Low back pain can vary from mild discomfort following exercise or unaccustomed activity to a severe and crippling pain that is constantly present. Chronic severe back pain can have a devastating impact both on individuals and their families. Low back pain is extremely common, and over 75% of adults will suffer with low back pain at some stage during their life. The commonest cause of back pain is muscular back pain. As clinicians, we are very good at ruling out potentially serious causes of back pain. We are much less good at understanding / identifying the causes of muscular back pain.

Back pain can be classified in a number of different ways. Most commonly back pain is classified by whether it is acute or chronic, or by its cause.

Acute Low Back Pain

Acute low back pain describes a pain that comes on suddenly in a patient with no previous history of low back pain. There is often no apparent trigger or preceding injury. The first episode of acute low back pain in a healthy individual can be a frightening experience, as the patient is suddenly rendered incapable and often totally dependent on others. The majority of episodes of acute low back pain resolve within 2-weeks.

Chronic Low Back Pain

The term ‘chronic low back pain’ is used to describe low back pain that has persisted for more than three months. Many patients with chronic low back pain report pain going on for years with a fluctuating level of symptoms.

This may present as recurrent episodes of acute low back pain. Many patients learn to control the frequency of these episodes by avoiding activity that appears to aggravate the problem, by undertaking appropriate exercise, and by making other lifestyle changes such as avoiding heavy lifting. Care must be taken not to allow deterioration in general fitness and de-conditioning of the muscles that support the spine, as these factors may contribute to an ongoing problem.

The management of most cases of low back pain is primarily conservative (non-operative), and physical therapy (physiotherapy / osteopathy / chiropractor treatment) is usually the mainstay of treatment. Patients may be referred to see a spinal surgeon after conservative measures have failed. Surgical management of low back pain should only be considered when all conservative options have been tried and when a source of the pain can be identified.

Occasionally, patients may have a cause for their low back pain that requires a more urgent assessment with a spinal surgeon. To help identify patients with a potentially serious cause of their pain your doctor should listen out for warning signs in your history. These warning signs are called ‘red flags’. The following are red flag symptoms:

• Thoracic pain (pain in the middle of your back)
• Fever
• Unexplained weight loss
• Bladder or bowel dysfunction
• Numbness in the ‘saddle’ area (between your legs)
• History of cancer
• Ill health
• Progressive neurological deficit (eg weakness)
• Change in the way you walk
• Age of onset <20 years or >55 years
• Continuous, progressive pain unrelated to posture
• Long term steroid medication

Causes of Low Back pain

• Muscular pain
• Facet joint arthritis
• Discogenic low back pain
• Spondylolysis / spondylolisthesis
• Inflammatory causes (eg. Ankylosing spondylitis)
• Spinal fractures
• Spinal infection
• Spinal tumours
• Non-specific low back pain

Muscular Low Back Pain

Muscular back pain is common. It typically occurs following unaccustomed activity or an accident, though it may be a protective response to an underlying lower back problem. It can also occur for no apparent reason. Muscular low back pain is characterized by muscle spasm, making any movement painful. The treatment for muscular low back pain is pain relief and activity. Lying still may be more comfortable, but this will not help your muscle spasm get better. You may get sufficient pain relief from over-the-counter medications such as ibuprofen and paracetamol, however, you may need to get something stronger from your GP. In addition, they may give you a muscle relaxant. You may also find that heat (such as a hot water bottle) helps.

As you get more comfortable you should try and do some gentle exercise. Both walking and swimming can be beneficial. Seeing a physiotherapist / osteopath / chiropractor can also be helpful. In the longer term it is important that you try and maintain some regular physical exercise, as well as some regular exercises that addresses your core stability muscles. Additionally, you need to look after your back by avoiding heavy lifting where possible (when it is not possible you must lift with your thighs not your low back muscles), maintaining good posture, and not smoking.

Facet Joint Arthritis

Facet joint arthritis causes low back pain with stiffness. This stiffness occurs following any prolonged period of immobility, especially first thing in the morning. The stiffness is due the joints being arthritic and inflamed, and it usually settles on movement. The pain from facet joint arthritis can also extend into your thighs, which may be confused with sciatica. Patients can also experience painful muscle spasms in their lower back. Treatment is generally conservative, and surgery is rarely considered. The mainstay of treatment is physical therapy to improve posture and muscle control (physiotherapy / chiropractic treatment / osteopathy). If you are really struggling with facetal pattern back pain or if you are unable to make progress with physical therapy, then you may be offered injections (medial branch blocks), and if you have a positive response to these injections a further procedure called facet joint radiofrequency denervation. Spinal fusion is only considered to be an option in very rare circumstances.

