Back Pain

What Is It?

Back pain can be a symptom of many different illnesses and conditions. The main cause of the pain can be a problem with the back itself or by a problem in another part of the body. In many cases, doctors can't find a cause for the pain. When a cause is found, common explanations include:

• Stress or injury involving the back muscles, including back sprain or strain; chronic overload of back muscles caused by obesity; and short term overload of back muscles caused by any unusual stress, such as lifting or pregnancy
• Disease or injury involving the back bones (vertebrae), including fracture from an accident or as a result of the bone-thinning disease osteoporosis
• Degenerative arthritis, a "wear and tear" process that may be related to age, injury and genetic predisposition.
• Disease or injury involving the spinal nerves, including nerve injury caused by a protruding disk (a fibrous cushion between vertebrae) or spinal stenosis (a narrowing of the spinal canal

• Kidney stones or a kidney infection (pyelonephritis)

Rarer causes include:

• Inflammatory arthritis, including ankylosing spondylitis and related conditions
• A spinal tumor or a cancer that has spread (metastasized) to the spine from elsewhere in the body
• Infection, which may be in the disk space, bone (osteomyelitis), abdomen, pelvis or bloodstream

Symptoms

Back pain varies widely. Some symptoms (often called "red flag" symptoms) may suggest that the back pain has a more serious cause. These include fever, recent trauma, weight loss, a history of cancer and neurological symptoms, such as numbness, weakness or incontinence (involuntary loss of urine).

Back pain is often accompanied by other symptoms that may help point to its cause. For example:

• Back sprain or strain – Back pain typically begins on the day after heavy exertion or an activity that requires twisting. Muscles in the back, buttocks and thighs are often sore and stiff. The back may have areas that are sore when touched or pressed.
• Fibromyalgia – In addition to back pain, there are usually other areas of pain and stiffness in the trunk, neck, shoulders, knees and elbows. Pain may be either a general soreness or a gnawing ache, and stiffness is often worst in the morning. People usually complain of feeling abnormally tired, especially of waking up tired, and they have specific areas that are painful to touch, called tender points.
• Degenerative arthritis of the spine – Together with back pain, there is stiffness and trouble bending over, which usually develops over many years.
• Inflammatory arthritis, including ankylosing spondylitis and related conditions – In these disorders, there is pain in the lower back, together with morning stiffness in the back, hips or both. There also can be pain and stiffness in the neck or chest or an extremely tired feeling. Other features may include psoriasis, eye pain and redness, or diarrhea, depending on the specific disorder causing back pain. This group of diseases is a relatively rare cause of back pain.
• Osteoporosis – This common condition is characterized by thinned, weakened bones that fracture easily. It is most common in postmenopausal women. When vertebrae become compressed because of fracture, posture may become stooped over or hunched along with back pain. Osteoporosis is not painful unless a bone fractures.
• Cancer in the spinal bones or nearby structures – Back pain is consistent and may become worse when you are lying down. Numbness, weakness or tingling of the legs that continues to get worse. If cancer spreads to spinal nerves that control the bladder and bowel, there may be bowel or bladder incontinence (loss of control).
• Protruding disk – People with significant disk disease sometimes have severe pain in the lower back. If a disk compresses a nerve, the pain may spread down one leg. The pain gets worse during bending or twisting.
• 
  • Spinal stenosis – Pain, numbness and weakness affect the back and legs. Symptoms get worse when you are standing or walking, but are relieved by sitting or leaning forward.
  • Pyelonephritis – People with a kidney infection typically develop sudden, intense pain just beneath the ribs in the back that may travel around the side toward the lower abdomen or sometimes down to the groin. There also can be a high fever, shaking chills and nausea and vomiting. The urine may be cloudy, tinged with blood or unusually strong or foul-smelling. There may be additional bladder related symptoms, such as the need to urinate more often than normal or pain or discomfort during urination.

