What causes low back pain?
Learn how acute and chronic signs and symptoms result in back pain and how to cope.
It should be remembered that it is not uncommon for doctors to be unable to make a precise diagnosis of the cause of low back pain. Common causes of low back pain include lumbar strain, nerve irritation, lumbar radiculopathy, bony encroachment, and conditions of the bone and joints. Each of these is reviewed below:
1. Lumbar Strain (Acute, Chronic)
A lumbar strain is a stretching injury to the ligaments, tendons, and/or muscles of the low back. The stretching incident results in microscopic tears of varying degrees in these tissues. Lumbar strain is considered one of the most common causes of low back pain. The injury can occur because of overuse, improper use, or trauma. Soft tissue injury is commonly classified as "acute" if it has been present for days to weeks. If the strain lasts longer than 3 months, it is referred to as "chronic."
Lumbar strain most often occurs in persons in their forties, but can happen at any age. The condition is characterized by localized discomfort in the low back area with onset after an event that mechanically stressed the lumbar tissues. The severity of the injury ranges from mild to severe, depending on the degree of strain and resulting spasm of the muscles of the low back.
The diagnosis of lumbar strain is based on the history of injury, the location of the pain, and exclusion of nervous system injury. Usually, x-ray testing is only helpful to exclude bone abnormalities.
The treatment of lumbar strain consists of resting the back (to avoid re-injury), medications to relieve pain and muscle spasm, local heat applications, massage, and eventual (after the acute episode resolves) reconditioning exercises to strengthen the low back and abdominal muscles. Long periods of inactivity in bed are no longer promoted as this treatment may actually slow recovery. Spinal manipulation for periods of up to 1 month has been found helpful in some patients that do not have signs of nerve irritation. Future injury is avoided by using back protection techniques during activities and support devices as needed at home or work.
2. Nerve Irritation
The nerves of the lumbar spine can be irritated by mechanical impingement or disease any where along their paths--from their roots at the spinal cord to the skin surface. These conditions include lumbar disc disease (radiculopathy), bony encroachment, and inflammation of the nerves caused by a viral infection (shingles). See discussions of these conditions below.
3. Lumbar Radiculopathy
Lumbar radiculopathy refers to nerve irritation which is caused by damage to the discs between the vertebrae. Damage to the disc occurs because of degeneration ("wear and tear") of the outer ring of the disc, traumatic injury, or both. As a result, the central softer portion of the disc can rupture (herniate) through the outer ring of the disc and abut the spinal cord or its nerves as they exit the bony spinal column. This rupture is what causes the commonly recognized "sciatica" pain that shoots down the leg. Sciatica can be preceded by a history of localized low back aching or it can follow a "popping" sensation and be accompanied by numbness and tingling. The pain commonly increases with movements at the waist and can increase with coughing or sneezing. In more severe instances, sciatica can be accompanied by incontinence of the bladder and/or bowels.
Lumbar radiculopathy is suspected based on the above symptoms. Increased radiating pain when the lower extremity is lifted supports the diagnosis. Nerve testing (EMG/electromyogram and NCV/nerve conduction velocity) of the lower extremities can be used to detect nerve irritation. The actual disc herniation can be detected with radiology testing, such as CAT or MRI scanning.
Treatment of lumbar radiculopathy ranges from medical management to surgery. Medical management includes patient education, medications to relieve pain and muscles spasm, cortisone injection around the spinal cord (epidural injection), physical therapy (heat, massage, ultrasound, electrical stimulation), and rest (not strict bed rest, but avoiding re-injury). With unrelenting pain, severe impairment of function, or incontinence (which can indicate spinal cord irritation), surgery may be necessary.
The operation performed depends on the overall status of the spine, and the age and health of the patient. Procedures include removal of the herniated disc with laminotomy (a small hole in the bone of the lumbar spine surrounding the spinal cord), laminectomy (removal of the bony wall), by needle technique (percutaneous discectomy), disc-dissolving procedures (chemonucleolysis), and others.
4. Bony Encroachment
Any condition that results in movement or growth of the vertebrae of the lumbar spine can limit the space (encroachment) for the adjacent spinal cord and nerves. Causes of bony encroachment of the spinal nerves include foraminal narrowing (narrowing of the portal through which the spinal nerve passes from the spinal column, out of the spinal canal to the body), spondylolisthesis (slippage of one vertebra relative to another), and spinal stenosis (compression of the nerve roots or spinal cord by bony spurs or other soft tissues in the spinal canal).
