis
There are several potential sources and causes of back pain. However, the diagnosis of specific tissues of the spine as the cause of pain presents problems. This is because symptoms arising from different spinal tissues can feel very similar and is difficult to differentiate without the use of invasive diagnostic intervention procedures, such as local anesthetic blocks.One potential source of back pain is skeletal muscle
Skeletal muscle
Skeletal muscle is a form of striated muscle tissue existing under control of the somatic nervous system- i.e. it is voluntarily controlled. It is one of three major muscle types, the others being cardiac and smooth muscle...
of the back. Potential causes of pain in muscle tissue include muscle strains (pulled muscles)
Strain (injury)
A strain is an injury to a muscle or tendon in which the muscle fibres tear as a result of overstretching. A strain is also colloquially known as a pulled muscle...
, muscle spasm
Spasm
In medicine a spasm is a sudden, involuntary contraction of a muscle, a group of muscles, or a hollow organ, or a similarly sudden contraction of an orifice. It is sometimes accompanied by a sudden burst of pain, but is usually harmless and ceases after a few minutes...
, and muscle imbalances. However, imaging studies do not support the notion of muscle tissue damage in many back pain cases, and the neurophysiology of muscle spasm and muscle imbalances is not well understood.
Another potential source of low back pain is the synovial joints of the spine (e.g. zygapophysial joints/facet joints. These 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. However, the cause of zygapophysial joint pain is not fully understood. Capsule tissue damage has been proposed in people with neck pain following whiplash. In people with spinal pain stemming from zygapophysial joints, one theory is that intra-articular tissue such as invaginations of their synovial membranes and fibro-adipose meniscoids (that usually act as a cushion to help the bones move over each other smoothly) may become displaced, pinched or trapped, and consequently give rise to nociception
Nociception
Nociception is defined as "the neural processes of encoding and processing noxious stimuli." It is the afferent activity produced in the peripheral and central nervous system by stimuli that have the potential to damage tissue...
(pain).
There are several common other potential sources and causes of back pain: these include spinal disc herniation
Spinal disc herniation
A spinal disc herniation , informally and misleadingly called a "slipped disc", is a medical condition affecting the spine due to trauma, lifting injuries, or idiopathic, in which a tear in the outer, fibrous ring of an intervertebral disc allows the soft, central portion A spinal disc herniation...
and degenerative disc disease
Degenerative disc disease
Degeneration of the intervertebral disc, often called "degenerative disc disease" of the spine, is a condition that can be painful and can greatly affect the quality of one's life...
or isthmic spondylolisthesis, osteoarthritis (degenerative joint disease)
Osteoarthritis
Osteoarthritis also known as degenerative arthritis or degenerative joint disease, is a group of mechanical abnormalities involving degradation of joints, including articular cartilage and subchondral bone. Symptoms may include joint pain, tenderness, stiffness, locking, and sometimes an effusion...
and lumbar spinal stenosis, trauma, cancer, infection, fractures, and inflammatory disease.
Radicular pain (sciatica
Sciatica
Sciatica is a set of symptoms including pain that may be caused by general compression or irritation of one of five spinal nerve roots that give rise to each sciatic nerve, or by compression or irritation of the left or right or both sciatic nerves. The pain is felt in the lower back, buttock, or...
) is distinguished from 'non-specific' back pain, and may be diagnosed without invasive diagnostic tests.
New attention has been focused on non-discogenic back pain, where patients have normal or near-normal MRI and CT scans. One of the newer investigations looks into the role of the dorsal ramus in patients that have no radiographic abnormalities. See Posterior Rami Syndrome
Posterior Rami Syndrome
Posterior Ramus Syndrome, also referred to as Thoracolumbar Junction Syndrome, Maigne Syndrome and Dorsal Ramus Syndrome is caused by the unexplained activation of the primary division of a posterior ramus of a spinal nerve . This nerve irritation causes referred pain in a well described...
.
Management
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
Chronic (medicine)
A chronic disease is a disease or other human health condition that is persistent or long-lasting in nature. The term chronic is usually applied when the course of the disease lasts for more than three months. Common chronic diseases include asthma, cancer, diabetes and HIV/AIDS.In medicine, the...
) is also a determining factor in the choice of treatment. Only a minority of back pain patients (most estimates are 1% - 10%) require surgery.
