Causes of Back Pain
Causes of Back Pain
Low back pain and lower extremity pain like sciatica and neuropathy often get put into one category, but the causes, and therefore the treatments, can be different. Lower extremity pain, when it radiates from the low back, is usually the result of pressure on a nerve. The Sciatic nerve is the one affected in sciatica, but there are other nerves that run from the lower back into the legs as well. This pain is often in the distribution which the nerve supplies. Low back pain is often related to the mechanics of the spine. Muscle strain, arthritis, trauma, osteoporosis, and fracture are often causes. Often, disease processes which cause lower extremity pain can also cause low back pain, and vice versa. For more information about the causes below simply click on the links (highlighted text).
Take a 3 Dimensional Look at Some of The Most Common Causes of Lower Back Pain and Sciatica by viewing the video above.
Herniation of the nucleus pulposus (HNP) occurs when the nucleus pulposus (gel-like substance) breaks through the anulus fibrosus (tire-like structure) of an intervertebral disc (spinal shock absorber).
A herniated disc occurs most often in the lumbar region of the spine especially at the L4-L5 and L5-S1 levels (L = Lumbar, S = Sacral). This is because the lumbar spine carries most of the body's weight. People between the ages of 30 and 50 appear to be vulnerable because the elasticity and water content of the nucleus decreases with age.
The progression to an actual HNP varies from slow to sudden onset of symptoms. There are four stages: (1) disc protrusion (2) prolapsed disc (3) disc extrusion (4) sequestered disc. Stages 1 and 2 are referred to as incomplete, where 3 and 4 are complete herniations. Pain resulting from herniation may be combined with a radiculopathy, which means neurological deficit. The deficit may include sensory changes (i.e. tingling, numbness) and/or motor changes (i.e. weakness, reflex loss). These changes are caused by nerve compression created by pressure from interior disc material.
Progression of Herniated Disc
The extremities affected are dependent upon the vertebral level at which the HNP occurred. Consider the following examples:
Cervical - Pain in the neck, shoulders, and arms
Thoracic - Pain radiates into the chest
Lumbar - Pain extends into the buttocks, thighs, legs
Cauda Equina Syndrome occurs from a central disc herniation and is serious requiring immediate surgical intervention. The symptoms include bilateral leg pain, loss of perianal sensation (anus), paralysis of the bladder, and weakness of the anal sphincter.
Diagnosis of a Herniated Disc
The spine is examined with the patient laying down and standing. Due to muscle spasm, a loss of normal spinal curvature may be noted. Radicular pain (inflammation of a spinal nerve) may increase when pressure is applied to the affected spinal level.
A Lasegue test, also known as Straight-leg Raising Test, is performed. The patient lies down, the knee is extended, and the hip is flexed. If pain is aggravated or produced, it is an indication the lower lumbosacral nerve roots are inflamed.
Other neurological tests are performed to determine loss of sensation and/or motor function. Abnormal reflexes are noted as these changes may indicate the location of the herniation.
Radiographs are helpful, but Computed Axial Tomography (CAT) or Magnetic Resonance Imaging (MRI) provides more detail. The MRI is the best method enabling the physician to see the soft spinal tissues unseen in a conventional x-ray.
Degenerative Disc Disease and Low Back Pain
Degenerative Disc Disease (DDD) is a gradual process that may compromise the spine. Although DDD is relatively common, its effects are usually not severe enough to warrant medical attention. In this discussion we address Degenerative Disc Disease in the lumbar spine.
Degenerative Changes to a Disc
Degenerative changes in the spine are often referred to those that cause the loss of normal structure and/or function. The intervertebral disc is one structure prone to the degenerative changes associated with wear and tear aging, even misuse (e.g. smoking).
Long before Degenerative Disc Disease can be seen radiographically, biochemical and histologic (structural) changes occur. Some of these changes are not unlike those associated with osteoarthritis. Over time the collagen (protein) structure of the annulus fibrosus weakens and may become structurally unsound. Additionally, water and proteoglycan (PG) content decreases. PGs are molecules that attract water. These changes are linked and may lead to the disc's inability to handle mechanical stress.
Understanding the lumbar spine carries a large portion of the body's weight; the stress from motion may result in a disc problem (e.g. herniation).
Non-Operative Treatment: Yesterday vs. Today
DDD is a disorder that may cause low back pain. It is interesting to note that although 80% of adults will experience back pain, only 1-2% will need lumbar spine surgery!
