Back pain

 

Back pain is sometimes known as "lumbago" or "fibrositis", and is usually experienced in the lower back (lumbar and lumbosacral spine). The spine itself is built from individual bones known as vertebrae. Each vertebra is separated from its neighbour by a disc (the intervertebral disc). A disc has a tough fibrous outer ring containing a jelly-like inner pulp. The vertebrae are connected to each other, above and below by joints called facet joints. Powerful muscles that cover the ligaments support the spine. These hold the bones and the joints in place.

Who gets it?

Almost everyone experiences an episode of back pain at some point. Back pain is thought to be more common in overweight people, those with a sedentary lifestyle and smokers. People whose work involves repeated heavy lifting with a poor posture are more likely to experience it.

Back pain is an extremely common condition causing around 230,000 people to be off work each and every day in the U.K. During any year it is estimated that about 7% of the population will consult a doctor with back pain and it is second only to bronchitis and flu as a cause of lost working days (60 million per year).

 

How does it occur?

The vertebrae above and below a disc and the muscles and nerves at that level behave as a functional unit. If for example the disc ring tears, ruptures or bulges, the pulp protrudes. (A so-called "slipped disc".) The protruding pulp may press on the nerve as it emerges from the spine. Arthritis of the spine may cause spikes of bone to grow. These too can press on nerves. Spondylosis is a term used to mean a weakness in the spine and spondylolisthesis is a more severe weakness where a whole vertebra may partially slip out of alignment with its neighbours.

Muscle spasm is the commonest cause of acute (short lived) back pain. The lumbar spine bears the greatest strain and is subject to more twisting and straining than the upper parts. This is why low back pain is so common. Rarer causes include inflammation and muscle tears. Poor posture, unaccustomed lifting, prolonged driving, lack of exercise and uncomfortable mattresses (too hard or too soft) can cause back pain.

The facet joints (which are joints between the side processes of one vertebra with the same processes of another) can become "strained" or slip out of alignment with ligament injury. It has been estimated that this can cause 15-40% of cases of chronic low back pain.

Damage to the joint between the pelvis and the spine (sacroiliac joint) may be an underestimated cause of back pain.

Rarer causes of back pain include ankylosing spondylitis (a form of arthritis which particularly affects the sacro-iliac joints and the lower spine), cancer and bone infection (osteomyelitis).

It may also result from osteoporosis (bone thinning) which can occur in women after the menopause, and also to a lesser extent in men.

Most acute back pain is self-limiting. However, if back pain shows no sign of improving or seems to be getting worse, or there are other symptoms (see below) the individual should go (back) to the doctor.

What are the symptoms?

  • Anything from a low nagging, intermittent backache to a crippling excruciating spasm.
  • Pain down the leg into the foot is usually caused by nerve compression and is called sciatica.
  • Nerve compression can also cause muscle weakness and numbness in a leg or foot.
 

What are the risks?

As most back pain is due to muscle spasm most people with low back pain will get better in days. The aim is to stay up and about and at work if possible. If the pain is manageable with simple painkillers (for example, paracetamol or ibuprofen/nurofen) and improves then there is no need to see a doctor. The following warning signs may indicate a more serious problem and the need to see a doctor:

  • Back pain associated with numbness in the ‘saddle’ area of both inner thighs and crotch and around the anus (back passage) or difficulty passing urine and or opening the bowels. These symptoms should prompt urgent medical attention since they may signify pressure on the spinal cord (the nerves in the spine).
  • Fever, weight loss associated with back pain.
  • Continuous pain and/or pain at night.
  • Marked stiffness first thing in the morning.
  • Numb, woolly feeling in the legs or feet or both.
  • Severe pain in the very young or very old.
  • Back pain following significant trauma such as a road traffic accident.
  • Back pain in someone who is known to have cancer in another part of the body since this may be a sign of spread of the cancer to the bones of the back.
  • Back pain in someone who has been on steroids for long periods of time since this may indicate crumbling of the bones of the back as a result of loss of calcium from the bones brought on by steroid use.
  • Low back pain for more than 6 weeks.
 

How is back pain diagnosed?

In most cases back pain and its cause is diagnosed by the doctor taking a history (asking about the pain and its details) and examining the patient. Tests are usually unnecessary. However, if the pain is particularly severe, long-lasting or has features not found in the majority of cases the doctor may organise further tests to diagnose the cause of the pain. These tests may include:

  • Blood tests: These may be useful to detect forms of arthritis including infection, inflammation or infection.
  • X-rays: These are rarely useful for uncomplicated first episodes of back pain of less than seven weeks' duration. Otherwise front-to-back and side-to-side views of the spine can help to show any disc narrowing or osteoarthritis (wear and tear) arthritis and to exclude some other significant causes of back pain.
  • Nuclear Magnetic Resonance (NMR) or Magnetic Resonance Imaging (MRI) scans: these are only usually useful if the doctor suspects a specific serious cause for the back pain such as a fracture, certain types of arthritis such as ankylosing spondylitis (see above), osteoarthritis or osteoporosis, infection or cancer. MRI scans are sometimes also done in advance of seeing a back specialist in order to give the specialist all the information possible in order to help in the decision about further management.
  • Computerised Tomography (CT) Scan (a special type of X-ray): can occasionally be useful in providing detailed x-ray pictures of bones, ligaments and discs of the back but more frequently an MRI scan is performed which tends to be even more detailed.
  • Isotope Bone scans: This type of scan is used in certain situations, usually by specialists, to detect some kinds of diseases inside the bones.
 

