Back Pain (15)
(ĐTĐ) - Neck pain is an extremely common complaint; some of it is caused by the standard wear-and-tear of aging, but many people can actually prevent it from occurring by making a few simple changes.
(ĐTĐ) - The word “spondylosis” means a stiffening or fixation of the vertebrae in the back and neck due to a disease process. Spondylosis is the degenerative changes such as degenerating discs and bone spurs. Quite often, these changes are called osteoarthritis. Spondylosis can occur anywhere on the spine: cervical (neck), thoracic (upper/mid back), and lumbar (low back). However, the most common is cervical and lumbar.
(ĐTĐ) - Although medical terms that might confuse many people, cervical spondylosis and radiculopathy have a common link with one another. Understanding one (cervical spondylosis) is needed to understand how the other (radiculopathy) works within contexts involving the former. That’s mainly because cervical spondylosis often plays a role in causing radiculopathy in people. In this article, let’s take a closer look at the relationship between cervical spondylosis and radiculopathy.
Understanding cervical spondylosis
Spondylosis is a generalized term referring to the gradual degradation of the spine as a person gets older. It typically starts affecting people sometime after age 30. Cervical spondylosis refers to a specific type of gradual degradation within the spine, namely the degradation of the vertebrae and small tissues of the spine’s cervical portion, otherwise known as the neck.
As people get older, they start losing both elasticity and moisture within the soft tissues of their back, including their ligaments, tendons and the gel-filled cartilage discs that act as cushions in between vertebrae. When the discs start drying out, they start becoming fragile, and cracks and fissures start forming within the drying cartilage. Once these discs start becoming damaged enough, conditions like disc herniation and degenerative disc disease may start developing.
Spondylosis, in general, also causes the cartilage around the spinal joints to eventually wear away. That cartilage plays a role in preventing the bones of each joint from rubbing against each other. When that protective layer wears away, the bones start sustaining damage from grinding against each other. If it persists, the bones might start developing bone spurs (osteophytes) or abnormal bone protrusions.
Understanding cervical spondylosis and radiculopathy
How does cervical spondylosis relate to radiculopathy? First, let’s look at what radiculopathy is. Radiculopathy is a medical term describing pain and other symptoms associated with a compressed nerve root. Sciatica is a common form of radiculopathy that affects the legs and lower back. That condition is caused by the compression of the nerve roots linked to the sciatic nerve within the lumbar spine, otherwise known as the lower back.
When the cervical spine starts degenerating, it may cause nerve root compression, too. Fluid from prolapsed discs or even spinal stenosis (the narrowing of the spine) may cause some form of radiculopathy. Bone spurs also cause compressed nerves, since they put pressure on nerves where the bones start to protrude and subsequently pinch nerves.
People who have developed radiculopathy from cervical spondylosis experience pain and stiffness within their necks, in addition to numbness and/or tingling within their shoulders and arms. Some also experience pain within their arms, chests and shoulders. The relationship of cervical spondylosis and radiculopathy has everything to do with compressed nerves. That’s why when cervical spondylosis is mentioned in some context, radiculopathy usually is a common symptom stemming from the aforementioned condition.
The symptoms of cervical spondylosis and radiculopathy
As we described in the previous section, both cervical spondylosis and radiculopathy have symptoms that best characterize each condition. In most cases, people with cervical spondylosis exhibit symptoms relating to radiculopathy.
Symptoms from cervical spondylosis typically start with sharp pain traveling down the arm, usually in the area of where the originating nerve resides. Some people feel a distinct ‘pins and needles’ sensation or, in uncommon cases, complete numbness. Some people feel weak when they perform certain activities, which is a direct result of the nerve issues caused by cervical spondylosis and radiculopathy
The symptoms may even worsen over time, especially due to certain movements. Movements like extending or straining the neck or even turning the head can worsen the condition.
Of course, the aforementioned symptoms aren’t the only symptoms associated with cervical spondylosis and, to a lesser extent, radiculopathy. Here’s an overview of cervical spondylosis symptoms:
- Pain in the neck that spreads to the shoulders or base of the skull.
- Pain in the neck that eventually spreads down to the arm, hand and/or fingers.
- Pain that tends to flare up on occasion, particularly when using a body part affected by the pain.
- Neck stiffness, sometimes after sleeping.
- Headaches that start from the back of the head (from above the neck) and travel over to the top of the forehead.
- A ‘pins and needles’ sensation in part of the arm or hand, typically originating from radiculopathy.
- Rarely, clumsiness in the hand, problems with walking and/or problems with bladder function.
Some people have their symptoms go away after a few days or a few weeks, though most people take much longer to relieve themselves of their symptoms originating from the condition. Though, it’s not uncommon for either condition to come back after a while. When that happens, people typically need a full medical examination and persistent treatment to subside the symptoms of the condition.
People with cervical spondylosis and radiculopathy are advised to talk to their doctor about their experience with one or both conditions. In most cases, doctors use symptoms from cervical spondylosis and radiculopathy to understand how to diagnose either condition and find solutions for treating them.
Treatment options for cervical spondylosis and radiculopathy
Speaking of treatment, people with cervical spondylosis or radiculopathy have the option of treatment to relieve mild or severe symptoms. Let’s take a look at the forms of treatment available.
Treatment for both cervical spondylosis and radiculopathy typically starts with non-surgical options. This is usually the best course of treatment for people with milder symptoms from either condition.
Soft collars help the muscles of the neck relax and limit the neck’s natural motions, while also decreasing the likelihood of the nerve roots pinching with each movement. They’re typically worn for a short amount of time to prevent the neck muscles form losing strength. Physical therapy also works, as it helps with stretching and strengthening the neck muscles.
Medications are a common form of non-surgical treatment. Non-steroidal anti-inflammatory medications, such as ibuprofen and aspirin are incredibly common for reducing pain from nerve swelling.
Narcotics help treat severe pain, though are prescribed for a limited time due to their addictive nature. Spinal injections of steroids, typically near the pinched nerve, provide near immediate relief for people with nerve pain and swelling.
In rare cases, surgical treatment may be needed to completely relieve symptoms from cervical spondylosis and radiculopathy. This usually involves removing certain parts of the damaged spinal cord or nerve roots (such as herniated discs or bone spurs) to make more room for them.
