Definition

Low back pain is an ache or discomfort in the area of the lower part of the back and spinal column. The lower spinal column consists of many small bones that surround and protect the spinal cord and nerves. Low back pain is very common, affecting most adults at some point in their lives.

	Skeleton and Nerves
	© 2008 Nucleus Medical Art, Inc.

Causes

There are many possible causes for low back pain, including:

• Sprain or strain of muscles or ligaments in the area (most common cause of back pain)
• Herniated (ruptured) disc —the cushions between the bones of the spine bulge out of place
• Disc degeneration , caused by aging or arthritis
• Spinal stenosis —narrowing of the spinal canal in the lumbar area
• Spondylolisthesis —slippage of a bone in the lower back
• Fractures due to trauma and/or osteoporosis
• Fibromyalgia —a condition that causes muscle aches and fatigue
• Ankylosing spondylitis —a hereditary disorder involving the spine
• In rare cases:
  • Benign or malignant tumors
  • Infections
  • Arterial problems such as as an aortic aneurysm

Risk Factors

A risk factor is something that increases your chance of getting a disease or condition.

Risk factors include:

• Older age
• Certain actitivies (such as lifting)
• Sedentary lifestyle
• Pregnancy
• Obesity
• Smoking
• Injury
• Preexisting back injury due to:
  • Lifting a heavy object
  • Improper lifting
  • Sudden movement, bending, or twisting
  • Prolonged sitting or standing
  • Bad posture
  • Vibration from vehicles or heavy equipment
• Prior back surgery
• Other factors which may negatively influence back pain include:
  • Psychological factors, such as low job satisfaction
  • Fatigue or sleep deficit
  • Drug or alcohol abuse
  • Stress

Symptoms

Pain is usually localized in the low back. It gets worse with back motion, sitting, standing, bending, and twisting. If a nerve is irritated, the pain may extend into the buttock or leg on the affected side, and muscle weakness or numbness may be present. It usually gets better with rest, and there is good bowel and bladder control.

More serious symptoms associated with back pain that may require immediate medical attention include:

• Pain that is severe or that has gotten dramatically worse
• Progressive weakness in a leg or foot
• Difficulty walking, standing, or moving
• Numbness in the genital or rectal area
• Loss of bowel or bladder control
• Difficulty with urination
• Fever, unexplained weight loss, or other signs of illness
• Pain that awakes you from sleep at night

Pain that doesn't improve or worsens with rest (even at night) may be an indication of a more serious disease.

Diagnosis

The doctor will ask about your symptoms and medical history, and perform a physical exam. In particular, the doctor will examine your back, hips, and legs and usually will test for strength, flexibility, sensation, and reflexes.

Other tests may include:

• X-rays —a test that uses radiation to take a picture of structures inside the body, especially bones. This test is usually done if you are over 50 years old or have persistent symptoms for more than a week. This test has its limitations in that it does not show herniated discs or spinal stenosis.
• CT scan —a type of x-ray that uses a computer to make pictures of structures inside the body. This test provides a good picture of the vertebrae and the spinal canal. This test is done when there are persistent symptoms.
• MRI scan —a test that uses magnetic waves to make pictures of structures inside the body and shows the intervertebral discs and any abnormality of the discs. This test is done when there are persistent symptoms.
• Bone scan —a test to determine mineralization of the bones
• Blood tests—such as complete blood count (CBC) or sedimentation rate
• Urine test—to check for urinary infection or blood in the urine

Treatment

Treatment options include:

Bed Rest

Short-term bed rest is not generally recommended in normal individuals. It is only recommended in those with severe debilitating back pain, and for not more that 1 to 2 days. Movement helps in cases of muscle spasm and to maintain muscle strength.

Medication

• Pain relievers such as acetaminophen (Tylenol), aspirin, or ibuprofen
• Muscle relaxants for muscle spasm—These medications are not used in cases where you need to be alert, such as driving or operating machinery.
• Cortisone injections
• Antidepressants for depression due to chronic pain

Physical Therapy

• Hot or cold packs
• Stretching and strengthening exercises for back and abdominal muscles
• Education about how to deal with back problems
• Massage
• Ultrasound treatments or electrical stimulation

Alternative Medicine

• Activities
  • Restrict activities for 3-6 weeks, then resume activities as soon as possible.
• Relaxation training
• Biofeedback
• Acupuncture
• Chiropractic or osteopathic manipulation
  • This is often beneficial when done by an experienced therapist.

Surgery

Only a small number of patients need surgery. It may be needed if nerve problems develop or other treatments fail to provide relief. Common procedures are discectomy , laminectomy , and spinal fusion .

Prevention

The following steps may help you avoid low back pain:

• Exercise regularly, at least 30 minutes most days of the week. Good choices include walking, swimming, or activities and exercises recommended by your doctor or physical therapist.
• Lose weight if you're overweight.
• Stop smoking.
• Practice good posture to reduce pressure on your spine.
• Avoid sitting or standing in one position for prolonged periods.
• If you must remain standing for long periods, rest one foot at a time on a small stool to relieve pressure on your low back.
• When lifting, hold the object close to your chest, maintain a straight back, and use your leg muscles to slowly rise.
• Avoid aggravating activities, for example bending , twisting, and sudden movements.
• Consider job retraining if your work requires a lot of heavy lifting or sitting.

RESOURCES:

American Academy of Family Physicians
http://www.familydoctor.org

American Academy of Orthopaedic Surgeons
http://www.aaos.org

CANADIAN RESOURCES

Canadian Orthopaedic Association
http://www.coa-aco.org/

Canadian Orthopaedic Foundation
http://www.canorth.org/default.asp

References:

American Academy of Family Physicians. Management of chronic musculoskeletal pain: focus on low back pain. CME videotape monograph; 1999.

American Association of Neurological Surgeons website. Available at: http://www.aans.org/ .

Back pain. Mayo Clinic website. Available at: http://www.mayoclinic.com/health/back-pain/DS00171/DSECTION=3 . Accessed March 4, 2008.

Bratton RL. Assessment and management of acute low back pain. Am Fam Physician . 1999;60:2299-2309.

Hagen KB, Hilde G, Jamtvedt G. Winnem M. Bedrest for acute low back pain and sciatica. Cochrane Database Rev . 2000;CD001254.

Katz, JN. Lumbar disc disorders and low-back pain: socioeconomic factors and consequences. J Bone Joint Surg Am. 2006;88 Suppl 2:21.

Low back pain. The Merck Manual. 17th ed. 1999.

Patel AT, Ogle AA. Diagnosis and management of acute low back pain. Am Fam Physician . 2000;62:2414-2415.

Press release. American Academy of Orthopedic Surgeons. 2006.

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