Low Back Pain

Low back pain is second only to the common cold and flu as a common cause of visits to the doctor's office and work absence in people less than 55. It is also a common reason for trips to the emergency room. Most people suffer at least one episode of back pain in their lives. In the vast majority of cases, back pain resolves on its own or with conservative measures, usually in less than two months.

Injuries are a common cause of low back pain. Muscle strains caused by overuse and ligamentous sprains are the most common types of injury and are usually brought on by poor posture and biomechanics.

Herniated disc is another common cause of low back pain and can be caused by trauma or degenerative changes resulting from aging. This can cause back pain with or without associated leg pain, numbness, or weakness.

Another cause is from spinal stenosis. This literally means narrowing of the spinal canal. This may compress the spinal cord centrally or may compress specific exiting spinal nerves. Symptoms include:

Internal disc disruption or discogenic pain syndrome is another condition that can cause back pain. This is usually the result of a structurally incompetent and internally painful intervertebral disc. Pain is predominantly axial in nature and may have a radicular component. The symptoms of internal disc disruption are usually of long-standing, chronic duration and typically worse with activities that increase intradiscal pressure. Such activities include bending, lifting and sitting.

Lumbar spondylosis describes bony overgrowths (osteophytes) and is sometimes referred to as osteoarthritis of the spine and can be a cause of low back pain. This dynamic process increases with age. Symptoms of spondylosis may overlap with other spinal conditions and there is no firm evidence for the presence or absence of an association between X-Ray findings and nonspecific low back pain.

Another type of back injury is attributed to fracture. Spine fractures have many causes such as falls, car accidents and direct blows. Osteoporosis can also cause spine fractures and is commonly referred to as compression fractures.

Scoliosis is another condition that can cause back pain. It is described as a curvature of the spine and will appear to have a "S" shape when viewed from behind. Scoliosis appears in many forms: idiopathic, congenital, degenerative and disease acquired. Idiopathic scoliosis usually affects children and is generally not painful. Congenital scoliosis occurs when the bony aspects of the spine are not properly formed during pregnancy. Adult scoliosis is usually from either undiagnosed idiopathic childhood scoliosis or degenerative scoliosis. Certain disease processes can cause scoliosis. Some of these include: cerebral palsy, muscular dystrophy, spina bifida and spinal muscular atrophy. Typically pain is described as a fatigue type pain that develops after strenuous activity or after a long day.

In addition, the sacroiliac joint has been thought to be a potential cause of low back pain. Sacroiliac joint pain is often described as being similar to that caused by a lumbar disc herniation. Alteration of joint movement, whether secondary to hyper or hypomobility, is thought to be the culprit for pain generation. Pain is typically felt to occur on one side of the low back or buttocks and can radiate down the leg. The pain usually remains above the knee.

Facet-mediated pain or posterior element pain is caused by irritation or inflammation of the facet joints (zygapophyseal joints). There are four facet joints associated with each vertebra. These facet joints interlock with other facets above and below the vertebra, thus forming a joint. Symptoms of facet-mediated pain are often difficult to isolate. Typically, the pain will occur in the low back and have a deep aching quality. The pain may radiate to the buttock and posterior thigh but rarely radiates below the knee. Pain is often exacerbated with lumbar extension, twisting or side-bending.

Spondylolysis/Spondylolisthesis can also be a cause of low back pain. Disruption of the facet or zygaphoseal joints usually caused by a defect in the pars interarticularis (thin part of the lamina located between the superior and inferior articular process). Spondylolysis describes a defect in the pars interarticularis, which usually represents a stress fracture. Spondylolisthesis describes subluxation of one vertebra relative to the vertebrae below and may occur in association with bilateral spondylolysis.

Failed back surgery syndrome refers to a chronic pain condition that involves back or leg pain. It can occur or persist following a technically successful back surgery. Symptoms associated with failed back surgery syndrome are usually one of severe back pain. The pain usually worsens throughout the day. Complications associated with failed back surgery syndrome are epidural fibrosis and adhesions, which damages nerve roots through compression.

How are the various causes of low back pain diagnosed?

A physician investigates the cause of back pain by starting with a thorough medical history and physical examination. The physical examination includes a neurological assessment which comprises of sensation, reflex and strength testing. Range of motion testing and further provocative maneuvers are performed to better explain the pain generator. Diagnostic studies may be performed to determine more precisely the nature and extent of the disorder. These studies may include: X-Ray, CT, MRI, electromyography/nerve conduction studies, and diagnostic lumbar facet joint and medial branch blocks.

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