Back pain is pain felt in the back. Episodes of back pain may be acute, sub-acute, or chronic depending on the duration. The pain may be characterized as a dull ache, shooting or piercing pain, or a burning sensation. The pain may radiate into the arms and hands as well as the legs or feet, and may include paresthesia (tingling with no apparent cause), weakness or numbness in the legs and arms. The anatomic classification of back pain follows the segments of the spine: neck pain (cervical), middle back pain (thoracic), lower back pain (lumbar) or coccydynia (tailbone or sacral pain) with the lumbar vertebrae area most common for pain.
The pain may originate from the muscles, nerves, bones, joints or other structures in the vertebral column (spine). Internal structures such as the gallbladder and pancreas may also cause referred pain in the back.
Back pain is common with about nine out of ten adults experiencing it at some point in their life, and five out of ten working adults having it every year. However, it is rare for it to be permanently disabling, and in most cases of herniated disks and stenosis, rest, injections or surgery have similar general pain resolution outcomes on average after one year. In the United States, acute low back pain is the fifth most common reason for physician visits and causes 40% of missed days off work. Additionally, it is the single leading cause of disability worldwide.
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Classification
Back pain may be classified by various methods to aid its diagnosis and management. The duration of back pain is considered in three categories, following the expected pattern of healing of connective tissue. Acute pain lasts up to 12 weeks, subacute pain refers to the second half of the acute period (6 to 12 weeks), and chronic pain is pain which persists beyond 12 weeks.
Acute Back Pain Differential Diagnosis Video
Associated conditions
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 typically lasts from two weeks to three months.
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.
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
There are many causes of back pain, including blood vessels, internal organs, infections, mechanical, and autoimmune causes. The spinal cord, nerve roots, vertebral column, and muscles around the spine can all be sources of back pain. The anterior ligaments of the intervertebral disc are extremely sensitive, and even the slightest injury can cause significant pain. In osteoporosis, the bones become weaker and can develop small cracks, or fractures, in the bones, resulting in pain. Arthritis in the joints of the back can also result in discomfort. The synovial joints of the spine (e.g. zygapophysial joints/facet joints) 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.
Approximately 98 percent of people with back pain are diagnosed with nonspecific acute back pain in which there is no serious underlying pathology. Nearly 2 percent are comprised by metastatic cancers, while serious infections such as spinal osteomyelitis and epidural abscesses account for fewer than 1 percent.
Back pain can be divided into non-radicular pain and radiculopathy. Radiculopathy occurs when there is irritation in the nerve root, causing neurologic symptoms, such as numbness and tingling. Disk herniation and foraminal stenosis are the most common causes of radiculopathy. Non-radicular back pain is most commonly caused by injury to the spinal muscles or ligaments, degenerative spinal disease, or a herniated disk. Spondylosis, or spinal degeneration, occurs when the intervertebral disc undergoes degenerative changes, causing the disc to fail at cushioning the vertebrae. The space between the vertebrae becomes more narrow, resulting in compression and irritation of the nerves.
Back pain can also be due to referred pain from another source. Referred pain occurs when pain is felt at a location different from the source of the pain. An abdominal aortic aneurysm and ureteral colic can both result in pain felt in the back.
Another possible cause of chronic back pain in people with otherwise normal scans is central sensitization, where an initial injury or infection causes a longer-lasting state of heightened sensitivity to pain. This persistent state maintains pain even after the initial injury has healed. Treatment of sensitization typically involves low doses of anti-depressants.
Risk factors
- Smokers are more likely to experience back pain than others.
Diagnosis
In most cases of low back pain medical consensus advises not seeking an exact diagnosis but instead beginning to treat the pain. This assumes that there is no reason to expect that the person has an underlying problem. In most cases, the pain goes away naturally after a few weeks. Typically, people who do seek diagnosis through imaging are not likely to have a better outcome than those who wait for the condition to resolve.
Prevention
There is moderate quality evidence that suggests the combination of education and exercise may reduce an individual's risk of developing an episode of low back pain. Lesser quality evidence points to exercise alone as a possible deterrent to the risk of the onset of this condition.
Management
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 people with back pain (most estimates are 1% - 10%) require surgery.
Non medication
Back pain is generally treated with non-pharmacological therapy first, as it typically resolves without the use of medication. Superficial heat and massage, acupuncture, and spinal manipulation therapy may be recommended.
- Heat therapy is useful for back spasms or other conditions. A review concluded that heat therapy can reduce symptoms of acute and sub-acute low-back pain.
- Regular activity and gentle stretching exercises is encouraged in uncomplicated back pain, and is associated with better long-term outcomes. Physical therapy to strengthen the muscles in the abdomen and around the spine may also be recommended. These exercises are associated with better patient satisfaction, although it has not been shown to provide functional improvement. However, one study found that exercise is effective for chronic back pain, but not for acute pain. If used, they should be performed under supervision of a licensed health professional.