Pain
- Heat therapyHeat therapyHeat therapy, also called thermotherapy, is the application of heat to the body for pain relief and health. It can take the form of a hot cloth, hot water, ultrasound, heating pad, hydrocollator packs, whirlpool baths, cordless FIR heat therapy wrap, and many others. It can be beneficial to those...
is useful for back spasms or other conditions. A meta-analysisMeta-analysisIn statistics, a meta-analysis combines the results of several studies that address a set of related research hypotheses. In its simplest form, this is normally by identification of a common measure of effect size, for which a weighted average might be the output of a meta-analyses. Here the...
of studies by the Cochrane CollaborationCochrane CollaborationThe Cochrane Collaboration is a group of over 28,000 volunteers in more than 100 countries who review the effects of health care interventions tested in biomedical randomized controlled trials. A few more recent reviews have also studied the results of non-randomized, observational studies...
concluded that heat therapy can reduce symptoms of acute and sub-acute low-back pain. Some patients find that moist heat works best (e.g. a hot bath or whirlpool) or continuous low-level heat (e.g. a heat wrap that stays warm for 4 to 6 hours). Cold compression therapyCold compression therapyCold Compression Therapy combines two of the principles of R.I.C.E. to reduce pain and swelling from a sports or activity injury to soft tissues and recommended by orthopedic surgeons following surgery...
(e.g. ice or cold pack application) may be effective at relieving back pain in some cases.
- Use of medicationMedicationA pharmaceutical drug, also referred to as medicine, medication or medicament, can be loosely defined as any chemical substance intended for use in the medical diagnosis, cure, treatment, or prevention of disease.- Classification :...
s in chronic back pain is controversial. The short term use of muscle relaxants is effective in the relief of acute back pain. Opioids have not been shown to be better than placebo for chronic back pain when the risks and benefits are considered. Non-steroidal anti-inflammatory drugs (NSAIDs/NSAIAs) have been shown to be more effective than placebo, but have not been shown to be more effective than paracetamol (acetaminophen)ParacetamolParacetamol INN , or acetaminophen USAN , is a widely used over-the-counter analgesic and antipyretic . It is commonly used for the relief of headaches and other minor aches and pains and is a major ingredient in numerous cold and flu remedies...
, and they have more adverse effects than paracetamol (acetaminophen)ParacetamolParacetamol INN , or acetaminophen USAN , is a widely used over-the-counter analgesic and antipyretic . It is commonly used for the relief of headaches and other minor aches and pains and is a major ingredient in numerous cold and flu remedies...
. A meta-analysisMeta-analysisIn statistics, a meta-analysis combines the results of several studies that address a set of related research hypotheses. In its simplest form, this is normally by identification of a common measure of effect size, for which a weighted average might be the output of a meta-analyses. Here the...
of randomized controlled trials by the Cochrane CollaborationCochrane CollaborationThe Cochrane Collaboration is a group of over 28,000 volunteers in more than 100 countries who review the effects of health care interventions tested in biomedical randomized controlled trials. A few more recent reviews have also studied the results of non-randomized, observational studies...
found that there is insufficient clinical trials to determine if injection therapy, usually with corticosteroids, helps in cases of low back pain A study of intramuscular corticosteroids found no benefit.
- Back schools appear to improve pain as compared to standard treatments.
- MassageMassageMassage is the manipulation of superficial and deeper layers of muscle and connective tissue to enhance function, aid in the healing process, and promote relaxation and well-being. The word comes from the French massage "friction of kneading", or from Arabic massa meaning "to touch, feel or handle"...
therapy, especially from an experienced therapist, can provide short term relief. Acupressure or pressure point massage may be more beneficial than classic (Swedish) massage.
Depending on the particular cause of the condition, posture
Human position
Human positions refers to the different positions that the human body can take.There are several synonyms that refer to the human position, often used interchangeably, but having specific flavors....
training courses and physical exercises might help with relieving the pain.
- Exercises can be an effective approach to reducing pain, but should be done under supervision of a licensed health professional. Generally, some form of consistent stretching and exercise is believed to be an essential component of most back treatment programs. However, one study found that exercise is also effective for chronic back pain, but not for acute pain. Another study found that back-mobilizing exercises in acute settings are less effective than continuation of ordinary activities as tolerated.
- Studies of manipulationJoint manipulationJoint manipulation is a type of passive movement of a skeletal joint. It is usually aimed at one or more 'target' synovial joints with the aim of achieving a therapeutic effect.- Biomechanics of joint manipulation :...
suggest that this approach has a benefit similar to other therapies and superior to placeboPlaceboA placebo is a simulated or otherwise medically ineffectual treatment for a disease or other medical condition intended to deceive the recipient...
