Low Back Pain

Professor Nicola Portinaro explains symptoms, causes, diagnosis and treatment of low back pain.

What is Low Back Pain

Low Back Pain it’s something we all feel at some point in our lives.
It is one of the most common causes for going to the doctor.

It is also one of the most common causes of missed work and job-related disability.

The lumbar region supports much of the weight of the upper body.
In the lower back, there are five vertebrae and between them, there are the intervertebral discs that act as a shock absorber. This area is also rich in ligaments and tendons that hold the vertebrae in place and, of course, also of nerves that control the movement of our body and transmit signals from the body to the brain.

Low back pain can have different intensity ranges. It can be constant or sudden. For example, if you lift something heavy, it can start all of a sudden.
If pain lasts more than three months is treated as chronic lower back pain.

Mechanical Causes of Low Back Pain

Frequently the main cause of low back pain is mechanical.
Examples of mechanical causes include:

• Strains and sprains. When ligaments and muscles stretch to tear, you can experience acute back pain. It can occur from excess activity or from lifting something clumsily or something too heavy. In such a situation, you can experience pain and stiffness and spasm in the back muscles.
• Disc injury or disc degeneration. As a process of ageing, an intervertebral disc can degenerate and lose its integrity. It is also more prone to injury. The intervertebral disc can tear or even herniate. As we said, these discs act as a cushion between two vertebrae. If a disc deteriorates the cartilage surrounding the disc pushes against the spinal cord and put pressure on the spinal nerve roots. In such a situation, you can experience very intense pain that lasts for more than 3/4 days.
• Sciatica. Sciatica is a consequence of a herniated disk. It occurs when the disc presses on the sciatic nerve. Since the sciatic nerve connects the spine to the legs, you can experience pain also in legs and feet.
• Spinal stenosis. When the spinal column narrows, it puts pressure on the spinal cord and spinal nerves. Symptoms can be numbness, leg weakness, and cramping.
• Abnormal spine curvatures and skeletal irregularities
• Congenital conditions such as scoliosis, lordosis, and kyphosis can cause pain in the lower back. They are usually diagnosed during childhood or adolescence.
• Traumatic injuries. Sports injuries or car accidents can damage muscles, tendons, and ligaments and cause low back pain as a consequence. A traumatic injury can also cause an intervertebral disc to rupture or herniate.

Other Causes of Low Back Pain

Many other conditions cause lower back pain. They are rarer but can be more severe and require immediate medical attention.

These conditions include:

• Arthritis
• Fibromyalgia (chronic pain and tenderness in the joints, muscles, and tendons that also causes widespread muscle aches and fatigue)
• Spondylitis (it is a severe inflammation between the spinal joints)
• Tumors
• Ovarian cysts
• Uterine fibroids
• Cauda equina syndrome
• Abdominal aortic aneurysms
• Kidney stones

Other underlying conditions that can cause low back pain

• Pregnancy
• Osteoporosis
• Endometriosis

Risk Factors

Besides the causes just mentioned, other risk factors can increase the chances of suffering from low back pain, such as:

• Age. Most people experience the first attack of low back pain between the ages of 30 and 50. The intervertebral discs start losing fluid and osteoporosis (LINK) causes the loss of bone strength and muscle elasticity
• Being overweight.
• Low level of physical activity. Low back pain affects sedentary people because they have weak abdominal and back muscles that don’t support well their spine.
• Genetics. Ankylosing spondylitis and some forms of arthritis can lead to immobility of the spine and cause back pain.
• Occupational risk factors. A job that involves lifting heavy weights, or twisting the spine; but also a sedentary job that makes you do a little movement, and that makes you sit in a wrong posture.
• Backpack overload. Although you may wear your backpack or briefcase over your shoulder, it is the lower back that supports the upper body – including any additional weight you carry. A backpack overloaded with schoolbooks can strain the back even in pree-teen and cause low back pain.

How is Low Back Pain Diagnosed

It is important to tell your doctor your complete medical history to help him identify the source of your low back pain.

You must inform your doctor about the type and severity of pain, the onset, other related symptoms, and any chronic condition you have.

The doctor will perform a physical examination to determine if the pain is also affecting your range of motion.

Imaging tests may not be required during the early phases of low back pain. Still, your doctor may order them under individual situations, in particular, to rule out specific causes such as infection, tumor, inflammation, disc rupture, disc herniation, or pressure on a nerve.

Also, specific symptoms may require more testing; for example, if you experience weakness, fever, weight loss.

The types of test that a doctor may prescribe are:

• X-ray (to look for broken bones or injured vertebrae)
• CT scans, ultrasounds and MRIs to see soft tissues, such as muscles, tendons, and ligaments that are not visible through X-rays
• Electromyography (EMG) to identify any problems involving nerves and muscles.
• Blood tests can be required in some cases, in particular, if your doctor suspects inflammation, infection, arthritis, or ankylosing spondylitis.

