When to get help for low back pain

Pain from ruptured discs and arthritis doesn't have to flatten you. There are a variety of ways to ease lower back pain discomfort and reduce disability, often without drugs.

Spinal problems are the price we pay for walking upright. Wear and tear on our backbones and the constant pull of gravity on our vertebrae take their toll over time. Nearly every adult has had a stiff or sore back at some time.

Sciatica is a term you've probably heard people use for pain in the lower back, radiating to the buttocks and down one or both legs. "When patients tell me they have sciatica, they could have one of two conditions—a leaking disc or spinal stenosis [narrowing of the spinal canal]," says Dr. Steven Atlas, associate professor of medicine at Harvard Medical School. These conditions in turn can put pressure on the sciatic nerve, which emerges from the lumbar (lower) spine, separates just above the buttocks, and runs down each leg.

Understanding your spine

The spine is a bony column formed by a stack of 24 vertebrae, which are open at the center, creating a channel or canal for the spinal cord. The spaces between the vertebrae are padded by gel-filled, fibrous-ringed discs, which absorb the force we put on the spine. Nerves run from the spinal cord at every vertebral space.

You get lower back pain that radiates into the leg when a disc or bone impinges on a nerve as it exits the spinal cord, most commonly between the 4th and 5th lumbar vertebrae. In people between ages 30 and 60, a ruptured disc is usually responsible; in people over 60, spinal stenosis is more likely to be the cause. In the latter, a reduction in the size of the spinal canal, often due to overgrown bone, puts pressure on the nerves.

Ruptured disc

Damage to discs can be caused by injury or simply by the activities of daily life. If a disc swells or slips out of place, it may press against a nerve. If it ruptures, the leaking gel can inflame the nerves. "Almost everyone has a ruptured disc at some time, but not everyone has symptoms," Dr. Atlas says.

Although the term sciatica is often used to describe the pain, your doctor may call it radicular leg pain—radiating pain due to a compressed nerve. The pain usually comes on suddenly after the disc ruptures. Sitting usually makes the pain worse, while standing and walking may relieve it.

Treatment usually begins with over-the-counter pain medication and exercise. Exercise helps because standing and moving can relieve the pressure on the disc.

Though it may be hard to believe, the pain will go away without medical attention once your body has absorbed the disc material—usually a matter of a few days or weeks. When the episode is over, there is no need for further treatment. "I know people want immediate relief, and I often have to convince them that they don't need surgery," Dr. Atlas says.

But there are rare exceptions, Dr. Atlas says. "If your leg is weak or numb, or if your bowel or bladder function is affected, you should get medical attention immediately to avoid permanent nerve damage," he advises.

Spinal stenosis

This condition becomes increasingly common with age. Over time, the cumulative effects of gravity bring the vertebrae closer together, and the discs also tend to dry out and become thinner. With less cushioning between them, the vertebrae rub against one another, causing arthritis. Arthritic bone deposits can narrow the channels through which nerves pass, putting pressure on them and producing pain.

Pain from spinal stenosis is known as neurogenic claudication (literally "difficulty walking originating in the nerves"). It is more subtle than pain caused by a damaged disc. You might have symptoms in your back, buttocks, or upper thighs, but the pain might not radiate all the way down your leg. The pain is also likely to affect both sides of your body. With spinal stenosis, your upper thighs or legs may hurt when you stand.

Sitting down to take the stress off your lower spine will relieve pain. Bending over slightly can also help by opening the spaces between the vertebrae to reduce pressure on the nerves. If you have braved the pain to get to the grocery store, you may be delighted to find that pushing a shopping cart can provide relief.

Treating spinal stenosis

Unlike disc herniation, spinal stenosis is a chronic condition. It can't be cured, but the pain can be effectively managed with a combination of the following:

• Oral analgesics. Nonsteroidal anti-inflammatory drugs (NSAIDs) like ibuprofen and naproxen (Aleve, Naprosyn) or the non-NSAID painkiller acetaminophen are generally safe to use for occasional flares, but they have side effects. NSAIDs are associated with an increased risk of heart attack and stroke, and acetaminophen with an increased risk of liver damage. Talk to your doctor about the right medication and dose for you.
• Spinal injections. Injections of lidocaine to relieve pain and corticosteroids to reduce inflammation are commonly delivered to the area of the spine where the pain originates. However, controlled clinical trials have cast doubt on steroid use: after six weeks, patients treated with lidocaine alone had as much pain relief and functional improvement—with fewer side effects—as those treated with both drugs. "I usually reserve injections for patients who need immediate relief so they can get to a physical therapist," Dr. Atlas says.
• Physical therapy. Exercise is the best long-term approach to managing spinal stenosis. A physical therapist can teach you the exercises that will strengthen your back muscles to better support your spine and compensate for the pain. Massage and manipulation may not help this kind of problem because it originates in your bones, not in your muscles or tendons. Acupuncture may be helpful, but it has to be repeated.
• Walkers. These devices can enable you to exercise without pain. Bending slightly to grip the handles of a walker can open the spine and relieve pain. "I often suggest that people with spinal stenosis get wheeled walkers with a seat," Dr. Atlas says. "They can go out for a walk, and when their backs or legs begin to ache, they can sit down and get immediate relief."
• Laminectomy. An option when more conservative treatment isn't effective, laminectomy involves removing the bony overgrowth that is impinging on the nerve. It usually requires one to three days of hospitalization, and often you can return to work within a couple of weeks. It may be performed with an open incision or through a tiny incision and guided by video from a miniaturized camera. "I often have a hard time convincing patients to have a laminectomy, and they may live in pain for a year or more before they agree, but they usually have relief," Dr. Atlas says.
• Spinal fusion. A spinal fusion procedure includes a laminectomy to remove pressure on the nerve. In addition, the discs between the affected vertebrae are removed and the spaces filled with a material made of bone dust or another bone-like material. In an instrumented spinal fusion, the vertebrae are held together with metal plates, rods, or screws. Spinal fusion surgery has several drawbacks. The six-week recovery time, during which the spine is immobilized, leads to muscle loss and necessitates physical therapy. The fused area of the spine is no longer mobile, so you can't bend as far as you once could. The rigid spine section also puts more stress on the vertebrae above and below it, setting the stage for future problems. "Most patients with spinal stenosis will do fine with a laminectomy. Spinal fusion can be helpful, but for only a very small percentage of people. I recommend it only for people with degenerative spondylolisthesis—really bad arthritis where vertebrae have slipped out of alignment," Dr. Atlas says.