. - AcupunctureAcupunctureAcupuncture is a type of alternative medicine that treats patients by insertion and manipulation of solid, generally thin needles in the body....
has some proven benefit for back pain; however, a recent randomized controlled trialRandomized controlled trialA randomized controlled trial is a type of scientific experiment - a form of clinical trial - most commonly used in testing the safety and efficacy or effectiveness of healthcare services or health technologies A randomized controlled trial (RCT) is a type of scientific experiment - a form of...
suggested insignificant difference between real and sham acupuncture. - Education, and attitude adjustment to focus on psychological or emotional causes - respondent-cognitive therapy and progressive relaxation therapy can reduce chronic pain.
Surgery
Surgery may sometimes be appropriate for patients with:- Lumbar disc herniation or degenerative disc diseaseDegenerative disc diseaseDegeneration of the intervertebral disc, often called "degenerative disc disease" of the spine, is a condition that can be painful and can greatly affect the quality of one's life...
- Lumbar spinal stenosis from lumbar disc herniation, degenerative joint disease, or spondylolisthesisSpondylolisthesisSpondylolisthesis describes the anterior or posterior displacement of a vertebra or the vertebral column in relation to the vertebrae below. It was first described in 1782 by Belgian obstetrician, Dr. Herbinaux. He reported a bony prominence anterior to the sacrum that obstructed the vagina of a...
- ScoliosisScoliosisScoliosis is a medical condition in which a person's spine is curved from side to side. Although it is a complex three-dimensional deformity, on an X-ray, viewed from the rear, the spine of an individual with scoliosis may look more like an "S" or a "C" than a straight line...
- Compression fractureCompression fractureA compression fracture is a collapse of a vertebra. It may be due to trauma or due to a weakened vertebra. This weakening is seen patients with osteoporosis or osteogenesis imperfecta, lytic lesions from metastatic or primary tumors, or infection. In healthy patients it is most often seen in...
Minimally invasive surgical procedures are often a solution for many symptoms and causes of back pain. These types of procedures offer many benefits over traditional spine surgery, such as more accurate diagnoses and shorter recovery times.
Surgery is usually the last resort in the treatment of back pain. It is normally recommended only if all other treatment options have been tried or if the situation is an emergency. 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.
There are different types of surgical procedures that are used in treating various conditions causing back pain. All of them can be classified into nerve decompression, fusion of body segments and deformity correction surgeries. The first type of surgery is primarily performed in older patients who suffer from conditions causing nerve irritation or nerve damage
Nerve Damage
Nerve Damage is a compilation album by Groove Metal band Skinlab, released in 2004. It is a 2CD collection of rare and unreleased material, including a live set, demos, remixes, alternate mixes, and two new tracks.-Disc 1:# "Losing All" – 4:04...
. Fusion of bony segments is also referred to as a spinal fusion
Spinal fusion
Spinal fusion, also known as spondylodesis or spondylosyndesis, is a surgical technique used to join two or more vertebrae. Supplementary bone tissue, either from the patient or a donor , is used in conjunction with the body's natural bone growth processes to fuse the vertebrae.Fusing of the...
, and it is a procedure used to fuse together two or more bony fragments with the help of metalwork. The latter type of surgery is normally performed to correct congenital deformities or those that were caused by a traumatic fracture. In some cases, correction of deformities involves removing bony fragments or providing stability provision for the spine.
The main procedures used in back pain surgery are discetomies, spinal fusions, laminectomies, removal of tumors, and vertebroplasties.
A discetomy is performed when the intervertebral disc have herniated or torn. It involves removing the protruding disc, either a portion of it or all of it, that is placing pressure
Pressure
Pressure is the force per unit area applied in a direction perpendicular to the surface of an object. Gauge pressure is the pressure relative to the local atmospheric or ambient pressure.- Definition :...
on the nerve root
Nerve root
A nerve root is the initial segment of a nerve leaving the central nervous system. Types include:* A cranial nerve root, the beginning of one of the twelve pairs leaving the central nervous system from the brain stem or the highest levels of the spinal cord;...