Spinal nerve compression in these conditions can lead to sciatica pain which radiates down the lower extremities. Spinal stenosis can cause lower extremity pains which worsen with walking and are relieved by resting (mimicking poor circulation). Treatment of these afflictions varies, depending on their severity, from rest to surgical decompression by removing the bone that is compressing the nervous tissue.
5. Bone & Joint Conditions
Bone and joint conditions that lead to low back pain include those existing from birth (congenital), those that result from wear and tear (degenerative) or injury, and those that are from inflammation of the joints (arthritis).
Congenital Bone Conditions - Congenital causes (existing from birth) of low back pain include scoliosis and spina bifida. Scoliosis is a sideways (lateral) curvature of the spine which can be caused when one lower extremity is shorter than the other (functional scoliosis) or because of an abnormal design of the spine (structural scoliosis). Children who are significantly affected by structural scoliosis may require treatment with bracing and/or surgery to the spine. Adults infrequently are treated surgically, but often benefit by support bracing.
Spina bifida is a birth defect in the bony vertebral arch over the spinal canal, often with absence of the spinous process. This birth defect most commonly affects the lowest lumbar vertebra and the top of the sacrum. Occasionally, there are abnormal tufts of hair on the skin of the involved area. Spina bifida can be a minor bony abnormality without symptoms. However, the condition can also be accompanied by serious nervous abnormalities of the lower extremities.
Degenerative Bone and Joint Conditions
As we age, the water and protein content of the body's cartilage changes. This change results in weaker, thinner, and more fragile cartilage. Because both the discs and the joints that stack the vertebrae (facet joints) are partly composed of cartilage, these areas are subject to wear and tear over time (degenerative changes). Degeneration of the disc is called spondylosis. Spondylosis can be noted on x-rays of the spine as a narrowing of the normal "disc space" between the vertebrae. It is the deterioration of the disc tissue that predisposes the disc to herniation and localized lumbar pain ("lumbago") in older patients. Degenerative arthritis (osteoarthritis) of the facet joints is also a cause of localized lumbar pain that can be detected with plain x-ray testing. These causes of degenerative back pain are usually treated conservatively with intermittent heat, rest, rehabilitative exercises, and medications to relieve pain, muscle spasm, and inflammation.
Injury to The Bones and Joints
Fractures (breakage of bone) of the lumbar spine and sacrum bone most commonly affect elderly persons with osteoporosis, especially those who have taken long-term cortisone medication. For these individuals, occasionally even minimal stresses on the spine (such as bending to tie shoes) can lead to bone fracture. In this setting, the vertebra can collapse (vertebral compression fracture). The fracture causes an immediate onset of severe localized pain that can radiate around the waist in a band-like fashion and is made intensely worse with body motions. This pain generally does not radiate down the lower extremities.
Vertebral fractures in younger patients occur only after severe trauma, such as from motor vehicle accidents. In both younger and older patients, vertebral fractures take weeks to heal with rest and pain relievers. Fractures associated with osteoporosis can also be treated with hormone therapy to stimulate the formation of new bone.
The spondyloarthropathies are inflammatory types of arthritis that can affect the lower back and sacroiliac joints. Examples of spondyloarthropathies include Reiter's disease, ankylosing spondylitis, psoriatic arthritis, and the arthritis of inflammatory bowel disease. Each of these diseases can lead to pain and stiffness in the low back which is typically worse in the morning. These conditions usually begin in the second and third decades of life. They are treated with medications directed toward decreasing the inflammation. For more information, please see the Reactive Arthritis, Ankylosing Spondylitis, and Psoriatic Arthritis articles.
Low Back Pain at a Glance
Functions of the low back, or lumbar area, include structural support, movement, and protection of certain body tissues. Symptoms in the low back can relate to the bony lumbar spine, discs between the vertebrae, ligaments around the spine and discs, spinal cord and nerves, muscles of the low back, internal organs of the pelvis and abdomen, and the skin covering the lumbar area. Treatment of low back pain is directed toward a diagnosed or suspected cause. Always consult your Doctor when questioning pain, injury or any nagging experience with possible injury. This and any article in our website on injury, disease or dysfunction is intended to inform — not to diagnose, treat or advise.