Back Pain: Is It Serious or Will It Go away?
Published and reviewed December 2008
Back pain is common. Up to 84% of adults will experience back pain at some point in their lives. At times a specific injury can be identified, but more commonly there is no obvious cause. For many individuals, episodes of back pain are self-limited and resolve in a few weeks without specific treatment. For others, back pain is recurrent or persistent and interferes with work and other activities. Rarely, back pain is a sign of serious medical illness such as infection or malignancy. Following are some common causes of back pain and their treatment.
Between each vertebra is a cartilaginous disc that serves as a cushion. The outer part of this disc is tough, fibrous material (the annulus), while the inner part is softer and more gelatinous (nucleolus pulposis). Some people have defects in this outer ring that may allow some of the soft center to protrude and in doing so, it may compress one or more of the nerve roots. The onset of pain with disc herniation may be sudden or the pain may last over several days. The pain often radiates into the buttock and intermittently or constantly down the leg as well. The person may also experience loss of sensation, pins and needles sensations and possibly weakness in the leg. In most people the symptoms will resolve over 1 to 8 weeks, as the disc material loses water and shrinks away from the nerve. However, anyone with leg weakness, symptoms in both legs or loss of bladder or bowel control should seek immediate medical attention. Pain that is very severe or lasts more than 2 weeks also warrants medical attention.
Much of the time, physical therapy or chiropractic treatment, along with anti-inflammatory medications, will reduce the symptoms. Some patients respond to steroid injections into the space around the nerves to reduce the inflammation. Few will have persistent symptoms that require surgery, called a laminectomy, where a piece of bone is removed to relieve pressure on the nerve.
Spinal stenosis refers to narrowing of the spinal canal and/or the areas where the nerve roots exit from the spinal canal, also know as foramina. This narrowing is usually caused by arthritic changes in the facet joints (the joints connecting one vertebra to the next) or by thickening of the supporting ligaments, as the spine ages. Acute episodes of stenosis, usually involving leg pain, may be triggered by disc herniation that further narrows the spinal canal and foramina.
Walking may provoke or worsen the leg pain of spinal stenosis, and the person often will flex forward at the waist to reduce the pain. Persons with bilateral leg pain, loss of bladder control or leg weakness should seek immediate medical attention.
Treatments include physical therapy and chiropractic care, both accompanied by home exercise programs that the patient should continue on a daily basis. Anti-inflammatory medications, medications for nerve pain such as gabapentin and amitriptyline, and injection of steroids into the space around the inflamed nerve may be added for symptom relief. Surgery may ultimately be required if the above measures fail. Such surgery may involve a simple laminectomy (see above), which is sometimes followed by a more extensive surgery with fusion of adjacent vertebrae to stabilize the spine. Surgery is often successful in providing some relief, but most patients have some residual symptoms, and some ultimately experience the return of previous symptoms.
Facet Joint Arthritis
Arthritic changes in the facet joints can lead to back pain. Most commonly the pain is localized to the mid low back, but may radiate to the buttocks. Therapy, anti-inflammatory medications, and occasionally directed steroid injections into the joint may be helpful.
Compression fractures of the vertebra (figure 4) can occur spontaneously in a spine weakened by osteoporosis, or as a result of an injury. The pain is usually acute, in the center of the lower back, aggravated by any motion and alleviated by lying still. Current treatment often involves kyphoplasty, which is the injection of a cement-like material into the bone. Kyphoplasty reduces pain and may help restore bone height.
Physical therapy is helpful to improve strength and posture while also providing instruction in proper body mechanics. Compression fracture may be associated with pain that radiates around the rib cage or down the leg due to nerve entrapment. Such pain may respond to gabapentin or amitriptyline.
There are multiple ligaments connecting the various bones in the spine. These ligaments can be injured during improper lifting, twisting and bending. Onset is usually immediate or within a day or so from the activity. Pain is usually localized to the mid back. Treatment includes anti-inflammatory medications, physical therapy and chiropractic treatment. Most ligament sprains resolve over 2-4 weeks.
Sacroiliac Joint Dysfunction
The two sacroiliac (SI) joints connect the lower spine to the pelvic bones on either side. The SI joints can be injured and can also develop arthritis. The joints become loosened during pregnancy and may be injured during childbirth. Pain is usually felt in the high buttock and is worsened with weight-bearing or twisting. Steroid injection into the joint may be used as a diagnostic test to confirm that the SI joint is the source of painful symptoms, and such an injection may also provide lasting relief. Physical therapy and chiropractic treatments as well as anti-inflammatory medications are often helpful.
Systemic Causes of Back Pain
Cancer that has spread to the bone can produce back pain. Anyone with a history of cancer and severe back pain, particularly pain that is worse at night, should seek medical attention. Infections of the spine, kidney stones, pancreatic cancer and aortic dissection are among the serious medical conditions that may cause back pain. These may represent medical emergencies.