In the past some physicians prescribed long courses of bedrest and/or lumbar traction for their patients with low back pain. However, that is not the attitude today. During the acute phase, bedrest may be recommended for a few days, but beyond that experts advocate stretching, flexion and extension exercises, and no/low impact aerobics. Of course, each patient is different and therefore so is their treatment plan.
Is a common cause of pain related to the spine. The facet joints are the articulations or connections between the vertebraes in the spine. They are like any other joint in the body like the knee or elbow that enable the bending or twisting movements of the spine. The facet joints can get inflamed secondary to injury or arthritis and cause pain and stiffness. When the facet joints are affected in the neck or cervical spine it typically causes pain in this area as well headaches and difficulty rotating the head.
People who suffer from this problem usually complain that they have to turn their entire body to look over to the right or left. Pain can be felt in other areas such as the shoulders or midback area. Low back pain is commonly caused by Facet Joint Syndrome. Pain is felt in the lower back and sometimes it can be felt in the buttock as well in the thighs usually not going below the knee.
Sciatica is a set of symptoms including pain that may be caused by general compression and/or irritation of one of five nerve roots that give rise to the sciatic nerve, or by compression or irritation of the sciatic nerve itself. The pain is felt in the lower back, buttock, and/or various parts of the leg and foot. In addition to pain, which is sometimes severe, there may be numbness, muscular weakness, and difficulty in moving or controlling the leg. Typically, the symptoms are only felt on one side of the body.
Although sciatica is a relatively common form of low back pain and leg pain, the true meaning of the term is often misunderstood. Sciatica is a set of symptoms rather than a diagnosis for what is irritating the root of the nerve, causing the pain. This point is important, because treatment for sciatica or sciatic symptoms will often be different, depending upon the underlying cause of the symptoms. Sciatic nerve irritation is often due to herniated or bulging disc material which limits the size of the holes that nerves exit the spinal cord from. It can also be the result of degerative changes to the spine as in degenerative disc disease and osteoarthritis. In some cases the sciatic nerve pierces through a muscle group called the piriformis and pain is activated when these pear shaped muscles compress the nerve. For this reason it is important to be evaluated by a doctor who has experience in treating all the potential causes of sciatica. Chiropractic adjustments, spinal decompression, and massage therapy are just some of the natural alternative treatments and cures for this condition.
This disease is associated with spinal stenosis, but it differs because it primary affects one or more vertebral foramen. Normally, nerve roots have enough room to easily slip through the foramen. However, with age and disease, the neuroforamen may become clogged with debris. The nerves can become trapped and compressed.
The symptoms of foraminal stenosis may include numbness, weakness, burning sensations, tingling, and pins and needles in the involved extremity, such as the leg. Not every stenosis is critical, but if spinal stenosis is ignored, nerves may die, which could result in a loss of function. The functional loss could involve the ability to feel (sensory) and/or move (motor).
If conservative forms of treatment are unsuccessful, surgery is an option. The procedure is termed a foraminotomy.
This refers to a narrowing of the spinal canal. Certain individuals may have a narrow canal from birth, but the majority of individuals develop narrowing with age. With age, wear and tear arthritic spurs build up on the facet joints in the posterior part of the spine. These arthritic spurs then encroach on the spinal canal and pinch the lumbar nerve roots. This condition can be worsened as well by narrowing and degeneration of the disc at that level as the space for exit of the nerve root (called the foramen) is narrowed further by a degenerated disc. Spinal stenosis is most common in the last three levels of the lumbar spine namely L3-4, L4-5 and L5-S1. It is diagnosed and confirmed by an MRI or CAT scan/myelogram. There are various signs and symptoms of spinal stenosis. A common one is referred to as spinal claudication. This refers to pain in the legs, the calves or the buttocks. This pain is associated with activity. The pain is often relieved by sitting and resting. It will then often times start up again with activity. A common complaint is that an individual will be able to walk several blocks then develops leg pain, is able to get rid of the leg pain by sitting and resting for five to ten minutes and then, upon trying to walk another several blocks the pain will return. The pain may be a radiating pain like a sciatica or it may be a cramping pain. At times though, the stenosis may be severe enough that the leg pain is constant and unremitting. It may at times be indistinguishable from the kind of pain that occurs with a herniated disc. Spinal stenosis is uncommon in younger people. It usually occurs at age 50 or older. Leg pains from spinal pathology are more common from herniated discs in people under 50. Over 50 it is more common that spinal stenosis will be the problem. In addition to developmental degenerative spinal stenosis, entrapped nerve roots may be caused as well by spondylolisthesis and scotiosis. There is really no conservative treatment for a spinal stenosis. It will rarely cause paralysis. The condition will tend to gradually worsen with time and cause increasing pain however. Patients with congenital spinal stenosis (such as achondroplastic dwarfs) may develop symptomatic stenosis as early as age 15 or 20.