For further information please go to the page on ‘Facet joint arthritis’

Discogenic Low Back Pain

As we get older our discs dry out. We call this disc degeneration. The majority of degenarative discs are not painful. Occasionally a disc can be painful. We call this discogenic back pain. Discogenic low back pain is a mechanical pain that arises from the disc. As some discs begin to degenerate they can become inflamed and painful, and any movement that places stress on the disc can result in back pain. Discogenic pain is typically made worse by movement, in particular bending forwards and lifting. Patients can also feel pain in their buttocks and upper thighs, as well as experience painful muscle spasms in their low back.

Treatment for discogenic low back pain is generally conservative. Treatment options include physical therapy to improve posture and muscle control (physiotherapy / chiropractic treatment / osteopathy). Improving your posture and muscle control aims to reduce the stresses being placed across the disc. To get benefit from any exercises that are prescribed it is important that you make time to do them at least once a day. Patients who continue to struggle despite physical therapy will be further investigated with an MRI scan before any further treatment is considered.

Following a MRI scan you will be seen back in the clinic and the further options discussed with you. Patients will normally be offered diagnostic medial branch block (facet joint) injections first, as there can be considerable cross over between discogenic and facetal symptoms. If you experience only temporary symptom relief following facet joint injections then it may be appropriate to consider facet joint radiofrequency denervation. If there is no benefit following the facet joint injections or if your symptoms and scan are strongly suggestive of your disc being the ‘pain generator’ then you will be offered a discogram and disc block.

For patients in whom everything points to the disc as being the pain generator then a low back fusion may be considered. A low back fusion is always a procedure of last resort when treating back pain, as the results of fusion surgery for back pain are not as good or as predictable as when treating other conditions, such as a spondylolisthesis. Despite having had a technically successful operation and with satisfactory fusion, there is still a 25% chance that a one-level lower back fusion for back pain will not improve your symptoms. The chance of your symptoms persisting following surgery is higher if the fusion involves more than one-level in your lower back.

Spondylolysis and spondylolisthesis

A spondylolysis is a bony defect in the pars interarticularis. The pars interarticularis is a part of a lamina. The lamina is the bony arch that forms the back part of a vertebra. A spondylolysis is also known as a pars defect. A spondylolysis is often thought to be a stress fracture and can often be a cause of back pain in young, sporty people.

A spondylolisthesis is when one vertebral body slips forwards relative to the vertebral body beneath it. This will produce a gradual deformity of the lower spine and a narrowing of the spinal canal or the exit foramen. A spondylolisthesis can cause pain in the back, pain in the legs, or both.

For further information please go to the page on ‘Spondylolysis and spondylolisthesis’

Inflammatory Arthropathy

There is a group of arthritic conditions that can cause an inflammatory process in the spine. This inflammation can cause tissue damage and destruction, resulting in back pain and stiffness. These conditions are called inflammatory arthropathies. Examples of inflammatory arthropathies are Ankylosing spondylitis and Rheumatoid arthritis.

Inflammatory arthropathies are diagnosed by a combination of blood tests, and x-rays and scans. A Rheumatologist rather than a Spinal surgeon generally manages these conditions.

Spinal Fractures

Generally a significant amount of force is required to sustain a spinal fracture. A spinal fracture may also result in a spinal cord or nerve injury. Most spinal cord or nerve damage occurs at the time of the accident, and may be permanent. If a spine is unstable following a fracture then there is also the potential for spinal cord or nerve injury after the accident. It is imperative therefore that spinal fractures are properly assessed.

Spinal fractures are evaluated by x-ray, MRI and CT scans. Less severe, stable fractures can often be managed using some form of brace. A brace would normally need to be worn for at least three months. This would need to be followed by a period of physical therapy to help your spine regain strength and mobility. More serious fractures may require surgical stabilisation. Most fractures are stable and do not require any form of surgical correction.

The elderly population can sustain fractures following minimal trauma. These are called vertebral compression fractures and are usually secondary to osteoporosis.

For further information please go to the page on ‘Vertebral compression fractures’

Spinal Infections

Infections in the spine are rare. When a spinal infection does occur the infection usually develops in the disc space and causes destruction of the bones above and below the infected disc. This type of infection is called a discitis. Discitis generally causes severe and persistent back pain, and should be considered as a diagnosis in any patient with severe back pain who has been generally unwell with signs of infection. Normally, the infection will have travelled to the spine from elsewhere in the body via the blood. The elderly and patients with chronic illness (especially diabetes and immuno-deficiency) are at the greatest risk.

Discitis is treated with intra-venous antibiotics. These may need to be given for several weeks, and followed by a prolonged course of oral antibiotics. The response to treatment is monitored with regular blood tests. Surgery may be required if the infection spreads to other tissues despite antibiotic treatment, or if an abscess forms putting pressure on the nerves.