When to Seek Help
If the back pain is severe, radiates to both legs, or is associated with leg weakness, loss of bladder or bowel control or a history of cancer, you should seek immediate attention. Also, if back pain persists or is worsening after a week, a visit or call to your primary care provider is warranted.
As noted above, conservative treatments are often extremely helpful in alleviating symptoms. Therapists will provide instruction in appropriate lifting, posture and home exercises. Such instruction will help to maintain the integrity of the spine, which minimizes the risk of further pain and disability. If conservative approaches do not work, referral to a spine expert or spine center is warranted.
Some people will be left with chronic pain that does not entirely resolve after available treatments have been exhausted. For such patients, programs are available through pain treatment clinics that can help people regain function and minimize pain.
Preventing Back Pain
Losing weight if you are overweight, general strengthening and conditioning, leading an active lifestyle, and maintaining proper posture are all helpful in preventing back pain. Post-menopausal women should talk to their physicians about medication to reduce bone loss or even improve their bone density. Routine exercise and adequate intake of calcium and Vitamin D are requirements for good bone health.
Terminology used in back pain
Spondylosis: arthritis of the spine. Seen radiographically as disc space narrowing and arthritic changes of the facet joint.
Spondylolisthesis: anterior displacement of a vertebra on the one beneath it. A radiologist determines the degree of slippage upon reviewing spinal x-rays. Slippage is graded I through IV:
Grade I - 1 percent to 25 percent slip
Grade II - 26 percent to 50 percent slip
Grade III - 51 percent to 75 percent slip
Grade IV - 76 percent to 100 percent slip
Generally, Grade I and Grade II slips do not require surgical treatment and are treated medically. However, Grade III and Grade IV slips, and some milder grade slips, may benefit from surgery if persistent and disabling symptoms are present.
Spondylolysis: a fracture in the pars interarticularis where the vertebral body and the posterior elements, protecting the nerves are joined. In a small percent of the adult population, there is a developmental crack in one of the vertebrae, usually at L5.
Spinal stenosis: local, segmental, or generalized narrowing of the central spinal canal by bone or soft tissue elements, usually bony hypertrophic changes in the facet joints and by thickening of the ligamentum flavum.
Radiculopathy: impairment of a nerve root, usually causing radiating pain, numbness, tingling or muscle weakness that corresponds to a specific nerve root.
Sciatica: pain, numbness, tingling in the distribution of the sciatic nerve, radiating down the posterior or lateral aspect of the leg, usually to the foot or ankle.
Cauda equina syndrome: loss of bowel and bladder control and numbness in the groin and saddle area of the perineum, associated with weakness of the lower extremities. This condition can be caused by abnormal pressure on the bottom-most portion of the spinal canal and spinal nerve roots, related to either bony stenosis or a large herniated disc.
Lordosis, kyphosis, scoliosis:
Kyphotic curves refer to the outward curve of the thoracic spine (at the level of the ribs).
Lordotic curves refer to the inward curve of the lumbar spine (just above the buttocks).
Scoliotic curving is a sideways curvature of the spine and is always abnormal.
A small degree of both kyphotic and lordotic curvature is normal. Too much kyphotic curving causes round shoulders or hunched shoulders (Scheuermann's disease). Too much lordotic curving is called swayback (lordosis). Lordosis tends to make the buttocks appear more prominent.
Piriformis syndrome: thought to be a condition in which the piriformis muscle compresses or irritates the sciatic nerve. The piriformis muscle is a narrow muscle located in the buttocks. There is debate among the medical community whether this is a discrete condition since it lacks objective diagnostic evidence and therefore cannot be reliably assessed.
1. Chou, R, Qaseem, A Snow, V, et al. Diagnosis and treatment of low back pain: a joint clinical practice guideline from the American College of Physicians and the American Pain Society, Ann Intern Med 2007; 147:148.
2. Bigos, S. et al. Acute low back problems in adults: clinical practical guidelines, quick reference guide number 14. US Department of Health and Human Services, Public Health Service, Agency for Health Care Policy and Research, Rockville, MD 1994
3. American College of Radiology Website
Mary Dombovy, M.D.
Dr. Mary Dombovy is the Medical Director of The Spine Center, Chair of the Department of Physical Medicine and Rehabilitation; and Medical Director of The Stroke Center, all at Unity Health System in Rochester, New York. She graduated from Mayo Medical School in 1981 and is Board Certified in both Neurology and Physical Medicine and Rehabilitation. She then completed her Master's in Health Systems Administration in 2001 and in 2006 received certification in Vascular Neurology through the American Board of Psychiatry and Neurology.
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