When
we think about it, our lower back goes through a lot in our lifetimes:
it carries the entire weight of the upper body any time we are
upright; it endures the twisting, turning, and bending forces
during activity; it helps us lift heavy objects; and for those
of us with poor posture, it has to perform all the above things
without even being in the right position. For the most part, it
does a pretty good job. Nevertheless, given all the strain and
wear over time, it is not surprising that lower back problems
do occur frequently. 
One of the most common manifestations of lower back problems is
pain. Low back pain (LBP) will affect 80-90 percent of us at some
point in our lives, and chances are that you or someone you know
has suffered this condition in the past. LBP can be quite debilitating,
particularly if it is recurring, and can affect people both young
and old. In fact, it is the leading cause of work disability in
adults under the age of 45 and is estimated to cost society $
20-50 billion annually. Because back pain is disabling and costly,
it is important for physicians and patients to understand the
significance of its symptoms.
Structures Of The Lower Back
| The
lower back is anatomically very complex and is comprised of
different structures that have to be balanced and aligned
with each other for the lower back as a whole to function
correctly. These structures include: |
|
Vertebrae:
These bones make up the "S-shaped" curve of
the spine
|
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Vertebral
discs: These discs, sandwiched between vertebrae, serve
as cushioning
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Nerves
and nerve roots: These nerves and nerve roots come out
of the gaps, called the
foramen, located between the vertebrae and go to the lower
body and legs;
|
Paraspinal
muscles: These muscles are located along the side of the
spine and support
the spine
|
Ligaments:
These ligaments wrap around the structures of the lower
back and help hold
everything in place
|
Minor
Low Back Pain
Pain can arise when any one of the structures of the lower back
is stressed, damaged, or functioning incorrectly. In most cases
of acute (new-onset) LBP, the pain is local (not radiating down
either leg) and not severe. The paraspinal muscles can often be
the source of pain if they are weak, twisted, or in spasm following
activity. The ligaments might suffer a minor tear and lead to
localized pain near the tear. In these cases of acute minor LBP,
immediate medical attention is usually not necessary. The local
inflammation often dissipates over the course of a few days, and
the patient can continue most low-impact activities in the meanwhile.
Over-the-counter (OTC) pain medications can help relieve the pain.
Once the LBP is diminished, the patient should be encouraged to
start back-strengthening exercises, as recent studies have shown
that back muscle weakness is often the culprit in acute LBP. It
should be emphasized that the patient cannot re-injure his back
doing these exercises; they can only help to prevent the return
of LBP.
| Medical
attention should be sought if the LBP: |
|
becomes
chronic (lasts for longer than a few weeks)
|
|
increases
in severity
|
|
is
accompanied by radiation of pain or weakness down into
the legs, or any other abnormal symptoms (including fever,
weight loss, palpable mass in abdomen or pelvis, new-onset
urinary or bowel incontinence)
|
When
To Seek Medical Attention
These
"red flags" might indicate that something more serious
is going on. Radiculopathy, or a pinched nerve root, can lead
to LBP that radiates down one or both legs. This is sometimes
accompanied by leg weakness or urinary or bowel incontinence.
This can happen is various ways. In older patients with osteoporosis,
one of the vertebral bones might collapse on itself, causing a
"compression fracture". A compression fracture causes
the neighboring nerve root to be pinned down where it comes out
of its foramen. In middle-aged patients, disc herniation can occur
when a vertebral disc is subject to such strong forces, such as
when lifting a heavy object that it ruptures and starts to impinge
on the nearby nerve root. There is also a condition called spinal
stenosis in which nerves are compressed in an abnormally narrow
spinal canal, even before they come out of the foramen.
In rare cases, tumors and infections can also compress or damage
spinal structures and lead to LBP. The pain in these cases usually
get progressively worse and is accompanied by other signs of illness
such as fever, palpable tumor mass or weight loss.
| When
seeking medical attention, it is very important to convey
an accurate description of the pain as possible. The doctor
will ask questions such as: |
|
Is
the pain sharp or dull?
|
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When
did the pain start? Did it have a sudden onset or a gradual
onset?
|
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Where
is the pain located? Does it radiate (or move), and if
so, where?
|
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Is
the pain associated with a particular activity? For example,
does it occur when standing still?
|
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What
makes the pain get worse (or better)?
|
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Do
you have any related symptoms? (For example, any weakness
or abnormal sensations in the leg.)
|
This description, together with a thorough history and physical
exam by the physician, can be very useful in determining which
structure might be causing the pain and why. For example, if the
problem is a pinched nerve root, the patterns of pain radiation
and leg weakness can sometimes help pinpoint which nerve root
is involved.
| Medical
Records Checklist: Low Back Pain |
|
If
you have a history of low back pain, be sure to keep the
following information in your medical records:
|
|
Name,
address, and telephone number of your doctor
|
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Previous
medical and surgical history
|
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Date
of your last visit to your doctor
|
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Results
of your last physical examination
|
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Results
of any tests performed for the low back pain, such as
a MRI or CT scan
|
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Treatment
plan and/or recommendations, including any medications prescribed
(OTC and prescription), physical therapy, exercise plan,
surgical procedures, etc
|
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Date
of your next appointment, or when you need to schedule
another examination
|
The doctor might decide to order additional tests to confirm the
diagnosis. Radiological testing, such as magnetic resonance imaging
(MRI) or computed tomography (CT) scans, can often provide a clear
anatomical picture of what is going on and help not only to confirm
the diagnosis but also to guide treatment planning. It is important
to keep in mind, however, that not every spinal abnormality seen
on a scan is an indication for treatment; many abnormalities (including
a large number of disc herniations and bulges) are asymptomatic.
It is thus necessary to put together the specific clinical symptoms
of the patient with the results of the scan to determine which
is the most likely lesion causing LBP in a particular patient
and how to treat it.
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