Back Pain

What is back pain?

Back pain can be a symptom of many different illnesses and conditions. The main cause of the pain can be a problem with the back itself or by a problem in another part of the body. In many cases, doctors can't find a cause for the pain. When a cause is found, common explanations include:

stress or injury involving the back muscles, including back sprain or strain; chronic overload of back muscles caused by obesity; and short term overload of back muscles caused by any unusual stress, such as lifting or pregnancy
disease or injury involving the back bones (vertebrae), including fracture from an accident or as a result of the bone-thinning disease osteoporosis
degenerative arthritis, a "wear and tear" process that may be related to age, injury and genetic predisposition
disease or injury involving the spinal nerves, including nerve injury caused by a protruding disk (a fibrous cushion between vertebrae) or spinal stenosis (a narrowing of the spinal canal)
kidney stones or a kidney infection (pyelonephritis).

Rarer causes include:

Inflammatory arthritis, including ankylosing spondylitis and related conditions
A spinal tumor or a cancer that has spread (metastasized) to the spine from elsewhere in the body
Infection, which may be in the disk space, bone (osteomyelitis), abdomen, pelvis or bloodstream.

Symptoms of back pain

Back pain varies widely. Some symptoms (often called "red flag" symptoms) may suggest that the back pain has a more serious cause. These include fever, recent trauma, weight loss, a history of cancer and neurological symptoms, such as numbness, weakness or incontinence (involuntary loss of urine or stool).

Back pain is often accompanied by other symptoms that may help point to its cause. For example:

Back sprain or strain – Back pain typically begins on the day after heavy exertion or an activity that requires twisting. Muscles in the back, buttocks and thighs are often sore and stiff. The back may have areas that are sore when touched or pressed.
Fibromyalgia – In addition to back pain, there are usually other areas of pain and stiffness in the trunk, neck, shoulders, knees and elbows. Pain may be either a general soreness or a gnawing ache, and stiffness is often worst in the morning. People usually complain of feeling abnormally tired, especially of waking up tired, and they have specific areas that are painful to touch, called tender points.
Degenerative arthritis of the spine – Together with back pain, there is stiffness and trouble bending over, which usually develops over many years.
Inflammatory arthritis, including ankylosing spondylitis and related conditions – In these disorders, there is pain in the lower back, together with morning stiffness in the back, hips or both. Back pain in these condition tends to improve with exercise. Other features may include psoriasis, eye pain and redness, or diarrhea, depending on the specific disorder causing back pain. This group of diseases is a relatively rare cause of back pain.
Osteoporosis – This common condition is characterized by thinned, weakened bones that fracture easily. It is most common in postmenopausal women. When vertebrae become compressed because of fracture, posture may become stooped over or hunched along with back pain. Osteoporosis is not painful unless a bone fractures.
Cancer in the spinal bones or nearby structures – Back pain is consistent and may become worse when you are lying down. Numbness, weakness or tingling of the legs that continues to get worse. If cancer spreads to spinal nerves that control the bladder and bowel, there may be bowel or bladder incontinence (loss of control).
Protruding disk – People with significant disk disease sometimes have severe pain in the lower back. If a disk compresses a nerve, the pain may spread down one leg. The pain gets worse during bending or twisting.
Spinal stenosis – Pain, numbness and weakness affect the back and legs. Symptoms get worse when you are standing or walking, but are relieved by sitting or leaning forward.
Pyelonephritis – People with a kidney infection typically develop sudden, intense pain just beneath the ribs in the back that may travel around the side toward the lower abdomen or sometimes down to the groin. There also can be a high fever, shaking chills and nausea and vomiting. The urine may be cloudy, tinged with blood or unusually strong or foul-smelling. There may be additional bladder related symptoms, such as the need to urinate more often than normal or pain or discomfort during urination.

Diagnosing back pain

Your doctor will ask about your symptoms and your medical history. He or she will examine your back muscles and spine and will move you certain ways to check for pain, muscle tenderness or weakness, stiffness, numbness or abnormal reflexes. For example, if you have a disk problem, you may have pain in your lower back when the doctor raises your straightened leg.

