Low Back Pain: Healing your aching back
/ Sep 23, 2013 / By / No Comments

Dear Reader,

Back pain is one of the most common, non-life-threatening, painful conditions, affecting four in five Americans at some point in their lives. And many of us — myself included — have to be wary of return bouts. But the good news is that back pain need not govern how you live your life.

Thanks to the pioneering work of back pain researchers, low back pain treatment has undergone a sea change. We now appreciate the central role of exercise in treating back problems and maintaining a healthy back. We also know that the best strategy for preventing back pain recurrence is to reduce the factors that raise your risk, like excess weight and sedentary living. This is good news both for people suffering with back pain and for society at large, because the overall costs of this common condition are staggering, with some estimates of economic impact running from $84.1 billion to $624.8 billion in the United States alone.

If you already suffer from low back pain, a program of medication, exercise, and lifestyle modification is likely to offer the most relief. Surgery is useful in select situations for patients whose conditions meet certain criteria. And if you are a candidate for surgery, you may find that you have options for minimally invasive procedures that can reduce surgical risk and have you back on your feet and getting on with your life quickly, sometimes within hours.

This report describes common types of back problems and the treatments that are likely to relieve them. Our Special Section is devoted to self-help information on exercises, healthy back habits, and strategies like choosing the right mattress or chair. The evidence for complementary therapies such as chiropractic care, acupuncture, and massage is also included.

Most back pain isn’t dangerous, but it’s important to learn the “red flag” situations that require immediate medical attention. Then, you and your health care team can choose the right treatment for your condition and your particular lifestyle. An athlete, for example, might need to undergo surgery to get back on the playing field as soon as possible, while someone with a desk job may have more freedom to try out different nonsurgical strategies. Be aware that a mismatch of condition and treatment can do more harm than good.

One thing is clear: a patient’s engagement in and determination to stick with a treatment program is vital, especially when it comes to exercise. So please work closely with your health care team as you evaluate the information in this report in light of your particular circumstances and find an approach that feels right for you.

Sincerely,

Jeffrey N. Katz, M.D.
Medical Editor

Who develops back problems?

If you’re like most adults, you’ll probably suffer from low back pain at some point in your life. Although anyone can develop backache regardless of their health or circumstances, research has found that some conditions or activities put you at greater risk for such problems. Key factors include the following.

Age

People are most likely to suffer from low back pain in midlife. During the middle years, even in the absence of any injury, the bones and joints in your lower back (the lumbar spine) begin to change (see Figure 1). Disks (the structures that serve as cushions between the bones in the spine) tend to wear out and sometimes become fragmented (see “Disk abnormalities”). These structural alterations sometimes cause pain. While back pain problems may be more common in people in their middle years, in older individuals back pain attacks are more severe and last longer.


Gender

Studies suggest that back pain plagues men and women equally. However, in Western industrialized societies, men are more apt to have disk problems, and they are more likely to be treated surgically. These differences most likely reflect the fact that a greater number of men than women work in jobs that involve heavy lifting, pushing, and pulling, and that men in such jobs often feel the need to return to work as soon as possible following an absence due to back pain.

On the other hand, osteoporosis (loss of bone density and strength) occurs in women much more often than men. This disorder can cause severe weakening of vertebrae and may eventually lead to vertebral fractures. Vertebral fractures can cause a loss of height and a rounding of the back. They can also be very painful. Women are also especially susceptible to degenerative arthritis of the lower spine (a condition that generally involves the vertebral joints). They are also more likely to develop spondylolisthesis (an abnormal forward displacement of a vertebra relative to the one below it).

What is low back pain?

Despite its being so common, low back pain remains something of a medical puzzle. Even after extensive tests, physicians often can’t pinpoint an exact cause. Many people with low back pain visit one doctor after another only to come away with conflicting opinions. Most cases of back pain are ultimately classified as “idiopathic,” meaning they have no known cause — yet the pain is all too real to the person affected.

Why is low back pain such an enigma? It is important to understand that back pain does not describe a single entity. Instead, back pain is an umbrella term that includes a number of discrete medical conditions that can vary in severity. In fact, some of these conditions don’t even originate in the back.

The way you manage your symptoms will depend on the type of low back condition you have and whether the pain is acute (that is, comes on suddenly but will likely get better in a matter of weeks) or chronic (lasting more than three months with no improvement, or even getting progressively worse).

One thing is clear, whether your back pain is acute or chronic: to regain your get-up-and-go, you need to do just that — become active, at least within reason. And as is often the case in medicine, the more active a role you play in your treatment plan, the better your recovery is likely to be.


Family history

Heredity appears to play a role in certain types of back pain. Defects of the disks seem more common in some families; a hereditary difference in the chemical makeup of disks may render them more prone to fragmentation or herniation, conditions that can trigger back pain. Ankylosing spondylitis (see “Arthritis”) and spondylolisthesis likewise seem to run in families.


Work and play

Certain jobs and activities put a greater strain on your back. Riding in motor vehicles is notoriously hard on your back, for instance, because it involves prolonged periods of sitting and exposure to vibration. The sitting positions necessary for office work — from typing to computer programming — can also eventually take a toll on your back regardless of your age.

Several other job-related activities increase the likelihood of future back problems:

  • lifting or forceful movements such as pulling and pushing

  • frequent bending or twisting of the back

  • heavy physical exertion

  • maintaining the same position for long periods

  • repetitive motion patterns

  • prolonged exposure to vibration.


Physical characteristics and posture

Your build, weight, and height seem to have little to do with your likelihood of developing back pain, although being overweight puts you at increased risk of having your symptoms return. Even a moderate difference in leg length (up to three-quarters of an inch) has no proven adverse effect on the lower back.

And despite your mother’s admonition to “sit up straight,” experts now agree that, in most cases, posture alone — whether bad or good — will neither predispose you to back pain nor shield you from it. Slumping and slouching don’t seem to have much effect on the basic health of your spine. But before you sit in your chair, note that poor posture can exacerbate existing back pain. Improving your body mechanics can help relieve your symptoms and prevent recurrences (see “Building muscles”).

Figure 1: Regions of the spine

Your spine is divided into three regions: the cervical, the thoracic, and the lumbar. Low back pain originates in the lumbar area, which extends from the bottom of your rib cage to your sacrum (the triangular bone found between your hipbones). For more information, see “The anatomy of your back.”


Psychological factors

A growing body of evidence shows that our emotions and psychological well-being have a significant influence on our physical health. It is not surprising, therefore, to learn that these factors also affect the back. Although study populations and methods vary, in general, research has shown that psychological factors such as stress, anxiety, and negative mood and emotions all increase the likelihood of developing acute (sudden) or chronic (longer-lasting) back pain (see “Acute or chronic?”). Such psychological factors seem to be especially important in determining whether an acute bout of back pain will become a chronic problem. One review of studies that examined this question, for example, found that people who were distressed or depressed were more likely to develop chronic back pain than other people. The reasons for this are not completely understood. Symptoms of chronic pain and depression share some of the same biochemical roots. The neurotransmitters serotonin and norepinephrine, for example, not only are involved in mood disorders such as depression but also are important in producing the sensation of pain.

Fortunately, this dynamic can also be reversed with cognitive behavioral therapy. By changing the behaviors and thinking patterns that may aggravate and worsen the situation, it is often possible to alleviate low back pain and prevent it from becoming a long-term problem.

Fast fact

Not only is low back pain the most common cause of work-related disability for people under age 45, but it is also the most costly. Expenses to individuals include lost wages and medical bills, and companies shoulder expenses related to worker compensation.


Other factors

How you live can make you more susceptible to back pain. Research shows that smokers are at greater risk. And being physically out of condition is an important reason people have a recurrence of the “sprain and strain” type of back pain.

A person’s education level and job situation appear to have an association with back pain, according to many studies. People who are unhappy at work because a job is unfulfilling or the pay is low tend to develop more back problems than the general population. The exact reasons for this are unclear, but these findings underscore the importance of psychological and social factors.



The anatomy of your back

The human spine consists primarily of a column of interlocking bones called vertebrae (derived from the Latin verb vertere, meaning “to turn”). Each vertebra has a roughly cylindrical body with a bony ring attached to its back surface. Projections called processes extend in several directions from this ring. Vertebrae are stacked on top of each other, and are linked together by ligaments to form joints (see Figure 2) that permit a small amount of forward, backward, and side-to-side bending, as well as some twisting and up-and-down movement.

The lower or lumbar spine consists of the lowest five vertebrae. It extends from the bottom of the rib cage to the sacrum (the large triangular bone found between your hip bones) and connects your upper and lower body. Lumbus, the Latin word for loin, is the root of the word lumbar and also of lumbago, a general term doctors often use to describe low back pain caused by sprain or strain of unknown origin. Your lumbar spine’s strength and flexibility allow you to twist, turn, bend, stand, walk, run, and lift. This part of the spine also supports most of your body’s weight and is subjected to great stress when you perform normal daily activities. Some actions, such as lifting or carrying heavy weights, can exert extreme forces on the lumbar spine. In many people, this type of high stress contributes to an aching back.

Figure 2: A closer look at your lumbar vertebrae

Each vertebra has a cylindrical body with a bony ring attached to its back surface as well as bony processes that project out in different directions from this ring. Intervertebral disks, tucked between each pair of vertebrae, serve as shock absorbers.

Each intervertebral disk has a gelatinous central part, called the nucleus pulposus, and a fibrous covering, called the annulus fibrosus. Each vertebra normally has seven processes (five are shown above; the other two are obscured in this illustration) that help stabilize your spine.

Disks: Your back’s shock absorbers

An intervertebral disk is tucked between each pair of vertebral bodies and serves as a small shock-absorbing cushion. These disks — picture them as miniature jelly donuts — prevent the vertebrae from scraping against each other. The disks also form universal joints between the vertebrae, permitting normal spinal motion. A normal disk has a jelly-like central part (the nucleus pulposus) and a tougher multilayered fibrous outer covering (the annulus fibrosus) that binds to the adjacent vertebrae.

In view of the many stresses that plague the lumbar spine throughout life, it is little wonder that the disks are the source of many back problems. Indeed, they begin to change relatively early in life — usually after age 30. The nucleus begins to dehydrate, harden, and lose its jelly-like property, while the annulus tends to fragment as its various layers disintegrate. During the early stages of this process, the mechanical function of the disk gradually deteriorates, like a tire losing air. This diminishes the disk’s ability to absorb shocks, making the affected intervertebral joint more vulnerable to mechanical load.


A flexible, protective column

The cylindrical vertebral bodies and the disks between them form only part of the spinal column. The portions of the vertebrae behind the bodies — known as posterior elements because they are located at the rear of the spine, the part under the skin on your back — fit together as well. The result is a tube of bone and ligament that extends from your head to your pelvis and serves as a conduit for the spinal cord and the nerve roots that extend from the bottom of the cord.

The posterior elements include the bony processes that project from the vertebrae. These processes play an important role as stabilizers of the spine. Each vertebra normally has seven: a spinous process down the middle of the back, two superior (upper) and two inferior (lower) articular processes, and right and left transverse processes on the sides. The articular processes mesh with those of adjacent vertebrae to form a series of small connections, called facet joints, which give the spine additional stability and also allow the type of motion normally possible between vertebrae.


Ligaments and muscles

Your spinal ligaments and muscles attach to the spinous and transverse processes. The ligaments connect the vertebrae to one another, making the spine a flexible column. The muscles enable your trunk to move, bend, twist, and stretch. More important, they limit and control back motions and support the spine — a bit like guy wires that support a tall television relay tower.

The muscles can be divided into three general groups (see Figure 3). The flat abdominal muscles in front are attached to the pelvis below and the ribs above. These muscles form the cavity that contains your stomach and other abdominal organs; they also support your lumbar spine in front.

The two iliopsoas muscles, one on each side of your lumbar vertebrae, are attached to the bodies of the vertebrae and to the inside of your pelvis. They pass downward in front of your hip joints and attach to the thighbones. These muscles not only support your spine but also flex your hips and help balance your trunk on your lower limbs when you stand.

The erector spinae (Latin for “upholder of the spine”) — located to the left and right of your spine in the rear — are the large muscle masses visible in the lower part of your back. They are composed of many muscle groups attached to the bony processes on the vertebrae, as well as to the pelvis below and the rib cage and thoracic and cervical spines above. They are the major supports of your spine during lifting. If you have acute back pain, these are the muscles that may go into spasm.

Figure 3: Back muscles and nerves

Three groups of muscles — the erector spinae, abdominal muscles, and iliopsoas muscles — support your spine and control back movements. The abdominal muscles also form your abdominal cavity, and the iliopsoas muscles allow you to flex your hips and help balance your trunk when you’re standing.

Your spinal cord runs from your brain down through your spinal canal and ends in the lumbar area. Nerve roots exit through the two narrow channels, one on each side, between adjacent vertebrae. In the lumbar spine, the remaining, lowermost nerve roots form a bundle of strands that resemble a horse’s tail — in Latin, the cauda equina.


Nerves

Although the spinal cord, or central nerve trunk, extends from the brain only to the upper part of the lumbar spine, right and left spinal nerve roots continue downward to the end of the spine.

The nerve roots in the lumbar spinal canal form a bundle of strands resembling a horse’s tail — hence the name cauda equina, which is Latin for “horse’s tail” (see Figure 3). These nerve roots contain the nerve fibers that control your leg muscles and play important roles in bladder, intestinal, and genital functions. Similarly, your sensory nerve fibers, which provide feeling from your toes up to your hips, travel through these same nerve roots on their way to your spinal cord and from there to your brain.

Although the spine provides a protective canal for the nerve roots and spinal cord, certain problems in the spine may also endanger these very structures. For example, the conduit can become too narrow, pressing on and pinching the nerve roots and their related nerve tissues. Pinched or irritated nerve roots within or near the lumbar vertebrae may cause low back or leg pain.

Various types of problems can cause this kind of painful nerve-root compression. For example, a disk can bulge in such a way that it pinches a nerve or protrudes into the spinal canal. Degenerative arthritis of the small joints coupled with the formation of small bone spurs (called osteophytes) around them can also compress one or more nerve roots. This problem is especially likely to occur in the two narrow channels, one on each side, between adjacent vertebrae, known as the intervertebral foramina.