Spinal Tumours

Tumours in the spine are usually secondary to a cancer that has spread from elsewhere in the body. It is possible to have primary tumours of the spine, but these are comparatively rare. Patients often present with a history of constant and increasing pain that is not related to any particular activity. There may well be an associated history of feeling unwell, weight loss, loss of appetite, and night sweats.

Spinal tumours must be properly assessed. This will usually require a number of blood tests, scans, and often a biopsy. A decision is then made as to whether the tumour requires surgical treatment. Radiotherapy or chemotherapy may also be necessary.

Non-Specific Low Back Pain

Non-specific low back pain accounts for the majority of cases of chronic low back pain. Non-specific low back pain is when there is no specific cause for your pain. Most of us will have something wrong with our backs on a MRI scan, but those structural abnormalities do not necessarily cause pain. Many patients with non-specific low back pain become very anxious, not just about their back but also about their general health and their future. This can lead to significant stress and tension resulting in further episodes of back pain. This can create a vicious cycle of fear and recurrent symptoms.

Factors that may contribute to the unnecessary continuation of non-specific low back pain include:

• Poor general health
• Lack of fitness
• Smoking
• Psychological Distress
• Work-related problems
• On-going compensation claim
• Fear of illness and disability

Exercise is vital to maintaining a healthy spine, and to help combat back problems. However, if you have a history of back problems you must talk to your doctor or physical therapist before you start an exercise routine as you need to make sure the exercises you choose are appropriate for you.

Tips for Managing your Low Back Pain

Treatment for your back problem may be as simple as reassuring you that there is nothing seriously wrong with your back. However, anyone who has had a back problem should consider some preventive measures to protect their back from further problems in the future. Most patients will benefit from seeing a physiotherapist, an osteopath, or a chiropractor.

There are a number of things that you can do to help you manage your back pain:

Stretching: The aim of stretching is to maintain the range of movement of your spine. You should also stretch your hamstrings and the rest of your body, as this will reduce the amount of movement required of the spine.

Core stability: The strength of the spine comes from the muscles of the stomach, back and upper thigh. These muscle groups form your own ‘internal muscular corset’ that serves to support and protect your spine. Your physical therapist (physiotherapist / osteopath / chiropractor) will teach you specific core strengthening exercises. As you become more comfortable with these exercises then you may benefit from joining a Pilates class.

Developing and maintaining your core muscle strength is most important part of your back rehabilitation, and is an investment against back problems in the future.

Anti-inflammatory medication: Inflammation of structures in the lower back is a big factor in lower back pain. Anti-inflammatory medication can be very effective in helping to reduce this inflammation and improve your symptoms.

When taking any medication always follow the instructions on the leaflet, and do not exceed the recommended dose. Anti-inflammatories are not be suitable for everyone, especially if you have a history of asthma, high blood pressure, kidney or heart failure, or heartburn or stomach ulcers. You should check with your GP or pharmacist if you have one of these conditions or if you are taking any other form of medication.

Lifestyle modification: Many people with low back pain will have particular things that they like or have to do in their daily lives that aggravates their back. You should consider your daily activities both at home and at work. Rather than giving up some activities, you should aim to reduce or modify those activities that appear to aggravate your back. This may bring down the amount of strain that you place on your spine to below the level at which you experience the onset of symptoms.

There are a number of activities in our daily lives that can contribute to back pain and which can be easily modified:

Workstation modifications: The back of your chair should be high enough to support your shoulders, and the back of the chair should be at right angles to the seat. The chair should be at a height that allows your knees to be bent at 90 degrees with your feet resting on the floor. Your computer screen needs to be raised off the desk, as the position of your screen determines the position of your head. You should never sit at your desk for more than one hour at a time.

If you spend a lot of time on the telephone then use a headset so that you do not sit with your head and neck tilted over to one side.

If your back is aggravated by long journeys in the car, allow a bit more time for your journey so that you can take regular breaks. Likewise, if you have to do heavy physical tasks at home such as hovering the house or digging the garden, then try to avoid doing it all at once and have regular breaks. Ideally you should try and avoid heavy lifting, but if this is not possible then make sure you lift by bending your knees, keeping your back straight.

High impact sports should be avoided if possible. These include squash, long distance jogging, fast bowling and rowing. Less high impact sporting activities such as tennis, cycling, badminton, golf, and football are usually fine. You will often feel sore the day following heavy exercise, rather than at the time of exercising. If you have a longstanding history of back pain then it is important that you increase your activity levels in small amounts so that you hopefully avoid getting into a cycle of activity followed by pain and subsequent inactivity.