(ĐTĐ) - The vertebrae of your spinal column are separated by cushiony disks, which absorb shock and allow for movement and flexibility in the spine. Sometimes these disks rupture or slip and bulge out where they shouldn’t, which is known as a slipped, ruptured, or herniated disk; when it occurs in the vertebrae of the neck, it’s called cervical disk herniation.
When a disk bursts or otherwise moves out of place, it can cause pain and other complications, and not only in the neck. Typical symptoms include pain, numbness, and a tingling sensation in the neck, shoulders, and arms, although in some cases, these may be felt in other parts of the body as well. If a particularly large disk has herniated, for example, the effects may be felt in the legs. There may be muscle weakness, usually in the arms or legs, which can affect how well you grip things or raise your arm or leg. Basically, the area of the body that is connected to the nerves around the slipped disk may experience some of the same effects as the neck itself.
The pain often comes on gradually and worsens over time. You may also notice an increase or a shooting pain after sudden movements like a cough or sneeze, or after you spend time in a certain position – sitting or standing for long periods, or just a particular posture.
Herniated disks can occur for a number of reasons. Usually, it’s just the result of wear and tear as we age, where the disks lose moisture and elasticity, making them more susceptible to damage from sudden twists. Heavy lifting is another leading cause: the advice to lift with your legs, not with your back exists for good reason. Twisting while lifting can also cause herniation. People whose jobs require frequent heavy lifting are more prone to herniated disks, as are people who are overweight, which strains the back.
To diagnose, a doctor will examine you for signs of muscle weakness, numbness, difficulty balancing, and diminished reflexes, and ask about any tingling. Other tests such as x-ray or MRI may also be performed. Ample rest is the foremost treatment, with medicine to reduce pain and inflammation; physical therapy or certain stretches may also be recommended, and posture modifications if necessary. In the rare cases involving loss of bladder function and severe pain, surgery may be required.
(ĐTĐ) - Sciatica can be a difficult condition to pin down, and confusing the issue there is also a condition that is commonly called “pseudo-sciatica.” The condition is called piriformis Syndrome. It has different causes from sciatica, but it mimics the symptoms so it won’t be a surprise if you and your doctor believe that it’s sciatica.
Sciatica is caused by the compression of the sciatic nerve by a slipped or herniated disc. This nerve runs from the lower back, through the buttocks and all the way down to the feet and toes. This means that you will experience pain throughout your lower body from this condition.
Piriformis syndrome is uncommon, but causes the same kind of compression. The piriformis is a flat muscle just above the buttocks. This muscle spasms and pinches the sciatic nerve, causing the same sort of pain as sciatica. However, it only seems to be sciatica. Sciatica is generally caused by compression caused by the discs in the back, so when the piriformis muscle is the culprit, it may cause some confusion.
Despite the name, there is nothing imaginary about “pseudo” sciatica. The sciatic nerve is being pinched and compressed in the same manner, just from a different cause. The pain is just as real and the “pseudo” in the name just refers to the fact that the syndrome falsely appears like sciatica.
Despite how similar the syndrome is to sciatica, there are two simple physical manoeuvres that can be used to distinguish between the two. This, of course, depends on a patient only having one or another of the conditions. If you have both conditions at the same time, these will not work. The first position is done this way: from a seated position, straighten the leg in which you are having pain, so that your leg is parallel with the floor. If the symptoms increase, there is a good chance that what you have is true sciatica.
The second position is achieved in two steps. Again, take a sitting position. Then, in the leg in which you have pain, bring the knee up to the shoulder on the same side. While this may sound painful, it generally isn’t except in the most severe cases. Once you have done this, move your knee over toward the opposite shoulder. If there is an increase in pain, there is a good chance that you are suffering with piriformis syndrome.
As the name implies, the symptoms are very similar to regular sciatica. The major symptom is pain and burning down the length of the nerve, from the buttocks to the feet. It usually affects only one side of the body, and can be more intense when you are sitting, or after sitting for a long time.
The main difference between regular sciatica and piriformis syndrome is that it often causes more intense pain in the hip, to the point where it can actually cause the patient to limp or have other difficulty walking. Conversely, people with pseudo-sciatica generally don’t have pain in the thigh. Unfortunately, these differences can appear very slight and may not be enough to give doctors a clue what is causing the pain.
Pseudo sciatica can be caused by poor posture or exercise related injury. This is very unlike the causes of regular sciatica, which are often being overweight or not being active enough. Regular sciatica is also often a side-effect of pregnancy.
Pseudo sciatica can also be caused by sitting too long at a computer with your head protruding to look at the screen. It can also be caused by muscular overuse, as in when a parent repeatedly lifts a child into a car seat in the rear of a car. Men can also develop this syndrome by sitting to long on a hard seat with a wallet in the back pocket.
The options for treatment of the syndrome will generally be very similar to the options available for regular sciatica. These include painkillers, anti-inflammatory medicines and physiotherapy. There are exercises you can do to help relieve pain and lessen the nerve compression that you piriformis muscle is causing.
Leg and Knee Stretch
One of the simplest and easiest ways to relieve pain is through a very basic leg stretch. Lie down on the floor with your legs straight. Then bring one knee up to your chest and hug it to you. Then slowly move it toward your opposite shoulder, so that your leg is stretched across your body diagonally. You should be feeling a stretch in your hip and buttock. Hold the stretch for a few seconds, then release it and repeat the stretch on the other side. Lie on the floor with your legs straight. Bend one knee into your chest, hugging it with your arms. Slowly bring the knee up towards your opposite shoulder, stretching it across your body. You should feel a decent stretch through your hip and buttock area. Hold the stretch for several breaths, then release and repeat on the opposite side.
A yoga pose called Parivrtta Trikonasana, also known as the revolved triangle pose, is able to stretch the piriformis muscle. This is a little more intense than a leg stretch and it will be important to consult with your doctor before you attempt it. However, once you have gotten the go-ahead, you’re ready to work on your yoga.
To perform this pose, come into a push-up position with your arms straight. Lift your buttocks towards the ceiling, coming into an inverted “V” shape pose. Step your right foot up between your hands. Keeping your left hand on the ground, revolve your chest towards the ceiling, bringing your arm straight up over your head so that it is pointing toward the ceiling. Don’t support your body with your left arm, rather support it with the muscles in your back. This position is meant to stretch your back and buttocks, so it’s important that you are using those muscles. Hold the pose for 30 seconds, then return to downward-facing dog pose and repeat on the opposite leg.
