Back Pain Overview

Side view of spine. (Source: NIH)

Back pain is an all-too-familiar problem that can range from a dull, constant ache to a sudden, sharp pain that leaves you incapacitated. It can come on suddenly—from an accident, a fall, or lifting something heavy—or it can develop slowly, perhaps as the result of age-related changes to the spine. Regardless of how back pain happens or how it feels, you know it when you have it. And chances are, if you don’t have back pain now, you will eventually.

How Common Is Back Pain?

In a 3-month period, about one-fourth of U.S. adults experience at least 1 day of back pain. It is one of our society’s most common medical problems.

What Are the Risk Factors for Back Pain?

Although anyone can have back pain, a number of factors increase your risk. They include:

Age: The first attack of low back pain typically occurs between the ages of 30 and 40. Back pain becomes more common with age.

Fitness level: Back pain is more common among people who are not physically fit. Weak back and abdominal muscles may not properly support the spine.

Normal vertabra. (Source: NIH)

“Weekend warriors”—people who go out and exercise a lot after being inactive all week—are more likely to suffer painful back injuries than people who make moderate physical activity a daily habit. Studies show that low-impact aerobic exercise is good for the disks that cushion the vertebrae, the individual bones that make up the spine.

Diet: A diet high in calories and fat, combined with an inactive lifestyle, can lead to obesity, which can put stress on the back.

Heredity: Some causes of back pain, such as ankylosing spondylitis, a form of arthritis that affects the spine, have a genetic component.

Race: Race can be a factor in back problems. African American women, for example, are two to three times more likely than white women to develop spondylolisthesis, a condition in which a vertebra of the lower spine—also called the lumbar spine—slips out of place.

The presence of other diseases: Many diseases can cause or contribute to back pain. These include various forms of arthritis, such as osteoarthritis and rheumatoid arthritis, and cancers elsewhere in the body that may spread to the spine.

Occupational risk factors: Having a job that requires heavy lifting, pushing, or pulling, particularly when this involves twisting or vibrating the spine, can lead to injury and back pain. An inactive job or a desk job may also lead to or contribute to pain, especially if you have poor posture or sit all day in an uncomfortable chair.

Cigarette smoking: Although smoking may not directly cause back pain, it increases your risk of developing low back pain and low back pain with sciatica. (Sciatica is back pain that radiates to the hip and/or leg due to pressure on a nerve.) For example, smoking may lead to pain by blocking your body’s ability to deliver nutrients to the disks of the lower back. Or repeated coughing due to heavy smoking may cause back pain. It is also possible that smokers are just less physically fit or less healthy than nonsmokers, which increases the likelihood that they will develop back pain. Smoking also increases the risk of osteoporosis, a condition that causes weak, porous bones, which can lead to painful fractures of the vertebrae. Furthermore, smoking can slow healing, prolonging pain for people who have had back injuries, back surgery, or broken bones.

What Are the Causes of Back Pain?

It is important to understand that back pain is a symptom of a medical condition, not a diagnosis itself. Medical problems that can cause back pain include the following:

Mechanical problems: A mechanical problem is a problem with the way your spine moves or the way you feel when you move your spine in certain ways. Perhaps the most common mechanical cause of back pain is a condition called intervertebral disk degeneration, which simply means that the disks located between the vertebrae of the spine are breaking down with age. As they deteriorate, they lose their cushioning ability. This problem can lead to pain if the back is stressed. Other mechanical causes of back pain include spasms, muscle tension, and ruptured disks, which are also called herniated disks.

Injuries: Spine injuries such as sprains and fractures can cause either short-lived or chronic pain. Sprains are tears in the ligaments that support the spine, and they can occur from twisting or lifting improperly. Fractured vertebrae are often the result of osteoporosis. Less commonly, back pain may be caused by more severe injuries that result from accidents or falls.

Acquired conditions and diseases: Many medical problems can cause or contribute to back pain. They include scoliosis, a curvature of the spine that does not usually cause pain until middle age; spondylolisthesis; various forms of arthritis, including osteoarthritis, rheumatoid arthritis, and ankylosing spondylitis; and spinal stenosis, a narrowing of the spinal column that puts pressure on the spinal cord and nerves. Although osteoporosis itself is not painful, it can lead to painful fractures of the vertebrae. Other causes of back pain include pregnancy; kidney stones or infections; endometriosis, which is the buildup of uterine tissue in places outside the uterus; and fibromyalgia, a condition of widespread muscle pain and fatigue.

Infections and tumors: Although they are not common causes of back pain, infections can cause pain when they involve the vertebrae, a condition called osteomyelitis, or when they involve the disks that cushion the vertebrae, which is called diskitis. Tumors also are relatively rare causes of back pain. Occasionally, tumors begin in the back, but more often they appear in the back as a result of cancer that has spread from elsewhere in the body.

Although the causes of back pain are usually physical, emotional stress can play a role in how severe pain is and how long it lasts. Stress can affect the body in many ways, including causing back muscles to become tense and painful.

Can Back Pain Be Prevented?

One of the best things you can do to prevent back pain is to exercise regularly and keep your back muscles strong. Four specific types of exercises are described in “Back Pain Treatments”. All may help you avoid injury and pain. Exercises that increase balance and strength can decrease your risk of falling and injuring your back or breaking bones. Exercises such as tai chi and yoga—or any weight-bearing exercise that challenges your balance—are good ones to try.