Discitis, or disc space infection, is an inflammatory lesion of the intervertebral disc that occurs in adults but more commonly in children. Its cause has been the subject of debate, although most authors believe it to be infectious. The infection probably begins in one of the continguous end plates, and the disc is infected secondarily. Severe back pain that begins insidiously is characteristic of the disease.
Discitis in Children
Although most children will continue to walk in spite of the pain, young children may refuse to ambulate. The characteristic finding is extension of the spine and the child's complete refusal to flex the spine. Children with discitis usually are not systemically ill. They rarely have an elevated temperature and their white blood cell count is frequently normal. However the erythrocyte sedimentation rate is usually increased. Lateral radiographs of the spine usually will reveal disc space narrowing with erosion of the vertebral end plates of the contiguous vertebrae. bone scanning may be helpful in localizing a lesion that is difficult to diagnose clinically. Some bone scans are falsely negative, so the diagnosis of disc space infection should not be excluded simply because the bone scan is normal. Magnetic resonance imaging (MRI) seems to be helpful in identifying a disc space infection.
Spondylolisthesis occurs when one lumbar vertebra slips forward in relationship to the adjacent vertebra. In the Greek language, the term spondylolisthesis means slipped vertebra. The neural arch (lamina) and the paired facet joints are anatomical structures that prevent vertebrae from slipping (Fig 1). A vertebra may slip following the development of a stress fracture through the neural arch. The defect in the lamina separates the back part of the vertebra from the remaining part; the vertebral body and disc. The stabilizing role of the paired facet joints is lost and the vertebral body slips forward. The laminar stress fracture (in Greek called spondylolysis) occurs in a specific region of the lamina called the pars interarticularis or isthmus. Hence the condition is called isthmic spondylolisthesis.
A defect of the Pars Interaticularis consists of an interruption of the vertebral arch at the bony bridge that holds together the superior (upper) and inferior (lower) articular processes (pars interarticularis). The defect is usually seen at L5 (82%) or L4 (15%), and rarely at L3 (1%). It may be unilateral (one sided) but it is most commonly bilateral (on both sides). If it is complete (all the way through the bone) and bilateral a virtual separation ensues in the vertebra between the body, (with pedicles, transverse processes and superior articular process) posteriorly (toward the back). With time, a sliding anterior (forward) movement of the vertebra (spondylolisthesis) is produced and the defect may become symptomatic (pain producing) by compression on neural structures like nerves and discs. In up to 80% of cases a diagnosis of a pars defect is associated with spondylolisthesis.
Scoliosis is a medical condition in which a person's spine is curved from side to side, and may also be rotated. It is an abnormal lateral curvature of the spine. On an A-P (frontal view) x-ray, the spine of an individual with a typical scoliosis may look more like an "S" or a "C" than a straight line. It is typically classified as congenital (caused by vertebral anomalies present at birth), idiopathic (sub-classified as infantile, juvenile, adolescent, or adult according to when onset occurred) or as having developed as a secondary symptom of another condition, such as cerebral palsy, spinal muscular atrophy or due to physical trauma. Contrary to popular thinking scoliosis is not a problem of bone as much as it is an imbalance in the muscles that attach to the spine and are responsible for supporting it. When muscles are asymmetrically or unevenly developed this will give rise to a shift of the bones that make up the spinal column.
The earlier treatment can be incorporated to correct muscular imbalances the better the outcomes. In the past treatment has consisted of bracing and in some cases the insertion of rods to support the spine. Although there are instances where this invasive intervention is necessary (unstable spines and internal organ compromise) there has been a progressive movement toward ACTIVE CARE in the treatment of abnormal spinal curvatures. Devices geared at helping patients improve muscular balance and increasing muscular strength have helped many enjoy healthy and active lifestyles without the implantation of medical hardware.
