Back Pain Causes, Diagnosis and Treatments Handout

This page is for people who have back pain, as well as family
members, friends, and others who want to find out more about back pain.

The post describes causes, diagnosis, and treatments, and research
efforts to learn more about back pain, many of which are supported by the
National Institute of Arthritis and Musculoskeletal and Skin Diseases
(NIAMS) and other components of the U.S. Department of Health and Human
Services’ National Institutes of Health (NIH). If you have further
questions after reading this booklet, you may wish to discuss them with
your doctor.

PDF Version of this Document

What Is Back Pain?

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
too 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 back pain. And chances are,
if you don’t have it now, you will eventually.

• How Common Is Back Pain?
• What Are the Risk Factors for Back Pain?
• What Are the Causes of Back Pain?
• Can Back Pain Be Prevented?
• When Should I See a Doctor for Pain?
• Which Type of Doctor Should I See?
• How Is Back Pain Diagnosed?
• What Is the Difference Between Acute and Chronic Pain?
• How Is Back Pain Treated?
• Nonsurgical treatments
• Surgical treatments
• What Kind of Research Is Being Done?
• For More Information
• Glossary

Illustrations

• Side View of Spine
• Normal Vertebra (Cross-Section)

How Common Is Back Pain?

At some point, back pain affects an estimated 8 in 10 people. 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. “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 discs 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, including disc disease, may 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.

Side View of Spine

Normal Vertebra

The presence of other diseases: Many
diseases can cause or contribute to back pain. These include various
forms of arthritis, such as osteoarthritis, rheumatoid arthritis, and
ankylosing spondylitis, 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 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 discs 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. 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 disc
degeneration, which simply means that the discs 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 discs, which are also called
herniated discs.

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, a condition that causes weak, porous bones.
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, which causes curvature of the spine and 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, which causes
fatigue and widespread muscle pain.

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 discs that cushion the vertebrae, which is called discitis.
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 “How Is Back Pain Treated?”.
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’s 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 more 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
discs, 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.

It is important to understand that medical tests alone may not
diagnose the cause of back pain. In fact, experts say that up to 90
percent of all MRI scans of the spine show some type of abnormality,
and sometimes the x rays and CT scans of people without pain show
problems. 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 just 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 more
than 3 months is considered chronic. Chronic pain is much less common
than acute pain.

How Is Back Pain Treated?

Treatment for back pain generally depends on what kind of pain you experience: acute or chronic.

Acute Back Pain: Acute back pain usually
gets better on its own and without treatment, although you may want to
try acetaminophen, aspirin, or ibuprofen to help ease the pain. Perhaps
the best advice is to go about your usual activities as much as you can
with the assurance that the problem will clear up. Getting up and
moving around can help ease stiffness, relieve pain, and have you back
doing your regular activities sooner. Exercises or surgery are not usually advisable for acute back pain.

Chronic Back Pain: Treatment for chronic
back pain falls into two basic categories: the kind that requires an
operation and the kind that does not. In the vast majority of cases,
back pain does not require surgery. Doctors will nearly always try
nonsurgical treatments before recommending surgery. In a very small
percentage of cases – when back pain is caused by a tumor, an
infection, or a nerve root problem called cauda equina syndrome, for
example – prompt surgery is necessary to ease the pain and prevent
further problems.

Following are some of the more commonly used treatments for chronic back pain.

Nonsurgical treatments

Hot or cold: Hot or cold packs – or
sometimes a combination of the two – can be soothing to chronically
sore, stiff backs. Heat dilates the blood vessels, both improving the
supply of oxygen that the blood takes to the back and reducing muscle
spasms. Heat also alters the sensation of pain. Cold may reduce
inflammation by decreasing the size of blood vessels and the flow of
blood to the area. Although cold may feel painful against the skin, it
numbs deep pain. Applying heat or cold may relieve pain, but it does
not cure the cause of chronic back pain.

Exercise: Although exercise is usually not
advisable for acute back pain, proper exercise can help ease chronic
pain and perhaps reduce the risk of it returning. The following four
types of exercise are important to general physical fitness and may be
helpful for certain specific causes of back pain:

Flexion: The purposes of flexion exercises, which
are exercises in which you bend forward, are to (1) widen the spaces
between the vertebrae, thereby reducing pressure on the nerves; (2)
stretch muscles of the back and hips; and (3) strengthen abdominal and
buttock muscles. Many doctors think that strengthening the muscles of
the abdomen will reduce the load on the spine. One word of
caution: If your back pain is caused by a herniated disc, check with
your doctor before performing flexion exercises because they may
increase pressure within the discs, making the problem worse.

