Back Pain

The Centers for Disease Control estimates that 70-85% of all people will have back pain at some time during their lives. The most common complaint of pain, back pain affects more and more people every year. It is the fifth most common reason for all physician visits. Back pain is most frequently the cause of limited activity in people, particularly those under the age of 45. It is also a significant cause for loss of productivity at work, costing employers more than $62 billion per year, mostly related to reduced performance rather than loss of time.

Back pain may originate from the discs, joints, muscles, bones, nerves, ligaments or other structures in the spine.

The spine is a network of nerves, discs, joints, muscles, tendons and ligaments, and all are capable of producing pain. Large nerves that originate in the spine supply the legs and arms and can cause pain to radiate to those extremities.

Anatomy Of The Spine

The back is composed of vertebrae stacked on each other. There are seven cervical (neck) vertebrae, 12 thoracic (mid-back) vertebrae, five lumbar vertebra, the sacrum, and the coccyx. They are stacked in a way to form an S-shaped column and are supported by muscle and ligaments.

The main function of the spine is to support the weight of the body, while maintaining flexibility. Between each vertebra is an intervertebral disc which acts as a shock absorber. The discs and the vertebrae work together in a series of joints that allow the spine to move forward, back, and sideways and also allow for rotation.

The spine also protects the spinal cord. The spinal cord is a tube of nervous tissue that runs from the brain through the spinal column ending up as a series of nerves. These nerves leave the spinal column at different levels to supply the limbs, organs of the body, and sensation to the skin.

The back is designed to support muscles, ligaments and organs. Because of our varied postures (sitting, standing, bending) and activities, the spine is subjected to numerous stresses during the day. It can cope with everyday stresses such as lifting, but when it is subjected to abnormally high stresses, the muscles and ligaments become overstretched and tear. The discs start to deteriorate, and the joint spaces start to decrease, causing joint damage that can lead to nerve compression. As we age, the discs in our back start to shrink and lose their elasticity. This progresses to degenerative disc disease.

Who is most affected by back pain?

Back pain is most common in adults, and more prevalent in men than in women. However, with children carrying heavier backpacks for school and being more sedentary in their activities, back pain is becoming more common in young people.

What causes back pain?

Back pain may be the result of an acute onset (sudden) or chronic (long-term) in nature, and can include:
• Traumatic injury
• Repetitive stresses
• Disc deterioration/degeneration
• Arthritis
• Poor posture
• Genetics

What are the characteristics of back pain?

The nature of the pain can be:
• Constant or intermittent
• Localized or refer and/or radiate to other areas
• A dull ache or a sharp, piercing or burning sensation
• In varied locations
• Neck (may radiate into the arm and hand)
• Upper/mid-back
• Low back (may radiate into the leg or foot)
• Symptoms other than pain, such as weakness, numbness, or tingling

How is back pain diagnosed?

In diagnosing the cause of back pain, it is important to review the history of the symptoms and injury. Your evaluation will also include an assessment of:
• The location, intensity, duration, and radiation of the pain
• Any past injury to the back
• What positions or motions aggravate and/or relieve the pain
• Range of motion and posture
• Tenderness and soft tissue restrictions
• The nervous system

Further testing of undiagnosed back pain can include:
• X-ray evaluation
• CT scan, bone scan
• MRI
• Myelogram
• Electromyography (EMG) and nerve conduction studies
• Epidural steroid injections
• Nerve blocks
• Discograms

How is back pain treated?

Most back pain will usually improve within a few weeks without medical intervention. Pain relievers, moist heat and/or ice may be all that you need to reduce or eliminate your pain. Bed rest typically does more harm than good. Excessive use of pain relievers may also not be in your best interest as inflammation is part of the healing process.

If home treatments are not working for you, your doctor may suggest stronger medications or other therapy. It should be noted that the focus of treatment at COVA is on restoring function and management without reliance on medications. Your treatment for back pain will be determined based on your symptoms and treatment history and may include any of the following:

• Medications
• Analgesics
• Muscle relaxers
• Antidepressant medications. Low doses of antidepressant medications have been found to have a positive effect on pain. The use of these medications is for pain medication, not depression.
• Narcotics (opioids). These medications, such as codeine or hydrocodone, may be used for a short period of time with close supervision by your doctor.
• Topical creams
• Pain patches

Physical Therapy
• Modalities to reduce pain, such as moist heat, ultrasound, massage, traction
• Manual techniques to release trigger points and restore muscle balance
• Strengthening, stabilization and flexibility exercises to restore function and strength
• Education to prevent further injury or recurrence of pain

Procedures to Reduce Pain
• Electrical stimulation
• TENS (Transcutaneous Electrical Nerve Stimulation)
• Home muscle stimulation units
• Epidural Steroid iInjections
• ProliferativeTherapy
• Platelet-Rich Plasma Injections
• Facet injections
• Nerve blocks
• Radiofrequency denervation
• Spinal cord stimulation
• Neurotoxin injections

Surgery
• Laminectomy:  • This procedure involves removing part of your vertebra called the lamina. That opens up the spinal canal space and reduces pressure on your spinal nerves. It can decrease and/or relieve extremity pain caused by bone spurs or disc fragments that may be causing pressure on your spinal cord or nerve roots.

•Fusion: This surgery involves joining two or more vertebrae. It is used primarily to eliminate pain caused by abnormal motion of the vertebrae or to remove or immobilize a painful disc segment by immobilizing the vertebrae themselves. A discogram may be performed in order to determine exactly which disc(s) is causing the pain and therefore determine the level or levels to be fused.

• Discectomy:  This is a surgical procedure in which a segment of the intervertebral disc that is causing pressure on the spinal nerves is removed.

How can I prevent back pain?

Back pain can be prevented by the following:
• Regular exercise
• Exercise regularly to improve posture and strengthen the back muscles for increased support of the spine.
• Learn how to stabilize your core muscles, as this will stabilize the spine during all activities.
• Maintaining good dietary habits
• Using good body mechanics when lifting or carrying

• Practice proper lifting and carrying techniques when lifting, squatting, bending
• Picking up a load – squat down and hold the object as close to the body as practical and lift using the legs, keeping your back straight.
• For heavy loads – get help or use a cart to avoid injury to your back.
• Having good sitting posture (avoid slouching)
• When driving or sitting for long periods of time, use a lumbar support to maintain the lumbar curve. If your legs are too short, use a foot rest.

Back pain in children can be reduced by:
• Using book bags properly

• Do not overload
• Make sure that the book bag does not weigh more than 10 percent of your child’s weight.
• Pack the heaviest items so that they are closest to the child’s back, and so that the items cannot move around as they travel.
• Use both straps
• Packs should be carried with a strap over each shoulder, not just on one shoulder.
• Use framed backpacks
• The pack should have a molded frame and/or adjustable hip strap so that the weight of the filled backpack will rest on the pelvis instead of being distributed over the shoulders and spine.

• Exercising regularly
• Learn to properly stretch, especially during growth spurts when bones lengthen faster than muscles and posture changes.
• Learning good dietary habits

Links:
NAMIS - Back Pain
MedlinePlus - How to Prevent Back Pain
NINDS - Back Pain Information Page
NINDS - Low Back Pain Fact Sheet
AAOS - Low Back Pain
RS Medical - Pain & Function Solutions