Low Back Pain
The human spine is comprised of 24 vertebrae separated from each other by discs that serve as shock absorbers and provide flexibility of the spine. In addition, they serve to allow adequate space for spinal nerves to exit, providing sensation and movement to all parts of the body.
The disc is composed of a thick, tough outer annulus fibrosus - constraining ring primarily composed of collagen and a soft inner core known as the nucleus pulposus which consists of a proteoglycan. A tear in the annulus may cause the nucleus to rupture. If the nucleus pours out through the tear in the annulus, the disc is said to be herniated.
Nuclear material, which is displaced into the spinal canal, is associated with a significant inflammatory response. The vertebrae between which the disc lies may press against each other and against the nerves that extend from either side of the vertebra. Compression of a motor nerve results in weakness, and compression of a sensory nerve results in numbness. In this instance, one may experience both back pain from the herniation or tear of the annulus, as well as pain from that part of the body served by the nerve. Radicular pain results from inflammation or compression of the nerve, explaining the lack of correlation between the actual size of a disc herniation with that of clinical symptoms.
What are some symptoms of a herniated disc?
Patients usually feel pain in the lower back and pain or numbness in the legs. The classic presentation of a herniated disc includes the complaint of sciatica (an intractable radiating pain), with associated objective neurological findings of weakness, reflex change or dermatomal numbness.
Spinal stenosis refers to narrowing of the spinal canal. This may cause compression of the spinal cord centrally or to the exiting nerves of the spinal cord laterally. It occurs as a result of degeneration and is often age related. As we age, the bones and ligaments of the spine may thicken and enlarge from arthritis and may contribute to further narrowing of the spinal canal. The intervertebral discs lose fluid and cause reduced height of the disc. As the disc height reduces and the disc hardens, it may bulge into the spinal canal, further narrowing the spinal canal. This degeneration alters the normal biomechanics of the spine and may cause increased stress to the facet joints/posterior elements causing facet arthropathy.
What are some symptoms of spinal stenosis?
The pain caused from spinal stenosis varies depending on the location of the narrowing. Stenosis of the cervical spine may cause neck pain or weakness affecting the upper extremities. Lumbar stenosis may cause low back pain or weakness in the legs and feet. Pain is often located in the buttocks and posterior thigh and is often exacerbated with prolonged walking. This is known as neurogenic claudication and the pain is often relieved with lumbar flexion ("shopping cart sign") and with rest.
Internal Disc Disruption
Internal disc disruption or discogenic pain syndrome is an entity affecting the intervertebral disc. It is caused by fissures in the ring of the disc that distort the internal architecture of the disc, making it structurally incompetent and a source of pain. Patients with internal disc disruption classically complain of low back pain and may have a radiating component with radicular or nerve root type of pain. Unlike disc herniations, this pain is not the result of disc compression affecting the exiting nerve root.
What are some symptoms of internal disc disruption?
The pain caused by internal disc disruption or discogenic pain syndrome is usually one of long-standing and chronic duration. The pain is exacerbated with activities that increase intradiscal pressure. Such activities include sitting, lifting and bending.
How is internal disc disruption diagnosed?
The diagnosis of internal disc disruption is often elusive and can overlap with many other conditions affecting the spine. Therefore, one has to rely on diagnostic testing to arrive at and confirm the diagnosis. A MRI is usually obtained but is non-specific for the diagnosis of internal disc disruption. The gold standard of diagnosis is provocative discography. This test when done properly may show both the structural abnormality of the disc and may demonstrate reproduction of similar pain that is the hallmark of this disorder.
Spondylosis, or disc degeneration, is sometimes referred to as osteoarthritis. It describes bony overgrowths (osteophytes), predominantly along the anterior, lateral, and less commonly the posterior aspects of the superior and inferior margins of the vertebral bodies. This dynamic process increases with, and is perhaps inevitable with age.
What causes spondylosis?
There is no specific cause of spondylosis and this condition appears to be a natural part of the aging process. Prior injuries or surgery to the spine may increase the risk of developing spondylosis.
What are some symptoms of spondylosis?
There are a number of symptoms of spondylosis that may occur with other spinal conditions. The nature of the symptoms varies depending on the location of the spondylosis.
Spondylosis affecting the cervical spine may cause:
Neck pain that may radiate to, or be felt in, the arms or the shoulders
Weakness or loss of sensations in the shoulders, arms and occasionally the legs
Stiffness in the neck that worsens over time
Problems with balance
Reduced or hyper reflexes
Headaches that tend to originate in the back of the head
Bladder and bowel control problems
Spondylosis affecting the lumbar spine is more elusive and is usually asymptomatic, with no diagnostic or prognostic significance. Given the frequency and size of lumbar osteophytes, they have long been thought to cause back pain. This has led to many studies. These studies reveal that there is no greater frequency of signs or symptoms among individuals with osteophytes than among those without osteophytes.
