Back Pain

What’s causing my back pain?

When a person says I have back pain, we usually interpret that to mean low back pain. For good reason, the pain and tightness most often hit the lower part of the back.

Back pain can be a symptom of many different illnesses and conditions.The main cause of the pain can be a problem with the back itself or by a problem in another part of the body. In many cases, doctors can't find a cause for the pain. When a cause is found, common explanations include:

• Stress or injury involving the back muscles, including back sprain or strain; chronic overload of back muscles caused by obesity; and short term overload of back muscles caused by any unusual stress, such as lifting or pregnancy
• Disease or injury involving the back bones (vertebrae), including fracture from an accident or as a result of the bone-thinning disease osteoporosis
• Degenerative arthritis, a “wear and tear” process that may be related to age, injury and genetic predisposition.
• Disease or injury involving the spinal nerves, including nerve injury caused by a protruding disk (a fibrous cushion between vertebrae) or spinal stenosis (a narrowing of the spinal canal)\
• Kidney stones or a kidney infection (pyelonephritis).

Rarer causes include:

• Inflammatory arthritis, including ankylosing spondylitis and related conditions
• A spinal tumor or a cancer that has spread (metastasized) to the spine from elsewhere in the body
• Infection, which may be in the disk space, bone (osteomyelitis), abdomen, pelvis or bloodstream.

When should I worry about back pain?

Back pain varies widely. Some symptoms (often called “red flag” symptoms) may suggest that the back pain has a more serious cause. These include fever, recent trauma, weight loss, a history of cancer and neurological symptoms, such as numbness, weakness or incontinence (involuntary loss of urine or stool). If any of these symptoms occur, contact your doctor immediately.

Back pain is often accompanied by other symptoms that may help point to its cause. For example:

• Back sprain or strain – Back pain typically begins on the day after heavy exertion or an activity that requires twisting. Muscles in the back, buttocks and thighs are often sore and stiff. The back may have areas that are sore when touched or pressed.
• Fibromyalgia – In addition to back pain, there are usually other areas of pain and stiffness in the trunk, neck, shoulders, knees and elbows. Pain may be either a general soreness or a gnawing ache, and stiffness is often worst in the morning. People usually complain of feeling abnormally tired, especially of waking up tired, and they have specific areas that are painful to touch, called tender points.
• Degenerative arthritis of the spine – Together with back pain, there is stiffness and trouble bending over, which usually develops over many years.
• Inflammatory arthritis, including ankylosing spondylitis and related conditions – In these disorders, there is pain in the lower back, together with morning stiffness in the back, hips or both.  Back pain in these condition tends to improve with exercise. Other features may include psoriasis, eye pain and redness, or diarrhea, depending on the specific disorder causing back pain. This group of diseases is a relatively rare cause of back pain.
• Osteoporosis – This common condition is characterized by thinned, weakened bones that fracture easily. It is most common in postmenopausal women. When vertebrae become compressed because of fracture, posture may become stooped over or hunched along with back pain. Osteoporosis is not painful unless a bone fractures.
• Protruding disk – People with significant disk disease sometimes have severe pain in the lower back. If a disk compresses a nerve, the pain may spread down one leg. The pain gets worse during bending or twisting.
• Spinal stenosis – Pain, numbness and weakness affect the back and legs. Symptoms get worse when you are standing or walking, but are relieved by sitting or leaning forward.
• Pyelonephritis – People with a kidney infection typically develop sudden, intense pain just beneath the ribs in the back that may travel around the side toward the lower abdomen or sometimes down to the groin. There also can be a high fever, shaking chills and nausea and vomiting. The urine may be cloudy, tinged with blood or unusually strong or foul-smelling. There may be additional bladder related symptoms, such as the need to urinate more often than normal or pain or discomfort during urination.

How do doctors diagnose the cause of back pain?

Your doctor will ask about your symptoms and your medical history. He or she will examine your back muscles and spine and will move you certain ways to check for pain, muscle tenderness or weakness, stiffness, numbness or abnormal reflexes. For example, if you have a disk problem, you may have pain in your lower back when the doctor raises your straightened leg.

Your symptoms and the physical examination may give your doctor enough information to diagnose the problem. However, with back pain, your doctor may only be able to tell you that the problem is not serious. If your doctor determines that your back pain is caused by muscle strain, obesity, pregnancy or another cause that is not urgent, you may not need any additional tests. However, if he or she suspects a more serious problem involving your vertebrae or spinal nerves, especially if your back pain has lasted longer than 12 weeks, you may need one or more of the following tests:

• X-rays of your back
• Blood test
• Urine tests
• Spinal magnetic resonance imaging (MRI)
• Computed tomography (CT) scan
• Nerve conduction studies and electromyography to determine whether nerves, muscles or both may be injured
• Bone scan, especially if you have a previous history of cancer

How long does back pain last?

