Low back pain is one of the most frequent musculoskeletal complaints. Pain may arise from damage or irritation to structures of the lower back including the vertebrae (bony spine), facet joints, discs between the vertebrae, vertebral ligaments, muscles of the lower back, spinal cord and peripheral nerves, as well as internal organs of the pelvis and abdomen (spleen, kidney, pancreas, liver).
Typically the symptoms of LBP resolve within four weeks, depending on the pathology associated with the complaint. However, the pain often returns leading to a high percentage of the American population with a chronic condition and requires lower back pain management.
Understanding the anatomy and physiological function of the lower back is key in evaluating a person with chronic pain. The bony spine is positioned so that individual vertebrae (bones of the spine) interconnect with other spine bones above and below. This provides a flexible support structure while also protecting the spinal cord. Conditions that can produce chronic pain from the spinal bones include:
Facet injections/denervation, Vertebroplasty, SI joint injection/denervation, Lysis of Adhesions, spinal cord stimulation, intrathecal pumps and other treatments can be extremely effective lower back pain treatment for many of these conditions.
In fact, a recent study in 2007 concluded that lumbar facet joint nerve blocks with local anesthetic may be effective in the treatment of chronic low back pain of facet joint origin. Physical therapy, cognitive behavioral therapy, biofeedback, diet and exercise, along with other alternative techniques have also been helpful
Separating adjacent vertebrae are discs that act as cushions to minimize the impact that the spinal column receives. Since the discs are designed to be soft and provide support, they have a tendency to herniate (bulge) posterior (or backwards) through the outer ligaments and cause irritation to the adjacent nerves.
Disc disease is one of the most common causes of chronic LBP and accounts for approximately 10% of all low back pain complaints. Disc disease may acutely be from herniation resulting from trauma or heavy lifting. More commonly chronic back pain is caused by degenerative disc disease. Degenerative disk disease is due to thinning and degeneration of the discs and can lead to spinal stenosis, nerve impingement, worsening facet arthritis, or peripheral nerve irritation.
Conditions that can produce chronic pain from the discs:
Facet injections/denervation, epidural steroid injections, Lysis of Adhesions, epidural infusions, spinal cord stimulation, intrathecal pumps and other treatments can be extremely effective treatment for lower back pain in many of these conditions.
There are ligaments that attach to each vertebrae and provide strength and mobility to the spine as well as the many groups of muscles that are responsible for the movement of the spine. The nerve roots are attached to the spinal cord and exit the spine to innervate the skin, muscles, and surrounding structures of the back and lower extremities. These muscles and ligaments have a tendency to become strained and irritated during strenuous lifting and excessive exercise and cause local nerve irritation. Myofascial (muscle and connective tissue) and ligament injury may account for the majority of low back pain. Conditions that can produce chronic pain from ligaments and musculature:
Trigger point injections widely popularized by Dr Travell are extremely successful in alleviating and managing lower back musculoskeletal pain. An alternative therapy that specifically targets ligaments is called Prolotherapy. This sort of therapy, also called Regenerative Injection Therapy has been successful for many chronic pain suffers. Physical therapy, acupuncture, massage, yoga, diet and exercise have also proven to be effective in treating myofascial pain.
Organs in the abdomen and pelvis can refer pain to the back. Specifically, the kidney, pancreas, spleen, and liver have been known to refer pain to this region. These organs may cause pain that is due to obstruction, inflammation, infection, decreased blood supply, enlargement and or cancer. These “activated nerves” cause referred pain by traveling into the spinal cord at the same level as other structures in the lower back. This can cause a person to experience pain in the back instead of their organs.
Common causes of LBP consist of Herniated Discs, Spinal Stenosis, Strained Muscles Sciatica, Arthritis (auto-immune vs. non auto-immune), Fibromyalgia, Vertebral Body Fractures, and Osteoporosis.
Less common causes include infections, Ankylosing Spondylitis, Psychological causes and Metastatic Cancer. Risk factors for malignancy include an age greater than 50, pain not relieved by lying down, symptoms worse at night, and pain for longer than one month.