. The disc material which is putting pressure on the nerve is removed through a small incision that is made over that particular disc. This is one of the most popular types of back surgeries and which also has a high rate of success. The recovery
Healing
Physiological healing is the restoration of damaged living tissue, organs and biological system to normal function. It is the process by which the cells in the body regenerate and repair to reduce the size of a damaged or necrotic area....
period after this procedure does not last longer than 6 weeks. The type of procedure in which the bony fragments are removed through an endoscope is called percutaneous disc removal.
Microdiscetomies may be performed as a variation of standard discetomies in which a magnifier
Magnifier
A magnifier is a device used for magnification.Magnifier can also refer to:*Magnifying glass, an optical device for magnification*Screen magnifier, software that magnifies part of a computer screen...
is used to provide the advantage of a smaller incision, thus a shorter recovery process.
Spinal fusions are performed in cases in which the patient has had the entire disc removed or when another condition has caused the vertebrae to become unstable. The procedure consists in uniting two or more vertebrae by using bone grafts and metalwork to provide more strength for the healing bone. Recovery after spinal fusion may take up to one year, depending greatly on the age of the patient, the reason why surgery has been performed and how many bony segments needed to be fused.
In cases of spinal stenosis or disc herniation, laminectomies can be performed to relieve the pressure on the nerves. During such a procedure, the surgeon enlarges the spinal canal by removing or trimming away excessive lamina which will provide more space for the nerves. The severity of the condition as well as the general health status of the patient are key factors in establishing the recovery time, which may be range from 8 weeks to 6 months.
Back surgery can be performed to prevent the growth of benign and malignant tumors. In the first case, surgery has the goal of relieving the pressure from the nerves which is caused by a benign growth, whereas in the latter the procedure is aimed to prevent the spread of cancer to other areas of the body. Recovery depends on the type of tumor that is being removed, the health status of the patient and the size of the tumor.
Of doubtful benefit
- Cold compression therapyCold compression therapyCold Compression Therapy combines two of the principles of R.I.C.E. to reduce pain and swelling from a sports or activity injury to soft tissues and recommended by orthopedic surgeons following surgery...
is advocated for a strained back or chronic back pain and is postulated to reduce pain and inflammation, especially after strenuous exercise such as golf, gardening, or lifting. However, a meta-analysisMeta-analysisIn statistics, a meta-analysis combines the results of several studies that address a set of related research hypotheses. In its simplest form, this is normally by identification of a common measure of effect size, for which a weighted average might be the output of a meta-analyses. Here the...
of randomized controlled trials by the Cochrane CollaborationCochrane CollaborationThe Cochrane Collaboration is a group of over 28,000 volunteers in more than 100 countries who review the effects of health care interventions tested in biomedical randomized controlled trials. A few more recent reviews have also studied the results of non-randomized, observational studies...
concluded "The evidence for the application of cold treatment to low-back pain is even more limited, with only three poor quality studies located. No conclusions can be drawn about the use of cold for low-back pain"
- Bed rest is rarely recommended as it can exacerbate symptoms, and when necessary is usually limited to one or two days. Prolonged bed rest or inactivity is actually counterproductive, as the resulting stiffness leads to more pain.
- ElectrotherapyElectrotherapyElectrotherapy is the use of electrical energy as a medical treatment In medicine, the term electrotherapy can apply to a variety of treatments, including the use of electrical devices such as deep brain stimulators for neurological disease. The term has also been applied specifically to the use of...
, such as a transcutaneous electrical nerve stimulationTranscutaneous electrical nerve stimulationTranscutaneous electrical nerve stimulation is the use of electric current produced by a device to stimulate the nerves for therapeutic purposes...
(TENS) has been proposed. Two randomized controlled trials found conflicting results. This has led the Cochrane CollaborationCochrane CollaborationThe Cochrane Collaboration is a group of over 28,000 volunteers in more than 100 countries who review the effects of health care interventions tested in biomedical randomized controlled trials. A few more recent reviews have also studied the results of non-randomized, observational studies...
to conclude that there is inconsistent evidence to support use of TENS. In addition, spinal cord stimulationSpinal Cord StimulatorA spinal cord stimulator is a device used to exert pulsed electrical signals to the spinal cord to control chronic pain. Spinal cord stimulation , in the simplest form, consists of stimulating electrodes, implanted in the epidural space, an electrical pulse generator, implanted in the lower...
, where an electrical device is used to interrupt the pain signals being sent to the brain and has been studied for various underlying causes of back pain.