As with any condition, it is important to know what the root cause of your pain is. Treatment for regular sciatica is not going to be useless, but obviously it will be more effective if you and your doctor understand what you have before you begin with treatment measures.
(ĐTĐ) - Stress has become an unfortunately commonplace part of life for many people, so much so that we forget how damaging it can be on the body. Aside from the emotional and mental toll it takes, stress can have negative physical effects as well, from fatigue to bodily pain. Neck pain is one of those physical symptoms of stress.
Stress is part of our ingrained fight-or-flight response, flooding our system with adrenaline and causing our muscles to tense in preparation; this stimulates nerves and diverts blood flow away from muscles, which causes stiffness and pain. With prolonged stress, this leads to sore, tight muscles and – in one of the body’s more vicious cycles – the pain causes muscles to tense further.
The neck is a one of the most common places for painful muscular tension as a result of stress. This is not only because the neck is one of the first places to tense up in response to stress, but also because stress exacerbates underlying neck problems, which many people have to begin with. Poor or improper posture is extremely common, especially between constant computer use and propping up phones between neck and shoulder, so in many cases the potential for neck pain is already in place when stress sets in.
Reducing your stress levels and learning to manage it is essential to treating and preventing neck pain. Being aware of stress and its potential triggers is step one; it may seem self-explanatory, but sometimes we just don’t notice it, or we decide to just push through. If you notice stress or tension building, stop, take a few deep breaths, and take a moment to stretch lightly or do some neck rolls. Make sure you’re maintaining a healthy diet and get some exercise, which is helpful for not only reducing stress but soothing muscle pain as well, because it gets blood flowing – and as we know, lack of blood flow to muscles causes pain.
While you’re working on your stress levels, check on postural triggers. Sit upright in your chair with your head directly above your neck, directly above your shoulders. Take frequent breaks, and adjust your car seat so that you can comfortably reach the wheel rather than leaning forward or extending your arms too far. And don’t forget, there’s always massage – you might have to treat yourself!
(ĐTĐ) - Lower back pain is the leading cause of disability worldwide, according to a large new study published in the Annals of the Rheumatic Diseases.
Researchers in the U.K., Australia and the U.S. studied data from the Global Burden of Disease study, which assessed the health of people in 187 countries. They found that almost one out of ten people (9.4%) suffers from lower back pain – a number likely to rise as the population ages.
Back Pain“Governments, health service and research providers and donors need to pay far greater attention to the burden that low back pain causes,” wrote lead author Dr. Tony Woolf from the Royal Cornwall Hospital in the UK.
“With aging populations throughout the world, but especially in low and middle income countries, the number of people living with low back pain will increase substantially over coming decades.”
Lower back pain was most common in Western Europe, where 15% of the population suffers from it; followed by North Africa and the Middle East. It was least common in the Caribbean and Latin America.
Lower back pain is not usually linked to any serious disease. It can be triggered by any number of everyday activities, including bad posture, bending awkwardly, lifting incorrectly or standing for long periods of time.
“Many people develop back pain for no obvious reasons, and research suggests that it’s impossible to identify a specific cause of pain for around 85 per cent of people in the early stages,” a spokeswoman for Arthritis Research UK told the Daily Express.
“Treatment such as physiotherapy, pain relief and exercise to keep the muscles supporting the spine strong can all help.”
Men (10.1%) are more likely to suffer from lower back pain than women (8.7%).
The study was funded by the Bill and Melinda Gates Foundation, the Australian Commonwealth Department of Health and Ageing, the Australian National Health and Medical Research Council, and the Ageing and Alzheimer’s Research Foundation.
(ĐTĐ) - Perhaps you bent the wrong way while lifting something heavy. Or you're dealing with a degenerative condition like arthritis. Whatever the cause, once you have low back pain, it can be hard to shake. About one in four Americans say they've had a recent bout of low back pain. And almost everyone can expect to experience back pain at some point in their lives.
Sometimes it’s clearly serious: You were injured, or you feel numbness, weakness, or tingling in the legs. Call the doctor, of course. But for routine and mild low back pain, here are a few simple tips to try at home.
Chill it. Ice is best in the first 24 to 48 hours after an injury because it reduces inflammation, says E. Anne Reicherter, PhD, PT, DPT, associate professor of Physical Therapy at the University of Maryland School of Medicine. "Even though the warmth feels good because it helps cover up the pain and it does help relax the muscles, the heat actually inflames the inflammatory processes," she says. After 48 hours, you can switch to heat if you prefer. Whether you use heat or ice -- take it off after about 20 minutes to give your skin a rest. If pain persists, talk with a doctor.
Keep moving. "Our spines are like the rest of our body -- they're meant to move," says Reicherter. Keep doing your daily activities. Make the beds, go to work, walk the dog. Once you're feeling better, regular aerobic exercises like swimming, bicycling, and walking can keep you -- and your back -- more mobile. Just don't overdo it. There's no need to run a marathon when your back is sore.
Stay strong. Once your low back pain has receded, you can help avert future episodes of back pain by working the muscles that support your lower back, including the back extensor muscles. "They help you maintain the proper posture and alignment of your spine," Reicherter says. Having strong hip, pelvic, and abdominal muscles also gives you more back support. Avoid abdominal crunches, because they can actually put more strain on your back.
Stretch. Don't sit slumped in your desk chair all day. Get up every 20 minutes or so and stretch the other way. "Because most of us spend a lot of time bending forward in our jobs, it's important to stand up and stretch backward throughout the day," Reicherter says. Don't forget to also stretch your legs. Some people find relief from their back pain by doing a regular stretching routine, like yoga.
Think ergonomically. Design your workspace so you don't have to hunch forward to see your computer monitor or reach way out for your mouse. Use a desk chair that supports your lower back and allows you to keep your feet planted firmly on the floor.
Watch your posture. Slumping makes it harder for your back to support your weight. Be especially careful of your posture when lifting heavy objects. Never bend over from the waist. Instead, bend and straighten from the knees.