Your symptoms and the physical examination may give your doctor enough information to diagnose the problem. However, with back pain, your doctor may only be able to tell you that the problem is not serious. If your doctor determines that your back pain is caused by muscle strain, obesity, pregnancy or another cause that is not urgent, you may not need any additional tests. However, if he or she suspects a more serious problem involving your vertebrae or spinal nerves, especially if your back pain has lasted longer than 12 weeks, you may need one or more of the following tests:

x-rays of your back
blood test
urine tests
spinal magnetic resonance imaging (MRI)
computed tomography (CT) scan
nerve conduction studies and electromyography to determine whether nerves, muscles or both may be injured
bone scan, especially if you have a previous history of cancer
positron emission tomography (PET) scan.

Expected duration of back pain

How long back pain lasts depends on its cause. For example, if your pain is caused by strain from overexertion, symptoms usually subside over days or weeks and you may be able to return gradually to your normal activities. However, you should avoid heavy lifting, prolonged sitting or sudden bending or twisting until your back gets better.

Women who have back pain caused by the added weight of pregnancy almost always will get better after delivery. People who are obese may need to lose weight before back pain eases.

People with back pain caused by pyelonephritis often begin to feel better within days after they start taking antibiotics, although they usually need to continue taking antibiotics for up to two weeks.

People with more serious forms of back pain caused by problems with the vertebrae or spinal nerves may have more persistent back pain that lasts for months and may last for years.

Preventing back pain

You can help prevent some forms of back pain by strengthening your back with exercises and by avoiding activities that lead to back injury. Measures that may help prevent back pain include:

Maintain good posture.
Sleep on your side or on your back, with a pillow under your knees if you can.
Exercise regularly, but stretch before and after.
Practice abdominal crunches to strengthen abdominal muscles, which support your lower back. Also, walk or swim regularly to strengthen your lower back.
Always lift objects from a squatting position, using your hips and your legs to do the heavy work. Avoid lifting, twisting, and bending at the same time.
Avoid sitting or standing for extended periods of time.
Wear soft-soled shoes with heels that are less than 1.5 inches high.

To help prevent osteoporosis, make sure you get enough calcium and vitamin D daily to meet the dietary requirements for your age group. Follow a routine program of weight-bearing exercise. Avoid smoking and limit the amount of alcohol you drink. If you are a woman who has entered menopause, speak with your doctor about testing for osteoporosis and medications that can help to prevent or reverse it. Screening men for osteoporosis is controversial, but some guidelines recommend bone density testing for men ages 70 and older.

Treating back pain

Most episodes of back pain are not serious and may be treated with:

limited bed rest (no more than two days)
acetaminophen (Tylenol and others) for pain or oral anti-inflammatory drugs, such as aspirin, ibuprofen (Advil, Motrin and others) or naproxen (Aleve, Naprosyn), for pain and inflammation
muscle relaxants or prescription pain relievers, if necessary, for a short period
hot or cold compresses.

People with back pain are encouraged to return to their normal activities gradually, and to temporarily avoid heavy lifting, prolonged sitting, or sudden bending or twisting.

If you are recovering from back pain, your doctor may ask you to call or return to his or her office for a follow-up visit in about two weeks to confirm that your symptoms are gone and that you can safely resume all of your normal activities.

If your back pain is related to more serious disorders of the vertebrae or spinal nerves or if it hasn't improved over a few weeks, you may be referred to a specialist, such as a pain specialist, an orthopedic surgeon (a doctor who specializes in diseases of the bones), a neurologist (a doctor who specializes in diseases of the nerves and brain) or a rheumatologist (an arthritis specialist).

When to call a professional

Contact your doctor if:

Severe back pain makes it impossible for you to do your normal daily activities.
Your back pain follows significant trauma.
Mild back pain gets worse after a few days or persists more than a week or two.
Back pain is accompanied by weight loss, fever, chills or urinary symptoms.
You develop sudden weakness, numbness or tingling in a leg.
You develop numbness in the groin or rectum or difficulty controlling bladder or bowel function.
You have had cancer previously and you develop persistent back pain.

Prognosis

More than 90% of people with back pain get better after conservative treatment. Only 5% of people with back pain will have symptoms for more than 12 weeks and even among these people, the cause is usually not serious.

Additional info

American College of Rheumatology
http://www.rheumatology.org/

Arthritis Foundation
http://www.arthritis.org/

National Institute of Arthritis and Musculoskeletal and Skin Diseases
http://www.niams.nih.gov/