It’s also possible for one or more nerve roots to be squeezed by one or more bulging disks or bone spurs within the canal of the lumbar spine itself. This causes the spinal canal to narrow, compressing nerves and causing a problem known as spinal stenosis.



Why does your back hurt?

Back pain has many causes, most of them difficult, if not impossible, to identify precisely. Although many episodes of acute low back pain seem related to some mechanical event — an injury, a sudden off-balance movement, an unfamiliar activity, overuse, or misuse — doctors can’t find an exact anatomical explanation for as many as 85% of low back episodes, despite advances in diagnostic technology.

Even so, it is usually possible to categorize the type of low back problem you have, which is important when it comes to treatment. When the treatment is appropriate for the problem, then recovery should go smoothly. With a mismatch, recovery may falter. This section of the report describes the major types of low back problems.

Sprains and strains

Sprains and strains are the most frequent causes of backache, but they are not always easy to diagnose quickly and accurately. Sprains affect ligaments, the tough fibrous tissue found where bones, such as the vertebrae in your spine, connect at joints. Strains are injuries of your muscles or tendons.

If you have a sprain or strain, the pain is usually confined primarily to the lower back. The pain often comes in the form of stiffness and spasms (muscle contractions). Because you may find it painful to move your trunk, you are likely to limit these movements or to be more guarded when making them. Sometimes the only way to relieve this discomfort is by lying down.

In cases of a back strain or sprain, your doctor will often observe the following during an exam: a characteristic forward or sideways bent-trunk posture, limited motion, and spasms in your chest and back muscles. Usually, there isn’t any clear evidence of nerve-root irritation, such as muscle weakness, changes in reflexes, or numbness and tingling. Nor can physicians confirm this sort of injury by using imaging techniques; an x-ray, for example, won’t show any abnormality or may show an abnormality that is unrelated.

Symptoms of back strain

  • stiffness

  • spasm

  • pain when moving torso



Nerve-compression syndromes

The next most common category of low back pain consists of conditions involving compressed nerves (often referred to as “pinched” nerves). Two major examples are disk problems, such as a herniated disk, and spinal stenosis, which occurs when a narrowing of the spinal column puts pressure on nerves in the spine.

Figure 4: Sciatica: Roots of the problem

Several nerve roots “merge” to form the sciatic nerve in the leg. If a bulging (herniated) disk pinches one of these three nerves, it can lead to sciatica, a sharp pain that radiates along the path of the sciatic nerve. The colored areas on the legs show where pain may be felt if a particular nerve root is affected.

Disk abnormalities

Disk abnormalities are more common among people in their middle years or older. As a disk degenerates over time, its gelatinous center tends to dry out. The layers of the outer shell — the annulus — that binds to the adjacent vertebrae often start to tear, thin, and weaken, especially in the parts of the disk closest to the nerve roots. A disk with these changes tends to bulge, looking like an underinflated tire.

Herniation occurs when the inner core of the disk bulges out of the annulus. People commonly refer to a herniated disk as a “slipped disk” or a “ruptured disk.” The protruding disk may press on a nearby nerve root. This kind of pressure usually causes inflammation and back pain, often accompanied by sciatica — a sharp pain that runs along the path of the sciatic nerve, which passes through the buttock, down the back of the leg, and into the foot (see Figure 4). Sciatic pain is often accompanied by a sensation of pins and needles in the affected leg, especially in the foot and toes, and it often causes people with this condition to limit their trunk movements.

The symptoms of a disk protrusion are worsened by coughing or sneezing, or doing anything that pulls on the sciatic nerve, such as bending forward from your waist or flexing your hips while keeping your knees straight. If the pain is constant, it will be difficult to find a comfortable position; if it is occasional, sharp, and shooting, it will feel like an electric shock.

Your symptoms and your doctor’s observations during a physical exam — leg weakness, diminished ankle reflexes, sensory changes — may help locate where the disk problem lies. Magnetic resonance imaging (MRI) is often used to detect herniated disks. A cautionary note: although MRI may reveal a disk problem, don’t assume that disk is the cause of your pain. Many people walk about with imperfect disks and have no symptoms. For people who do experience pain and other symptoms, it isn’t always obvious which disk is causing the problems.

If acute sciatic pain persists without any improvement for more than one month, in spite of treatment, further evaluation — and a different treatment approach — should be considered.


Symptoms of disk herniation

  • slight to intense pain in back

  • numbness or weakness in lower back, buttocks, or legs

  • shooting pain in legs


Spinal stenosis

Spinal stenosis — a narrowing of the spinal canal — most commonly affects people over age 50, since degenerative changes are often the source of the problem. Some people naturally have smaller spinal canals and are thus more prone to such difficulties and to encountering them earlier in life.

Many different factors can cause the spinal canal to become constricted. For example, disks may degenerate and bulge. Ligaments may thicken. Or small bony growths, known as bone spurs or osteophytes, may develop and protrude into the spinal canal. Other possible causes include displacement of a ligament, thickening of a vertebra’s bony plate (the lamina), or Paget’s disease.

Lumbar spinal stenosis causes low back pain and usually discomfort in the thighs or lower legs when you stand up straight, bend backward, or walk even short distances — as little as 50 to 100 yards. It’s common for people with stenosis to be more comfortable when leaning forward (for example, when pushing a grocery cart or sitting).

Your doctor is usually able to diagnose stenosis based on your symptoms, medical history, and physical exam. He or she may also use x-rays, an MRI scan, or a computed tomography (CT) scan to help assess your condition.


Symptoms of spinal stenosis

  • pain in lower back when standing up straight, bending backward, or walking

  • pain that subsides when sitting or bending forward

  • pain in buttocks or legs



“Red flag” situations

Although back pain resulting from sprain-and-strain syndrome or discomfort resulting from disk and other back problems may come on suddenly, these are not emergency situations requiring immediate or prompt action. However, certain low back pain conditions do call for timely medical attention. These are unusual causes of back pain, but they are “red flag” situations that require prompt — or, in the case of cauda equina syndrome, immediate — action.

See a doctor immediately if you have a problem with bladder or bowel control, numbness in the groin or anal area, or progressive leg weakness. These symptoms are typical of nerve irritation that could lead to irreversible damage if left untreated (see “Is it an emergency?”).

Is it an emergency?

Call your doctor immediately if

you have any of the following “red flag” symptoms along with your back pain:

  • any bowel or bladder control problems

  • numbness in your groin or anal area

  • progressive weakness in your legs.

Call your doctor when you have a chance if

your back pain is intense enough to prevent you from doing ordinary daily tasks, and it has lasted for more than three or four days.

Try home treatment if

your back pain has lasted for less than three or four days and has not involved any of the “red flag” symptoms listed above.

Cauda equina syndrome

On rare occasions, when disk herniation is very large and several nerves are compressed, your bladder and bowel function may be disturbed, resulting in severe weakness in one or both legs and even “saddle anesthesia,” which is numbness in the anal and genital areas. If you have these symptoms, you should see a doctor immediately to avoid possible serious neurological damage. Cauda equina syndrome may require emergency surgery.


Symptoms of cauda equina syndrome

  • low back pain

  • pain in one or both legs

  • nocturnal incontinence

  • ankle numbness

  • impotence


Infection

A rare cause of low back pain is bacterial infection involving a disk (diskitis), the bone of one or more vertebrae (osteomyelitis), or the facet joints (infectious arthritis). Bacteria can reach the spine from various sites via the bloodstream. The source might be a boil or other skin infection, a urinary tract infection, an abscessed tooth, or an unsterilized hypodermic needle. You’re more likely to develop a spinal infection if your resistance is compromised by a condition such as liver failure, diabetes, or AIDS, or by medications that interfere with your immune system, such as steroids or anticancer drugs.

Back pain caused by a spinal infection is often severe, and its symptoms may include back muscle spasms, fever, and tenderness around the infected vertebrae.


Symptoms of spinal infection

  • low back pain

  • pain that radiates to other areas

  • pain that increases with movement


Vertebral fractures

A sudden fall or impact that places extraordinary pressure on the spine can fracture vertebrae in the back. Vertebral fractures may also occur in people with osteoporosis, even in the absence of an injury (see “Osteoporosis”). The pain may be severe and disabling, and is usually located in the area of the injured vertebra.

Seek help quickly if you suspect you have suffered a vertebral fracture. Treatment depends on the location and nature of the fracture; in most cases, a wait-and-watch approach is best, but in other cases, where the fracture leads to spinal compression, surgery may be necessary.


Symptoms of vertebral fracture

  • low back pain

  • pain that radiates to other areas

  • pain that increases with movement

  • numbness or tingling

  • impaired bladder or bowel function


Tumors

Spinal cancer is rare, affecting far fewer than one in 100 people with back pain. But when malignant — or even benign — tumors grow in the back, they can be quite painful. Most spinal tumors develop after the spread (metastasis) of cancer that originated elsewhere, especially in the breast, lung, or prostate gland. Less often, tumors originate in the tissues of the spine (including bones and ligaments), while others start in the spinal cord or nerve roots.

Depending on its location, a spinal tumor may mimic, at least for a time, almost any other cause of back pain, including a strain or sprain, a disk problem, or a fracture. However, the discomfort caused by a tumor is often constant and progressive. Bed rest and the other measures that give at least temporary or partial relief to people with the common forms of backache tend not to be helpful for tumor pain.

Because such tumors are relatively rare and their symptoms can be so similar to those of other back ailments, the correct diagnosis is sometimes delayed.


Symptoms of a spinal tumor

  • back pain that grows worse over time

  • abnormal sensations of pain, numbness, or cold in the leg or ankle

  • back pain that is worse when lying down or when coughing or laughing

Fast fact

An estimated one in four postmenopausal American women has experienced a spinal fracture due to osteoporosis.



Other causes of back problems

Low back pain may also develop for a variety of other reasons. Some of the more common examples include arthritis, osteoporosis, and pregnancy. Less common causes of back pain include spondylolisthesis, congenital problems, and disorders affecting other organs.

Arthritis

Degenerative arthritis of the facet joints is common among older people. It often causes varying degrees of back pain, usually intermittent, over a period of months or years. Ankylosing spondylitis (from the Greek ankylos, for bent, and spondylos, for vertebra) — a condition in which the spine becomes inflamed and stiff — is the most common of these arthritic ailments. This disorder, which usually begins before age 40, can be mistaken for a back strain or a disk problem when mild. Sometimes, people with this condition have pain in both sides of their lower back or pelvis. When severe, it can cause increasing pain over time, eventually resulting in fusion of the spinal joints and a completely rigid back.


Symptoms of ankylosing spondylitis

  • back pain and stiffness

  • over time, limited movement of the spine


Osteoporosis

In older people, especially women who are postmenopausal, bones become weaker, more porous, and more susceptible to breaks. In such people, one or more vertebrae may fracture even if no actual injury has occurred. Something as innocuous as lifting a gallon of milk or sneezing can cause a vertebral fracture. This type of fracture is also referred to as a compression fracture because the broken vertebra may collapse under pressure, causing the spine to compress.

When a compression fracture occurs, back pain — sometimes severe and disabling — comes on suddenly. The discomfort tends to be localized in the region of the affected vertebra, but it may radiate around one or both sides of your trunk. While movement increases pain, lying down typically relieves it.

The most common site for osteoporotic fractures is the spine. Each year, osteoporosis causes more than half a million vertebral fractures. As many as two-thirds of these fractures go undiagnosed, with the accompanying pain attributed to sprains or strains of the back.

Spinal fractures can result in a loss of height, and, more seriously, a rounding of the back. Sometimes wearing a back brace can help ease the pain of a fracture.


Symptoms of osteoporosis of the spine

  • pain that comes on gradually

  • loss of height over time

  • in case of sudden fracture, intense pain in the middle lower back


Pregnancy

Pregnancy can cause backache, especially in the final trimester. And although the discomfort usually recedes and disappears after childbirth, it can become chronic. The exact reason for this kind of low back pain isn’t known. But several factors probably contribute: ligaments normally loosen during the third trimester, abdominal muscles stretch and weaken, and carrying the fetus and giving birth stress the back. Following childbirth, the task of caring for — and carrying — an infant or small child further taxes the lower back.


Spondylolisthesis

A defect in the bony posterior elements of one vertebra sometimes allows the front portion of that vertebra as well as the vertebra above it to slip forward out of normal alignment with the spine below. The defect may be something you were born with or may result from injury or degenerative changes over time. The result, known as spondylolisthesis, can cause severe low back pain, as well as discomfort in the thighs and hips. You may also experience sciatica, usually in both legs. Certain types of athletes — including weight lifters, football players (particularly interior linemen), gymnasts, and sumo wrestlers — are especially prone to this defect.

Deformation, molding, or yielding of the bone of the facet joints causes a condition called degenerative spondylolisthesis. This condition occurs because of gradual wear and tear, rather than heavy lifting or flexion-extension movements (such as those done by gymnasts). People with diabetes have four times the average risk for this problem.


Symptoms of spondylolisthesis

  • lower back pain

  • muscle tightness (tight hamstring muscle)

  • pain in the thighs and buttocks

  • stiffness


Congenital abnormalities

The formation of the spine during fetal development is a complex process. A number of variations may occur during development, and even show up on x-rays later on. Most of them are not significant, but some, such as spina bifida, can be symptomatic and disabling.


Disorders of other organs

A backache may be caused by an aneurysm — a ballooning weakness — of your aorta, the very large blood vessel that carries blood from your heart to your lower trunk and legs. Disorders of various abdominal or pelvic organs, including the pancreas, kidneys, or uterus, can also cause back pain. Pain in the back from conditions that have nothing to do with the spine or related structures is usually called referred pain. Ordinarily, such pain is not affected by motions or activities that put stress on the spine. Moreover, x-rays and other diagnostic tests show nothing to implicate the back.




Diagnosing back pain

For most people with low back pain, the problem usually stems from strain or sprain due to overuse, unaccustomed activity, excessive lifting, or an accident of some kind. Less often, a nerve-compression problem is to blame. In most cases the best thing to do is to wait and watch to see if the problem resolves on its own. It’s time to see a doctor if your back pain does not improve after trying home remedies for three to four days. And consult a doctor immediately if you experience any “red flag” symptoms (see “Is it an emergency?”).