  • Diagnosis

    Your doctor will ask about your symptoms and your medical history. He or she will examine your back muscles and spine and will move you certain ways to check for pain, muscle tenderness or weakness, stiffness, numbness or abnormal reflexes. For example, if you have a disk problem, you may have pain in your lower back when the doctor raises your straightened leg.
    Your symptoms and the physical examination may give your doctor enough information to diagnose the problem. However, with back pain, your doctor may only be able to tell you that the problem is not serious. If your doctor determines that your back pain is caused by muscle strain, obesity, pregnancy or another cause that is not urgent, you may not need any additional tests. However, if he or she suspects a more serious problem involving your vertebrae or spinal nerves, especially if your back pain has lasted longer than 12 weeks, you may need one or more of the following tests:
    • X-rays of your back
    • Blood test
    • Urine tests
    • Spinal magnetic resonance imaging (MRI)
    • Computed tomography (CT) scan
    • Nerve conduction studies and electromyography to determine whether nerves, muscles or both may be injured
    • Bone scan, especially if you have a previous history of cancer

    Expected Duration

    How long back pain lasts depends on its cause. For example, if your pain is caused by strain from overexertion, symptoms usually subside over days or weeks and you may be able to return gradually to your normal activities. However, you should avoid heavy lifting, prolonged sitting or sudden bending or twisting until your back gets better.
    Women who have back pain caused by the added weight of pregnancy almost always will get better after delivery. People who are obese may need to lose weight before back pain eases.
    People with back pain caused by pyelonephritis often begin to feel better within days after they start taking antibiotics, although they usually need to continue taking antibiotics for up to two weeks.
    People with more serious forms of back pain caused by problems with the vertebrae or spinal nerves may have more persistent back pain that lasts for months and may last for years.

    Prevention

    You can help prevent some forms of back pain by strengthening your back with exercises and by avoiding activities that lead to back injury. Measures that may help prevent back pain include:
  • Maintaining good posture.
  • Sleeping on your side or on your back with a pillow under your knees if you can.
  • Exercising regularly, but stretch before and after.
  • Practicing abdominal crunches to strengthen abdominal muscles, which support your lower back. Also, walk or swim regularly to strengthen your lower back.
  • Always lifting objects from a squatting position, using your hips and your legs to do the heavy work. Avoid lifting, twisting and bending at the same time.
  • Avoiding sitting or standing for extended periods of time.
  • Wearing soft soled shoes with heels that are less than 1 and one-half inches high.
  To help prevent osteoporosis, make sure you get enough calcium and vitamin D daily to meet the dietary requirements for your age group. Follow a routine program of weight-bearing exercise. Avoid smoking and limit the amount of alcohol you drink. If you are a woman who has entered menopause, speak with your doctor about testing for osteoporosis and medications that can help to prevent or reverse it

  Treatment

  Most episodes of back pain are not serious and may be treated with:
  • Limited bed rest (no more than two days)
  • Acetaminophen (Tylenol and others) for pain or oral anti-inflammatory drugs, such as aspirin, ibuprofen (Advil, Motrin and others) or naproxen (Aleve, Naprosyn), for pain and inflammation
  • Muscle relaxants or prescription pain relievers, if necessary, for a short period
  • Hot or cold compresses
  People with back pain are encouraged to return to their normal activities gradually, and to temporarily avoid heavy lifting, prolonged sitting, or sudden bending or twisting.
  If you are recovering from back pain, your doctor may ask you to call or return to his or her office for a follow-up visit in about two weeks to confirm that your symptoms are gone and that you can safely resume all of your normal activities.
  If your back pain is related to more serious disorders of the vertebrae or spinal nerves or if it hasn't improved over a few weeks, you may be referred to a specialist, such as a pain specialist, an orthopedic surgeon (a doctor who specializes in diseases of the bones), a neurologist (a doctor who specializes in diseases of the nerves and brain) or a rheumatologist (an arthritis specialist).

  When To Call a Professional

  Contact your doctor if:
  • Severe back pain makes it impossible for you to do your normal daily activities.
  • Your back pain follows significant trauma.
  • Mild back pain gets worse after a few days or persists more than a week or two.
  • Back pain is accompanied by weight loss, fever, chills or urinary symptoms.
  • You develop sudden weakness, numbness or tingling in a leg.
  • You develop numbness in the groin or rectum or difficulty controlling bladder or bowel function.
  • You have had cancer previously and you develop persistent back pain.

  Prognosis

  More than 90% of people with back pain get better after conservative treatment. Only 5% of people with back pain will have symptoms for more than 12 weeks and for most of these people, the cause is not serious.

  Overview

  Back pain is one of the most common reasons people go to the doctor or miss work, and it is a leading cause of disability worldwide. Most people have back pain at least once.
  Fortunately, you can take measures to prevent or relieve most back pain episodes. If prevention fails, simple home treatment and proper body mechanics often will heal your back within a few weeks and keep it functional. Surgery is rarely needed to treat back pain.