What is the treatment?

General

The most effective treatment of acute back pain is simple pain relief and continuing with normal activities. Bed rest is not an effective treatment.

The best form of pain relief initially is regular paracetamol in the form of 1-2 tablets 4 times a day and if this is not sufficient to add a so-called non- steroidal anti-inflammatory (NSAID) drug such as ibuprofen (Nurofen) as long as the person does not have a contra-indication to this group of drugs. Continuing with normal activities and returning to work as soon as possible.

Some people find heat pads give symptomatic relief. In general, the sooner the person returns to normal activities the better.  So, once the condition starts to improve, the individual should become more mobile although they should avoid heavy lifting or too much bending until the back pain has gone.  

Good doctor-patient communication

An important part of treatment is a good explanation of the disorder and how symptoms are produced, and what to expect from the investigation and treatment options. The Royal College of General Practitioners and the National Institute of Clinical Excellence have produced guidelines to GPs on the most effective ways of treating back pain.

Drug treatment

As mentioned above if simple painkillers are insufficient, then painkillers with anti-inflammatory properties (also called NSAIDs or non Steroidal Anti-Inflammatory Drugs) may be advised.  Sometimes muscle relaxants are also given to reduce the involuntary muscle spasm. If paracetamol and NSAIDs are insufficient to control the pain then a stronger form of pain relief such as codeine may be added and, in severe cases, short courses of stronger opioid painkillers such as dihydrocodeine or morphine may be used. However, since these are potentially addictive, long-term use of these is not recommended.

Initially medication must be taken regularly to control pain and spasm but after a few days it should be possible to take them as required. In very severe cases a painkilling injection may be given.

Those people unfortunate enough to develop chronic (i.e. long-lasting or recurrent) back pain may be given additional drug treatment in the form of tricyclic anti-depressants such as one called amitriptyline or anti-epileptic drugs such as carbamazepine or gabapentin. This may seem a very strange treatment to give but these drugs have been found to have a beneficial pain- relieving effect in many types of chronic pain. It is thought that they work by modifying the pain pathways to the brain as well as helping to lift mood. 

Other Treatments

Physiotherapy

Is widely available and concentrates on promoting mobility, strengthening muscles, and avoiding further attacks as well as improving posture which is responsible for many of the simpler forms of back pain.

Chiropractic and Osteopathy manipulation can also be successful in providing relief of pain and speeding recovery. However manipulation suits some better than others and you should check first with your doctor that there is no underlying bone disorder, and make sure that the practitioner is a recognised practitioner (see list of contacts at the end of this factsheet).

Special Back Exercises

These probably have little benefit in acute low back pain, but may have a place in the treatment of some individuals with chronic low back pain by strengthening the back muscles and correcting posture.

Pain clinics

In most areas of the country it is possible for the GP or specialist to refer patients with continuing back pain to clinics called pain clinics. The clinics are usually run by anaesthetists with a special interest in the control of chronic pain for which no solution can be found with the above types of treatment. The anaesthetist will initially rule out any obvious cause for the pain, although this has usually already been done by the referring doctor. In pain clinics a number of specialist treatments are available including epidural and facet joint injections.

Epidural injection

Involves injecting a substance (usually cortisone) into a layer surrounding the spinal cord called the epidural space. It is the same type of injection as is used for some mothers in labour to reduce the pain. It may produce benefit in those with acute back pain and sciatica or other nerve pain. It can be effective although the outcome tends to be very variable from one person to another.

Facet joint injections

Involve injecting steroid and/or local anaesthetic (and occasionally other substances) into the facet joints mentioned at the beginning of this factsheet. These are joints connecting each vertebra to the one above or below and are thought to be the cause of many cases of back pain. By numbing the joint in this way the pain can be relieved. The injection is usually done by an anaesthetist under X-ray control, i.e. he or she can guide the needle into exactly the right place by viewing it with the aid of real-time x-ray screening. Again the results are unpredictable in each individual case but there is little evidence for its effectiveness as a treatment.

Acupuncture

May be effective in reducing pain and improving mobility in chronic back pain. Its success is variable, and whilst it works very well for some, may not be as good in others.

TENS (Transcutaneous Electrical Nerve Stimulation)

Stimulates the spinal cord to close pain pathways and reduce the subjective sensation of pain. Like Acupuncture, it may suit some people better than others.

