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Back Pain Is Not Created Equal

backpain25Back pain has many faces and to many people, it can be distressing, disabling or even frightening. Back pain can be due to a strain, degenerative disc disease, a herniated disc, spinal stenosis, spondylolisthesis, a complex spinal deformity, a fracture, or even a tumor. It is clear that back pain is not created equal and effective treatment depends on what's wrong. 

Almost everyone experiences low back pain at one time or another. In fact, it is one of the most common reasons we visit the doctor. Although 80-90% of people experience an episode of low back pain in their lifetime, the good news is that most low back pain resolves on its own in a short period of time. Typically, low back pain will get better after six to eight weeks of rest, stretching, and non-steroidal anti-inflammatory medications (NSAIDS), such as ibuprofen or naproxen. Commonly, acute episodes are muscular in nature from strains or overuse injuries but sometimes it is more.

Back Pain Causes

The time to see a doctor for help is when there has not been improvement after six weeks of rest and NSAIDS use, or after a significant fall or injury. Pain that does not resolve on its own indicates something more significant may be causing the pain. Undergoing plain spine x-rays and an evaluation by your primary care physician or spine specialist is usually the next step. Although some patients may discover there is a serious cause of their pain, most problems can be treated and resolved. 

Back pain is a symptom, not a diagnosis. Low back pain can be due to a variety of reasons related to the spinal anatomy and muscles but remember, pain can arise from other causes as well. Pain due to the lumbar spine can be broken down into three main areas. First, pain can be related to degenerative or arthritic conditions that affect the discs in the front, or the small (facet) joints in the back of the spine. Next, nerve compression from the surrounding arthritic spine, herniated discs or instability of the spine can result in back or leg pain. Finally, instability of the spine can cause mechanical low back. The most common type of instability is that from slippage of one vertebra on the other, known as spondylolisthesis.

In patients, ranging between 18 and 40 years old, the most common problem is related to a disc herniation. A herniated disc, which can result from injury or disc degeneration, is when the inner core breaks through the outer part of the disc and extrudes into the spinal canal, putting pressure on the nerve. This causes pain to radiate down the patient's leg to the foot. This damage to the disc can lead to early arthritis in the back.

The most common problems seen in adults older than 40 are usually degenerative in nature. This is usually a result of wear-and-tear arthritis of the spine. It affects the discs in the front of the spine, the facet joints in the back of the spine, or a combination of the two. Occasionally, arthritis of the spine leads to narrowing of the spinal canal. When the space available narrows where the nerves pass through, it causes pain and numbness in the legs which can severely affect walking and being active. This condition is known as spinal stenosis. 

Back Pain Symptoms

Since there are many causes of low back pain, it is important to note your specific symptoms particularly when discussing your problem with your doctor. Pain and its patterns can help your doctor put a name to your problem which is the first step to getting the right treatment to resolve it. 

Questions your doctor may ask you include:

  1. Did your pain begin suddenly after an activity or did the pain begin gradually?
  2. Does the pain radiate down the front, side or back of your leg, or is it confined to your low back?
  3. Does your pain become worse or better with activity?
  4. Is your pain worse at night or with prolonged sitting?
  5. Do you experience numbness or weakness in part of your leg?

Steps to an Accurate Diagnosis

Medical History

Your medical history is the most important part of your visit with the doctor. Questions you are asked may not seem associated to your complaint but are very important in determining the source of your pain. Your doctor will ask you about recent illnesses and other questions about your general health that may be related. 

Physical Examination

Your doctor will look for signs of nerve impingement or damage by asking you to walk on your heels, toes and soles of your feet. He will check your reflexes as well as muscle strength and whether there is tension on your sciatic nerve. He will check sensation or your ability to feel to assess possible loss of sensation to areas of your legs. 

Diagnostic Methods

Although a medical history and physical exam will usually identify various conditions that may be associated with the pain, diagnostic tests are used to assist the physician to confirm the cause of low back pain.

Diagnostic imaging is used to get a better idea as to the cause of the back pain but it is important to understand that no single test is perfect nor will it identify the absence or presence of the disease with 100% accuracy. Diagnostic imaging is a very helpful tool when used as an adjunct to the history and physical examination. 

Determining the Pain Generator

Different diagnoses dictate options for successful treatment. This is why it is critical for the patient with ongoing back pain to try to determine the exact cause of the pain, or what we refer to as the "pain generator". This can be accomplished many times with magnetic resonance imaging, or MRI, which shows the precise anatomy of the spine: discs, spinal cord, nerve roots, facet joints, and surrounding muscle. If there is a single anatomic problem seen on this study and it fits with the complaints, further testing sometimes is not needed. In degenerative problems of the low back, several spinal levels can be involved. This can be challenging for a spine specialist since at each level, the pain can come from its parts -- the degenerative disc in the front, the facet joints in the back, or a combination. When the pain generator is still uncertain, other tests may be helpful. Diagnostic and symptom-relieving pain blocks of a specific arthritic facet joint or injecting medication around the suspected pinched nerve compressed by the arthritic process can help pinpoint the pain source. The treatment strategy can be tailored for that particular problem resulting in more effective relief. 

Once when the pain generator is determined, the patient has three main treatment options. The first is to do nothing and try to live with it. This option has usually been exhausted by the time a patient is seen by the spine specialist. The second option is to treat the symptoms and see how well it goes. This can include selective blocks of the pain generator, medications, massage, chiropractic, acupuncture, physical therapy, and a myriad of other treatments. These treatments do not change the underlying structural problem, but may improve function and decrease pain. When the pain is no longer a simple nuisance, but instead, an impairment of the person's lifestyle, a surgical intervention may be the option to consider. The goal is to change the structural abnormality that is causing the pain. Surgery can be as simple as a minimally invasive decompression of the nerves being pinched by a herniated disc or arthritic problem. Occasionally when the problem is a result of instability or severe arthritis of the spine, a spinal fusion is indicated for pain relief and increased function for the patient. On the horizon are many non-fusion technologies that may provide alternatives to fusion surgery for some conditions. Emerging technologies include total disc replacement for the treatment of degenerative disc disease. There are other technologies being studied and tested as well. 

The common back pain that most Americans have experienced in their life is not the same for everyone. There are many causes for back pain. Most of the time, it is related to sprains or strains of the muscles and ligaments, but when back pain does not resolve after 6-8 weeks, it is time to find out exactly what is going on. It is refreshing to know that when low back pain is accurately diagnosed, there are actually many effective treatments available. This is when most patients learn that back pain is really not created equal.

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