Acute LBP typically comes on abruptly and occurs during a specific activity. Acute lower back injury is more commonly due to overuse by excessive exercise, lifting of heavy objects, motor vehicle accidents, or any trauma involving the lower back. The anatomy typically involved in acute LBP is the muscles and surrounding ligaments. Vertebral body fractures, ruptured discs and spinal cord compressions can also be seen acutely with pre-existing osteoporosis, cancer, or spinal stenosis. Acute pain due to ligament and muscle injury typically responds to activity and NSAIDs (Ibuprofen like drugs). Acute back pain should be evaluated by a physician to rule out other causes like: kidney stones, kidney infection, and acute pancreatitis. In some cases of acute back pain a specialists and proper imaging is required for immediate evaluation (Emergency Room, Pain Specialists, Spine Surgeon). These cases might include:
Chronic low back pain is defined as pain over 3-6months in duration. Typically the symptoms are more gradual and occur over an extended period of time. With chronic LBP a person may experience pain in their back as well as down either leg. Causes of chronic LBP are numerous and include:
Central Sensitization is a common complication associated with chronic pain of all kinds. This is a development involving both the peripheral nervous system (PNS) and the central nervous system (CNS). Local tissue injury and inflammation activate the PNS, which sends signals through the spinal cord to the brain.
Central sensitization occurs when there is an increase in the excitability of neurons within the CNS at the level of the spinal cord and higher. Eventually normal inputs from the PNS begin to produce abnormal responses. Low-threshold sensory fibers activated by very light touch of the skin activate neurons in the spinal cord that normally only respond to painful stimuli. As a result, an input that would normally produce a harmless sensation now produces significant pain.
Sacroiliac Joint (SIJ) Disease is another major cause of LBP. The SIJ is located at the junction between the spine and the pelvis. Many muscles and ligaments support the SIJ. This joint allows the weight of the spine and upper body to be transmitted into the pelvis and finally into the legs. The SIJ is richly innervated by free nerve endings and spinal nerve roots, explaining the severe pain caused by inflammation in the SIJ. Pain associated with SIJ can worsen with sitting for long periods of time, or twisting motions and certain movements. Often the pain begins spontaneously, while others recognize a specific traumatic event that triggered the occurrence of the pain.
While conservative treatment for lower back pain such as NSAIDs and physical therapy may be effective, Murakami and Tanaka reported in 2007 that the effect of periarticular lidocaine injection into the SIJ was 96% effective in pain improvement in patients with SIJ complaints with minimal complications (2007 Murakami). Florida Spine Institute now offer SIJ injections and longer lasting denervation procedures for better management of lower back pain when warranted.
Diagnosis of LBP can be difficult and the Pain Physicians at Florida Spine Institute have received extra training to examine and diagnose your painful condition. The physician may perform a physical exam demonstrating tenderness over certain areas of the spine as well as assessing the various limitations in movement. The physician may also order radiological imaging such as x-ray, CT scan, MRI, or bone scan depending on his clinical suspicion and the history obtained.
Bed rest is contraindicated in most causes of LBP. Staying active and physical therapy are indicated. There are many interventions offered by Arizona Pain Specialists for those with severe LBP to assist you in managing your lower back pain. Below we list a basic overview of pain relief options.
We are happy to offer these exciting pain management techniques to the Phoenix area:
Surgical procedures are typically done when all conservative managements are unsuccessful in reducing pain or when the spinal cord or exiting nerves are being severely compressed. Serious compressions are characterized by bladder and/or bowel incontinence, lower extremity weakness, spasticity, and/or loss of sensation.
Invasive Surgical Procedures Include:
Long-term, surgical fusion or discectomy may not provide relief. In addition, surgical options for LBP were found to be associated with a significant risk of complications, including bleeding, nerve damage, epidural scarring, and prolonged recovery times. Surgical procedures are typically done when conservative management by pain specialists have been exhausted, life-threatening complications have ensued, or neurological symptoms like weakness, bowel or bladder changes, and/or loss of sensation. The evidence at the present time does not support routine surgical fusion or surgery for the treatment of chronic lower back pain alone.
There have been great strides in lower back pain treatments and pain management. Early intervention can make a big difference.