- Inversion therapyInversion therapyInversion therapy involves hanging upside down or at an inverted angle with the intention of therapeutic benefits. However, it is rarely regarded as a serious treatment for back pain.-Traction and stretching:...
is useful for temporary back relief due to the traction method or spreading of the vertebrae through (in this case) gravity. The patient hangs in an upside down position for a period of time from ankles or knees until this separation occurs. The effect can be achieved without a complete vertical hang (90 degree) and noticeable benefits can be observed at angles as low as 10 to 45 degrees.
- UltrasoundUltrasoundUltrasound is cyclic sound pressure with a frequency greater than the upper limit of human hearing. Ultrasound is thus not separated from "normal" sound based on differences in physical properties, only the fact that humans cannot hear it. Although this limit varies from person to person, it is...
has been shown not to be beneficial and has fallen out of favor.
Pregnancy
About 50% of women experience low back pain during pregnancy.Back pain in pregnancy may be severe enough to cause significant pain and disability and pre-dispose patients to back pain in a following pregnancy. No significant increased risk of back pain with pregnancy has been found with respect to maternal weight gain, exercise, work satisfaction, or pregnancy outcome factors such as birth weight, birth length, and Apgar scores.
Biomechanical factors of pregnancy that are shown to be associated with low back pain of pregnancy include abdominal sagittal and transverse diameter and the depth of lumbar lordosis. Typical factors aggravating the back pain of pregnancy include standing, sitting, forward bending, lifting, and walking. Back pain in pregnancy may also be characterized by pain radiating into the thigh and buttocks, night-time pain severe enough to wake the patient, pain that is increased during the night-time, or pain that is increased during the day-time.
The avoidance of high impact, weight-bearing activities and especially those that asymmetrically load the involved structures such as: extensive twisting with lifting, single-leg stance postures, stair climbing, and repetitive motions at or near the end-ranges of back or hip motion can ease the pain.
Direct bending to the ground without bending the knee causes severe impact on the lower back in pregnancy and in normal individuals, which leads to strain, especially in the lumbo-saccral region that in turn strains the multifidus.
Economics
Back pain is regularly cited by national governments as having a major impact on productivityProductivity
Productivity is a measure of the efficiency of production. Productivity is a ratio of what is produced to what is required to produce it. Usually this ratio is in the form of an average, expressing the total output divided by the total input...
, through loss of workers on sick leave
Sick leave
Sick leave is time off from work that workers can use during periods of temporary illness to stay home and address their health and safety needs without losing pay. Some workplaces offer paid sick time as a matter of workplace policy, and in few jurisdictions it is codified into law...
. Some national governments, notably Australia
Australia
Australia , officially the Commonwealth of Australia, is a country in the Southern Hemisphere comprising the mainland of the Australian continent, the island of Tasmania, and numerous smaller islands in the Indian and Pacific Oceans. It is the world's sixth-largest country by total area...
and the United Kingdom
United Kingdom
The United Kingdom of Great Britain and Northern IrelandIn the United Kingdom and Dependencies, other languages have been officially recognised as legitimate autochthonous languages under the European Charter for Regional or Minority Languages...
, have launched campaigns of public health awareness to help combat the problem, for example the Health and Safety Executive
Health and Safety Executive
The Health and Safety Executive is a non-departmental public body in the United Kingdom. It is the body responsible for the encouragement, regulation and enforcement of workplace health, safety and welfare, and for research into occupational risks in England and Wales and Scotland...
's Better Backs campaign.
In the United States
United States
The United States of America is a federal constitutional republic comprising fifty states and a federal district...
lower back pain’s economic impact reveals that it is the number one reason for individuals under the age of 45 to limit their activity, second highest complaint seen in physician’s offices, fifth most common requirement for hospitalization, and the third leading cause for surgery.
External links
- Handout on Health: Back Pain at National Institute of Arthritis and Musculoskeletal and Skin DiseasesNational Institute of Arthritis and Musculoskeletal and Skin DiseasesThe National Institute of Arthritis and Musculoskeletal and Skin Diseases, or NIAMS, is an institute of the National Institutes of Health, an agency of the United States Department of Health and Human Services...
- Back pain on MedlinePlusMedlinePlusMedlinePlus is a free Web site that provides consumer health information for patients, families, and Health care providers. The site brings together information from the United States National Library of Medicine, the National Institutes of Health , other U.S. government agencies, and...
, US National Library of Medicine - Back pain, American Academy of Orthopaedic Surgeons summary