Back Pain

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 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.

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

  Associated Back Pain Conditions 

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.

Underlying sources and 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.

Management 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.

Short-term relief 

Conservative treatments

• Exercises can be an effective approach to reducing pain, but should be done under supervision of a licensed health professional. Generally, some form of consistent stretching and exercise is believed to be an essential component of most back treatment programs. However, one study found that exercise is also effective for chronic back pain, but not for acute pain. Another study found that back-mobilizing exercises in acute settings are less effective than continuation of ordinary activities as tolerated.  
• Physical therapy consisting of manipulation and exercise, including stretching and strengthening (with specific focus on the muscles which support the spine). 'Back schools' have shown benefit in occupational settings. The Schroth method, a specialized physical exercise therapy for scoliosis, kyphosis, spondylolisthesis, and related spinal disorders, has been shown to reduce severity and frequency of back pain in adults with scoliosis.  
• A randomized control trial, published in the British Medical Journal, found that the The Alexander Technique provided long term benefits for patients with chronic back pain.
• Manipulation, as provided by an appropriately trained and qualified chiropractor, osteopath, physical therapist, or a physiatrist.
• Acupuncture has some proven benefit for back pain
• Education, and attitude adjustment to focus on psychological or emotional causes - respondent-cognitive therapy and progressive relaxation therapy can reduce chronic pain.

Back Surgery

Surgery may sometimes be appropriate for patients with: 

Conservative, Pallative Treatment Options

• Cold compression therapy is advocated for a strained back or chronic back pain and is postulated to reduce pain and inflammation, especially after strenuous exercise such as golf, gardening, or lifting.
• Bed rest is rarely recommended as it can exacerbate symptoms, and when necessary is usually limited to one or two days. Prolonged bed rest or inactivity is actually counterproductive, as the resulting stiffness leads to more pain.
• Electrotherapy, such as a transcutaneous electrical nerve stimulation (TENS) has been proposed. In addition, spinal cord stimulation, where an electrical device is used to interrupt the pain signals being sent to the brain and has been studied for various underlying causes of back pain.
• Inversion therapy is useful for temporary back relief due to the traction method or spreading of the back vertebres through (in this case) gravity. The patient hangs in an upside down position for a period of time from ankles or knees until this separation occurs. The effect can be achieved without a complete vertical hang ( 90 degree) and noticeable benefits can be observed at angles as low as 10 to 45 degrees.
• Ultrasound is sometimes used to alleviate pain symptoms