If you decide to see a doctor, your first stop is likely to be with your primary care physician, usually an internist or family practitioner. For especially troublesome or atypical back pain, your doctor may send you to a specialist such as an orthopedist, rheumatologist, neurologist, or physiatrist (see “It takes a team”).

Your medical history and exam

Despite impressive diagnostic methods developed since the 1980s, the key to successful diagnosis of back problems is seeing a competent physician who will take a detailed medical history and conduct a thorough examination.

The medical history includes a precise account of your back pain — its duration and intensity, whether it radiates down the legs, whether it is accompanied by numbness or tingling, whether it is exacerbated by coughing or sneezing, and whether it has occurred in the past. Other questions are aimed at determining if there is any underlying cancer or infection that might be causing your pain. Telltale clues include weight loss, fever, anemia, a history of cancer or immunodeficiency, or diabetes. Since nicotine is toxic to the intervertebral disks, your clinician may ask if you smoke. And because genes play a role in some types of back pain, your physician will want to know about any family history of back pain.

As part of the physical examination, your doctor will check the contour and range of motion of your back. He or she will also examine your knee and ankle reflexes, test for weakness in certain muscles (particularly those in the legs), and check the sensation in your legs and feet. The physician will also search for signs of irritation of your nerve roots, often by using a straight leg–raising test. This test, by pulling on the sciatic nerve, can produce pain in your leg if the nerve root is irritated or if a disk presses on it. If individual reflexes and muscles are affected and the physician can establish the precise location of any numbness or tingling, it is often possible to identify which nerve root or roots are affected.


Imaging studies and other testing

Although it’s often tempting to enlist technology in the effort to identify the cause of vexing symptoms, most experts now question the value of early imaging tests for garden-variety back pain. In fact, the current consensus is that diagnostic imaging tends to be overused at the onset of back pain symptoms — the very time when it is least useful.

Here’s why: in most cases, x-rays and other imaging tests, such as CT and MRI scans, are not useful in determining the cause of low back pain. Most people’s tests show some sort of abnormal result, yet these abnormalities are seldom related to the person’s symptoms. Indeed, the abnormalities may not cause any pain at all. For example, nearly two-thirds of MRI examinations of adults with no back pain reveal disk bulges or protrusions in the lumbar spine. Similarly, in people over age 50, an astounding 90% of x-rays and other imaging scans will show abnormalities resulting from aging, but such age-related changes are often present regardless of whether the individuals have any back pain. In other words, even if you have wear from aging, that may not be the source of your pain.

However, there are times when imaging tests may be appropriate. If an initial medical evaluation leads your physician to suspect a serious condition such as a tumor, infection, fracture, or compression of the cauda equina, or if the pain becomes chronic (continues with little or no improvement for three months or more), imaging studies and other tests can help identify the source of your back pain and rule out serious problems.

CT and MRI are expensive tests, a factor that becomes something to consider if you have a copayment or deductible requirement on your insurance plan. And most convincing of all, roughly 90% of people with low back pain recover on their own without these expensive tests, often in a matter of weeks.

The bottom line? Unless a physician suspects a severe or systemic condition that needs immediate attention, it’s wise to wait four weeks before considering the more sophisticated imaging tests. Chances are, you’ll recover on your own. But if you and your physician agree an imaging test may be helpful, here’s what to expect.

X-rays

X-rays primarily show your bones and other calcium-containing tissues (see Figure 5). Although they help determine the condition of the vertebrae, x-rays of the lumbar spine offer little information about the disks, ligaments, muscles, and other soft tissues. Nonetheless, despite their limited diagnostic value in some situations, x-rays are indispensable for identifying fractures, as well as bone changes caused by tumors, infection, and certain forms of arthritis. X-rays expose you to some radiation, but the doses are low and, in the absence of other, significant radiation exposure, shouldn’t pose a danger.

Figure 5: X-ray of the spine

An x-ray primarily shows bones and other tissues that contain calcium. A typical series of lower spine x-rays takes about 20 minutes, and exposes the patient to 1,200 millirem of radiation — about four times the amount of radiation people get from natural sources each year.


Computed tomography (CT)

CT imaging can sometimes, but not always, find the source of back pain. For this test, you must lie still for about 20 minutes on a table that slides into a tunnel-like scanner. An x-ray device moves along your body taking multiple pictures, each from a slightly different angle. Instead of sending a single x-ray beam through your body, this device uses many narrow beams. The beams are collected by a detector that rotates around you and then sent to a specialized computer, which instantaneously analyzes and synthesizes multiple images of your back. The result is a set of remarkably detailed composite views of nearly any anatomic plane. One downside: a CT scan exposes you to much more radiation than conventional x-rays.

CT scans provide distinct outlines of the various structures of the back (see Figure 6). While they can show arthritis or spinal stenosis, for example, they may not indicate clearly whether a herniated disk is causing problems, such as sciatica.

Figure 6: CT scan

Computed tomography (CT) provides images of the body in different planes and shows distinct outlines of the various structures. A CT scan of the lumbar spine takes 10 to 15 minutes. Radiation doses vary, depending on various factors such as the type of equipment used and the size of the patient, but generally range between 400 and 1,500 millirem of radiation.

CT scan courtesy of Daniel I. Rosenthal, M.D., Radiology Dept., Massachusetts General Hospital.


Magnetic resonance imaging (MRI)

MRI technology uses electromagnetic waves to create images of your tissues, thus avoiding the radiation hazard of x-rays and CT scans. MRI scans also delineate soft tissues, including intervertebral disks, spinal nerves, and tumors (see Figure 7).

The MRI procedure usually takes about 45 minutes, during which you lie motionless in a large tube located in the center of a room-sized machine. Detailed images are obtained from the minute electromagnetic waves emitted by body tissues that are subjected to an intense magnetic field. Although MRI is so noisy that the patient must wear ear protectors, the procedure is not invasive in any way and is believed to be harmless. However, some people feel claustrophobic in the tube.

Although MRI scans and, to a lesser extent, CT scans are expensive, when used in conjunction with a detailed medical history and the results of a physical examination, they can eliminate some of the guesswork involved in making a diagnosis. But even when an imaging technique uncovers an abnormality, it isn’t necessarily the cause of your back pain.

Figure 7: Magnetic resonance imaging

Like CT, magnetic resonance imaging (MRI) provides images of your body in different planes. Unlike CT, it also shows soft tissues in some detail. An MRI scan of the spine takes about 45 minutes and does not involve any exposure to radiation.

MRI courtesy of Daniel I. Rosenthal, M.D., Radiology Dept., Massachusetts General Hospital.


Myelography

This form of diagnostic imaging can reveal the positions of the lumbar nerve roots. It can also indicate distortions in the shape of the fluid-filled sheath that surrounds the spinal cord and the cauda equina. In this test, a contrast medium (a fluid opaque to x-rays) is injected into the sheath, and its flow is observed with a fluoroscope (a special x-ray machine). Myelography thus allows a clinician to locate any abnormalities — such as herniated disks, stenosis, or spinal tumors — that cause distortion of the sheath.

However, myelography is expensive. It is also invasive, in that it requires injecting fluid into the sheath that surrounds the spinal cord and cauda equina. And some people find it to be quite uncomfortable. Possible complications include headache (which can occasionally be severe), allergic reaction to the contrast fluid, and even infection resulting from the injection of the fluid, although this is rare. Since the advent of the imaging techniques described in this section, myelography is performed only when a diagnosis is particularly difficult or when it’s necessary to pinpoint the location of a problem in preparation for a complex surgery. In such cases, myelography is often performed in combination with CT imaging.


Other techniques

Upon occasion, a physician will recommend other tests. As with the tests already described, these are useful once your physician has ruled out some probable causes of your pain and is therefore using the tests to further narrow the possibilities.

Bone scan. For this test, the doctor injects a virtually harmless, short-lived radioactive substance into your bloodstream. Your bones absorb this substance at rates that vary according to the activity of the bone cells. An electronic device records this absorption on photographic film, thereby locating areas of rapid bone formation. A tumor, an infection, or a healing fracture will appear as a “hot spot” on the image. Once the location of an abnormality is known, other techniques can be used to make the diagnosis. A bone scan, which is nearly as expensive as a CT scan, takes about four hours, starting from the time of the injection of the radioactive material. The exposure to radioactivity associated with this procedure is a fraction of that required for a regular x-ray of the lower spine. The only discomfort is in having the injection and lying face-down for up to an hour while the scan is completed.

Electromyography and nerve conduction tests. For electromyography, fine needles are inserted into your muscles to detect and record electrical patterns generated either in response to electrical stimulation of nerves or through voluntary muscle activity. Pressure and irritation affecting the spinal nerves and certain diseases can change the nature and speed of the signals. Electromyography can help provide a more detailed analysis of nerve function, enabling your doctor to monitor the condition of your nerves. It is often painful. Electromyography is done along with nerve conduction testing (which determines how fast individual nerves relay signals), another approach to monitoring the function of spinal nerve roots.




Assessing your treatment options

A number of options exist for managing low back pain, ranging from doing little to undergoing surgery. (For discussion of treatment options, see “Special section: Healing your back,” “Medications for back pain,” and “When surgery is an option.”) But the abundance of choices provides as much reason for caution as cause for celebration. Nearly as many different therapies and so-called cures exist as there are practitioners.

Keep several things in mind before deciding on a course of treatment. Identifying the type of back disorder you suffer from is the first — and most important — step in finding how best to treat it (see “Why does your back hurt?”). Although options abound, not all are appropriate for your specific back problem.

Second, whether you’re experiencing back pain for the first time or you’ve suffered a relapse, it’s important to seek the advice of an experienced, certified, and well-recommended health specialist. You could visit an internist, family practitioner, orthopedist, rheumatologist, neurologist, neurosurgeon, or physiatrist (see “It takes a team,” below).

Finally, it’s important to be an active participant in your care. This means being as informed as possible about the risks and benefits of the various management strategies you are considering for your particular back problem. You also need to be very clear about what it is you want from treatment. Perhaps you don’t intend to hike up a mountain, but you do want to go on that long-awaited trip and enjoy the view from the top of the Eiffel Tower.

And don’t be afraid to question advice. If a health professional recommends an invasive, experimental, or very expensive treatment, consider seeking a second opinion from a physician who frequently deals with your specific condition.

It takes a team

You may need to see more than one type of practitioner to alleviate back pain, starting with a generalist and then seeking more specific types of help. Here’s a quick guide to the types of clinicians you might encounter.

Physicians

Primary care physician: Trained in general medicine, internal medicine, or family practice; makes referrals to specialists as necessary.

Neurologist: Focuses on treatment of the nerves and nervous system.

Neurosurgeon: Provides surgical care of nerve-related problems.

Orthopedist: Diagnoses and treats problems of the skeletal system and its muscles, joints, and ligaments.

Osteopath: Has training similar to that of an M.D., but with an emphasis on the musculoskeletal system and the body’s ability to heal itself.

Physiatrist: Specializes in rehabilitation.

Rheumatologist: Specializes in the treatment of rheumatic diseases (those affecting the joints, muscles, bones, skin, and other tissues), some of which can affect the back.

Other professionals

Chiropractor: Trained in manipulation of the bones and joints, including those in the spine.

Physical therapist: Focuses on exercises and other rehabilitative techniques to restore function and mobility.

Factors to consider

Ultimately the management strategy or treatment you choose to ease your back pain will depend on several factors. Chief among these are medical considerations, such as your back problem’s natural history, whether the problem is acute or chronic, and your personal situation and preferences. Taking all these factors into account will help you and your physician determine which of the available options are right for you.


Natural history: Know your condition’s timeline

When used in a medical context, natural history is a term that refers to how long the problem would persist and how it would affect you if it were left untreated. Based on scientific research, physicians can now predict the natural histories of various types of back pain. This information is very helpful, especially if you’re considering a surgical option. If the natural history suggests your pain will be of relatively short duration and mild severity, you might decide to hold off on surgery. If it suggests that the timeline will be longer and more difficult, surgery might be an option worth more consideration.

In time, most acute backaches due to sprain or strain will get better without medical intervention. Sometimes recovery happens within days. More often, however, painful backs mend more slowly, over four to eight weeks.

Although it may take longer for them to heal, many people with nerve-compression problems (pinched nerve syndromes) will also benefit from a wait-and-watch approach. For example, 90% of people with sciatica or herniated disks will recover on their own within six months. Chronic back pain problems, which are conditions that last more than three months, are admittedly more difficult to treat. But again, there is much you can do to assist your healing process.


Acute or chronic?

Acute low back pain strikes swiftly. It may follow something you did at work or at play. It can also be caused by a pinched nerve or a degenerative condition such as arthritis. Studies suggest that one-third of people with acute low back pain will be much improved in as little as one week after the start of their symptoms, and two-thirds will experience improvement within seven weeks.

But the problem tends to recur: about 40% of people who develop low back pain will experience another bout of symptoms within six months. So after the initial acute attack retreats, prevention is the name of the game.

Chronic low back pain is a very different story. This is pain that shows little or no improvement after three months. Often the precise cause of the pain is difficult to pinpoint, and it gets progressively worse.

In general, chronic back pain responds best to a management program that includes several different approaches — for example, a combination of pain-relieving medication, physical activity, and a complementary therapy such as acupuncture. If your pain persists, your doctor may refer you to a pain clinic. These centers use a variety of approaches — including education, cognitive behavioral therapy, exercise programs, biofeedback, relaxation techniques, and selective nerve blocks — to ease the pain or minimize its effect on your daily routine. The primary goal is to help people return to a more active life.


Personal considerations

Just as there is no single cause of back pain, so too there is no “one size fits all” solution. Once you’ve answered the medical questions and narrowed your treatment choices, your final choice about how best to proceed will depend on your personal situation and preferences.

For example, your back pain may have been caused by something physical, such as an injury or a fall. It may be the result of your sedentary lifestyle; over time, your body has become deconditioned. Or perhaps you are having a hard time at work: low pay and job dissatisfaction influence back problems. And then there are your genes — you may have a family predisposition to develop certain back problems. Some of these things you can do something about; others you can’t.