Wear low heels. Exchange your four-inch pumps for flats or low heels (less than 1 inch). High heels create a more unstable posture, and increase pressure on your lower spine. According to research, nearly 60% of women who consistently wear high-heeled shoes complain of low back pain.
Kick the habit. Smoking can increase your risk for osteoporosis of the spine and other bone problems. Osteoporosis can lead to compression fractures of the spine. One study found that smokers are about a third more likely to have low back pain compared with nonsmokers.
Watch your weight. Use diet and exercise to keep your weight within a healthy range for your height. Being overweight puts excess stress on your spine.
Try an over-the-counter pain reliever. Anti-inflammatory drugs such as aspirin, ibuprofen (Advil, Motrin, Nuprin), and naproxen sodium (Aleve, Anaprox, Naprosyn) can help reduce back pain. Acetaminophen (Actamin, Panadol, Tylenol) is another over-the-counter option for pain management. Be sure to check with your doctor or pharmacist about any interactions over-the-counter pain relievers may have with other medications you are taking. People with a history of certain medical conditions (such as ulcers, kidney disease, and liver disease) should avoid some medicines.
Call your doctor if:
- Your low back pain doesn't go away after a few days, and it hurts even when you're at rest or lying down.
- You have weakness or numbness in your legs, or you have trouble standing or walking
- You lose control over your bowels or bladder
- These could be signs that you have a nerve problem or another underlying medical condition that needs to be treated.
Reviewed By Louise Chang, MD - Source WebMD.com
A thorough history and physical examination is paramount to arrive at a diagnosis, and initially imaging is often unnecessary.
- Patients most often complain of pain in the lumbosacral area.
- Determine whether pain is exacerbated by movement or by prolonged sitting or standing.
- Determine the duration of pain.
- Determine if pain is relieved by lying down.
- Establish if pain was sudden in onset or gradual over days or months.
- Determine if pain is worse in the morning or at night.
- Find out if the patient can identify a precipitating event such as lifting or moving furniture.
- Explore the presence of systemic symptoms such as fever, weight loss, dysuria, cough, and bowel or bladder problems.
- Inquire about current medications that may produce symptomatology.
- Chronic steroids may predispose to infection or compression fractures.
- Anticoagulants may result in a bleed or hematoma.
- Any history of new-onset bowel or bladder dysfunction (eg, urinary hesitancy, overflow incontinence) with back pain is suggestive of cauda equina syndrome. This is particularly true if other, new neurologic deficits are also present.
- Physical examination of a patient with back pain should include range of motion and a thorough neurologic examination, including assessment of peripheral motor function, sensation, and deep tendon reflexes.
- Perform straight leg testing with the patient in a supine position. Record response to raising each leg. An approximation of the test may also be performed with the patient sitting and each leg straightened at the knee. An elevation of the leg to less than 60° is abnormal. The straight leg test result is positive only if the pain radiates to below the knee and not merely in the back or the hamstrings. This is the single best test for determining radiculopathy due to disc herniation with a high sensitivity and moderate specificity.
- Perform an abdominal examination to exclude intra-abdominal pathology.
- Perform a rectal examination on men older than 50 years to assess prostate size and exclude prostatitis. Also perform a rectal examination on any patient who may have cauda equina syndrome to assess rectal tone and perineal sensation. If cauda equina syndrome is suspected, urinary catheterization for a postvoid residual or bedside ultrasonography of the bladder may be helpful to assess for urinary retention.
- Perform a rectal examination, if necessary, in younger males who are febrile and have urinary complaints.
- Perform a pelvic examination, if necessary, in females complaining of menstrual abnormalities or vaginal discharge.
- Patients with true herniated discs may not present with any findings other than a positive straight leg raising test. Classic presentation includes numbness in a dermatomal distribution corresponding to the level of disc involved, with findings of motor weakness and reflex loss as described below. Herniated discs have different presentations depending on the location as follows:
- At L4: Pain along the front of the leg; weak extension of the leg at the knee; sensory loss about the knee; loss of knee-jerk reflex
- At L5: Pain along the side of the leg; weak dorsiflexion of the foot; sensory loss in the web of the big toe; no reflexes lost
- At S1: Pain along the back of the leg; weak plantar flexion of the foot; sensory loss along the back of the calf and the lateral aspect of the foot; loss of ankle jerk
- L5 and S1: These nerve roots are involved in approximately 95% of all disc herniations.
- Spinal stenosis may be present when evidence of degenerative joint disease is present on radiographic studies.
- Patients with this disease process often complain of progressive pain down the lateral aspect of the leg during ambulation (pseudoclaudication). This pain results from neurologic compression rather than actual arterial insufficiency, which produces true claudication. In cases of spinal stenosis, the straight leg test result is often negative.
- The stoop test helps distinguish true claudication from pseudoclaudication. Patients with true claudication sit down to rest when pain occurs, while patients with pseudoclaudication attempt to keep walking by stooping or flexing the spine to relieve the stretch on the sciatic nerve.
- Sacroiliitis usually presents with pain over the involved joints and no peripheral neurologic findings.
- Osteomyelitis may be subacute or acute.
- Clinical findings are nonspecific, and the patient may be afebrile on presentation.
- Classic presentation includes pain on palpation of the vertebral body, elevated sedimentation rate, and complaints of pain out of proportion to physical findings.
- Patients particularly at risk for development of osteomyelitis include patients who have undergone recent back surgery, intravenous (IV) drug users, patients with immunosuppression, and those with a history of chronic pelvic inflammatory disease (PID).
Please refer to Pathophysiology, which describes specific causes of back pain in detail. Certain clinical clues can help differentiate between causes. Generally, impingement syndromes produce positive straight leg raising tests, whereas pure irritation does not. To assess for a functional disorder as the cause of low back pain, consider the following:
- Mechanical low back pain is a common complaint in patients with functional disorders. In addition, a functional overlay or component of secondary gain may be present in some patients with true organic pathology. The degree of psychosocial issues affecting the patient's condition may be assessed by the following:
- Patient may receive compensation for injury.
- Patient has pending litigation.
- Patient dislikes job.
- Patient has symptoms of depression.
- Patient caused the accident resulting in back pain.