  Symptoms

  Signs and symptoms of back pain can include:
  • Muscle ache
  • Shooting or stabbing pain
  • Pain that radiates down your leg
  • Pain that worsens with bending, lifting, standing or walking
  • Pain that improves with reclining

  When to see a doctor

  Most back pain gradually improves with home treatment and self-care, usually within a few weeks. If yours doesn't improve in that time, see your doctor.
  In rare cases, back pain can signal a serious medical problem. Seek immediate care if your back pain:
  • Causes new bowel or bladder problems
  • Is accompanied by fever
  • Follows a fall, blow to your back or other injury
  Contact a doctor if your back pain:
  • Is severe and doesn't improve with rest
  • Spreads down one or both legs, especially if the pain extends below the knee
  • Causes weakness, numbness or tingling in one or both legs
  • Is accompanied by unexplained weight loss
  • Also, see your doctor if you start having back pain for the first time after age 50, or if you have a history of cancer, osteoporosis, steroid use, or excessive drug or alcohol use.

    Causes

    Back pain that comes on suddenly and lasts no more than six weeks (acute) can be caused by a fall or heavy lifting. Back pain that lasts more than three months (chronic) is less common than acute pain.
    Back pain often develops without a cause that your doctor can identify with a test or an imaging study. Conditions commonly linked to back pain include:
    • Muscle or ligament strain. Repeated heavy lifting or a sudden awkward movement can strain back muscles and spinal ligaments. If you're in poor physical condition, constant strain on your back can cause painful muscle spasms.
    • Bulging or ruptured disks. Disks act as cushions between the bones (vertebrae) in your spine. The soft material inside a disk can bulge or rupture and press on a nerve. However, you can have a bulging or ruptured disk without back pain. Disk disease is often found incidentally when you have spine X-rays for some other reason.
    • Arthritis. Osteoarthritis can affect the lower back. In some cases, arthritis in the spine can lead to a narrowing of the space around the spinal cord, a condition called spinal stenosis.
    • Skeletal irregularities. A condition in which your spine curves to the side (scoliosis) also can lead to back pain, but generally not until middle age.
    • Osteoporosis. Your spine's vertebrae can develop compression fractures if your bones become porous and brittle.

    Risk factors

    Anyone can develop back pain, even children and teens. These factors might put you at greater risk of developing back pain:
  • Age. Back pain is more common as you get older, starting around age 30 or 40.
  • Lack of exercise. Weak, unused muscles in your back and abdomen might lead to back pain.
  • Excess weight. Excess body weight puts extra stress on your back.
  • Diseases. Some types of arthritis and cancer can contribute to back pain.
  • Improper lifting. Using your back instead of your legs can lead to back pain.
  • Psychological conditions. People prone to depression and anxiety appear to have a greater risk of back pain.
  • Smoking. This reduces blood flow to the lower spine, which can keep your body from delivering enough nutrients to the disks in your back. Smoking also slows healing.

  • Prevention

    You might avoid back pain or prevent its recurrence by improving your physical condition and learning and practicing proper body mechanics.
    To keep your back healthy and strong:
    • Exercise. Regular low-impact aerobic activities — those that don't strain or jolt your back — can increase strength and endurance in your back and allow your muscles to function better. Walking and swimming are good choices. Talk with your doctor about which activities you might try.
    • Build muscle strength and flexibility. Abdominal and back muscle exercises, which strengthen your core, help condition these muscles so that they work together like a natural corset for your back. Flexibility in your hips and upper legs aligns your pelvic bones to improve how your back feels. Your doctor or physical therapist can tell you which exercises are right for you.
    • Maintain a healthy weight. Being overweight strains back muscles. If you're overweight, trimming down can prevent back pain.
    • Quit smoking. Talk to your doctor about ways to quit.
    Avoid movements that twist or strain your back. Use your body properly:
    • Stand smart. Don't slouch. Maintain a neutral pelvic position. If you must stand for long periods, place one foot on a low footstool to take some of the load off your lower back. Alternate feet. Good posture can reduce the stress on back muscles.
    • Sit smart. Choose a seat with good lower back support, armrests and a swivel base. Placing a pillow or rolled towel in the small of your back can maintain its normal curve. Keep your knees and hips level. Change your position frequently, at least every half-hour.
    • Lift smart. Avoid heavy lifting, if possible, but if you must lift something heavy, let your legs do the work. Keep your back straight — no twisting — and bend only at the knees. Hold the load close to your body. Find a lifting partner if the object is heavy or awkward.