Muscle strains and lumbar sprains are the most common causes of low back pain. A low back muscle strain occurs when the muscle fibers are abnormally stretched or torn. A lumbar sprain occurs when the ligaments, the tough bands of tissue that hold bones together, are torn from their attachments. Differentiating a strain from a sprain can be difficult, as both injuries will show similar symptoms. Many doctors refer to both injuries as a category called "musculoligamentous injuries" of the lumbar spine. In general, it doesn't matter what you call the problem because the treatment and prognosis for both back strains and sprains is the same.
Strains are frequently the result of motor vehicle accidents and other traumas including sports activities, especially those that require lifting or coupled motions like twisting and bending. In the case of motor vehicle accidents side impacts tend to be especially harmful since when coupled with the use of a seat belt there is often a side bending (lateral flexion) injury on the side of the impact and an overstretching of the muscles on the opposite side.
Although sprains and strains often will resolve on their own in a short period of time (mild cases in about 2 weeks; more moderate cases in 4 to 6 weeks) these "self healing" sprains and strains can in the long term accelerate arthritic changes in the spine if not given the proper medical attention. Typically strains and sprains heal by a process known as second intention meaning new muscle and ligament fiber is not produced but rather replaced by a lesser fiber known as a scar or adhesion. These lessser fibers are more likely to be reinjured, are less flexible, and tend to form in a pattern perpendicular (across) the already healthy surrounding tissue.
Active care to help realign the fibers (parallel to the healthy surrounding tissue) of this scar tissue is an important part of preventive treatment even in the absence of pain.
Fibromyalgia syndrome (or fibromyalgia) is a chronic disorder associated with widespread muscle and soft tissue pain, tenderness, and fatigue. A person with fibromyalgia will experience pain when up to 18 specific areas called tender points are pressed. Pushing carefully on these specific trigger points during an examination causes discomfort or sharp pain.
The cause of fibromyalgia is not known. Fibromyalgia has been recognized as a medical disorder only since the 1980s, although there is evidence it may have existed for centuries.1
The pain of fibromyalgia is more than normal muscle aches common after physical exertion. Fibromyalgia often can be severe enough to disrupt a person's daily work and activities.
Other symptoms that commonly occur with fibromyalgia include:
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Unrestful sleep.
Fatigue.
Morning stiffness.
Less common symptoms or conditions that can accompany fibromyalgia include: -
Headache.
Raynaud's syndrome.
Irritable bowel syndrome (present in about one-half of those with fibromyalgia).2
Depression.
Fibromyalgia can be difficult to diagnose because its symptoms are similar to many other disorders and diseases. There are no lab tests to diagnose fibromyalgia. It is often diagnosed after other conditions have been ruled out. Fibromyalgia is diagnosed when:3
A person has had widespread pain for at least 3 months. To be considered "widespread," the pain must be both above and below the waist and on both sides of the body.
At least 11 of 18 specific tender points are painful when pressed. (Because symptoms vary widely from person to person, some people with fibromyalgia may have fewer painful tender points.)
Fibromyalgia is not a psychological condition, although it has some psychological components. As with many conditions that cause chronic pain, anxiety and depression are common in people with fibromyalgia and may make symptoms worse.
While there is no specific cure for fibromyalgia, symptoms of this syndrome can be treated. If you have fibromyalgia, taking an active role in your treatment is very important to managing your condition.
Treatment may be different for each individual. It can include:
Medications to help you sleep better and to relieve pain.
Exercise therapy to help with muscle aches and stiffness.
Counseling to help you manage chronic pain.
Research is ongoing to understand the cause of fibromyalgia and its cure.
lumbar radiculopathy, which refers to pain in the lower extremities in a dermatomal pattern. A dermatome is a specific area in the lower extremity innervated by a specific lumbar nerve. This pain is caused by compression of the roots of the spinal nerves in the lumbar region of the spine. Diagnosing leg and back pain begins with a detailed patient history and examination.
Compression fractures can occur in any vertebra (spinal bones) and is described as a collapse of the vertebra.
Symptoms - The first symptom of a compression fracture may be sudden and severe back pain that remains in one local area. Some persons may experience numbness/tingling, or weakness in the arms or legs if the spinal cord or nerves leading away from the fracture have been compressed. If multiple fractures occur in an area of the back, the person will develop a forward hump-like curvature to the back.