Eating a healthy diet also is important. For one thing, eating to maintain a healthy weight—or to lose weight, if you are overweight—helps you avoid putting unnecessary and injury-causing stress and strain on your back. To keep your spine strong, as with all bones, you need to get enough calcium and vitamin D every day. These nutrients help prevent osteoporosis, which is responsible for a lot of the bone fractures that lead to back pain. Calcium is found in dairy products; green, leafy vegetables; and fortified products, like orange juice. Your skin makes vitamin D when you are in the sun. If you are not outside much, you can obtain vitamin D from your diet: nearly all milk and some other foods are fortified with this nutrient. Most adults don’t get enough calcium and vitamin D, so talk to your doctor about how much you need per day, and consider taking a nutritional supplement or a multivitamin.

Practicing good posture, supporting your back properly, and avoiding heavy lifting when you can may all help you prevent injury. If you do lift something heavy, keep your back straight. Don’t bend over the item; instead, lift it by putting the stress on your legs and hips.

When Should I See a Doctor for Pain?

In most cases, it is not necessary to see a doctor for back pain because pain usually goes away with or without treatment. However, a trip to the doctor is probably a good idea if you have numbness or tingling, if your pain is severe and doesn’t improve with medication and rest, or if you have pain after a fall or an injury. It is also important to see your doctor if you have pain along with any of the following problems: trouble urinating; weakness, pain, or numbness in your legs; fever; or unintentional weight loss. Such symptoms could signal a serious problem that requires treatment soon.

Which Type of Doctor Should I See?

Many different types of doctors treat back pain, from family physicians to doctors who specialize in disorders of the nerves and musculoskeletal system. In most cases, it is best to see your primary care doctor first. In many cases, he or she can treat the problem. In other cases, your doctor may refer you to an appropriate specialist.

How Is Back Pain Diagnosed?

Diagnosing the cause of back pain requires a medical history and a physical exam. If necessary, your doctor may also order medical tests, which may include x rays.

During the medical history, your doctor will ask questions about the nature of your pain and about any health problems you and close family members have or have had. Questions might include the following:

Have you fallen or injured your back recently?
Does your back feel better—or hurt worse—when you lie down?
Are there any activities or positions that ease or aggravate pain?
Is your pain worse or better at a certain time of day?
Do you or any family members have arthritis or other diseases that might affect the spine?
Have you had back surgery or back pain before?
Do you have pain, numbness, or tingling down one or both legs?

During the physical exam, your doctor may:

watch you stand and walk
check your reflexes to look for slowed or heightened reflexes, either of which might suggest nerve problems
check for fibromyalgia by examining your back for tender points, which are points on the body that are painful when pressure is applied to them
check for muscle strength and sensation
check for signs of nerve root irritation.

Often a doctor can find the cause of your pain with a physical and medical history alone. However, depending on what the history and exam show, your doctor may order medical tests to help find the cause.

Following are some tests your doctor may order:

X rays: Traditional x rays use low levels of radiation to project a picture onto a piece of film (some newer x rays use electronic imaging techniques). They are often used to view the bones and bony structures in the body. Your doctor may order an x ray if he or she suspects that you have a fracture or osteoarthritis or that your spine is not aligned properly.

Magnetic resonance imaging (MRI): MRI uses a strong magnetic force instead of radiation to create an image. Unlike an x ray, which shows only bony structures, an MRI scan produces clear pictures of soft tissues, too, such as ligaments, tendons, and blood vessels. Your doctor may order an MRI scan if he or she suspects a problem such as an infection, tumor, inflammation, or pressure on a nerve. An MRI scan, in most instances, is not necessary during the early phases of low back pain unless your doctor identifies certain “red flags” in your history and physical exam. An MRI scan is needed if the pain persists for longer than 3 to 6 weeks or if your doctor feels there may be a need for surgical consultation. Because most low back pain goes away on its own, getting an MRI scan too early may sometimes create confusion for the patient and the doctor.

Computed tomography (CT) scan: A CT scan allows your doctor to see spinal structures that cannot be seen on traditional x rays. A computer creates a three-dimensional image from a series of two-dimensional pictures that it takes of your back. Your doctor may order a CT scan to look for problems including herniated disks, tumors, or spinal stenosis.

Blood tests: Although blood tests are not used generally in diagnosing the cause of back pain, your doctor may order them in some cases. Blood tests that might be used include the following:

Complete blood count (CBC), which could point to problems such as infection or inflammation
Erythrocyte sedimentation rate (also called sed rate), a measure of inflammation that may suggest infection. The presence of inflammation may also suggest some forms of arthritis or, in rare cases, a tumor.
C-reactive protein (CRP), another blood test that is used to measure inflammation, may indicate an infection or some forms of arthritis.
HLA-B27, a test to identify a genetic marker in the blood that is more common in people with ankylosing spondylitis (a form of arthritis that affects the spine and sacroiliac joints) or reactive arthritis (a form of arthritis that occurs following infection in another part of the body, usually the genitourinary tract).

It is important to understand that medical tests alone may not diagnose the cause of back pain. Often, MRI scans of the spine show some type of abnormality, even in people without symptoms. Similarly, even some healthy pain-free people can have elevated sed rates.

Only with a medical history and exam—and sometimes medical tests—can a doctor diagnose the cause of back pain. Many times, the precise cause of back pain is never known. In these cases, it may be comforting to know that most back pain gets better whether or not you find out what is causing it.

What Is the Difference Between Acute and Chronic Pain?

Pain that hits you suddenly—after falling from a ladder, being tackled on the football field, or lifting a load that is too heavy, for example—is acute pain. Acute pain comes on quickly and often leaves just as quickly. To be classified as acute, pain should last no longer than 6 weeks. Acute pain is the most common type of back pain.

Chronic pain, on the other hand, may come on either quickly or slowly, and it lingers a long time. In general, pain that lasts longer than 3 months is considered chronic. Chronic pain is much less common than acute pain.

Search