Back pain

What's causing my back pain?

When a person says they have back pain, it usually means low back pain. And it's true: the most common location for back pain is in the lower back. But pain in the upper back and neck are common as well.

Back pain can be a symptom of many different illnesses and conditions. Some are problems within the back itself, or the cause can be in another part of the body. In many cases, doctors can't find a single, specific cause for the pain.

When a cause can be identified, common explanations include:

• stress or injury involving the back muscles, such as 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, past injury, and genetic predisposition
• disease or injury involving the spinal nerves, including nerve injury caused by a protruding disc (a fibrous cushion between vertebrae) or spinal stenosis (a narrowing of the spinal canal)

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
• kidney stones or a kidney infection (pyelonephritis).

When should I worry about a serious cause of back pain?

Certain symptoms (often called "red flag" symptoms) may suggest that the back pain has a more serious cause. These include fever, recent trauma, unintentional weight loss, a history of cancer, and neurological symptoms such as numbness, weakness, or incontinence (involuntary loss of urine or stool). If any of these symptoms accompany your back pain, contact your doctor immediately.

How do doctors diagnose the cause of back pain?

Details regarding the nature and onset of back pain can 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.
• Protruding disc: People with significant disc disease sometimes have severe pain in the lower back. If a disc 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.

To sort out the cause of 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 in 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. 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, your doctor may recommend one or more of the following tests:

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

How long does back pain last?

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 triggered by pregnancy almost always get better soon 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 a week to 10 days.

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.

Up to 20% of people with new back pain develop chronic (long-lasting) symptoms.

What's the best way to prevent 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.

Movement is one of the best ways to prevent back pain. Regular physical activity can make the back stronger to reduce the chances of recurrent or chronic pain. Exercises should focus on increasing strength and improving range of motion, as well as ensuring balance on both sides of the body, as some back pain can start when one side of the body is stronger than the other.

In addition, whenever possible, avoid prolonged sitting. If you work at a desk all day, get up periodically - at least every 30 to 60 minutes.

Other measures that may help prevent back pain include:

• Maintaining good posture: certain exercises and stretches can help.
• Using proper lifting technique: 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.
• Reducing your risk of 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.

What treatments can help relieve back pain?

Medications for back pain tend to have only modest and temporary benefits, so it makes sense to try something other than a pill for back pain relief. The specifics depend on the type and duration of back pain.

For new low back pain relief (lasting less than 12 weeks), initial approaches include:

• heat
• massage
• acupuncture
• yoga or tai chi.

If these don't work, a nonsteroidal anti-inflammatory drug (NSAID) such as ibuprofen or naproxen, or a muscle relaxant, are reasonable options. But given their potential to cause side effects and their modest benefit, they aren't usually the first choice.

For chronic low back pain relief (lasting 12 weeks or more), try:

• exercise (including stretching, improving balance, and strengthening core muscles)
• physical therapy
• acupuncture
• mindfulness-based programs intended to manage stress.

Other approaches, such as chiropractic treatments, tai chi, yoga, or progressive relaxation techniques, may also be helpful.

If these don't work, treatment with an NSAID or duloxetine (an antidepressant medication that can reduce chronic pain) is worth consideration. However, opioids should be avoided for chronic low back pain in most cases.

It's important to emphasize these suggestions are not for serious causes of back pain such as a major injury, cancer, infection, or fractures.

When is back surgery needed?

New back pain will usually resolve within six to eight weeks (and often within a few days), so it's usually best to be patient and give nonsurgical options time to work. Even if the discomfort persists, surgery is usually not the best approach. Surgery is most likely to be successful when the person's pain is clearly due to a problem (such as a herniated disc) that can be successfully corrected with surgery.

While surgery is usually a treatment of last resort, there are exceptions. For example, if a person has a herniated disc causing severe pain, progressive weakness in one or both legs, or loss of control of the bladder or bowels, prompt surgical intervention may be necessary.

Keep in mind that imaging tests often show abnormalities that have nothing to do with the pain, and surgery is unlikely to help. For this reason, it is essential that the results of imaging studies be considered in combination with details of the history, physical examination, and other test results.

The procedures back surgeons perform most often for back pain (especially for disc herniation or spinal stenosis) are discectomy and laminectomy.

In a discectomy, the surgeon removes part of a herniated disc.

Laminectomy is a common operation for spinal stenosis. The surgeon removes the bony plate (lamina) on the back of the vertebra where the stenosis is located. This opens up more space for the spinal nerves. Laminectomy can be performed through a tiny incision and guided by video from a miniature camera.

Sometimes there is so much narrowing that a simple laminectomy is not enough. In such cases, a laminectomy with spinal fusion may be needed. In addition to removing one or more bony plates, the surgeon removes discs and other tissues, and then stabilizes the spine with cement or hardware.