Causes - There are many possible causes of compression fractures. Car accidents, falls, and weakening of the bone due to pathology (i.e. cancer), or Osteoporosis are common.
Diagnosis - The diagnosis is based on observation of the aforementioned symptoms and x-rays of the spine. Additional tests (i.e. bone scan, blood tests) may be needed to diagnose the actual cause of the compression fracture.
Osteoarthritis, also called degenerative joint disease, is the most common type of arthritis. It is associated with a breakdown of cartilage in joints and can occur in almost any joint in the body. It most commonly occurs in the fingers, hips, knees and spine.
Cartilage is a firm, rubbery material that covers the ends of bones in normal joints. Its main function is to reduce friction in the joints and serve as a "shock absorber." The shock-absorbing quality of normal cartilage comes from its ability to change shape when compressed (flattened or pressed together).
Osteoarthritis causes the cartilage in a joint to become stiff and lose its elasticity, making it more susceptible to damage. Over time, the cartilage may wear away in some areas, greatly decreasing its ability to act as a shock absorber. As the cartilage wears away, tendons and ligaments stretch, causing pain. If the condition worsens, the bones could rub against each other.
There is a reason why osteoporosis is commonly called the "fragile bone disease." It is due to loss of bone density caused by a deficiency in such bone-building nutrients as calcium, vitamin D, magnesium and other vitamins and minerals.
One of the most common results of fragile bones is vertebral compression fractures. While these types of fractures can be the result of trauma or tumors, they are seen most often in people with osteoporosis. In fact, they are the most common complication of osteoporosis. In people with advanced osteoporosis, compression fractures can occur as the result of simple daily activities such as bending, carrying heavy loads, or a minor fall. See Compression Fractures
Ligaments run up and down the spinal column. Hypertrophy of the ligaments in the vertebral canal (the posterior longitudinal ligament -- runs up and down along the back side of the vertebral bodies, and the ligamentum flavum -- runs up and down under the posterior bone ring made up of the lamina and spinous process) can increase their mass enough that they narrow the canal (stenosis) sometimes to the point that the spinal cord and/or nerve roots running through the canal are compressed. When the posterior longitudinal ligament in front and ligamentum flavum behind the spinal cord hypertrophy the cord is almost "circumferentially" surrounded and compressed).
Hypertrophy of the ligamentum flavum laterally near the facet joint can also contribute to foraminal narrowing (stenosis) with potential nerve compression (pinching).
Lordosis is a disorder defined by an excessive inward curve of the spine. It differs from the spine's normal curves at the cervical, thoracic, and lumbar regions, which are, to a degree, either kyphotic or lordotic. The spine's natural curves position the head over the pelvis and work as shock absorbers to distribute mechanical stress during movement.
Lordosis can be found in all age groups. It primarily affects the lumbar spine, but does occur in the neck (cervical). When found in the lumbar spine, the patient may appear swayback, the buttocks more prominent, and in general an exaggerated posture. A lumbar lordosis can be painful sometimes affecting movement.
Certain disease processes can adversely affect the structural integrity of the spine and contribute to lordosis. Some common causes include achondroplasia, discitis, kyphosis, obesity, osteoporosis, and spondylolisthesis.
Kyphosis is the abnormal forward bending of the spine. In kyphosis, the curve of the spine is abnormal, forming a hump.
What is going on in the body?
The normal spine rounds slightly in the chest area, with arching in the lower back and neck regions. Excessive kyphosis can occur mainly in the chest area of the spine, causing the roundness of the back to appear exaggerated.
What are the signs and symptoms of the condition?
Symptoms are usually minimal, unless the deformity is severe. In that case, the back may ache or, rarely, nerve problems may arise. The hamstrings, or muscles at the back of the thigh, may also be tight.
What are the causes and risks of the condition?
Kyphosis is generally caused by an abnormal posture. Other possible causes include: · a significant fracture of the vertebra, which can cause the back to angle forward · spinal surgery · Scheuermann's disease, which results in wedging of the vertebrae. This disease is usually seen in teenage boys, and its cause is unknown. · Pott's disease, which refers to kyphosis due to collapse of the vertebra when tuberculosis infects the spine · osteoporosis in elderly women, which causes a type of kyphosis known as dowager's hump · spinal tumors, or surgery to remove them · nerve disorders
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