In all of these situations, you may opt for pain relief medication as a first step (see “Medications for back pain”), but your long-term strategy will depend on what triggered the back pain in the first place. If the problem was caused by an injury, for example, you may work with a physical therapist to find ways to avoid a similar injury in the future. If you are out of shape, you may start a regular walking routine to improve your overall physical condition. If stress at work has contributed to your back problem, it may be time to find ways to reduce your stress level or find a job that is more satisfying.

The point is this: since many factors can influence the onset of back pain, treatment also comes in several shapes and sizes. Often the best outcome is achieved with a combination, rather than a single treatment approach.




Special section: Healing your back

Today’s treatment decisions for most cases of back pain are patient-driven. In other words, you’re in the driver’s seat (with your doctor beside you) when it comes to deciding what would be an appropriate treatment path for you based on your type of back problem and the physical and other demands of your lifestyle. Since you have a considerable number of options at your disposal and a lifestyle to accommodate, it’s worth not rushing into a decision. Besides, if you allow yourself some deliberation time, your back problem may clear up with little or no medical intervention within a few weeks. Indeed, awareness of your condition’s timeline is the first crucial step. To a considerable extent, this knowledge determines the steps you can take toward healing yourself during an initial attack and maintaining a healthy back thereafter.

Taking time to deliberate doesn’t mean you do nothing. On the contrary, there’s much you can do to ease your pain and speed your healing from the start. Obviously, reducing pain is a No. 1 priority. (For a discussion of pain medications and therapies, see “Medications for back pain.”) Following are other ways you can help yourself during an acute attack and strategies to prevent a repeat episode. Note that for some therapies, a lack of high-quality studies means the effectiveness of those treatments remains unclear.

Early days: Cold and heat

Applying moderate cold or heat to your back can reduce your discomfort. It’s best to use cold compresses or an ice pack, not heat, immediately following injury, since this can alleviate pain by numbing the area and prevent or reduce swelling caused by inflammation. About 48 hours after the onset of back pain, though, applying heat to your back may be more helpful. The warmth soothes and relaxes aching muscles; it also increases blood flow, which carries oxygen and nutrients to the injured area and thus promotes the healing process. Generally, electric heating pads and hot-water bottles are effective and easy to use. Heat therapy tends to help only in the early days of an acute attack (up to a week).


Limited bed rest

Bed rest was once a mainstay of treatment for low back pain, but no longer. Bed rest can be useful, particularly if you are in severe pain while sitting and standing. But limit bed rest during the day to a few hours at a time, for no more than a couple of days.

You can lie down on a bed or sofa, in any comfortable position. Many people wonder whether their choice of mattress makes a difference; see “Ask the doctor: What type of mattress is best for people with low back pain?” for guidance. To ease the strain on your back, try putting pillows under your head and between your knees when lying on your side, under your knees when lying on your back, or under your hips when lying on your stomach. These positions reduce forces that sitting or standing impose on the back — especially on the disks, ligaments, and muscles.

An extended period of bed rest is not appropriate for moderate back strain at any stage of therapy. Although lying in bed does minimize stress on the lumbar spine, extended bed rest creates other problems. For example, muscles lose conditioning and tone. You may also develop gastrointestinal problems, such as constipation. There is some risk of blood clotting in the veins of your pelvis and legs and thus of pulmonary embolism (a serious medical condition where a blood clot, usually dislodged from a vein in your pelvis or leg, blocks an artery in your lung). Depression, as well as an increased sense of physical weakness and malaise, is common among people confined to bed rest.

For these reasons, it’s far better to engage in a limited amount of activity than to lie in bed. Well-designed research trials indicate that an early return to work — with some restrictions or light duty, if necessary — is preferable to staying home from work for an extended period.

Ask the doctor: What type of mattress is best for people with low back pain?

Considering that most people spend roughly a third of their lives lying in bed, this is a very good question. While there’s not a great deal of research on this topic, a few studies offer some guidance. In the past, doctors often recommended very firm mattresses. But in one study, in which 313 people slept on a medium-firm or firm mattress for three months, those with the medium-firm mattresses reported less pain when lying in bed as well as less pain-related disability compared with those with the firm mattresses. Another report, based on a waiting-room survey of 268 patients with low back pain, found that patients sleeping on orthopedic (very hard) mattresses experienced the poorest sleep quality. But patients experienced no difference in sleep quality between medium and firm mattresses.

While a softer mattress that conforms to your body’s natural curves may help the joints align favorably, you might also sink in so deeply that your joints twist and become painful during the night.

I usually advise my patients to try sleeping on many different mattresses and beds to see if they can find a type that feels best. If you spend a night at a hotel or someone else’s house, make note of how you feel after sleeping on the “new” bed. You might also try placing a plywood board under your current mattress, which will dampen any movement from bedsprings, or put your mattress on the floor, which simulates the feeling of a firm bed. Finally, go to a mattress showroom and try a variety of different models before buying a new one.

— Jeffrey N. Katz, M.D.


Getting going: Exercise

Exercise therapy can help the healing process during an acute episode, prevent repeat episodes of acute low back pain, and improve function in chronic low back pain.

Developing a suitable exercise program under expert supervision will enable you to build strong, flexible muscles that will be less prone to injury. If you have acute back pain, the goal is to help you resume normal activities as soon as possible and to remain symptom-free following recovery from the immediate attack. If you have chronic back pain, work with your physician to define your desired functional goal — whether it involves being able to take a tour of European museums, play with your grandchildren, or simply sit in the backyard reading a good novel.

Any exercise program should be customized to meet your individual needs and introduced gradually a couple of weeks after the onset of symptoms or when you are feeling reasonably comfortable. One golden rule about any exercise program is to stop if it becomes painful. Exercise is meant to help, not hurt. If you were exercising before an episode of back pain and then had to slow down or stop for a while because of the pain, don’t resume exercising at the same level as before the episode. Deconditioning occurs quickly; if you try to pick up your exercise routine where you left off, you might get hurt. Start by doing less (fewer minutes or repetitions) and gradually build back up to where you were before.

Building muscles

Weak back and abdominal muscles — resulting from deconditioning or age — cause or exacerbate many cases of low back pain. That’s why stretching and strengthening both your back and abdominal muscles is important not only for treating low back pain, but also for helping to prevent a recurrence of the problem.

Exercise strengthens and stretches the muscles that support the spine. A stretching and strengthening regimen should target the back, abdominal, and buttock muscles. (For suggested exercises, see Figure 8.) Strong abdominal or flexor muscles, for example, help people maintain an upright posture, as do strong extensor muscles, which run the full length of the back and maintain alignment of the vertebrae. Meanwhile, two iliopsoas muscles — which run from the lumbar vertebrae to the hips — and the buttock muscles help support the back during walking, standing, and sitting. In addition, the muscles of the upper legs should be flexible and strong, because they’re connected to the iliopsoas and buttock muscles and, if weak and tight, can strain the supporting structures of the back.

Figure 8: Back strengthening exercises

1. Lie on the floor on your back. Bend your knees and keep your feet flat on the floor. Squeeze your buttocks and pull your abdomen in toward your back. Your lower back should be pressed flat on the floor. Now raise your buttocks about an inch off the floor. Your lower back will lift slightly off the floor while your upper back remains flat. Hold for a few seconds before relaxing. Repeat 10 times.

2. While lying on the floor on your back, with your head and neck supported, grasp your leg just below your knee. Pull your leg gently toward your chest. Hold for 20 seconds. Repeat on other side. Repeat 10 times.

3. Stand with your feet slightly apart and your hands on the top of your buttocks. While looking up, push your hips forward slightly and gently bend backward. Keep your knees straight. Hold for 10 seconds. Relax. Repeat 10 times.

4. Lie on your back and bend your knees. With your arms crossed in front of your chest, slowly lift your shoulders a few inches off the floor as you pull your abdomen in and tighten your buttocks. Lower your back gently to the ground. Repeat 8–20 times.


Stretching

Stretching is a valuable component of any treatment plan for a person plagued by back problems. Most experts believe that supple, well-stretched muscles are less prone to injury. Indeed, shorter, less flexible muscle and connective tissues restrict joint mobility, which increases the likelihood of sprains and strains.

Stretch regularly but gently, without bouncing, as that can cause tissue injury. Beginners should start by holding the stretch for a short time and gradually build up to roughly 30-second stretches over time.


Aerobic exercise and sports

In addition to doing exercises that increase the strength and flexibility of the lower back, you should also engage in regular aerobic exercise, which has many benefits for general health and also helps prevent episodes of back pain.

Certain aerobic activities are safer for your back than others. For instance, bicycling (either stationary or regular), swimming, and walking lead the list of low-risk, high-benefit activities for most people’s backs. All are low- or minimal-impact exercises that strengthen the erector spinae and abdominal muscles. None involve awkward or stressful actions that are detrimental to back muscles. Participating in any or all of these activities at least three times a week is a good strategy for anyone who tends to have recurrent episodes of mild to moderate low back pain.

Sports and activities such as football, tennis, gymnastics, wrestling, weight lifting, rowing (crew), running, aerobic dance, and ballet involve a relatively high risk for back injury because of the extension, lifting, or impact involved. Other unnatural motions that could induce pain include back arching (during gymnastics and diving), twisting (while hitting a golf ball, swinging at a baseball, or bowling), vertical jolting (while riding a horse), and stretching your legs strenuously (when hiking or when balancing a sailboat during a race).

If you want to continue with one of these sports following a back problem, try it, but be careful. It is helpful to work with a physical therapist to guide your return to full activity. And don’t assume you can resume your previous level of activity right away. It’s wise to resume exercise at a much lower level of intensity and duration and build up slowly over several months.

Too much of a good thing

Although weight-bearing exercise is a standard prescription for building bone, exercising to an extreme can have a deleterious effect on your bones and — ultimately — on your back. Studies have shown conclusively that women who exercise so intensively and strenuously that they stop menstruating lose calcium from their bones and thereby heighten their risk for osteoporosis and other spinal problems later in life.



Complementary therapies

When back pain strikes, people often turn to complementary therapies to augment traditional medical treatments. Well-designed studies have shown that some of these therapies can help speed recovery from acute back pain, especially when combined with an exercise program. Some of the therapies have also proven to be of long-term benefit to some chronic back pain sufferers.

Chiropractic care

Spinal manipulation has long been used as a therapy for back pain. It is most often performed by chiropractors, although it may also be done by osteopaths and orthopedists (see “It takes a team”).

Spinal manipulation therapists apply pressure directly to the spinous processes of one or more vertebrae using a finger or the palm of the hand. Most manipulations also involve indirect force: the practitioner carefully twists the patient’s head, shoulders, and hips, temporarily displacing parts of the spine. When treating people with low back pain, chiropractors commonly also use a variety of other interventions, including massage, heat and cold therapies, and electrotherapies, as well as advice about nutrition, exercise, and other lifestyle choices.

A 2010 review of 12 different studies involving 2,887 people with low back pain concluded that combined chiropractic care improved short- and medium-term pain more than other treatments, including exercise, physical therapy, and medication. But the overall differences were slight, and there was no difference in long-term pain. People who saw chiropractors also reported being less disabled over the short term (one month) compared with people who received other treatments such as standard medical therapy, but again, the difference was small.

For some people, chiropractic manipulation lessens the amount of medication needed for pain control. But not enough studies have been done to recommend chiropractic manipulation for relief from chronic back pain. And chiropractic techniques are not advisable if you are suffering from leg numbness, pain, or weakness, which suggest nerve-related back pain or another serious condition.

Chiropractic manipulation carries a small degree of risk, especially for people with neck pain. Very rarely, chiropractic manipulations can exacerbate or even cause disk herniation and nerve-root irritation. And people with rheumatoid arthritis should avoid chiropractic care because they are more likely to experience complications. The best candidates for chiropractic manipulation are people who have no sign of nerve impairment. For them, chiropractic care tends to be satisfying and effective for acute low back pain.

If you do try spinal manipulation, always receive treatment from an experienced practitioner. And until there is more evidence, a short-term approach is best. If you don’t experience considerable improvement after about six spinal manipulations, additional treatments aren’t likely to be of much benefit.


Acupuncture

Perhaps the best known — and oldest — alternative treatment is acupuncture, an ancient Chinese physical science and art. Acupuncture can be used as either an anesthetic or a treatment for many types of physical pain and dysfunction. Extremely thin sterilized needles, sometimes electrified by a low-voltage power source, are inserted for brief periods at precise points along a complex network of body pathways termed meridians, or lines of energy, that encircle the body like global lines of longitude and latitude.

So far the evidence is inconsistent but seems to suggest that acupuncture may have some effectiveness in treating chronic, but not acute, low back pain.

Several studies have evaluated the effectiveness of acupuncture for chronic low back pain. A review of 23 studies including 6,359 patients, published in 2008 in the journal Spine, showed that while real acupuncture was no more effective than a fake (sham) acupuncture procedure, acupuncture was more effective in relieving low back pain than no treatment at all. The authors concluded that acupuncture can be useful as a supplement to conventional back pain treatments and therapies.

Acupuncture-like treatments helped some people with low back pain in the study, but the fact that real acupuncture was no better than sham acupuncture raises questions about this ancient technique’s purported mechanism of action.

If you want to try acupuncture, be sure to choose a licensed acupuncturist. Most states require a license to practice acupuncture. If you live in a state that does not require a license, choose a practitioner who is licensed in another state or is certified by the National Certification Commission for Acupuncture and Oriental Medicine (see “Resources”). It’s also important to make sure that all needles used have been properly sterilized.


Massage

As alternative therapies have gained popularity, many people with low back pain are turning to therapeutic massage. A 2009 article in Spine that reviewed findings from 13 studies concluded that massage may ease chronic low back pain, especially when done in tandem with exercise and education. Few studies compared different types of massage, but one suggested that acupressure massage (also called shiatsu), which involves applying finger pressure to points that lie along acupuncture meridians, gave greater relief than traditional Swedish massage. Another found similar results from Swedish and Thai massage, in which the therapist moves the massage recipient into a series of poses, and includes muscle compression, joint mobilization, and acupressure. The cost of a massage is covered by some health insurance plans if prescribed by a doctor. As the study authors note, receiving massages may enable you to spend less on doctor visits and pain medications. See “Resources” for information on finding a licensed massage therapist.