How long back pain lasts depends on its cause. For example, if your pain is caused by strain from overexertion, symptoms usually subside over days or weeks and you may be able to return gradually to your normal activities. However, you should avoid heavy lifting, prolonged sitting or sudden bending or twisting until your back gets better.

Women who have back pain caused by the added weight of pregnancy almost always will get better after delivery. People who are obese may need to lose weight before back pain eases.

People with back pain caused by pyelonephritis often begin to feel better within days after they start taking antibiotics, although they usually need to continue taking antibiotics for up to two weeks.

People with more serious forms of back pain caused by problems with the vertebrae or spinal nerves may have more persistent back pain that lasts for months and may last for years.

What’s the best way to prevent back pain?

You can help prevent some forms of back pain by strengthening your back with exercises and by avoiding activities that lead to back injury.

Movement is the best way to ward off back pain. Regular physical activity can make the back stronger to reduce future episodes of pain. Exercises should focus on increasing strength and improving range of motion — as well as ensuring balance on both sides of the body, as some back pain can start when one side of the body is stronger than the other.

In addition, whenever possible, avoid prolonged sitting. If you sit at a desk in the office all day, get up periodically — at least every 30 minutes — and walk around. Walk to get a drink of water or to pick up your mail. Take breaks throughout the course of the day to prevent future bouts of pain.

Other measures that may help prevent back pain include:

• Maintaining good posture.
• Always lifting objects from a squatting position, using your hips and your legs to do the heavy work. Avoid lifting, twisting and bending at the same time.

To help prevent osteoporosis, make sure you get enough calcium and vitamin D daily to meet the dietary requirements for your age group. Follow a routine program of weight-bearing exercise. Avoid smoking and limit the amount of alcohol you drink. If you are a woman who has entered menopause, speak with your doctor about testing for osteoporosis and medications that can help to prevent or reverse it.

What treatments relieve back pain?

Medications tend to have only temporary and modest benefits, so it makes sense to try something other than a pill for back pain relief. The specifics depend on the type and duration of back pain.

For new low back pain relief (lasting less than 12 weeks), try:

• heat
• massage
• acupuncture
• spinal manipulation, as with chiropractic care.

If these don’t work, an NSAID such as ibuprofen or naproxen or a muscle relaxant are reasonable options. But given their potential to cause side effects and their modest benefit, they aren’t the first choice.

For chronic low back pain relief (lasting 12 weeks or more), try:

• exercise (including stretching, improving balance, and strengthening core muscles)
• physical therapy
• acupuncture
• mindfulness-based programs intended to cope with or reduce stress.

Other approaches, such as tai chi, yoga, or progressive relaxation techniques may also be helpful.

If these don’t work, treatment with an NSAID or duloxetine is worth consideration. However, opioids should be avoided for chronic low back pain in most cases.

It’s important to emphasize these suggestions are for low back pain that might begin after an unusually strenuous workout or shoveling snow. It’s not for serious causes of back pain such as a major injury, cancer, infection, or fractures.

When is back surgery needed?

The decision to consider back surgery should always come after trying nonsurgical or "conservative" options. There are exceptions. For example, if a person has back pain and progressive weakening in one or both legs or loses control of bladder or bowel function, prompt surgical intervention may be necessary.

Most often acute back pain will resolve after 6 to 8 weeks. So, it’s usually best to be patient and give nonsurgical options time to work. Even if the discomfort persists, surgery is most likely to be successful when the person’s pain clearly correlates to abnormal findings on an imaging test like an MRI.

However, imaging tests often show abnormal changes that have nothing to do with the pain. That’s when surgery is unlikely to help and perhaps offers no relief, as well as risking complications.

When conservative measures have not provided sufficient pain relief for a herniated disc causing persistent sciatica or spinal stenosis, you and your doctor might consider surgery. The procedures back surgeons perform most often are discectomy and laminectomy.

In a discectomy, the surgeon removes part of a herniated disc, which occurs when a disc ruptures and its jelly-like center leaks, irritating nearby nerves.

Back surgeons perform laminectomy for spinal stenosis (narrowing of spaces in the spine), causing pressure on a nerve going into the legs. The surgeon removes the bony plate (lamina) on the back of the vertebra where the stenosis is located. This opens up more space for the spinal nerves. Laminectomy can be performed through a tiny incision and guided by video from a miniature camera.

Sometimes there is so much narrowing that a simple laminectomy won’t do the job. In such cases, a laminectomy with spinal fusion may be needed. In addition to removing one or more bony plates, the surgeon removes discs and other tissues, and then stabilizes the spine with cement or hardware.

Laminectomy alone is usually just as effective as spinal fusion, and so is the preferred option when possible to help relieve lower back pain.