Low Back Pain
Lower back pain is one of the common musculoskeletal complaints and can arise from a number of different ailments. Pain will often be produced from damage or irritation to the structures of the lower back including facet joints, vertebrae, vertebral discs, vertebral ligaments, muscles (of the lower back), spinal cord, peripheral nerves, as well as internal organs. Lower back pain will often resolve itself within a month, but will usually return if the underlying problem is not dealt with.
Low back pain has a number of common causes as well as some less common causes. Some of the common causes consist of: arthritis, herniated discs, strained muscles, spinal stenosis, sciatica, fibromyalg
Some of the conditions that produce pain from the spine include: facet joint osteoarthritis, infections, neoplasms, spondylolisthesis, spinal stenosis, vertebral body fractures, and osteoporosis. Some of the
techniques that are effective in treating lower back pain include: Physical therapy, cognitive behavioral therapy, diet, exercise, biofeedback, and other alternative therapies.
Between each of the vertebrae is a disc that acts as a cushion to reduce strain due to impact in the spinal column. Because the discs are soft, they have a tendency to herniate posterior (out of the back of the spine) causing irritation to the adjacent nerves. About ten percent of low back pain complaints are caused by disc disease, which may acutely be from herniation due to trauma or excessive lifting. More commonly, though, back pain is caused by degenerative disc disease, which can lead to spinal stenosis, nerve impingement, worsening facet arthritis, or peripheral nerve irritation. Some of the conditions that can potentially produce chronic pain from discs include: degenerative disc disease, disc protrusion, disc infection, nerve root irritation or compression (sciatica), disc herniation, disc extrusion, facet joint osteoarthritis, and spinal stenosis (the narrowing of the spinal canal). Many of these conditions can be greatly improved with: Facet injection/denervation, spinal cord stimulation, epidural steroid injections, as well as other treatments.
Each vertebrae of the spine has associated ligaments to provide strength and mobility to the spine and muscle, which are responsible for the spinal movements. The nerve roots are attached to the spinal cord and innervate the skin, muscles, structures of the back and the lower extremities. Excessive exercise or lifting will often irritate these muscles and ligaments. Conditions that can cause chronic musculoskeletal pain include: Myofascial Pain Syndrome, Ligamentous Tear, Torn Muscle, Ligamentous Strain, and Muscular Strain. Trigger point injections have proved to be very successful in the alleviation of musculoskeletal pain.
Lower lumbar back pain is considered chronic if it persists for 3-6 months, the symptoms are gradual and occur over an extended periods of time. Chronic pain is experienced in the back and often down the legs. Some causes of chronic low back pain include: Infections, neoplasms, ankylosing spondylitis, spondylolisthesis, osteoporosis, vertebral body fractures, psychological and emotional factors, poor posture, excessive breast size, central sensitization, nerve root irritation or compression (sciatica), facet joint osteoarthritis, disc extrusion, disc herniation, disc protrusion, degenerative disc disease, fibromyalgia, spinal stenosis (narrowing of the spinal canal), sacroiliac joint disease, and arthritis of the facet joint.
Sacroiliac Joint Disease is another common contributor to Low back Pain. The Sacroiliac Joint is located between the spine and pelvis and allows the weight of the upper body to be transferred to the legs. SIJ pain can worsen with sitting for extended periods of time, as well as twisting motions and certain other movements.
If pain persists for longer than 4 weeks or is severe, it is advisable to seek a pain specialist to find individualized treatment options . There are several routes that can be taken and often a combination of treatments will result in optimal pain relief. Some of the options to consider in treating low back pain include:
Pharmacotherapy- The most effective pharmaceuticals for treating low back pain include NSAIDs (ibuprofen), Acetaminophen (Tylenol), membrane stabilizing drugs, and muscle relaxants.
Epidural Steroid Injections– ESI involves the injection of steroids into the epidural space inside of the spine. From here, it spreads to other levels and portions of the spine and reduces inflammation and irritation.
Medial Branch Blocks/Denervation– MBBs are minimally invasive treatments that reduce inflammation and irritation of the facet joint, ultimately relieving pain
Massage- A massage can be beneficial in reducing stress and tension that might contribute to pain symptoms, and can also help relieve muscle spasm and contractions.
Nutrition and Exercise- A proper diet accompanied with exercise often reduces the pain associated with sciatica by increasing flexibility and range of motion. This also releases endorphins, which are the body’s natural pain reliever.
Physical Therapy- Physical therapy can be very helpful by building muscles around a degenerated area and reducing pain signals. Physical therapy works best when combined with other modalities.
Biofeedback- Biofeedback is a treatment that teaches patients to be more in tune with their body and helps them regulate otherwise involuntary processes (such as heart rate or blood pressure). When a patient is more in tune with their body, it is easier for them to relax which can in turn alleviate pain.
Transcutaneous Electrical Nerve Stimulation (TENS)– TENS works by introducing electrical stimulation through the skin of the affected area. The electrical signals interrupt pain signals, causing a tingling sensation rather than pain.
Botox- Botox works by paralyzing the nerve ending at the site of injection. Although Botox was originally used for cosmetic purposes, it can also be helpful in pain relief, especially if a patient suffers from whiplash injuries and cervical dystonia. This treatment will reduce pain, and often times increase range of motion within the affected area.
Trigger Point Injections– These injections are an effective treatment for muscle spasms. The procedure involves the injection of local anesthetic and steroids into a “trigger point”, or the origin of the pain.
Peripheral Nerve Blocks and Radio Frequency Ablation- The nerves that are away from the spinal cord are called peripheral nerves. They can often be sources of pain which can be blocked using local anesthetic. If a block works, an ablation (destruction of nerve endings) is also a possibility for longer term pain relief.
Kyphoplasty and Vertebroplasty– Both of these methods involve injecting acrylic cement into collapsed vertebra, which relieves pain and increases stability of the spine.
Spinal Cord Stimulation (SCS)– A spinal cord stimulator is an electrical device that is implanted in the body to decrease pain by confusing the spinal cord and brain pain processing centers. A trial SCS will be externally placed in order to test how effective it will be to a particular patient. If pain is relieved during a trial period, a permanent Spinal Cord Stimulator will likely bring great back pain relief.
Peripheral Nerve Stimulation (PNS)-This treatment is similar to a spinal cord stimulator, but here electrodes are placed near affected peripheral nerves instead of directly to the spinal cord.<
Surgery is only done when all conservative treatments are exhausted and little relief has been achieved, or if the exiting nerves of the spine are being severely compressed. Severe compression is characterized by spasticity, loss of sensation, lower extremity weakness, and bowel/bladder incontinence. Invasive but sometime necessary surgical procedures include: Discectomy, Laminectomy, Spinal Fusion, and Spinal Instrumentation.There are several risks associated with lower back surgery including bleeding, nerve damage, infection, epidural scarring, and prolonged recovery time. Surgery should only be considered after conventional treatments have been tried and have failed.