Low Back Pain Treatment

Home Care
If Low Back Pain is due to muscle strain will usually get better on its own. In such a situation, you can apply ice for 2 or days and then switch to heat. A warm bath or a heating pad may help you feel better.
Alternating ice and heat relax muscles.

You can also take NSAIDs to relieve pain.

You should also avoid bed rest. It is better to do stretching exercises, trying to avoid movements that can worsen the pain.

Medical Treatments
If the pain doesn’t improve after 5-6 days of home treatment, you should call your doctor.

The doctor will determine which is the best treatment for your situation and decide whether you need to take any test among the one suggested above.

The doctor may prescribe you some medications such as

• Muscle relaxants
• Nonsteroidal anti-inflammatory drugs (NSAIDs)
• Analgesic medications and opioids such as codeine, oxycodone, hydrocodone, and morphine
• Narcotic drugs
• Steroids to reduce inflammation
• Corticosteroid injections

Other non-surgical treatments may include:

• Physical Therapy (massage, stretching and strengthening exercises, yoga)
• Traction with weights and pulleys to progressively “stretch” your skeletal structure into better alignment
• Nerve block therapies. These therapies block blocking nerve conduction from specific areas of the body and may include injections of local anesthetics, botulinum toxin, or steroids into affected soft tissues or joints.
• Epidural steroid injections. If low back pain is associated with inflammation, these injections may be a short-term option for releasing pain.

Also, Alternative Medicine is becoming a treatment option for many people.  Even if there is no scientific evidence to support these remedies, some of them can offer some relief and improvement, such as:

• Acupuncture 
• Spinal manipulation and spinal mobilization with highly qualified chiropractors and osteopathic doctors
• Yoga, tai chi, and similar Eastern disciplines that involve slow movements
• Anti-inflammatory diet: certain foods can help reducing inflammation, such as vegetables, fruits, nuts, fish, curcumin
• TENS (Transcutaneous Electrical Nerve Stimulation). The physical therapist places electrodes on your skin around the painful area. These electrodes generate electrical impulses whose aim is to block incoming pain signals from the peripheral nerves.

Low Back Pain Surgery Treatment

Surgery may be required only in most severe cases, and if all other treatments failed.

Surgery may also be an emergency option if there is a progressive neurological loss or a loss of bowel control.

Surgery treatment depends on the cause of your pain:

• Vertebroplasty and kyphoplasty are minimally invasive surgeries that fix compression fractures of the vertebrae.
• Discectomy. If you have a herniated ruptured disc that presses on a nerve root or the spinal cord, the orthopedic surgeon may perform this surgery. The surgeon will remove the herniated.
• Spinal laminectomy (spinal decompression). The orthopedic surgeon removes the lamina of the vertebrae and any other bone spurs. This procedure aims to make the size of the spinal canal bigger and remove pressure on the nerves.
• Foraminotomy. This kind of surgical procedure opens up the bony hole (foramen), which is the place where the nerve root exits the spinal canal. In this way, the surgeon can relieve pressure on the nerve.
• Intradiscal electrothermal therapy (IDET). The orthopedic surgeon performs this procedure when the discs are fractured or gibbous because of degenerative disc disease. The surgeon makes a small incision at the site of the disk and inserts a catheter into the disc. Then the disc is heated through an electrical current for about 20 minutes. This strengthens the collagen fibers around the disc walls and makes them thicker. The aim is to reduce the irritation of the spinal nerve and the bulging.
• Nucleoplasty or Plasma Disc Decompression (PDD). It is a laser surgery that removes inner disc material, heating the disc and vaporizing he tissue in it to reduce its size. In this way, it is possible to reduce pressure on the nerves.
• Radiofrequency denervation uses radio waves and electrical impulses to interrupt nerve conduction. It is an X-ray guided surgical procedure in which the surgeon inserts a needle into the nerves. Then the needle is heated, and heats destroy the target nerves. This procedure helps to relieve pain, but the relief is temporary.
• Spinal fusion. The orthopedic surgeon removes the spinal disc between two or more adjacent vertebrae and fuses them using bone grafts or other metal devices and screws. This procedure strengthens the spine even if it may cause some loss in flexibility. It requires a lengthy recovery period, and it is mainly performed in people suffering from degenerative disc disease or spondylolisthesis
• Artificial disc replacement. This surgical procedure is performed on people with severely damaged discs. The surgeon removes the disc and replaces it with a synthetic one. It is considered an alternative to spinal fusion.

Preventing Low Back Pain

There are many ways to prevent low back pain even if there is no sure way in particular as you age.

Anyway, prevention techniques may reduce the severity of your symptoms.

Prevention tips involve:

• Stay at a healthy weight
• Exercise and strengthen the muscles in your abdomen and back
• Lift items bending your knees and not your back
• Keep a correct posture at work, using ergonomically designed furniture
• Avoid high-heeled shoes
• Avoid smoking that can cause degeneration of the spinal discs
• Sleep on a firm surface

The experience of Prof. Portinaro

Although Prof Portinaro is mainly a Pediatric Orthopedic Surgeon, he has been treating back diseases, including scoliosis, for more than 30 years both in young and adult patients.