Transcutaneous electrical nerve stimulation (TENS)

This therapy, which involves applying electrical stimulation to the body, is thought to provide pain relief by stimulating the release of endorphins. TENS has been around for many years, but guidelines from the American Academy of Neurology published in 2009 in the journal Neurology concluded that the technique does not help long-term back pain. Insurers could use these guidelines to deny coverage of TENS for low back pain, which could further reduce the use of this uncommonly used treatment.


Complementary exercise programs

Two popular complementary exercise programs are yoga and tai chi. Some people with chronic back pain benefit from introducing these programs into a traditional treatment regimen.

Yoga. Yoga combines exercise with mental focus achieved through special breathing techniques (pranayama). While the physical exercise is valuable in itself, the mind-body connection may also be of benefit to people with back pain. One 12-week-long trial of 101 people with low back pain found that people who practiced Viniyoga (a therapeutically oriented style of yoga that emphasizes safety) had less pain and functioned better than people who read a self-care book about back pain.

A 2009 study in Spine explored the potential of Iyengar yoga, which uses props such as blankets, blocks, benches, and belts to help people perform poses to the fullest extent possible even if they lack experience or have physical limitations (see Figure 9). The study included 90 people with chronic low back pain. About half of them were assigned to 24 weeks of a twice-weekly, 90-minute regimen taught by a certified Iyengar yoga instructor. On days when they didn’t have a yoga class, they were instructed to practice at home for 30 minutes using a DVD, props, and an instruction manual. The rest of the participants (the control group) continued with usual medical care and were followed with monthly telephone calls to gather information about their medications or other therapies.

Figure 9: Iyengar adjustments to classic yoga poses

Iyengar yoga uses blocks, belts, and other props to help students perform classic yoga poses such as those shown in the gray inserts above: parivrtta trikonasana, or the revolved triangle pose (A), and ardha uttanasana, or the standing half forward bent (B). Instructions are individualized, with adjustments made for age, experience, body type, physical condition, and medical problems.

All subjects reported on a variety of measures, including how much difficulty they had doing daily activities (known as functional disability), pain intensity, depression, and medication use at the start of the study, midway through (12 weeks), immediately afterward (24 weeks), and at a follow-up six months later. Compared with the control group, the Iyengar group experienced a 29% reduction in functional disability, a 42% reduction in pain, and a 46% reduction in depressive symptoms at 24 weeks. There was also a greater trend toward lower medication use in the yoga group. There were no reports of adverse effects.

Six months after the trial ended, 68% of the people in the yoga group were still practicing yoga — on average, three days a week for at least 30 minutes. Among those who were still practicing, levels of functional disability, pain, and depression had increased slightly but were still lower than those of the control group.

If you try yoga for back pain, work with a teacher who has experience with people who have back pain.

Tai chi. Tai chi is an ancient Chinese martial art that incorporates slow turning movements, weight shifts, and deep breathing. It is designed to engage and benefit all parts of the body — not just the musculoskeletal system. While tai chi has not been studied carefully as a specific treatment for back pain, its benefits to overall health and well-being have been well documented in a number of populations, especially the elderly, in terms of improved balance, muscle tone, flexibility, and bone density.

Other exercise approaches. Other complementary exercise programs include the Alexander technique and Pilates. Although not medically accredited programs, the techniques may be helpful and safe when conducted by a trained, experienced instructor. But, as with any exercise program, in the wrong hands they can be harmful.

It is important to note that all these programs are “off the shelf,” meaning that they are not necessarily designed with your specific back problem in mind. Admittedly, you could amend some of the exercises, but only as long as you know which ones you should adapt. In contrast, if you instead work with a conventional physical therapist, the therapist typically designs a unique exercise program tailored to meet your specific needs. Another difference may be the beliefs that underlie the complementary exercises, which can lead to a particular emphasis on certain types of exercises. This is not necessarily wrong, just different. If you sign up for a complementary exercise program, be sure you understand its emphasis and whether it is suitable for your back condition. Ideally, you should describe the exercise program to your doctor so he or she can help you decide if it is a good choice for you.

Don’t rely on a back belt

Once worn only by weight lifters, back belts have gained popularity among workers who must often lift goods — from grocery store clerks to airline baggage handlers. With back problems accounting for nearly 20% of all workplace injuries and costing anywhere from $20 billion to $50 billion a year, it’s no surprise that some companies require their workers to use these belts.

But studies have cast doubt on whether these belts help protect workers’ backs or reduce sick time and workers’ compensation claims. For instance, a study in The Journal of the American Medical Association found that these belts didn’t curtail back injuries. The two-year study, which included several thousand employees who handled merchandise, found that using back belts reduced neither the incidence of low back pain nor the number of back injury claims. A 2007 study looked at two groups of patients with work-related low back disorders: one group wore a back belt and received education on back health; the other received the educational component only. Researchers found no significant difference in the recovery of the two groups.

Although a few small studies have found back belts to be protective, the consensus is that they do not reduce back injuries. And the National Institute of Occupational Safety and Health (NIOSH) has expressed concern that these belts may even do harm by giving workers a false sense of security. According to NIOSH, some workers think they can lift heavier items when wearing the belts.

NIOSH also points out that there is no scientific evidence to back up claims that these belts decrease the force exerted on the spine, that they remind wearers to lift properly (see Figure 10), or that they reduce workplace injuries. As a result, the agency doesn’t recommend employers insist that their workers use back belts to prevent back injuries.



Look to your lifestyle

A recurring back problem may be a signal to examine aspects of your lifestyle that might be contributing to the problem.

Maintain a healthy weight

Although carrying too much weight per se has not been proven to be a primary cause of back pain disorders, being overweight or obese can slow your recovery. Those extra pounds also increase the risk that back pain will return.

The heavier you are, the greater the load your spine must carry. To make matters worse, if the bulk of your weight comes in the form of abdominal fat, rather than muscle, your center of gravity can shift forward — a condition that puts added pressure on your back. By maintaining a healthy weight, you can ease the burden on your spine. To see if you are at a healthy (normal) weight, calculate your body mass index (BMI), which takes both your height and weight into consideration (see www.nhlbisupport.com/bmi/ for a calculator). Not only will you help your back if you maintain a normal BMI (in the range of 19–25), but you’ll also lower your risk for many diseases, including heart attack, stroke, diabetes, and high blood pressure.


Kick the habit

You’ve undoubtedly heard this message before: smoking harms your health. Not only does this habit raise your risk for lung cancer, heart disease, hypertension, and a plethora of other health problems, it also jeopardizes your back.

Research shows that smokers have more frequent episodes of back pain than nonsmokers, and the more people smoke, the higher the risk of such episodes, according to one study. Nicotine may in fact be toxic to the vertebral disks, contributing to low back pain in two ways. First, nicotine hampers the flow of blood to the vertebrae and disks. This impairs their function and may trigger a bout of back pain. Second, smokers tend to lose bone faster than nonsmokers, putting them at greater risk for osteoporosis, another common cause of back pain (see “Osteoporosis”).


Lighten your load

Backpacks have become ubiquitous — at school, at work, at play. But an overstuffed backpack can be a harbinger of back pain.

Most orthopedic doctors have long recognized that backpacks increase the risk of certain types of back pain, especially in students. A survey by the American Academy of Orthopaedic Surgeons found that nearly 60% of the doctors responding had treated school-age patients complaining of back and shoulder pain caused by heavy backpacks. Hauling an overloaded backpack can also cause muscle fatigue and strain and encourage the wearer to bend forward unnaturally.

If you use a backpack, you can take steps to protect yourself. For starters, use both the pack’s straps instead of slinging one strap over a shoulder. Try to carry only the essentials, and lighten your load whenever possible. Opt for backpacks that have different-sized compartments to help distribute weight evenly. And look for wide, padded straps and a padded back. When carrying a heavy load, put the heaviest items as close as possible to the center of the back, and use the hip strap for support. For very heavy loads, use a backpack with wheels. Above all, remember to bend from your knees when picking up your pack (see Figure 10).

Figure 10: The laws of lifting

Follow these basic steps whenever you need to lift something:

  • Face the object and position yourself close to it.

  • Bend at your knees, not your waist, and squat down as far as you comfortably can.

  • Tighten your stomach and keep your buttocks tucked in.

  • Lift with your legs, not your back muscles.

  • Don’t try to lift the object too high. Don’t raise a heavy load any higher than your waist; keep a light load below shoulder level.

  • Keep the object close to you as you lift it.

  • If you need to turn to set something down, don’t twist your upper body. Instead, turn your entire body, moving your shoulders, hips, and feet at the same time.

  • Ask for help with lifting anything that’s too heavy.


Develop back-healthy habits

Everyday activities, from vacuuming your house to sitting in front of the computer for hours, can take a toll on your back, particularly if you aren’t schooled in proper body mechanics. But you can take some of the pressure off your back by following these simple tips:

  • While standing to perform ordinary tasks like chopping vegetables or folding laundry, keep one foot on a small step stool.

  • Don’t remain sitting or standing in the same position for too long. Stretch, shift your position, or take a short walk when you can.

  • When bending from the waist, always use your hands to support yourself.

  • When sitting, keep your knees a bit higher than your hips and bend them at a 90-degree angle. Sit with your feet comfortably on the floor. If your feet don’t reach the floor, put a book or a small stool under them.

  • Because vacuuming can take a toll on your back, tackle rooms in chunks, spending no more than five to 10 minutes at a time doing this task.

  • Choose an office chair that offers good back support (preferably with an adjustable backrest, lumbar support, armrests, and wheels) and set up your work space so you don’t have to do a lot of twisting.

  • Try not to overload briefcases or backpacks (see “Lighten your load”).

  • Make frequent stops when driving long distances.

  • While driving, sit back in your seat, and if your seat does not provide sufficient lumbar support, place a rolled blanket or some towels behind your lower back. Try to shift your weight occasionally. If you have cruise control, use it when you can. Also consider using a foam seat cushion to absorb some of the vibration.

  • Sleep on your side if you can, and bend your knees toward your chest a bit. Also, choose a pillow that keeps your head level with your spine; your pillow shouldn’t prop your head up too high or let it droop. Choose a mattress that’s firm enough to support your spine (so that it doesn’t sag into the bed) and that follows your body’s contours (see “Ask the doctor: What type of mattress is best for people with low back pain?”).

Mind-body connection

Although there’s a lack of high-quality data on the connection between the mind and low back pain, mind-body therapies are known to help with pain control in some situations. The following are the more common therapies that help some back patients when used in conjunction with other treatments.

  • Cognitive behavioral therapy (CBT). Used to treat a wide range of conditions, including chronic back pain, this “talk therapy” aims to help patients modify how they think, feel, and behave in a given situation. In other words, if you can’t change your situation, you can change how you respond to it — and that can make a difference in your ability to cope. The recommended eight to 20 treatment sessions should be done with a therapist trained in cognitive behavioral therapy.

    A 2011 Cochrane review of 30 studies found moderately strong evidence that CBT was more effective than the usual care for back pain including physical therapy and/or medical treatments for short-term relief in people who’d had back pain for more than 12 weeks and that the type of CBT didn’t make any difference. The same review reported that CBT was about as effective as group physical exercise over the long term.

  • Relaxation. There are a number of relaxation techniques, such as progressive muscle relaxation, a technique that is often coordinated with breathing techniques.

  • Breathing. Focusing on conscious, controlled breathing is a staple technique in relaxation.

  • Meditation. Like focus breathing, the meditative state is a building block for many relaxation therapies.

  • Imagery. Guided imagery or visualization, wherein the patient conjures up soothing mental images, can promote relaxation.

  • Hypnosis. Guided hypnosis helps some people better tolerate pain.

  • Biofeedback. This technique may help some people by enabling them to relax their muscles and promotes muscular healing.


Safeguard your neck

Like your back, your neck is vulnerable to aches and pains. Neck pain can be brought on by a variety of things, including strains, sprains, muscle tension, poor posture (especially when working at a computer), sleeping on a pillow that’s too high or too low, and stress. To prevent neck pain, the following tips can help:

Keep your head straight. Poor head posture can strain your neck muscles. Try to avoid having your head rest too far forward while driving or looking at a computer monitor. Move your head back so that your ear canal is aligned with the front of your shoulders. If you sleep on your side, choose a pillow that keeps your neck muscles aligned with your spine (so you could draw a straight line down the center of your head and body while resting on your side).

Get moving. Try not to sit for long stretches at a time. Take a break by stretching or going for a mini-walk every 20 minutes or so.

Use a headset or speaker phone. Cradling the telephone between your ear and shoulder can strain your neck. If you use the phone a lot, invest in a headset or speaker phone.

Keep stress in check. It’s easier said than done, but managing your stress level has many health benefits, including warding off neck pain. Find a relaxation technique — such as yoga, meditation, or deep breathing — that works for you.

Flex your muscles. Strengthen your neck muscles by performing neck exercises every day. Here are three to try:

  • Slowly bend your head forward, hold for 10 seconds, and then bend it back, holding for another 10 seconds. Move your head back to center and then gently drop it toward your left shoulder and then your right shoulder, holding each stretch for 10 seconds. Repeat five times.

  • Lie on your stomach with your arms by your side. While keeping your abdomen and hips flat on the floor, lift your head and stomach straight up from the floor. Lift only as high as you comfortably can. Repeat five times.

  • You can do this while sitting or standing up straight: Look straight ahead. Tuck your chin in slightly and move your head backward, slowly and smoothly. Be sure to keep your head level; you should be gliding your head backward, not bending or tipping it. Hold for five seconds. Repeat five times.




Medications for back pain

Pain relief is the first step in the treatment of back pain. Pain medications are available either over the counter or by prescription. Some — such as ibuprofen and naproxen — are available in both forms, albeit at different doses.

Over-the-counter pain relievers

Over-the-counter pain relievers — such as acetaminophen, aspirin, or a nonsteroidal anti-inflammatory drug (NSAID) such as ibuprofen (see Table 1) — are usually all that is needed to relieve acute low back pain. Aspirin and NSAIDs have an advantage over acetaminophen in their ability to reduce inflammation in strained tissues, but they also cause gastric irritation and bleeding in some people. It’s important to remember that any over-the-counter medication can have toxic effects when taken in higher-than-recommended doses (see “Save your stomach, hurt your liver?”).