- Physical clues that help identify patients with significant functional overlay or component of secondary gain include the following:
- Findings of nonanatomic motor or sensory loss
- Nonspecific tenderness or generalized tenderness over the entire back
- Overly dramatic behavior and loss of positive straight leg raising test when patient is distracted
- A particularly useful test is to have patients hold their wrists next to their hips and turn their body from side to side. This test gives the illusion that you are testing spinal rotation, but no actual stress is placed on any muscles or ligaments. Any complaint of pain during this maneuver is strongly suggestive of a functional overlay or component of secondary gain in the presentation.
- Consider performing urinalysis if the problem is not clearly musculoskeletal or an exacerbation of chronic back pain.
- Perform a complete blood count (CBC) and erythrocyte sedimentation rate (ESR) if the patient is febrile or if an epidural or spinal abscess, or osteomyelitis is suspected. While ESR has moderate specificity, the sensitivity is relatively high in cases of abscess, and it can be used as a screening test.
- Other laboratory studies are rarely needed unless a disorder other than back pain is strongly suspected.
- Lumbosacral spine series are expensive and expose the reproductive organs to significant radiation. Annually, 7-8 million such tests are obtained, but most have little value in directing therapy, particularly among adults younger than 50 years.
- Osteophytes are the most frequently seen abnormality of plain films followed by intervertebral disc space narrowing. Both increase with age. Disc space narrowing appears to be more frequent in women. Disc space narrowing at 2 or more levels is strongly associated with back pain pathology.
- Unless a history of traumatic injury or systemic illness is present, such films should be obtained only for suspicion of malignancy or infection. Malignant involvement of vertebral bodies can be evident on plain film when as little as 30% of the vertebral body has been replaced.
- Other indications that suggest the need for radiographic imaging include chronic steroid use and acute onset of pain in patients older than 50 years or in the pediatric age group.
- The physician may also consider obtaining radiographs in patients whose cases involve (or potentially involve) litigation or for patients seeking compensation.
- CT and MRI
- CT and MRI are generally considered the studies of choice for more precise imaging of the vertebrae, paraspinal soft tissues, discs, or spinal cord. CT images cortical bone with higher resolution and can delineate some fractures better than MRI.
- MRI is generally the preferred imaging modality for detecting disc, cord, or soft tissue abnormalities.
- Ultrasonography may be useful if the differential diagnosis includes appendicitis, a pathologic pelvic process, or abdominal aneurysm.
- True emergencies that necessitate imaging include the following:
- Patients with a history of malignancy and new evidence of nerve entrapment
- Patients with back pain associated with paralysis or gross muscle weakness
- Patients with bilateral neurologic deficits associated with bowel or bladder function loss
- Patients in whom an epidural hematoma or epidural abscess is suspected
- Postoperative patients with a recent lumbar laminectomy or hip replacement
Improvement occurs in almost all patients within 4-6 weeks, except those with infection, occult malignancy, or systemic illness. If pain fails to significantly improve or resolve in this time frame, imaging is always indicated.
- Perform the straight leg raising test with the patient in a supine position. Record the response to raising each leg. An approximation of the test may be performed with the patient sitting and each leg straightened at the knee. The examiner should take care to make sure that the quadriceps muscle is relaxed while passively raising the leg to ensure that the sciatic nerve is being adequately stretched during the testing. If the quadriceps is contracted, it will take the pressure off the sciatic nerve and may give a false-negative result.
- The stoop test helps distinguish true claudication from pseudoclaudication. Patients with true claudication sit down to rest when pain occurs, while patients with pseudoclaudication attempt to keep walking by stooping or flexing the spine to relieve the stretch on the sciatic nerve.
Mechanical low back pain is one of the most common patient complaints expressed to emergency physicians in the United States accounting for more than 6 million cases annually. Approximately two thirds of adults are affected by mechanical low back pain at some point in their lives, making it the second most common complaint in ambulatory medicine and the third most expensive disorder in terms of health care dollars spent surpassed only by cancer and heart disease.
Low back pain reportedly occurs at least once in 85% of adults younger than 50 years, and 15-20% of Americans have at least one episode of back pain per year. Of these patients, only 20% can be given a precise pathoanatomic diagnosis. Low back pain affects men and women equally. The onset most frequently occurs in people aged 30-50 years. Low back pain is the most common and most expensive cause of work-related disability in the United States. Smokers appear to have an increased incidence of back pain compared with nonsmokers. Furthermore, the incidence of current smoking and the association with low back pain is higher in adolescents than in adults.
Many causes of mechanical low back pain exist. The most common causes are age-related degenerative disc and facet processes and muscle- or ligament-related injuries. Discussion in this article is limited to musculoskeletal causes. These can be divided into nerve root syndromes, musculoskeletal pain syndromes, and skeletal causes.
Nerve root syndromes
Classic nerve root syndrome is characterized by radicular pain arising from nerve root impingement due to herniated discs. A similar syndrome can also be produced by inflammation and irritation, which may explain why patients whose presentation is consistent with this diagnosis respond to conservative therapies.
Impingement pain tends to be sharp, well localized, and can be associated with paresthesia, whereas irritation pain tends to be dull, poorly localized, and without paresthesia. Impingement is associated with a positive straight leg raising sign (ie, shooting pain down contralateral leg with leg raising), while irritation is not. Neurologic deficits and pain radiation below the knee are rarely seen in irritation alone and are most commonly found with impingement.
The cause of impingement syndrome is most commonly herniated discs, but it may also be caused by spinal stenosis, spinal degeneration, or cauda equina syndrome.
Herniated discs are produced as spinal discs degenerate. After growing thinner, the nucleus pulposus herniates out of the central cavity against a nerve root. Intervertebral discs begin to degenerate by the third decade of life, and herniated discs are found on autopsy in one third of adults older than 20 years. Only 3% of these, however, are symptomatic. The most common locations for herniation are L4, L5, and S1.
Spinal stenosis occurs when disc spaces decrease as intervertebral discs lose moisture and volume with age. Even minor trauma under these circumstances can cause inflammation or nerve root impingement, which can produce classic sciatica pain without disc rupture. The pain can often be bilateral.
