Back pain has the most far-reaching implications of any physical malady in the human body. Over 85% of the adult population will experience at least one debilitating episode of back pain in their life. It is the third most common reason to visit the doctor (https://www.advisory.com/daily-briefing/2013/01/22/study-ids-the-top-10-reasons-for-doctors-visits). It is difficult to diagnose and expensive to treat. The cost of treating low back pain is staggering, in 2005, the U.S. spent $85.9 billion treating back pain. It affects all areas of life, at home as well as in the work place. It can be mild or severe enough to cause life long disability and inability to work. There is no way to predict who will have chronic back pain problems, although psychosocial risk factors can help predict chronic disabling pain. Fortunately, at least 85-90% of this pain will resolve spontaneously.
Back Pain Divided into 3 Categories:
The diagnosis or cause is the most frustrating and elusive aspect of dealing with this pain. In fact, in about 85% of the cases, no specific cause can be identified. This is partly due to the fact that the location or quality of pain does not give any consistent clues to where the pain is originating. The fact that there are so many cases that don’t have a specific cause led the American College of Physicians and the American Pain Society to place patients into 3 categories: 1) nonspecific low back pain 2) back pain potentially associated with disc herniation and radiculopathy/sciatica or spinal stenosis, or 3) back pain associated with another specific cause (remember that the source of pain may not be from the spine). A good history and physical is necessary to place a patient into one of these categories. The most important and critical finding during the physical exam is a neurological deficit.
Questions about the location, duration, and frequency of pain are all very important to guide the investigation further. Was there a trauma? Did the pain occur in the past? If so, what happened?
Is there a history of cancer or unexplained weight loss? Remember there are problems outside the back that can cause back pain. Pain can radiate to the back from the kidneys, large blood vessels (aortic aneurysm), pancreas or even the intestines (Crohn’s disease).
Is there a history of progressive weakness or loss of bowel or bladder control that suggests a large herniated disc.
Osteoporosis in the elderly may suggest a vertebral compression fracture.
Younger age group patients may give a history of morning stiffness, buttock pain and improvement with exercise consistent with ankylosing spondylitis.
Back and leg pain (sciatica) in a person less than 60 years of age suggest a herniated disc. Back and leg pain in people over 60 years suggests spinal or foraminal stenosis, especially if the back and leg pain are relieved by pushing a grocery cart.
The Mechanism of Injury
Most of the time (>65%) the patient will have no idea what caused the pain.
A traumatic episode is different. There are a lot of moving parts in the back that include joints, discs, nerves, and all the muscles, tendons and ligaments that control the motion of the spine. All of these structures are at risk during a traumatic episode such as a car accident. At the same time, a disc can spontaneously rupture without any warning or obvious cause. The multi-directional forces applied to the back during a car accident can be phenomenal. Torn soft tissues may never really heal properly and can be a chronic source of pain. Sprains refer to injuries of the ligaments and strains refer to injuries of the muscles and tendons. The pain and suffering after an auto accident represents another huge cost to society in terms of treatment and litigation. This problem is magnified by not being able to “measure” pain. If someone says they have pain, there is no objective way to confirm or deny that they do, let alone measure an intensity level.
There are also mechanical factors that simply entrap or impinge sensitive tissues in the back like the annulus surrounding the disc that is loaded with sensory nerves. If there is degenerative disc disease with loss of the disc height, the vertebrae might come too close together and compress the annulus. Another example is bony stenosis or a disc herniation that traps or pinches a nerve or soft tissues.
Most people think that some type of imaging study (X-ray, CT scan, MRI) will help determine the cause of the pain, but there is not much evidence to show imaging is of much value for 1) nonspecific back pain (85%). After all, imaging studies image, they don’t tell you where pain is originating. Imaging might be considered after 1-2 months in this group if pain persists.
The history can guide the imaging study. For example in a person with a history of osteoporosis or steroid use should get a plain x-ray to look for a compression fracture.
If there is a neurologic deficit present or a serious underlying condition is suspected (based on the history and physical), then an MRI or CT of the spine is recommended. This can show spinal stenosis, infection, cancer, a fracture or a large disc herniation.
In our culture, we want answers and relief fast. We want to know the reason for our aches and pains, especially when it comes to the back. The fact is that an accurate diagnosis is difficult to arrive at and that a high percentage of pains will resolve spontaneously within 4-6 weeks of onset. This demand for quick answers and quick relief makes this a very costly problem for society.
Treatment of Back Pain
Treatment options will depend the group number being treated, the personality and demands of the patient. Groups 2) and 3) will likely be referred to a specialist, although a first time episode for a person in group 2) can be treated conservatively for at least a month if there are no neurologic deficits.
Initially, education is the most important part of treatment. In particular, explaining the fact that about 90% of the time, the pain will resolve in 4-6 weeks. This improvement will occur with or without any treatment. Supervised treatment from a chiropractor might speed things up a little bit in the first 4 weeks. Activity is more helpful than bed rest. Self-education books or videos are helpful. Heating pads are a short-term option.
All pain is the result of chemical reactions in the body. The feeling of pain is a result of these chemical reactions involving numerous inflammatory substances. This is one reason that non-steroidal anti-inflammatories and steroids can be helpful.
Other classes of medications can be helpful such as opioids, muscle relaxants, gabapentin and herbal therapies.
A more multidisciplinary approach can be taken between weeks 4-8 that includes formal physical therapy, referral to a specialist and possibly psychological counseling.
The treatment for low back pain ranges from “benign neglect” to exercise and manipulation, to endoscopic spine surgery, and then all the way to fusion surgery. Fusion surgery is based on the idea that a spine that doesn’t move won’t hurt, but the results of this surgery is hardly overwhelming in terms of good to excellent results, with only 60% of patients being satisfied or somewhat satisfied. If fusion surgery fails, there are very few options available.
There are a multitude of causes and treatments of back pain. Experience of the person treating you can make all the difference in your recovery.