The best pain control is achieved when the medication is taken on a regular schedule rather than after the pain flares up again. That’s because practicing pain control is a bit like fighting a brush fire: it’s better to intervene when the problem is just smoldering. Once it flares up, it’s much harder to damp down again.

Table 1: Frequently used over-the-counter medications

Generic name
(brand name)

How long does it take to work?

How long does it last?

Maximum daily dose

Comments

Acetaminophen
(Tylenol and others)

30 minutes

4–6 hours

4,000 mg

  • Fewer gastric side effects make it useful for mild pain.

  • In high doses, possible liver and kidney toxicity especially in heavy drinkers.

  • May be combined with opioid medications.

Aspirin
(Bayer, Bufferin, others)

30 minutes

4–6 hours

4,000 mg

  • Inhibits blood clotting and shouldn’t be used before or after surgery. Aspirin products also pose a risk of gastrointestinal discomfort and bleeding.

  • Drugs in the same salicylate group as aspirin — such as trisalicylate (Trilisate), diflunisal (Dolobid), and salsalate (Disalcid) — are preferred for people with stomach and bleeding problems.

Ibuprofen
(Advil, Motrin, others)

30 minutes

4–6 hours

2,400 mg

  • Safer and better tolerated than aspirin.

  • Potent inhibitor of cyclooxygenase, an enzyme involved in the mechanism of pain, swelling, and inflammation.

Indomethacin
(Indocin)

30 minutes

4–6 hours

200 mg

  • A very strong NSAID. Used primarily to treat people with arthritis.

  • High rate of side effects; up to 20% of people stop using it because of headache, gastric irritation, and other problems.

  • Sulindac (Clinoril) is a closely related drug with fewer side effects. It is a “prodrug” that doesn’t become active until it is metabolized in the liver.

naproxen sodium
(Aleve)

30 minutes

8–12 hours

1,100 mg

  • Like ibuprofen, a derivative of propionic acid, and therefore has some of the same clinical characteristics.

  • Stays in the blood longer than ibuprofen so it needs to be taken only twice a day.

  • Higher rates of gastrointestinal side effects than ibuprofen.


Prescription pain relievers

If your low back pain is severe (as is often the case in nerve-compression syndromes), or if it becomes a chronic condition, your doctor may prescribe stronger doses of over-the-counter medications (such as NSAIDs) or different classes of medications.

COX-2 inhibitors

Once touted as offering pain relief with less risk of the unwelcome gastrointestinal side effects that could accompany long-term use of standard NSAIDs, COX-2 inhibitors, a later generation of NSAIDs, have fallen from their pinnacle.

Studies have confirmed a link between taking COX-2 inhibitors and increased risk of developing heart disease and stroke. In light of the evidence, experts at the FDA and elsewhere are rethinking when and how these drugs should be used — and by whom. Celecoxib (Celebrex) is the only COX-2 inhibitor still available. Still, COX-2 inhibitors can be helpful to certain patients with musculoskeletal pain who can’t tolerate traditional NSAIDs because of gastrointestinal problems.

Save your stomach, hurt your liver?

People suffering from low back pain sometimes choose a pain reliever that contains acetaminophen in order to avoid the stomach upset and gastrointestinal bleeding that can result from regular use of aspirin or certain NSAIDs. But acetaminophen, like any drug, has its own risks — especially for the liver. One study reported that acetaminophen was to blame for 42% of the cases of acute liver failure seen at hospitals during the study period. Many of these poisonings were accidental.

To avoid an accidental poisoning, don’t exceed the recommended maximum per day — generally set at 4 grams (4,000 milligrams), the equivalent of eight extra-strength Tylenol tablets. Remember that acetaminophen is an ingredient in many over-the-counter cold, flu, and sleep medications, so it’s important to read all medication labels carefully. In particular, if you drink alcohol on a regular basis, it is wise to avoid acetaminophen altogether, as the threshold for toxicity for drinkers appears to be lower than it is for other people.


Muscle relaxants

Muscle relaxants are sometimes prescribed for treating the symptoms of acute low back pain. A short course of muscle relaxants, taken as prescribed by a physician, can be useful for people who have severe muscle spasms following the onset of low back pain. And studies show that the muscle relaxant tizanidine (Zanaflex) combined with acetaminophen or an NSAID provided more short-term pain relief than acetaminophen or an NSAID used alone.

Living with chronic pain

For an unfortunate few, back pain never completely disappears. In such instances, rather than freedom from pain, the goal of treatment becomes “functional restoration.” This means a highly qualified team of professionals from a number of medical specialties work with the patient to reclaim doing the things that matter to him or her. These teams, which typically consist of a pain-management specialist, a physiotherapist, and a psychologist, are found in medical centers. As people in this chronic pain situation become more physically conditioned, they become able to do things they thought they’d never be able to do again. The focus switches from feeling hopeless to feeling hopeful.


Antidepressants

Antidepressants are sometimes prescribed for chronic back pain, especially when it is nerve pain. However, in 2008, a Cochrane review of studies on the topic refuted the effectiveness of antidepressants for nonspecific chronic back pain. Still, these drugs may be worth a try, especially for people with symptoms of depression. But because antidepressants can have negative side effects, their use should be monitored closely by a physician.


Neuropathy drugs

Medications typically used for neuropathy (a form of nerve pain) may also be helpful in treating low back pain. One example is gabapentin (Neurontin), a drug originally developed to treat epilepsy that may also be effective at treating back pain in some people. However, it has been linked to an increased risk for suicide and should be used cautiously.


Opioid analgesics

If your pain is intense and has not responded to other medications, or if you are suffering from very severe pain from a compression fracture, your doctor may give you a prescription for opioids for a limited period (see Table 2). Long-term use of opioids for the treatment of a chronic back problem is controversial, with some doctors reluctant to prescribe them because of dependency concerns. Other physicians argue that narcotics are safe in low doses and have a low risk of abuse among patients with no prior history of substance dependency.

Table 2: Prescription opioids for back pain

Generic name
(brand name)

Usual dosage

Comments

Codeine
(usually generic)

15–60 mg every 4 hours

  • Often combined with acetaminophen.

  • Perhaps the most commonly prescribed pain medication.

  • Has a ceiling effect: dosages greater than 60 mg often have no additional painkilling benefit.

  • Used for mild to moderate pain resulting from a variety of causes, such as injury and surgery.

Fentanyl
(Duragesic patch)

Fentanyl patches deliver tiny doses at a rate of 25–100 micrograms (mcg) per hour.

  • Related to meperidine.

  • 75–125 times more potent than morphine for temporary pain and 30–40 times more potent for persistent pain.

  • Unlike morphine, does not promote histamine release, which can cause allergic reactions and other side effects.

  • Can be given via skin patches because it is highly fat-soluble.

Hydromorphone
(Dilaudid)

2 mg every 4–6 hours

  • A derivative of morphine but about five times more potent, with a slightly shorter duration.

  • Oral, rectal, and injectable formulations are available.

Meperidine
(Demerol)

50–100 mg every 3 hours

  • Available as a syrup or in an injectable form. Far less effective when taken orally.

  • Short duration of action; lasts about three hours.

  • Large and frequently repeated doses are dangerous and may cause seizures.

  • Potentially fatal if given to patients using the antidepressants known as MAO inhibitors.

Methadone
(Dolophine)

2.5–10 mg every 3–8 hours

  • Used as a maintenance drug for people addicted to opioids. Also used to treat severe pain.

  • Stays active in the body longer than other opioids.

  • Side effects, such as sedation and slowed breathing, outlast pain-relieving effects.

Morphine
(Kadian, MS Contin, Oramorph)

10–30 mg every 4 hours for immediate-release oral morphine, but dosages vary widely depending on route of administration; long-acting formulations last 12–24 hours

  • Can be taken in many forms: by mouth, as a rectal suppository, through injection, or through catheters threaded into spaces surrounding the spinal cord.

  • The oral form is one-sixth to one-third as effective as other forms because the drug is metabolized in the liver.

  • Small amounts of morphine given through catheters threaded into spaces of the spine can produce profound pain relief that lasts 12–24 hours.

  • MS Contin is a sustained-release formula created by covering morphine granules with a waxy coating.

Oxycodone
(OxyContin, Percocet, Percodan, Roxicet, Roxicodone, Tylox)

Variable

  • Semisynthetic compound related to codeine.

  • Roxicodone and OxyContin are oxycodone alone; Percodan is oxycodone combined with aspirin; Percocet, Roxicet, and Tylox are oxycodone combined with acetaminophen.

  • Effective when taken orally.

  • OxyContin has high abuse potential because it is quickly absorbed into the bloodstream when crushed and swallowed. This produces a rapid “high.”

  • Used to treat pain after injury or surgery.

Tramadol
(Ultram)

50–100 mg every 4–6 hours; should not exceed 4,000 mg

  • A semisynthetic opiate; has effects and toxicities similar to other opiates.

  • About 15% less potent than codeine.

  • Usefulness as a postoperative drug still being researched.


Injection therapies

Injection therapy may benefit people suffering sharp, shooting pain caused by nerve compression, such as sciatica. Research has not shown benefits for people with long-term backache.

Depending on your diagnosis, injections of long-acting corticosteroids might target the epidural space, lumbar disks, or facet joints (see Figure 11). Injection therapies are given on an outpatient basis by a skilled specialist, such as an orthopedist, anesthesiologist, radiologist, physiatrist, or neurologist. The specialist injects the back with anesthetic agents, corticosteroids (more commonly known as steroids, although they differ from the drugs some athletes take to build muscle), or both.

Research findings on injection therapies have been conflicting and controversial. Studies show that 70% to 80% of people with acute sciatica experience an improvement in their leg symptoms following epidural injections. However, the injections don’t predictably reduce back pain or improve function. Nor do they reduce the frequency of lumbar surgery. Thus, the epidural injection is not a cure per se, but rather a way to relieve sciatic pain while the back heals naturally.

For people with chronic back pain, a 2011 Cochrane review of 18 studies concluded that there was not enough evidence to support the use of injection therapies for this purpose. Other data on injection therapies are even more conflicting. This is a complex area for making decisions; speak with your doctor about the options.

Another issue to consider is that the injections themselves can be quite painful. And repeated exposure to corticosteroids may result in elevations in blood sugar and blood pressure. These medicines are also linked with higher rates of osteoporosis.

Figure 11: A look at two injection therapies

Epidural steroid injections involve the injection of steroid medications into the epidural space. This area lies outside the dura mater, a membrane that covers the spinal cord.

When back pain is caused by an irritated facet joint, a doctor may suggest treating the problem with an injection of a steroid combined with a local anesthetic. Known as a facet joint injection, this therapy delivers medication directly into the affected joint.


Prolotherapy injections

Repeatedly injecting ligaments in the back with dextrose (sugar) and lidocaine (an anesthetic) has been a treatment for chronic low back pain for decades, but it remains controversial. The premise is that causing acute inflammation at the injection sites will kick-start the natural healing process and strengthen the supportive back ligaments. Prolotherapy injections are sometimes combined with other therapies, such as steroid injections, exercise, and spinal manipulation. A 2007 Cochrane review of three studies found prolotherapy on its own was not effective. Two studies showed some benefit when prolotherapy was combined with other types of back treatment.




When surgery is an option

Only certain types of back problems benefit from surgical intervention. Your doctor may recommend surgery if you are suffering from a herniated disk, cauda equina syndrome, spinal stenosis, a spinal compression fracture, or spondylolisthesis, and if other, less invasive methods have not provided sufficient relief. Surgery is also used to treat an infection that has not responded to other treatments, a tumor, or an injury that has caused severe damage to vertebrae and the spinal cord.

To determine whether you are a candidate for surgery, you and your doctor first need to consider whether you meet certain criteria. If you have cauda equina syndrome or some other emergency situation, your doctor makes the decision, which may be surgery right away.

For chronic back pain, your doctor is most likely to recommend surgery if you have been in substantial distress for a sufficient period — usually a minimum of six weeks — to convince both of you that more conservative approaches are not helping you enough. In cases of nerve-compression problems, you’ll need clear evidence that nerve-root function is impaired. And a reliable imaging procedure, such as a CT or MRI scan, must show that a surgically correctable anatomical abnormality is causing pressure on a nerve root. If diagnostic tests do not reveal clear signs of pressure on a particular nerve, the origin of the low back pain may lie elsewhere in the body.

But, unless you are the victim of a traumatic accident and require emergency surgery, or have an infection, tumor, or serious nerve-compression problem, the decision to have back surgery is yours to make. This means that you need to carefully consider all the risks and benefits involved.

The Spine Patient Outcomes Research Trial (SPORT)

The three most common back conditions leading to surgery are a herniated disk with sciatica, spinal stenosis, and spondylolisthesis. But is surgery the best option for these conditions? In 2000, investigators at 13 sites around the country launched a seven-year study to find out. The federally funded Spine Patient Outcomes Research Trial (SPORT) involved about 2,500 patients with these three conditions. Surgeries performed were diskectomy for herniated disk, laminectomy for spinal stenosis, and laminectomy with or without fusion for spondylolisthesis.

A control group of patients who did not undergo surgery received “usual care,” which included active physical therapy, education, counseling, home exercise instruction, and over-the-counter pain relievers.

Over all, the findings suggested that people who received surgery improved more quickly than those who didn’t. And four years later, the advantages of surgery were still measurable. However, more than one-third of the patients randomly assigned to the surgical group never received surgery for various reasons (for example, they had insurance approval issues or changed their minds about having surgery). This problem has made the SPORT findings difficult to interpret. Note, too, that surgery does pose risks (see “Weighing risks and benefits”) beyond those from usual care, and depending on your situation, nonsurgical treatment may be a reasonable approach to managing your symptoms in the long run.

Weighing risks and benefits

All operations carry the risk of infection at the site of the incision. Although there is also a small risk when undergoing general anesthesia, anesthesia is much safer today than in the past. In addition, back surgery poses a small risk of serious complications. You may have a nerve injury and experience weakness, numbness, or tingling in one or both legs. And there is the chance of bleeding from the large vessels that lie in front of the disks, which can be damaged during the procedure. You can also suffer an infection of the disk or adjacent tissues, requiring prolonged antibiotics and sometimes a second operation. These serious problems are rare when an experienced orthopedist or neurosurgeon performs the operation (see “Choosing a surgeon,” below).