Facet-mediated pain or posterior element pain is caused by irritation or inflammation of the facet joints (zygapophyseal joints). The facet joints are diarthrodial joints with a synovial lining, the surfaces of which are covered with hyaline cartilage, susceptible to arthritic changes and arthropathies. Repetitive stress and osteoarthritic changes to the facet joint can lead to facet overgrowth. Like any synovial joint, degeneration, inflammation, and injury can lead to pain with joint motion, causing restriction of motion secondary to pain, and thus deconditioning. 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.
What are some signs and symptoms of facet-mediated pain?
Facet joint pathology should be suspected if the patient describes nonspecific low back pain with a deep and achy quality, usually localized to one or both sides of the spine. This pain may radiate to the buttock and posterior thigh, but usually not below the knee. The pain is often exacerbated by extension, twisting of the back, stretching and when there is a torsional load. Some patients describe their pain as worse in the morning, aggravated by rest and hyperextension and relieved by repeated motion.
How is facet-mediated pain diagnosed?
Establishing a diagnosis of facet-mediated pain is difficult due to nonspecific findings and poor correlation between the history and physical examination. Obtaining a detailed history and physical examination helps rule out other entities and also assists with guiding the examiner in establishing the diagnosis of facet-mediated pain. The basic history should include a temporal account of the symptoms and a complete description of the complaint, as well as the associated activities that cause or alleviate the pain. The patient should describe the location of pain, whether it is isolated or radiating, and its intensity, character and frequency. The clinician should also obtain a prior treatment history (eg, injections, medications, therapy) and their success.
"Excruciating pain in my back after a fall…" You may suffer from a compression fracture.
A compression fracture is a common fracture of the spine. It implies that the vertebral body has suffered a crush or wedging injury. The vertebral body is the block of bone that makes up the spinal column. Each vertebral body is separated from the other with a disc. When an external force is applied to the spine, such as from a fall or carrying of a sudden heavy weight, the forces may exceed the ability of the bone within the vertebral body to support the load. This may cause the front part of the vertebral body to crush forming a wedge shape. This is known as a compression fracture.
The compression fracture may range from mild to severe in terms of severity. A mild compression fracture causes minimal pain, minimal deformity and is often treated with time and activity modification. A severe compression fracture may be such that the spinal cord or nerve roots are involved, as they are draped over the sudden angulation of the spine. This may cause severe pain, a hunched forward deformity and rarely neurologic deficit from spinal cord compression.
How is it diagnosed?
A compression fracture is usually diagnosed by the history, physical exam, x-rays, CT scan or MRI. MRI scan can also rule out disc herniation and nerve roots involvement along with a compression fracture.
The majority of mild to moderate compression fractures is treated with immobilization in a brace or corset. Bracing helps to reduce acute pain by immobilizing the fracture. It also helps to reduce the eventual loss in height and in angulation from the fracture. Neck compression fractures may be immobilized using a rigid collar and/or a soft collar. Pain medications may help lessen the pain of a compression fracture. Spinal surgery is rarely indicated for patients with compression fractures.
Kyphoplasty or Vertebroplasty are newer minimally invasive procedures performed to stabilize vertebral compression fractures and reduce pain.
Most patients can expect to make a full recovery from their compression fractures. Typically, braces are worn for six to twelve weeks followed by three to six weeks of physical therapy and exercise. This is to help regain strength of the trunk muscles and to increase endurance of the trunk musculature. Overall strength, aerobic capacity and flexibility are also helped by physical therapy. Most patients can return to a normal exercise program six months after suffering their compression fracture. Regular exercise is one of the activities recommended to help prevent compression fractures in the future.
"I have back pain. My spine is curved."
We all have curves in our spines, but scoliosis causes the spine to curve in the wrong direction. It is commonly associated with pain. It causes sideways curves, and those are different from the spine's normal curves. If you were to look at your spine from the side, you would see that it curves out at your neck, in at your mid-back, and out again at your low back. Your back is supposed to have those curves. However, if you look at your spine from behind, you should not see any curves at all. When there are sideways curves in the spine, that is scoliosis. The curves can look like an 'S' or a 'C.'
How is scoliosis diagnosed?
Scoliosis is generally found in children, but adults can have it, too. This typically happens when scoliosis is not detected during childhood or the disease progresses aggressively. The diagnosis of scoliosis is made by a careful physical exam and an x-ray to evaluate the magnitude of the curve.
How is scoliosis treated?
The majority of patients are observed at regular intervals (usually every 4 to 6 months) by a physical exam and a low radiation x-ray. Bracing is the usual treatment choice for adolescents. Those who have or develop significant curves may become candidates for surgery. If scoliosis associated with pain, pain medications and interventional pain procedures (i.e. spine injections) may be very helpful to provide a relief. Scoliosis is nothing to be scared or ashamed of. With the proper treatment, scoliosis does not have to define your life.
Sacroiliac Joint Pain
While still somewhat controversial, it has become increasingly accepted that the sacroiliac joint can be a major focus of back pain. Mechanical dysfunction, inflammation, infection, trauma, and degeneration all have been attributed to the sacroiliac joint. Once diagnosis is established, treatment can be directed to the affected joint, often with satisfying results.