- Massage therapy may give short-term pain relief, but not functional improvement, for those with acute lower back pain. It may also give short-term pain relief and functional improvement for those with long-term (chronic) and sub-acute lower pack pain, but this benefit does not appear to be sustained after 6 months of treatment. There does not appear to be any serious adverse effects associated with massage.
- Acupuncture may provide some relief for back pain. However, further research with stronger evidence needs to be done.
- Spinal manipulation is a widely-used method of treating back pain, although there is no evidence of long-term benefits.
- "Back school" is an intervention that consists of both education and physical exercises. A 2016 Cochrane review found the evidence concerning back school to be very low quality and was not able to make generalizations as to whether back school is effective or not.
Medication
If non-pharmacological measures are not effective, medications may be tried.
- Non-steroidal anti-inflammatory drugs (NSAIDs) are typically tried first. NSAIDs have been shown to be more effective than placebo, and are usually more effective than paracetamol (acetaminophen).
- In severe back pain not relieved by NSAIDs or acetaminophen, opioids may be used. However, long-term use of opioids has not been proven to be effective at treating back pain. Opioids have not always been shown to be better than placebo for chronic back pain when the risks and benefits are considered.
- Skeletal muscle relaxers may also be used. Their short term use has been shown to be effective in the relief of acute back pain. However, the evidence of this effect has been disputed, and these medications do have negative side-effects.
- In people with nerve root pain and acute radiculopathy, there is evidence that a single dose of steroids, such as dexamethasone, may provide pain relief.
- Epidural corticosteroid injection (ESI) is a procedure in which steroid medications are injected into the epidural space. The steroid medications reduce inflammation and thus decrease pain and improve function. ESI has long been used to both diagnose and treat back pain, although recent studies have shown a lack of efficacy in treating low back pain.
Surgery
Surgery for back pain is typically used as a last resort, when serious neurological deficit is evident. A 2009 systematic review of back surgery studies found that, for certain diagnoses, surgery is moderately better than other common treatments, but the benefits of surgery often decline in the long term.
Surgery may sometimes be appropriate for people with severe myelopathy or cauda equina syndrome. Causes of neurological deficits can include spinal disc herniation, spinal stenosis, degenerative disc disease, tumor, infection, and spinal hematomas, all of which can impinge on the nerve roots around the spinal cord. There are multiple surgical options to treat back pain, and these options vary depending on the cause of the pain.
When a herniated disc is compressing on the nerve roots, hemi- or partial- laminectomy or discectomy may be performed, in which the material compressing on the nerve is removed. A mutli-level laminectomy can be done to widen the spinal canal in the case of spinal stenosis. A foraminotomy or foraminectomy may also be necessary, if the vertebrae are causing significant nerve root compression. A discectomy is performed when the intervertebral disc have herniated or torn. It involves removing the protruding disc, either a portion of it or all of it, that is placing pressure on the nerve root. Total disc replacement can also be performed, in which the source of the pain (the damaged disc) is removed and replaced, while maintaining spinal mobility. When an entire disc is removed (as in discectomy), or when the vertebrae are unstable, spinal fusion surgery may be performed. Spinal fusion is a procedure in which bone grafts and metal hardware is used to fix together two or more vertebrae, thus preventing the bones of the spinal column from compressing on the spinal cord or nerve roots.
If infection, such as a spinal epidural abscess, is the source of the back pain, surgery may be indicated when a trial of antibiotics is ineffective. Surgical evacuation of spinal hematoma can also be attempted, if the blood products fail to break down on their own.
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. Those with significant back pain are at greater risk of back pain 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, may help. 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-sacral region that as a result strains the multifidus.
Economics
Back pain is regularly cited by national governments as having a major impact on productivity, through loss of workers on sick leave. Some national governments, notably Australia and the United Kingdom, have launched campaigns of public health awareness to help combat the problem, for example the Health and Safety Executive's Better Backs campaign. In the United States lower back pain's economic impact reveals that it is the number one reason for individuals under the age of 45 to limit their activity, second highest complaint seen in physician's offices, fifth most common requirement for hospitalization, and the third leading cause for surgery.
Evolutionary perspective
An evolutionary perspective has been used to try to explain why humans have back pain. Selective pressures often resulted in our evolution as a species. At times we are able to postulate the reason for these changes, and other times we cannot seem to arrive at a logical conclusion about the possible benefits of the tradeoff. In the case of back pain, researcher Aaron G. Filler believes the evolutionary changes seen in the human skeleton occurred to ensure the survival of the species. Of special mention here is our ability to walk upright. Walking upright meant that our hands were now free to carry heavy objects and the young across great distances.
Source of the article : Wikipedia
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