Referral to a Back Pain Specialist

For those people who continue to experience back pain in spite of pain relief, physiotherapy etc or whose symptoms are severe or suggest pressure on a nerve root from a ‘slipped disc’, a referral to a Back Pain Specialist for consideration of surgery may be considered.

Surgery

Since most back pain resolves with time and other types of treatment, surgery is only appropriate for a small percentage of cases of persistent or severe back pain. It may be effective for those people whose symptoms or MRI scan suggest that surgery may relieve pressure on a nerve causing such symptoms as sciatica or whose persistent debilitating back pain may be resolved with an operation to fuse two or more vertebrae together, a so-called spinal fusion operation.

Urgent surgery is considered in those people whose back pain is associated with loss of bladder or bowel control or who experience numbness of the ‘saddle’ area (the region around the back passage).

Percutaneous intradiscal radiofrequency

This procedure is a method of treating discs between the vertebrae in cases of sciatica or where it is thought that the disc is the cause of persistent back pain. Under sedation, heat is delivered to the damaged disc via an electrode or flexible catheter which is inserted through the skin under x-ray guidance. The needle or electrode is inserted into the centre of the disc and heat is administered for a carefully measured length of time, usually about 50-80 for up to 6 minutes.

This form of treatment is in its infancy and as yet unproven but it may be useful for those with severe back pain which has not responded to other types of treatment.

A similar procedure can be carried out on the facet joints (see above) which are thought to be the cause of back pain in many cases.

Intradisc electrotherapy

This is very similar to intradiscal radiofrequency treatment. A hollow needle is inserted into the painful disc through which a special catheter (tube) is inserted which is electrically heated, destroying the nerve endings in the disc which are transmitting the pain signals. Although the procedure only takes less than an hour, the patient may have to wear a corset for several weeks afterwards. Like percutaneous radiofrequency, its place in the treatment of chronic back pain is yet to be established.

 

What are the side effects of treatment?

All drug treatment can potentially cause side effects. A careful assessment of their likelihood as well as whether the risk is worth taking will be made by the prescribing doctor.

Morphine-based painkillers can often cause constipation, especially in combination with the immobility in the early stages of an acute back problem. It is helpful to eat plenty of fruit and vegetables and drink plenty of fluid to encourage a soft motion. They can also cause nausea and drowsiness.

Anti-inflammatory drugs may cause indigestion, nausea, vomiting and/or other stomach upset. If this happens they should be stopped straight away. They should not be taken by asthmatics or anyone with a history of a peptic ulcer.

The non-drug treatments should be discussed with the practitioner giving the treatment, who should be able to explain what is involved, what to expect and what the risks are.

What self-help strategies are there?

Support at home is important if disability is severe. A urine bottle and bedpan can reduce the agony of getting to the bathroom when the pain is severe.

Chronic back pain makes the sufferer irritable, and can lead on to clinical depressive illness. This may need treatment in itself.

Preventive measures are important: when lifting heavy weights, use the legs to do the work; bend the knees rather than stoop to pick up a child or a bag of shopping.

Chairs should be firm, high enough to allow easy rising, and deep enough to stop slumping. Avoid high heels and tight clothing.

Eat a high-fibre diet to avoid constipation and straining, which can bring on back pain. Being overweight is a major cause of back strain, so lose extra pounds.

 

Where can I get further information?

Apart from contacting your own GP, the following organisations may be of further help:

The British Orthopaedic Association
35-43 Lincolns Inn Field
London
WC2A 3PE
Telephone: 020 7405 6507
Web page: www.boa.ac.uk

Back Care (formerly National Back Pain Association),
16, Elmtree Road
Teddington
Middlesex
TW11 8ST
Telephone: 020 8977 5474 
Helpline: 0845 130 2704
Email: info@backcare.org.uk
Web page: www.backcare.org.uk

Chartered Society of Physiotherapy
14, Bedford Row
London
WC1R 4ED
Telephone: 020 7306 6666
Website: www.csp.org.uk

British Chiropractic Association
59 Castle Street
Reading
Berkshire
RG1 7SN
Telephone:0118 950 5950
Email: enquiries@chiropractic-uk.co.uk
Web page: www.chiropractic-uk.co.uk

General Osteopathic Council
Osteopathy House
176 Tower Bridge Road
London
SE1P 3LU
Telephone: 020 735 76655
Email: contactus@osteopathy.org.uk
Web page: www.osteopathy.org.uk

General Chiropractic Council
44 Wicklow Street
London
WC1X 9HL
Tel: 020 771 35155
Email: enquiries@gcc-uk.org.uk
Website: www.gcc-uk.org

The Back Book
This is written by a GP, orthopaedic surgeon, physiotherapist, osteopath and a psychologist. Roland M. et al. (2002). The Back Book. London: ~The stationery office