Spinal degeneration is caused by alterations in the hygroscopic quality of the nucleus pulposus. This process progresses to annular degeneration. Coupled with progressive posterior facet disease, this process leads to spinal canal or foraminal encroachment. These retrogressive and proliferative changes in the disc anteriorly and the joints posteriorly produce clinical symptoms and radiographic findings termed 3-joint complex degeneration. Spinal degeneration has 3 distinct stages, as follows:
- Dysfunction with complaints of pain only
- Instability with advanced degeneration, pseudospondylolisthesis, and neurologic abnormalities
- Stabilization with morning stiffness and with prolonged standing or walking, producing radicular pain
Cauda equina syndrome is produced by massive midline extrusion of nuclear material or tumor into the spinal canal, which compresses the caudal sac. The classic presentation is bilateral sciatica, with lower extremity bowel or bladder dysfunction present in 90% of patients. Urinary retention is initially observed and followed by overflow incontinence. Perineal or perianal anesthesia is present in 60-80% of patients.
Musculoskeletal pain syndromes
Musculoskeletal pain syndromes that produce low back pain include myofascial pain syndromes and fibromyalgia.
Myofascial pain is characterized by pain and tenderness over localized areas (trigger points), loss of range of motion in the involved muscle groups, and pain radiating in a characteristic distribution but restricted to a peripheral nerve. Relief of pain is often reported when the involved muscle group is stretched.
Fibromyalgia results in pain and tenderness on palpation of 11 of 18 trigger points, one of which is the low back area, as classified by the American College of Rheumatology. Generalized stiffness, fatigue, and muscle ache are reported.
Other skeletal causes
Other skeletal causes of low back pain include osteomyelitis, sacroiliitis, and malignancy.
Osteomyelitis results from infectious processes involving the bones of the spine, while sacroiliitis results from inflammatory changes in the sacroiliac joints. This pain presents over the sacroiliac joints and radiates to the anterior and posterior thighs. This pain is usually worse at night and is exacerbated by prolonged sitting or standing.
Malignant tumors of the spine can be primary or metastatic. Most primary spinal tumors are found in patients younger than 30 years and usually involve the posterior vertebral elements. Metastatic tumors are found mostly in patients older than 50 years and tend to occur in the anterior aspects of the vertebral body.
Mechanical low back pain is one of the most common patient complaints expressed to emergency physicians in the United States accounting for more than 6 million cases annually.
- Most etiologies of mechanical low back pain are not life threatening; however, significant morbidity is associated with chronic low back pain syndromes.
- A significant number of patients are unable to return to their normal daily routines or function in a productive work environment secondary to low back pain.
- Most cases of back pain treated in the emergency department are not true emergencies, with the exception of cauda equina syndrome. Patients who have cauda equina syndrome must undergo surgical decompression as soon as possible or face permanent neurologic damage.
No differences exist in incidence of back pain between racial groups.
Both male and female populations are affected; however, there is a tendency towards a higher incidence in male patients.
Low back pain is a common complaint in adults of all ages, and it is becoming an increasing complaint in children and adolescents.
Common causes of low back pain (lumbar backache) include lumbar strain, nerve irritation, lumbar radiculopathy, bony encroachment, and conditions of the bone and joints. Each of these is reviewed below.
- Lumbar strain (acute, chronic) A lumbar strain is a stretch injury to the ligaments, tendons, and/or muscles of the low back. The stretching incident results in microscopic tears of varying degrees in these tissues. Lumbar strain is considered one of the most common causes of low back pain. The injury can occur because of overuse, improper use, or trauma. Soft-tissue injury is commonly classified as "acute" if it has been present for days to weeks. If the strain lasts longer than three months, it is referred to as "chronic." Lumbar strain most often occurs in people in their 40s, but it can happen at any age. The condition is characterized by localized discomfort in the low back area with onset after an event that mechanically stressed the lumbar tissues. The severity of the injury ranges from mild to severe, depending on the degree of strain and resulting spasm of the muscles of the low back. The diagnosis of lumbar strain is based on the history of injury, the location of the pain, and exclusion of nervous system injury. Usually, X-ray testing is only helpful to exclude bone abnormalities. The treatment of lumbar strain consists of resting the back (to avoid reinjury), medications to relieve pain and muscle spasm, local heat applications, massage, and eventual (after the acute episode resolves) reconditioning exercises to strengthen the low back and abdominal muscles. Initial treatment at home might include heat application, acetaminophen (Tylenol) or ibuprofen (Advil, Motrin), and avoiding reinjury and heavy lifting. Long periods of inactivity in bed are no longer recommended, as this treatment may actually slow recovery. Spinal manipulation for periods of up to one month has been found to be helpful in some patients who do not have signs of nerve irritation. Future injury is avoided by using back-protection techniques during activities and support devices as needed at home or work.
- Nerve irritation The nerves of the lumbar spine can be irritated by mechanical pressure (impingement) by bone or other tissues, or from disease, anywhere along their
paths -- fromtheir roots at the spinal cord to the skin surface. These conditions include lumbar disc disease (radiculopathy), bony encroachment, and inflammation of the nerves caused by a viral infection (shingles). See discussions of these conditions below.
- Lumbar radiculopathy Lumbar radiculopathy is nerve irritation that is caused by damage to the discs between the vertebrae. Damage to the disc occurs because of degeneration ("wear and tear") of the outer ring of the disc, traumatic injury, or both. As a result, the central softer portion of the disc can rupture (herniate) through the outer ring of the disc and abut the spinal cord or its nerves as they exit the bony spinal column. This rupture is what causes the commonly recognized "sciatica" pain of a herniated disc that shoots from the low back and buttock down the leg. Sciatica can be preceded by a history of localized low-back aching or it can follow a "popping" sensation and be accompanied by numbness and tingling. The pain commonly increases with movements at the waist and can increase with coughing or sneezing. In more severe instances, sciatica can be accompanied by incontinence of the bladder and/or bowels. The sciatica of lumbar radiculopathy typically affects only one side of the body, such as the left side or right side, and not both. Lumbar radiculopathy is suspected based on the above symptoms. Increased radiating pain when the lower extremity is lifted supports the diagnosis. Nerve testing (EMG/electromyogram and NCV/nerve conduction velocity) of the lower extremities can be used to detect nerve irritation. The actual disc herniation can be detected with imaging tests, such as CAT or MRI scanning. Treatment of lumbar radiculopathy ranges from medical management to surgery. Medical management includes patient education, medications to relieve pain and muscle spasms, cortisone injection around the spinal cord (epidural injection), physical therapy (heat, massage by a therapist, ultrasound, electrical stimulation), and rest (not strict bed rest but avoiding reinjury). With unrelenting pain, severe impairment of function, or incontinence (which can indicate spinal cord irritation), surgery may be necessary. The operation performed depends on the overall status of the spine and the age and health of the patient. Procedures include removal of the herniated disc with laminotomy (a small hole in the bone of the lumbar spine surrounding the spinal cord), laminectomy (removal of the bony wall), by needle technique (percutaneous discectomy), disc-dissolving procedures (chemonucleolysis), and others.