The decision to have back surgery is a big one. How do you make it? One way to do this is to answer the questions below. There are no “right” answers — only your answers.

  • Do you fully understand everything there is to understand about your back problem? Your answer should include up-to-date information about your condition, the various ways to treat it, and the likely outcomes of these treatments.

  • Have the risks and benefits of surgery for your back problem been explained to you, in a way that you understand?

  • Do you know the likely natural history of your back condition so you can choose between a wait-and-watch approach and surgery?

  • How do you feel about taking risks of any sort? Consider your personality, lifestyle, age, other medical conditions, and so forth.

  • How do you feel about the risks associated with both the surgical and the nonsurgical treatment options for your back problem?

  • How much do you value functioning at a high level, and how much risk are you willing to take to get to a higher level of function? For example, a professional athlete would most likely want more functionality and be prepared to take more risk. For most other people, the stakes are not so high.

Talk these questions over with your physician. A careful and thorough discussion between you and your physician will help you reach an informed decision that reflects your preferences and is right for you.

Choosing a surgeon

Choose your surgeon carefully. A good place to start is with a referral from your primary care doctor. You might also seek recommendations from people who’ve recently undergone successful back surgery.

Training and experience in back surgery are essential, as is board certification in orthopedic surgery or neurosurgery and special training in spine surgery. In addition, look for a surgeon who is attentive and concerned about you and takes the time to answer questions in appropriate detail. It’s important to ask a surgeon about his or her experience and comfort with a specific operation, and to get a direct, candid response.


After surgery

The guidelines for recuperation after surgery depend on the particular operation you have undergone. Your surgeon will help you work out a specific program for recovery, which typically includes physical therapy. Pain medications are usually very helpful in the first few days following the operation. It’s vital to be out of bed, sitting up, and walking as soon as possible after the procedure, although you should resume exercise and increase activities gradually. Talk to your doctor about the specific timetable that is right for you.



Surgery for disk disease

More than 90% of people with herniated disks will recover within several months without surgery by using conservative measures. But if you are among the other 10% — or if you simply don’t have the time to wait — surgery can be a good choice.

Several options exist for disk surgery, which is sometimes referred to as decompression surgery because the operation relieves the compression on the spinal nerve roots. Your surgeon can help to determine which operation is best for you. One of the most common types is diskectomy, the removal of a portion of a damaged disk. Although diskectomies provide better pain relief over a four-year period than nonsurgical treatments, it’s not clear whether surgery offers a greater advantage after 10 years.

Standard diskectomy

A standard diskectomy involves making an opening in the spinal canal between adjacent laminae (the bony plates of each vertebra that join in the midline) and removing material protruding from the abnormal disk. Since the problem area is directly exposed and visible to the surgeon during the procedure, the risk of inadvertent damage to neighboring bone, ligaments, and nerve roots is minimized.

The surgeon will clear out any detached disk material (known as free fragments). If the disk has not fragmented but a significant portion protrudes extensively into the spinal canal, compressing a nerve root, the surgeon will trim the bulging portion. He or she will also remove some portion of the soft part of the disk between the vertebrae. Several different procedures may be part of the operation, including the following:

Laminotomy or laminectomy. With a laminotomy, the surgeon removes a small part of the bone of the lamina; for a laminectomy, he or she removes the entire lamina, which increases the size of the spinal canal to relieve pressure (see Figure 12).

Foraminotomy or foraminectomy. These procedures expand the openings for the nerve roots to exit the spinal cord. Larger amounts of bone and tissue are removed in a foraminectomy.

Standard diskectomy has traditionally involved a hospital stay of a couple of days, typically followed by a course of physical therapy at home. But increasingly, diskectomy is done on an outpatient basis for otherwise healthy patients, who then can go home the same day.

Recovery is gradual. For the first six weeks or so following surgery, try not to sit for longer than 15 to 20 minutes at a time. When you do sit, recline your chair back about 30 degrees from vertical. Avoid bending, lifting, and twisting, but start walking as soon as you can tolerate it. Two weeks after the operation, you can begin stationary bicycling and swimming. If you develop back or leg pain, though, ease off and talk with your doctor.

You can usually resume normal, nonvigorous activities six weeks following surgery, although you and your surgeon can speed up or slow down the schedule according to your individual situation. Results from the Spine Patient Outcomes Research Trial, or SPORT, show that people who had diskectomy surgery improved somewhat more quickly than those who received usual care, and these improvements continued for at least four years.

Figure 12: Repairing a herniated disk

A. When a disk is herniated, the material within the disk (nucleus pulposus) bulges into the opening between vertebrae through which nerves leave the spine and extend to other parts of the body. This presses on the nerve root, causing pain.

B. During a diskectomy, a portion of the bony arch of the vertebra (lamina) is removed, a procedure known as a laminectomy. This allows the surgeon to reach and remove the disk material causing the nerve-root compression.


Microdiskectomy

Microdiskectomy is a type of standard diskectomy that involves a smaller incision. Its benefits include a shorter hospital stay and less risk of the complications that can come with a longer hospitalization, such as postoperative blood clots. However, it is more technically challenging surgery and requires the use of a magnifying instrument to view the disk and nerves. Like all spinal surgery, the procedure poses some risk, such as nerve damage and infection, but these are very rare. The success rate of microdiskectomy is similar to that of standard diskectomy.


Percutaneous diskectomy

This procedure involves the removal of a portion of a damaged disk through an instrument inserted in the back. “Percutaneous” means through the skin, so the technique is, by definition, a less invasive technique than standard diskectomy.

In percutaneous diskectomy, the surgeon makes a tiny incision and inserts a hollow probe 2 millimeters (1/16 inch) in diameter. Visualizing the site by fluoroscopy, in which x-rays project a continuous image of the body’s internal structures on a fluorescent screen, the surgeon guides the probe precisely through the skin, muscle sheath, and muscles to reach the affected disk. The surgeon then guides the probe into the center of the disk and uses an automated cutting-irrigating-suctioning tool, which is inserted through the probe, to remove some of the nucleus and annulus from the herniated disk.

This delicate operation can reduce both the pressure and volume of the material inside the disk, thus relieving the irritation of the nerve root. The incision is small, the procedure requires local anesthesia only, and you can usually return home on the same day or the next. For the next few weeks, you’ll need to avoid sitting for longer than 15 to 20 minutes at a time, as well as bending, twisting, and lifting.

But this procedure also has substantial disadvantages compared with standard diskectomy or microdiskectomy. Since the compressed nerve root remains hidden from direct observation during the operation, the surgeon often cannot be sure that the pressure on it has been reduced or eliminated. Should a bit of the soft center of the disk slip out through the annulus, the surgeon has no way of finding and removing it. Such a free-floating piece of disk can cause pain. In addition, there is a small risk of infection and of damage to nerves, organs, and blood vessels in the area.

As well as describing a surgical technique, percutaneous diskectomy is an umbrella term for a number of other percutaneous techniques, as follows.

Laser diskectomy. In this procedure, rather than removing some of the disk material with a cutting-irrigating-suctioning tool, the surgeon uses a medical laser to vaporize part of the nucleus. The benefits, risks, and success rates associated with laser diskectomy are the same as those for percutaneous diskectomy.

Nucleoplasty. In this technique, the surgeon passes a small instrument into the disk nucleus and destroys a small amount of the nucleus tissue, reducing pressure inside the disk. Nucleoplasty is a minimally invasive technique that can be done on an outpatient basis, but it isn’t appropriate for people with severe disk deterioration.

Chemonucleolysis. This procedure, which is more popular in Europe than in the United States, involves injecting an enzyme (chymopapain) that dissolves a portion of the herniated disk. The treatment may trigger an allergic reaction to the enzyme used in the procedure; reactions can range from a simple rash, itching, and localized swelling to anaphylactic shock, a life-threatening condition characterized by an extremely rapid, sharp drop in blood pressure. The risk of an allergic reaction can be significantly reduced, although not eliminated, by having an allergen skin test before surgery.

Intradiscal electrothermal annuloplasty (IDET). For this technique, a surgeon inserts a hollow needle into the affected disk, threads a thin catheter through the needle, and positions the catheter along the inner wall of the disk. The catheter is then heated to a high temperature, which cauterizes the nerve fibers in the disk, making them less sensitive. Although generally considered safe, IDET is not particularly effective, with 50% of patients unhappy with the outcome of their therapy and continuing to have pain.

Fast fact

One study of back surgery in 11 countries — including Sweden, England, Australia, Denmark, and Norway — found that the rate of back surgery in the United States was 40% higher than that of any other country surveyed. But all that extra surgery doesn’t seem to be helping: the rate of work disability is just as high in the United States as it is in these other countries.



Surgery for spinal stenosis

Spinal stenosis is far less likely than a herniated disk problem to clear up on its own. People with spinal stenosis tend to be older and often have other conditions that can exacerbate their back problem. These factors may explain why only about 20% of people with spinal stenosis improve substantially over time without treatment. In turn, many patients consider surgery as an option to relieve their symptoms.

Surgery involves removing the key structures that press on the nerve and contribute to the stenosis. Between 65% and 75% of people treated in this way eventually obtain good to excellent results — meaning that if their pain persists at all, it can be controlled by non-narcotic or over-the-counter medications, and they can engage in physical activity with few or no restrictions. In 2010, findings from SPORT published in the journal Spine showed that patients who opted for surgery experienced significant pain relief in the months after surgery and four years later, compared with patients who didn’t have surgery. One caveat to keep in mind: other studies have shown that 10% to 23% of spinal stenosis patients have a second surgery within seven to 10 years of their initial surgery.

Sometimes a spinal fusion (see Figure 13) is performed to fix the position of the vertebrae permanently and prevent future displacement. In this procedure, a surgeon fuses adjacent misaligned vertebrae. The success rate for such operations varies according to the underlying problem. Fusion for a disk problem in the cervical section of the spine is highly effective (more than 85% of procedures successful), whereas fusion for back pain in the lumbar spine has a lower rate of success.

Surgeons can use several different methods of fusion to join two or more adjacent vertebrae. The space between the vertebrae can be bridged with a graft of bone from elsewhere in the body or from a bone bank. The graft also stimulates bone growth in the area of the fusion. In addition, metal implants may be secured to the vertebrae, where they serve as internal splints to hold the vertebrae until new bone has consolidated the grafts into a strong bony strut. Finally, small cylindrical metal cages may be inserted into the vertebrae to work as internal splints that hold the vertebrae together while the fusion takes place. These are typically made of titanium and are about an inch long.

Following spinal fusion surgery, you might wear a brace, a cast, or neither — depending on the specifics of your operation and the opinion of your surgeon. It usually takes about six months for a spine to fuse.

Successful surgery results in a stable union of the fused vertebrae. Within four to nine months, your body replaces most of the grafted bone at the surgical site with new bone. By reducing motion in the affected area of the spine, a bone fusion relieves the pain caused by abnormal movement. After fusion, your range of spinal motion will be approximately 20% to 30% less than it was originally. However, compared with your condition before surgery, when pain most likely limited your motion, you are likely to have a greater effective range of movement, as well as freedom from chronic pain.

People with spondylolisthesis, as well as other types of back problems, may benefit from spinal fusion surgery or implantation of an artificial disk. However, a 2010 study in The Journal of the American Medical Association raises some questions about the growing use of spinal fusion surgery in the United States. Researchers reviewed Medicare claims for spinal stenosis operations between 2002 and 2007 and found that the rates of complex spinal fusion surgeries rose 15-fold over the six-year period. As the authors point out, it’s unlikely that the number of people with complex spinal problems increased that much in just six years. The introduction and marketing of new surgical devices could be a factor; so could improvements in technique and supportive care that makes more invasive surgery feasible, they suggest. Surgeons may believe that more aggressive treatment yields better results, and there may be financial incentives for hospitals, too: the average hospital charge for decompression surgery alone was just under $24,000, whereas a complex fusion runs nearly $90,000, on average. Yet, as the study revealed, fusion surgery was not only more expensive but also more risky. Nearly six in 100 patients who had fusions suffered major complications, such as strokes, compared with two in 100 who had decompression surgery. Those who had fusion were also slightly more likely to die within a month of surgery than those who had decompression alone.

Figure 13: Spinal fusion surgery for spinal stenosis

Spinal stenosis of the lumbar spine

Spinal stenosis, a narrowing of the spinal canal, usually results from degeneration of the disks, the ligaments, or the facet joints on the posterior (rear) part of the spine. Age-related changes can cause the disks to shrink, which reduces the space between the vertebrae and the facet joints. Stress on these joints can lead to arthritic changes, which can cause one vertebra to slip forward, a condition called spondylolisthesis. In this example, the fifth lumbar vertebra (L5) has slipped forward a few millimeters with respect to the first sacral vertebra (S1).

Spinal fusion surgery for stenosis

Surgery for spinal stenosis aims to relieve pressure on the spinal cord and nerve roots. A surgeon typically performs a laminectomy and may also remove part of the paired facet joints and any bone spurs or disk herniation. To stabilize a spondylolisthesis, the surgeon inserts pedicle screws to join the vertebra, which fixes them in place permanently.


Surgery for compression fractures

Vertebral compression fractures from osteoporosis mainly affect postmenopausal women. About one in four postmenopausal women has had such a fracture. The standard treatment was — and still is — to wait it out while the fractured bone heals. This process can take six weeks on average and is very painful; often narcotic painkillers are necessary to provide relief.

Two procedures for treating vertebral fractures have emerged: vertebroplasty and kyphoplasty. These procedures are suitable to treat only compression fractures, not other types of back problems, and their success rates are not well established. They are usually recommended to people who cannot tolerate the more conservative measures of rest and pain medications. More research is needed to determine the long-term benefits and risks associated with the two techniques.

Vertebroplasty

This technique, which was developed in France and first introduced in the United States in 1993, is done on an outpatient basis and takes less than an hour. After you receive mild sedation, the physician inserts a needle into the compressed vertebra, using an x-ray for guidance. The surgeon injects bone cement, called methylmethacrylate, into the vertebra, filling the holes and crevices. The cement hardens in about 20 minutes, stabilizing the vertebra, creating a support that helps prevent any further collapse, and alleviating pain.