    Buyer beware

    Because back pain is so common, numerous products promise prevention or relief. But there's no definitive evidence that special shoes, shoe inserts, back supports, specially designed furniture or stress management programs can help.
    In addition, there doesn't appear to be one type of mattress that's best for people with back pain. It's probably a matter of what feels most comfortable to you.

    Diagnosis

    Your doctor will examine your back and assess your ability to sit, stand, walk and lift your legs. Your doctor might also ask you to rate your pain on a scale of zero to 10 and talk to you about how well you're functioning with your pain.
    These assessments help determine where the pain comes from, how much you can move before pain forces you to stop and whether you have muscle spasms. They can also help rule out more-serious causes of back pain.
    If there is reason to suspect that a specific condition is causing your back pain, your doctor might order one or more tests:
    • X-ray. These images show the alignment of your bones and whether you have arthritis or broken bones. These images alone won't show problems with your spinal cord, muscles, nerves or disks.
    • MRI or CT scans. These scans generate images that can reveal herniated disks or problems with bones, muscles, tissue, tendons, nerves, ligaments and blood vessels.
    • Blood tests. These can help determine whether you have an infection or other condition that might be causing your pain.
    • Bone scan. In rare cases, your doctor might use a bone scan to look for bone tumors or compression fractures caused by osteoporosis.
    • Nerve studies. Electromyography (EMG) measures the electrical impulses produced by the nerves and the responses of your muscles. This test can confirm nerve compression caused by herniated disks or narrowing of your spinal canal (spinal stenosis).

    Treatment

    Most acute back pain gets better with a few weeks of home treatment. However, everyone is different, and back pain is a complex condition. For many, the pain doesn't go away for a long period, but only a few have persistent, severe pain.

    For acute back pain, over-the-counter pain relievers and the use of heat might be all you need. Bed rest isn't recommended.

    Continue your activities as much as you can tolerate. Try light activity, such as walking and activities of daily living. Stop activity that increases pain, but don't avoid activity out of fear of pain. If home treatments aren't working after several weeks, your doctor might suggest stronger medications or other therapies.

    Medications

    Depending on the type of back pain you have, your doctor might recommend the following:

    • Over-the-counter (OTC) pain relievers. Nonsteroidal anti-inflammatory drugs (NSAIDs), such as ibuprofen (Advil, Motrin IB, others) or naproxen sodium (Aleve), might relieve acute back pain. Take these medications only as directed by your doctor. Overuse can cause serious side effects. If OTC pain relievers don't relieve your pain, your doctor might suggest prescription NSAIDs.
    • Muscle relaxants. If mild to moderate back pain doesn't improve with OTC pain relievers, your doctor might also prescribe a muscle relaxant. Muscle relaxants can make you dizzy and sleepy.
    • Topical pain relievers. These are creams, salves or ointments you rub into your skin at the site of your pain.
    • Narcotics. Drugs containing opioids, such as oxycodone or hydrocodone, may be used for a short time with close supervision by your doctor. Opioids don't work well for chronic pain, so your prescription will usually provide less than a week's worth of pills.
    • Antidepressants. Low doses of certain types of antidepressants — particularly tricyclic antidepressants, such as amitriptyline — have been shown to relieve some types of chronic back pain independent of their effect on depression.
    • Injections. If other measures don't relieve your pain, and if your pain radiates down your leg, your doctor may inject cortisone — an anti-inflammatory medication — or numbing medication into the space around your spinal cord (epidural space). A cortisone injection helps decrease inflammation around the nerve roots, but the pain relief usually lasts less than a few months.

    Prevention

    Education

    There's no commonly accepted program to teach people with back pain how to manage the condition effectively. So education might involve a class, a talk with your doctor, written material or a video. Education emphasizes the importance of staying active, reducing stress and worry, and learning ways to avoid future injury.

    Physical therapy and exercise

    A physical therapist can apply a variety of treatments, such as heat, ultrasound, electrical stimulation and muscle-release techniques, to your back muscles and soft tissues to reduce pain.

    As pain improves, the therapist can teach you exercises to increase your flexibility, strengthen your back and abdominal muscles, and improve your posture. Regular use of these techniques can help keep pain from returning.

    Treatment

    Surgery

    Few people need surgery for back pain. If you have unrelenting pain associated with radiating leg pain or progressive muscle weakness caused by nerve compression, you might benefit from surgery. Otherwise, surgery usually is reserved for pain related to structural problems, such as narrowing of the spine (spinal stenosis) or a herniated disk, that hasn't responded to other therapy.