What are some signs and symptoms of sacroiliac joint pain?
The key element in sacroiliac dysfunction diagnosis is pain. Many have attempted to define a typical pain pattern associated with the sacroiliac joint. Patients usually describe as having pain in one or both buttocks at or near the posterior superior iliac spine (PSIS). However, pain radiating to the hip, posterior thigh, or even the calf has been described. Patients often relate that the pain worsens especially when sitting for long periods of time or performing twisting or rotary motions.
Pain quality - Sharp, stabbing, knifelike, dull ache
Pain distribution - Buttock, back of thigh, upper back, unilateral or bilateral
Past history - Important to exclude past history of inflammatory disorders (eg, inflammatory bowel disease, Reiter syndrome). Pain that is worse in the morning (morning stiffness) and resolves with exercise is consistent with inflammatory disease.
Fevers, weight loss, and pain in the night with night sweats must receive proper attention as potential red flags for systemic illness.
Spondylolysis/Spondylolisthesis is caused by a disruption of the facet or zygapophyseal joints and is usually the result of a defect in the pars interarticularis (thin part of the lamina located between the superior and inferior articular process). Spondylolysis therefore represents 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.
What causes spondylolisthesis?
There continues to be debate as to the actual cause of spondylolisthesis. It may be caused by an inherited defect of the pars interarticularis. Some argue that a subset of the population has a predisposition to develop injury at the pars interarticularis from repetitive or significant trauma. Sports specific activities (ex. gymnastics, weight-lifting, rowing, and football) have also been attributed to causing increased stress to the back.
What are the symptoms associated with spondylolysis/spondylolisthesis?
Most children with spondylolysis and some with spondylolisthesis experience no symptoms and may grow unaware that they have the condition. Back pain is the most common presenting symptom. Growth during the adolescent years coupled with injury may lead to slippage. This slippage may cause biomechanical dysfunction and cause poor posture or changes in gait.
Biomechanical (Postural) Pain
Back pain is pervasive throughout the adult population. It is one of the most common reasons to visit a doctor. Back pain usually results from repetitive loading as well as improper mechanics, not to mention older adults are getting weaker and less physically active, leading to inability to handle the load.
Major contributing factors:
Muscle imbalances: too weak in the abdominal area, shoulder blades, and/or lower body
Slumped posture while standing and sitting
Posture changes: arching the back, leaning forward, leaning to one side
These factors may cause improper loading on the spine, which in turn can cause poor alignment of the vertebrae, which negatively impacts the function of the discs as shock absorbers.
Proper exercises and nutrition are key to preventing injuries immediately, as well as later in life. Natural supplements, interventional pain procedures and possible medications can provide symptomatic pain relief and assist in the treatment of pain and in the improvement of well being.
Sciatica refers to pain that radiates along the path of the sciatic nerve, which branches from your lower back through your hips and buttocks and down each leg. Typically, sciatica affects only one side of your body. Sciatica most commonly occurs when a herniated disk or a bone spur on the spine compresses part of the nerve. This causes inflammation, pain and often some numbness in the affected leg. Although the pain associated with sciatica can be severe, most cases resolve with just conservative treatments in a few weeks. People who continue to have severe sciatica after six weeks of treatment might be helped by surgery to relieve the pressure on the nerve.
What are some symptoms of sciatica?
Pain that radiates from your lower (lumbar) spine to your buttock and down the back of your leg is the hallmark of sciatica. You may feel the discomfort almost anywhere along the nerve pathway, but it's especially likely to follow a path from your low back to your buttock and the back of your thigh and calf. The pain can vary widely, from a mild ache to a sharp, burning sensation or excruciating discomfort. Sometimes it may feel like a jolt or electric shock. It may be worse when you cough or sneeze, and prolonged sitting can aggravate symptoms. Usually only one side of your body is affected. Some people also experience numbness, tingling or muscle weakness in the affected leg or foot. You may have pain in one part of your leg and numbness in another.
What causes sciatica?
Sciatica occurs when the sciatic nerve becomes pinched, usually by a herniated disk in your spine or by an overgrowth of bone (bone spur) on your vertebrae. More rarely, the nerve can be compressed by a tumor or damaged by a disease such as diabetes.
Medications The types of drugs that might be prescribed for sciatica pain include:
Once your acute pain improves, your doctor or a physical therapist can design a rehabilitation program to help you prevent recurrent injuries. This typically includes exercises to help correct your posture, strengthen the muscles supporting your back and improve your flexibility.
In some cases, your doctor may recommend injection of a corticosteroid medication into the area around the involved nerve root. Corticosteroids help reduce pain by suppressing inflammation around the irritated nerve. The effects usually wear off in a few months. The number of steroid injections you can receive is limited because the risk of serious side effects increases when the injections occur too frequently.
This option is usually reserved for times when the compressed nerve causes significant weakness, bowel or bladder incontinence or when you have pain that progressively worsens or doesn't improve with other therapies. Surgeons can remove the bone spur or the portion of the herniated disk that's pressing on the pinched nerve.