Picture of herniated disc between L4 and L5
- Bony encroachment Any condition that results in movement or growth of the vertebrae of the lumbar spine can limit the space (encroachment) for the adjacent spinal cord and nerves. Causes of bony encroachment of the spinal nerves include foraminal narrowing (narrowing of the portal through which the spinal nerve passes from the spinal column, out of the spinal canal to the body, commonly as a result of arthritis), spondylolisthesis (slippage of one vertebra relative to another), and spinal stenosis (compression of the nerve roots or spinal cord by bony spurs or other soft tissues in the spinal canal). Spinal-nerve compression in these conditions can lead to sciatica pain that radiates down the lower extremities. Spinal stenosis can cause lower-extremity pains that worsen with walking and are relieved by resting (mimicking the pains of poor circulation). Treatment of these afflictions varies, depending on their severity, and ranges from rest to surgical decompression by removing the bone that is compressing the nervous tissue.
- Bone and joint conditions Bone and joint conditions that lead to low back pain include those existing from birth (congenital), those that result from wear and tear (degenerative) or injury, and those that are due to inflammation of the joints (arthritis).
conditions-- Congenital causes (existing from birth) of low back pain include scoliosis and spina bifida. Scoliosis is a sideways (lateral) curvature of the spine that can be caused when one lower extremity is shorter than the other (functional scoliosis) or because of an abnormal architecture of the spine (structural scoliosis). Children who are significantly affected by structural scoliosis may require treatment with bracing and/or surgery to the spine. Adults infrequently are treated surgically but often benefit by support bracing. Spina bifida is a birth defect in the bony vertebral arch over the spinal canal, often with absence of the spinous process. This birth defect most commonly affects the lowest lumbar vertebra and the top of the sacrum. Occasionally, there are abnormal tufts of hair on the skin of the involved area. Spina bifida can be a minor bony abnormality without symptoms. However, the condition can also be accompanied by serious nervous abnormalities of the lower extremities.
Degenerative bone and joint
conditions-- As we age, the water and protein content of the body's cartilage changes. This change results in weaker, thinner, and more fragile cartilage. Because both the discs and the joints that stack the vertebrae (facet joints) are partly composed of cartilage, these areas are subject to wear and tear over time (degenerative changes). Degeneration of the disc is called spondylosis. Spondylosis can be noted on X-rays of the spine as a narrowing of the normal "disc space" between the vertebrae. It is the deterioration of the disc tissue that predisposes the disc to herniation and localized lumbar pain ("lumbago") in older patients. Degenerative arthritis (osteoarthritis) of the facet joints is also a cause of localized lumbar pain that can be detected with plain X-ray testing. These causes of degenerative back pain are usually treated conservatively with intermittent heat, rest, rehabilitative exercises, and medications to relieve pain, muscle spasm, and inflammation.
Injury to the bones and
joints-- Fractures (breakage of bone) of the lumbar spine and sacrum bone most commonly affect elderly people with osteoporosis, especially those who have taken long-term cortisone medication. For these individuals, occasionally even minimal stresses on the spine (such as bending to tie shoes) can lead to bone fracture. In this setting, the vertebra can collapse (vertebral compression fracture). The fracture causes an immediate onset of severe localized pain that can radiate around the waist in a band-like fashion and is made intensely worse with body motions. This pain generally does not radiate down the lower extremities. Vertebral fractures in younger patients occur only after severe trauma, such as from motor-vehicle accidents or a convulsive seizure.
In both younger and older patients, vertebral fractures take weeks to heal with rest and pain relievers. Compression fractures of vertebrae associated with osteoporosis can also be treated with a procedure called vertebroplasty, which can help to reduce pain. In this procedure, a balloon is inflated in the compressed vertebra, often returning some of its lost height. Subsequently, a "cement" (methymethacrylate) is injected into the balloon and remains to retain the structure and height of the body of the vertebra.
Arthritis-- The spondyloarthropathies are inflammatory types of arthritis that can affect the lower back and sacroiliac joints. Examples of spondyloarthropathies include reactive arthritis (Reiter's disease), ankylosing spondylitis, psoriatic arthritis, and the arthritis of inflammatory bowel disease. Each of these diseases can lead to low back pain and stiffness, which is typically worse in the morning. These conditions usually begin in the second and third decades of life. They are treated with medications directed toward decreasing the inflammation. Newer biologic medications have been greatly successful in both quieting the disease and stopping its progression.
Uncommon causes of low back pain
Uncommon causes of low back pain include Paget's disease of bone, bleeding or infection in the pelvis, infection of the cartilage and/or bone of the spine, aneurysm of the aorta, and shingles.
Paget's disease of bone
Paget's disease of the bone is a condition of unknown cause in which the bone formation is out of synchrony with normal bone remodeling. This condition results in abnormally weakened bone and deformity and can cause localized bone pain, though it often causes no symptoms. Paget's disease is more common in people over the age of 50. Heredity (genetic background) and certain unusual virus infections have been suggested as causes. Thickening of involved bony areas of the lumbar spine can cause the radiating lower extremity pain of sciatica.
Paget's disease can be diagnosed on plain X-rays. However, a bone biopsy is occasionally necessary to ensure the accuracy of the diagnosis. Bone scanning is helpful to determine the extent of the disease, which can involve more than one bone area. A blood test, alkaline phosphatase, is useful for diagnosis and monitoring response to therapy. Treatment options include aspirin, other anti-inflammatory medicines, pain medications, and medications that slow the rate of bone turnover, such as calcitonin (Calcimar, Miacalcin), etidronate (Didronel), alendronate (Fosamax), risedronate (Actonel), and pamidronate (Aredia).
