Back Pain

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Back pain (also known "dorsalgia") is pain felt in the back that usually originates from the muscles, nerves, bones, joints or other structures in the spine.

The pain can often be divided into neck pain, upper back pain, lower back pain or tailbone pain. It may have a sudden onset or can be a chronic pain; it can be constant or intermittent, stay in one place or radiate to other areas. It may be a dull ache, or a sharp or piercing or burning sensation. The pain may be felt in the neck (and might radiate into the arm and hand), in the upper back, or in the low back, (and might radiate into the leg or foot), and may include symptoms other than pain, such as weakness, numbness or tingling.

Back pain is one of humanity's most frequent complaints. In the U.S., acute low back pain (also called lumbago) is the fifth most common reason for physician visits. About nine out of ten adults experience back pain at some point in their life, and five out of ten working adults have back pain every year.

The spine is a complex interconnecting network of nerves, joints, muscles, tendons and ligaments, and all are capable of producing pain. Large nerves that originate in the spine and go to the legs and arms can make pain radiate to the extremities.

 

Classification of Back Pain

Back pain can be divided anatomically: neck pain, upper back pain, lower back pain or tailbone pain.

By its duration: acute (less than 4 weeks), subacute (4 – 12 weeks), chronic (greater than 12 weeks).

By its cause: MSK, infectious, cancer, etc.

 

Conditions Associated with Back Pain

Back pain can be a sign of a serious medical problem, although this is not most frequently the underlying cause:

* Typical warning signs of a potentially life-threatening problem are bowel and/or bladder incontinence or progressive weakness in the legs.
* Severe back pain (such as pain that is bad enough to interrupt sleep) that occurs with other signs of severe illness (e.g. fever, unexplained weight loss) may also indicate a serious underlying medical condition.
* Back pain that occurs after a trauma, such as a car accident or fall may indicate a bone fracture or other injury.
* Back pain in individuals with medical conditions that put them at high risk for a spinal fracture, such as osteoporosis or multiple myeloma, also warrants prompt medical attention.
* Back pain in individuals with a history of cancer (especially cancers known to spread to the spine like breast, lung and prostate cancer) should be evaluated to rule out metastatic disease of the spine.

Back pain does not usually require immediate medical intervention. The vast majority of episodes of back pain are self-limiting and non-progressive. Most back pain syndromes are due to inflammation, especially in the acute phase, which typically lasts for two weeks to three months.

A few observational studies suggest that two conditions to which back pain is often attributed, lumbar disc herniation and degenerative disc disease may not be more prevalent among those in pain than among the general population, and that the mechanisms by which these conditions might cause pain are not known. Other studies suggest that for as many as 85% of cases, no physiological cause can be shown.

A few studies suggest that psychosocial factors such as on-the-job stress and dysfunctional family relationships may correlate more closely with back pain than structural abnormalities revealed in x-rays and other medical imaging scans.

 

Causes of Back Pain

There are several potential sources and causes of back pain. However, the diagnosis of specific tissues of the spine as the cause of pain presents problems. This is because symptoms arising from different spinal tissues can feel very similar and is difficult to differentiate without the use of invasive diagnostic intervention procedures, such as local anesthetic blocks.

One potential source of back pain is skeletal muscle of the back. Potential causes of pain in muscle tissue include Muscle strains (pulled muscles), muscle spasm, and muscle imbalances. However, imaging studies do not support the notion of muscle tissue damage in many back pain cases, and the neurophysiology of muscle spasm and muscle imbalances are not well understood.

Another potential source of low back pain is the synovial joints of the spine (e.g. zygapophysial joints). These have been identified as the primary source of the pain in approximately one third of people with chronic low back pain, and in most people with neck pain following whiplash. However, the cause of zygapophysial joint pain is not fully understood. Capsule tissue damage has been proposed in people with neck pain following whiplash. In people with spinal pain stemming from zygapophysial joints, one theory is that intra-articular tissue such as invaginations of their synovial membranes and fibro-adipose meniscoids (that usually act as a cushion to help the bones move over each other smoothly) may become displaced, pinched or trapped, and consequently give rise to nociception.

There are several common other potential sources and causes of back pain: these include spinal disc herniation and degenerative disc disease or isthmic spondylolisthesis, osteoarthritis (degenerative joint disease) and spinal stenosis, trauma, cancer, infection, fractures, and inflammatory disease.

Radicular pain (sciatica) is distinguished from 'non-specific' back pain, and may be diagnosed without invasive diagnostic tests.

New attention has been focused on non-discogenic back pain, where patients have normal or near-normal MRI and CT scans. One of the newer investigations looks into the role of the dorsal ramus in patients that have no radiographic abnormalities. See Posterior Rami Syndrome.

 

Treatment of Back Pain

The management goals when treating back pain are to achieve maximal reduction in pain intensity as rapidly as possible; to restore the individual's ability to function in everyday activities; to help the patient cope with residual pain; to assess for side-effects of therapy; and to facilitate the patient's passage through the legal and socioeconomic impediments to recovery. For many, the goal is to keep the pain to a manageable level to progress with rehabilitation, which then can lead to long term pain relief. Also, for some people the goal is to use non-surgical therapies to manage the pain and avoid major surgery, while for others surgery may be the quickest way to feel better.

Not all treatments work for all conditions or for all individuals with the same condition, and many find that they need to try several treatment options to determine what works best for them. The present stage of the condition (acute or chronic) is also a determining factor in the choice of treatment. Only a minority of back pain patients (most estimates are 1% - 10%) require surgery.

 

Back Pain - Pregnancy

About 50% of women experience low back pain during pregnancy. Back pain in pregnancy may be severe enough to cause significant pain and disability and pre-dispose patients to back pain in a following pregnancy. No significant increased risk of back pain with pregnancy has been found with respect to maternal weight gain, exercise, work satisfaction, or pregnancy outcome factors such as birth weight, birth length, and Apgar scores.

Biomechanical factors of pregnancy that are shown to be associated with low back pain of pregnancy include abdominal sagittal and transverse diameter and the depth of lumbar lordosis. Typical factors aggravating the back pain of pregnancy include standing, sitting, forward bending, lifting, and walking. Back pain in pregnancy may also be characterized by pain radiating into the thigh and buttocks, night-time pain severe enough to wake the patient, pain that is increased during the night-time, or pain that is increased during the day-time. The avoidance of high impact, weight-bearing activities and especially those that asymmetrically load the involved structures such as: extensive twisting with lifting, single-leg stance postures, stair climbing, and repetitive motions at or near the end-ranges of back or hip motion can easen the pain. Direct bending to the ground without bending the knee causes severe impact on the lower back in pregnancy and in normal individuals, which leads to strain, especially in the lumbo-saccral region that in turn strains the multifidus.

 

 

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