But while initial reports of this procedure seemed promising, two studies comparing vertebroplasty to a sham intervention (in which surgeons simulated the procedure but did not inject any cement) question the benefit of this commonly used procedure. Both studies, published in The New England Journal of Medicine in 2009, found no clinically important differences in pain relief or disability between the two groups. But the studies were small, leaving the question unresolved.


Kyphoplasty

This procedure is a refinement of vertebroplasty. Like vertebroplasty, kyphoplasty aims to stabilize compressed vertebrae and relieve pain. It also offers several advantages over the original procedure: it restores the height of previously compressed vertebrae and reduces spinal deformity, and it minimizes the risk of cement leakage.

Kyphoplasty takes less than an hour, although you may need to remain in the hospital overnight. After you receive mild sedation, the physician inserts a small tube-like instrument into the affected vertebra, using a special viewing instrument called a fluoroscope as a guide. Once the instrument is correctly placed, a balloon is inserted and inflated, creating a cavity in the bone. The balloon is then deflated, and the physician injects surgical cement into the cavity. The creation of this cavity minimizes the risk that the cement will leak and also pushes the vertebral endplates apart, thus restoring some height. The few studies conducted on kyphoplasty do not firmly establish its effectiveness.

Artificial disks

Damaged knee and hip joints are routinely replaced with artificial joints, so why not a replacement for a damaged disk? Since the late 1950s, when the first artificial disk was designed, scientists have developed many different versions. In contrast to the rigidity of spinal fusion, an artificial disk is designed to mimic a natural disk, providing normal movement between the vertebrae and maintaining the distance between them.

A 2010 article in European Spine Journal reviewed 19 studies designed to evaluate the effectiveness and safety of disk replacement surgery. However, only three of the studies were randomized controlled trials that compared artificial disks to spinal fusion surgery. The replacement disks didn’t provide superior results to spinal fusion surgery, and complication rates varied widely in the studies. The authors recommend that people receive artificial disk implants only as part of a carefully controlled study to evaluate their safety and potential benefits.

A recent trial suggested disk replacement may offer advantages over nonsurgical regimens for degenerative disk disease. More research is needed in this area.



Surgeries for other back problems

Other back problems that may benefit from prompt surgery include infections, tumors, and certain kinds of fractures. In these situations, timely surgery is essential. In other situations — notably when surgery is recommended to cut or destroy nerves to control pain — it’s best to be skeptical, as the benefits may not materialize.

Infections

If an infection is causing your back pain and antibiotics haven’t been completely effective, surgery may be necessary. In an operation usually called a debridement, the surgeon removes pus and the infected and dead parts of the bone. The surgeon then washes out the affected area with a sterile solution containing antibiotics to kill the bacteria or fungi that are causing the infection. A bone fusion (see “Surgery for spinal stenosis”) is also recommended when large portions of one or more vertebrae must be taken out to control the infection. Antibiotics are needed for several weeks after surgery.


Tumors

For a bone tumor originating in the spine, surgery may or may not be useful, depending on various factors. For example:

  • Is the growth malignant?

  • Can it be treated by radiation or chemotherapy?

  • Is it making the spine unstable and vulnerable to fracture?

  • Is it compressing the spinal canal or nerve roots?

  • Is it located in a part of the spine where surgical removal is possible?

If the goal of an operation is to cure a cancer, the entire tumor must be removed, along with a portion of healthy bone. When the spine is weakened by the surgical removal of bone or by the destruction of bone by the tumor, the weakened area must be stabilized. This is usually done with metal implants, sometimes supplemented by methylmethacrylate (bone cement) or by bone grafts.

For cancerous tumors that have spread to the spine from another site — such as the breast — radiation, surgery, chemotherapy, or some combination of these treatment options is used, as appropriate.

Some tumors, including lipomas, teratomas, ependymomas, and neurofibromas, arise directly from the spinal cord or the nerve roots. Although rare, such growths are often painful. Whether a surgical approach is possible depends on the type of tumor, as well as its size and location.


Dislocations and vertebral fractures

Slightly displaced spinal fractures or dislocations usually heal without causing severe pain or spinal instability. Surgery is generally reserved for serious ligament and bone damage. Your doctor will determine the extent of the damage through a physical examination and analysis of imaging studies, such as MRI scans.

During an operation, the surgeon can, if necessary, remove bone fragments from the spinal canal and can implant metal plates or rods — either temporarily or permanently — to stabilize the spine and maintain its alignment during healing. Spinal fusion (see Figure 13) is usually needed to reconstruct or substitute for damaged vertebrae or ligaments, or both.




Guidelines for recovery

After an episode of back pain, whatever the treatment, it’s essential to properly time your return to normal activities: too rapid a return is likely to precipitate a relapse, but too timid a return can delay — or even prevent — recovery. If you are recovering from back pain, seek detailed information from your doctors about what you can do and when. Ask whether physical therapy might be helpful.

Five rules for a safe comeback

The following are a few general principles for safe and effective recovery.

Symptoms should be your guide. As a general rule, avoid doing anything that hurts. If there is pain, stop the offending activity.

Increase activities gradually, according to tolerance. For example, you might start by doing four or five repetitions of an abdominal exercise, three times a day. If this doesn’t cause your pain to worsen, you can increase the number of repetitions every few days — and add new exercises — as tolerated. If the exercises increase your discomfort, they can be cut back for a while, then resumed and again gradually increased. You can usually resume sexual activity once you’re up and walking with minimal discomfort (see “Sex and your aching back”).

Avoid twisting your trunk or making sudden off-balance movements. Try to rid your house of clutter that can trip you up. Slippery surfaces and throw rugs are notorious for causing falls. Activities such as diving and swimming in surf can cause problems, as can lifting objects while your body is in an awkward position.

Exercise regularly. Appropriate exercise — such as swimming, walking, or bicycle riding (either stationary or regular) — should become an established part of your regular exercise routine.

Keep good habits even after your discomfort is gone. During an episode of low back pain, a person typically moves cautiously, bending the knees when picking something up, carrying objects close to the body to minimize leverage on the back, and sitting down and getting up with care. To some extent, such back-saving maneuvers — as well as any back exercise program started in time of need — should become lifelong habits, whether or not you’re concerned about impending pain. Practices such as these can help minimize the frequency of back woes.

Sex and your aching back

It’s not uncommon for backaches to interfere with an individual’s lovemaking. Often, people are reluctant to talk with their doctor about how their back pain affects their sexual activity. But if you find that backaches — or fears of reinjuring your back — put a damper on your sex life, ask your doctor for advice.

Here are a few suggestions that might also be helpful:

  • Talk openly with your partner about your concerns.

  • Avoid positions that hurt.

  • Try positions that are easier on your back, such as lying on your side with your hips and your knees slightly bent.

  • Be judicious and gentle. If your back is bothering you, don’t aim for long, vigorous, gymnastic lovemaking.

  • Making love in the water — in a pool or hot tub — can take some of the stress off your back, because water is buoyant and offers support.

  • Be patient. Don’t try to resume sex too soon after having a backache. If you find that your back hurts when you resume sexual activity, wait a few days before trying again.



Resources

Organizations

American Academy of Orthopaedic Surgeons
6300 N. River Road
Rosemont, IL 60018
847-823-7186
www.aaos.org

This nonprofit organization informs the public about orthopedics, including information on the causes, treatment, and prevention of back pain. Free fact sheets and brochures are available online. The website includes a surgeon locator.

American Academy of Physical Medicine and Rehabilitation
9700 W. Bryn Mawr Ave., Suite 200
Rosemont, IL 60018
847-737-6000
www.aapmr.org

This professional organization for physiatrists (doctors who specialize in physical medicine and rehabilitation for musculoskeletal and neurological problems) provides information on a variety of conditions such as low back and neck pain, spinal cord and brain injuries, osteoporosis, and arthritis. The website includes a physician locator.

American Massage Therapy Association
500 Davis St.
Evanston, IL 60201
877-905-0577 (toll-free)
www.amtamassage.org

This organization promotes the art, science, and practice of massage therapy and provides a free locator for licensed massage therapists at www.findamassagetherapist.org or 888-THE-AMTA (888-843-2682; toll-free).

American Pain Foundation
201 N. Charles St., Suite 710
Baltimore, MD 21201
888-615-7246 (toll-free)
www.painfoundation.org

This nonprofit organization serves as an information clearinghouse and resource center for people with pain, including back pain.

American Physical Therapy Association
1111 N. Fairfax St.
Alexandria, VA 22314
800-999-2782 (toll-free)
www.apta.org

This national professional organization for physical therapists provides links to related sites. The website includes a physical therapist locator.

National Center for Complementary and Alternative Medicine
National Institutes of Health
9000 Rockville Pike
Bethesda, MD 20892
888-644-6226 (toll-free)
www.nccam.nih.gov

This government agency provides science-based information on the safety and efficacy of complementary and alternative medicine. NCCAM does not provide medical advice for individuals or referrals to practitioners.

National Certification Commission for Acupuncture and Oriental Medicine
76 S. Laura St., Suite 1290
Jacksonville, FL 32202
904-598-1005
www.nccaom.org

This nonprofit organization, accredited by the National Commission for Certifying Agencies, seeks to promote nationally recognized standards of competency and safety in acupuncture, Chinese herbology, and Oriental bodywork therapy.

Spine-health
790 Estate Drive
Deerfield, IL 60015
847-607-8577
www.spine-health.com

This commercial website provides in-depth information on back pain, including common causes, diagnostic measures, treatments, and surgery. The site also features information on recent advances. Medical professionals review all content.


Books

Heal Your Aching Back
Jeffrey N. Katz, M.D., and Gloria Parkinson
(McGraw-Hill, 2007)

This comprehensive guide to back pain, co-authored by the medical editor of this Special Health Report, covers such topics as diagnosing your problem, controlling your pain, traditional and complementary treatments, and ways to maintain a healthy back after an episode of back pain.



Glossary

ankylosing spondylitis: An inflammatory disease of the spine that often leads to pain and stiffness of the spine.

annulus fibrosus: The multilayered, fibrous outer portion of an intervertebral disk.

articular processes: The two upper and two lower bony projections on the back part of each vertebra that form the facet joints.

bone scan: A diagnostic procedure in which radioactive material is injected into the patient’s bloodstream to produce images of the skeleton. Used to locate areas of rapid bone formation that might signal, for example, a tumor or an infection.

cauda equina: The bundle of nerve fibers that starts at the top of the small of the back and continues to the bottom of the spinal canal. This bundle of nerves is called cauda equina because it resembles a horse’s tail.

computed tomography (CT): A diagnostic technique in which x-rays are taken from many different directions. A computer synthesizes the x-rays to generate cross-sectional and other images of the body.

diskectomy: The surgical removal of all or part of an intervertebral disk.

diskitis: Inflammation of an intervertebral disk, including disk infection.

electromyography (EMG): A series of diagnostic procedures that involve measuring electrical activity in muscles to help diagnose neuromuscular disorders.

facet joint: Any of the joints between the interlocking vertebrae that form the spine.

herniated disk: Displacement of some portion of the disk out of its normal location.

iliopsoas muscles: The two muscles that are attached to each side of the lumbar vertebrae, the inside of the pelvis, and the thighbone.

intervertebral foramina: The two narrow spaces between adjacent vertebrae (one on each side), through which nerve roots pass.

kyphoplasty: A minimally invasive procedure to alleviate pain from spinal compression fractures. A balloon-like structure is placed in the affected vertebra and is inflated; the resulting cavity is filled with bone cement to stabilize the vertebral fracture.

lamina: One of the two thin, platelike parts of each vertebra that join in the midline and form the base of the spinous process of that vertebra.

laminectomy: An operation to remove all or a portion of one or both laminae, to provide access to the spinal canal or to decompress the spinal cord and nerve roots.

lumbar spine: The five lowermost vertebrae of the spine.

magnetic resonance imaging (MRI): A diagnostic technique in which radio waves generated in a strong magnetic field are used to provide information about the tissues within the body; a computer uses this information to produce images of the tissues in many different planes.

myelography: A diagnostic technique in which x-rays are taken of the spine after a contrast medium has been injected into the space within the sheath that surrounds the spinal cord and the cauda equina.

nucleus pulposus: The gel-like central portion of an intervertebral disk.

osteophyte: A bony outgrowth, or spur, on the margin of a joint or intervertebral disk.

percutaneous diskectomy: The removal of part of an intervertebral disk by means of a narrow probe inserted through the skin and muscle of the back.

processes: The several bony projections from each vertebra, some of which mesh with similar structures on the vertebrae immediately above and below.

sciatica: Pain along the course of the sciatic nerve (from the buttock, down the back and side of the leg, and into the foot and toes), often because of a herniated disk.

spinal fusion: A procedure to join two or more vertebrae with a bone graft in order to eliminate motion and relieve pain.

spinal stenosis: A narrowing of the spinal canal, which can result in compression of nerve roots.

spinous process: The lever-like backward projection from each vertebra, to which muscles and ligaments are attached.

spondylolisthesis: Forward displacement of a vertebra in relation to the vertebra immediately below.

transverse processes: The ringlike projections on the sides of a vertebra to which muscles and ligaments are attached and, in the chest area, to which the ribs are connected.

vertebroplasty: A minimally invasive procedure to stabilize compressed vertebrae and alleviate pain. A needle is inserted into the compressed portion of a vertebra and surgical cement is injected into it.


Credits

Medical Editor
Jeffrey N. Katz, M.D.
Professor of Medicine and Orthopedic Surgery, Harvard Medical School

Editor, Special Health Reports
Kathleen Cahill Allison

Art Director
Heather Derocher

Production Editors
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Melissa Rico

Illustrators
Alex Gonzalez
Harriet Greenfield
Scott Leighton

Published by Harvard Medical School
Anthony L. Komaroff, M.D., Editor in Chief
Edward Coburn, Publishing Director

In association with Belvoir Media Group, LLC
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Timothy H. Cole, Executive Vice President and Editorial Director

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Natalie Ramm


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