Bleeding or infection in the pelvis
Bleeding in the pelvis is rare without significant trauma and is usually seen in patients who are taking blood-thinning medications, such as warfarin (Coumadin). In these patients, a rapid-onset sciatica pain can be a sign of bleeding in the back of the pelvis and abdomen that is compressing the spinal nerves as they exit to the lower extremities. Infection of the pelvis is infrequent but can be a complication of conditions such as diverticulosis, Crohn's disease, ulcerative colitis, pelvic inflammatory disease with infection of the Fallopian tubes or uterus, and even appendicitis. Pelvic infection is a serious complication of these conditions and is often associated with fever, lowering of blood pressure, and a life-threatening state.
Infection of the cartilage and/or bone of the spine
Infection of the discs (septic discitis) and bone (osteomyelitis) is extremely rare. These conditions lead to localized pain associated with fever. The bacteria found when these tissues are tested with laboratory cultures include Staphylococcus aureus and Mycobacterium tuberculosis (TB bacteria). TB infection in the spine is called Pott's disease. These are each very serious conditions requiring long courses of antibiotics. The sacroiliac joints rarely become infected with bacteria. Brucellosis is a bacterial infection that can involve the sacroiliac joints and is usually transmitted in goat's milk.
Aneurysm of the aorta
In the elderly, atherosclerosis can cause weakening of the wall of the large arterial blood vessel (aorta) in the abdomen. This weakening can lead to a bulging (aneurysm) of the aorta wall. While most aneurysms cause no symptoms, some cause a pulsating low back pain. Aneurysms of certain size, especially when enlarging over time, can require surgical repair with a grafting procedure to repair the abnormal portion of the artery.
Shingles (herpes zoster) is an acute infection of the nerves that supply sensation to the skin, generally at one or several spinal levels and on one side of the body (right or left). Patients with shingles usually have had chickenpox earlier in life. The herpes virus that causes chickenpox is believed to exist in a dormant state within the spinal nerve roots long after the chickenpox resolves. In people with shingles, this virus reactivates to cause infection along the sensory nerve, leading to nerve pain and usually an outbreak of shingles (tiny blisters on the same side of the body and at the same nerve level). The back pain in patients with shingles of the lumbar area can precede the skin rash by days. Successive crops of tiny blisters can appear for several days and clear with crusty inflammation in one to two weeks. Patients occasionally are left with a more chronic nerve pain (postherpetic neuralgia). Treatment can involve symptomatic relief with lotions, such as calamine, or medications, such as acyclovir (Zovirax) for the infection and pregabalin (Lyrica) or lidocaine (Lidoderm) patches for the pain.
Other causes of lower back pain
Other causes of low back pain include kidney problems, pregnancy, ovary problems, and tumors.
Kidney infections, stones, and traumatic bleeding of the kidney (hematoma) are frequently associated with low back pain. Diagnosis can involve urine analysis, sound-wave tests (ultrasound), or other imaging studies of the abdomen.
Pregnancy commonly leads to low back pain by mechanically stressing the lumbar spine (changing the normal lumbar curvature) and by the positioning of the baby inside of the abdomen. Additionally, the effects of the female hormone estrogen and the ligament-loosening hormone relaxin may contribute to loosening of the ligaments and structures of the back. Pelvic-tilt exercises and stretches are often recommended for relieving this pain. Women are also recommended to maintain physical conditioning during pregnancy according to their doctors' advice.
Ovarian cysts, uterine fibroids, and endometriosis not infrequently cause low back pain. Precise diagnosis can require gynecologic examination and testing.
Low back pain can be caused by tumors, either benign or malignant, that originate in the bone of the spine or pelvis and spinal cord (primary tumors) and those which originate elsewhere and spread to these areas (metastatic tumors). Symptoms range from localized pain to radiating severe pain and loss of nerve and muscle function (even incontinence of urine and stool) depending on whether or not the tumors affect the nervous tissue. Tumors of these areas are detected using imaging tests, such as plain X-rays, nuclear bone scanning, and CAT and MRI scanning.
It is important to understand that back pain is a symptom of a medical condition, not a diagnosis itself. Medical problems that can cause back pain include the following:
Mechanical problems: A mechanical problem is due to the way your spine moves or the way you feel when you move your spine in certain ways. Perhaps the most common mechanical cause of back pain is a condition called intervertebral disc degeneration, which simply means that the discs located between the vertebrae of the spine are breaking down with age. As they deteriorate, they lose their cushioning ability. This problem can lead to pain if the back is stressed. Other mechanical causes of back pain include spasms, muscle tension, and ruptured discs, which are also called herniated discs.
Injuries: Spine injuries such as sprains and fractures can cause either short-lived or chronic back pain. Sprains are tears in the ligaments that support the spine, and they can occur from twisting or lifting improperly. Fractured vertebrae are often the result of osteoporosis, a condition that causes weak, porous bones. Less commonly, back pain may be caused by more severe injuries that result from accidents and falls.
Acquired conditions and diseases: Many medical problems can cause or contribute to back pain. They include scoliosis, which causes curvature of the spine and does not usually cause pain until mid-life; spondylolisthesis; various forms of arthritis, including osteoarthritis, rheumatoid arthritis, and ankylosing spondylitis; and spinal stenosis, a narrowing of the spinal column that puts pressure on the spinal cord and nerves. While osteoporosis itself is not painful, it can lead to painful fractures of the vertebrae. Other causes of back pain include pregnancy; kidney stones or infections; endometriosis, which is the buildup of uterine tissue in places outside the uterus; and fibromyalgia, which causes fatigue and widespread muscle pain.
Infections and tumors: Although they are not common causes of back pain, infections can cause pain when they involve the vertebrae, a condition called osteomyelitis, or when they involve the discs that cushion the vertebrae, which is called discitis. Tumors, too, are relatively rare causes of back pain. Occasionally, tumors begin in the back, but more often they appear in the back as a result of cancer that has spread from elsewhere in the body.
Although the causes of back pain are usually physical, it is important to know that emotional stress can play a role in how severe pain is and how long it lasts. Stress can affect the body in many ways, including causing back muscles to become tense and painful.