Extension: With extension exercises, you bend
backward. They may minimize radiating pain, which is pain you can feel
in other parts of the body besides where it originates. Examples of
extension exercises are leg lifting and raising the trunk, each
exercise performed while lying prone. The theory behind these exercises
is that they open up the spinal canal in places and develop muscles
that support the spine.

Stretching: The goal of stretching exercises, as
their name suggests, is to stretch and improve the extension of muscles
and other soft tissues of the back. This can reduce back stiffness and
improve range of motion.

Aerobic: Aerobic exercise is the type that gets
your heart pumping faster and keeps your heart rate elevated for a
while. For fitness, it is important to get at least 30 minutes of
aerobic (also called cardiovascular) exercise three times a week.
Aerobic exercises work the large muscles of the body and include brisk
walking, jogging, and swimming. For back problems, you should avoid
exercise that requires twisting or vigorous forward flexion, such as
aerobic dancing and rowing, because these actions may raise pressure in
the discs and actually do more harm than good. In addition, avoid
high-impact activities if you have disc disease. If back pain or your
fitness level make it impossible to exercise 30 minutes at a time, try
three 10-minute sessions to start with and work up to your goal. But
first, speak with your doctor or physical therapist about the safest
aerobic exercise for you.

Medications: A wide range of medications
are used to treat chronic back pain. Some are available over the
counter. Others require a doctor’s prescription. The following are the
main types of medications used for back pain.

Analgesics: Analgesic medications are those designed specifically to relieve pain. They include over-the-counter acetaminophen (Tylenol)¹
and aspirin, as well as prescription narcotics, such as oxycodone with
acetaminophen (Percocet) or hydrocodone with acetaminophen (Vicodin).
Aspirin and acetaminophen are the most commonly used analgesics;
narcotics should only be used for a short time for severe pain or pain
after surgery. People with muscular back pain or arthritis pain that is
not relieved by medications may find topical analgesics helpful. These
creams, ointments, and salves are rubbed directly onto the skin over
the site of pain. They use one or more of a variety of ingredients to
ease pain. Topical analgesics include such products as Zostrix, Icy
Hot, and BenGay.

¹ Brand names included
in this booklet are provided as examples only, and their inclusion does
not mean that these products are endorsed by the National Institutes of
Health or any other Government agency. Also, if a particular brand name
is not mentioned, this does not mean or imply that the product is
unsatisfactory.

NSAIDs: Nonsteroidal anti-inflammatory drugs
(NSAIDs) are drugs that relieve pain and inflammation, both of which
may play a role in some cases of back pain. NSAIDs include the
nonprescription products ibuprofen (Motrin, Advil), ketoprofen (Actron,
Orudis KT), and naproxen sodium (Aleve). More than a dozen others,
including a subclass of NSAIDs called COX-2 inhibitors, are available
only with a prescription.

All NSAIDs work similarly – by blocking substances called
prostaglandins that contribute to inflammation and pain. However, each
NSAID is a different chemical, and each has a slightly different effect
on the body.²

²Warning:
NSAIDs can cause stomach irritation or, less often, they can affect
kidney function. The longer a person uses NSAIDs, the more likely he or
she is to have side effects, ranging from mild to serious. Many other
drugs cannot be taken when a patient is being treated with NSAIDs
because NSAIDs alter the way the body uses or eliminates these other
drugs. Check with your health care provider or pharmacist before you
take NSAIDs. Also, NSAIDs sometimes are associated with serious
gastrointestinal problems, including ulcers, bleeding, and perforation
of the stomach or intestine. People age 65 and older and those with any
history of ulcers or gastrointestinal bleeding should use NSAIDs with
caution.

Side effects of all NSAIDs can include stomach upset and stomach
ulcers, heartburn, diarrhea, and fluid retention; however, COX-2
inhibitors are designed to cause fewer stomach ulcers. For unknown
reasons, some people seem to respond better to one NSAID than another.
It’s important to work with your doctor to choose the one that’s safest
and most effective for you.

Other medications: Muscle relaxants and certain antidepressants have also been prescribed for chronic back pain, but their usefulness is questionable.

Traction: Traction involves using pulleys
and weights to stretch the back. The rationale behind traction is to
pull the vertebrae apart to allow a bulging disc to slip back into
place. Some people experience pain relief while in traction, but that
relief is usually temporary. Once traction is released, the stretch is
not sustained and back pain is likely to return. There is no scientific evidence that traction provides any long-term benefits for people with back pain.

Corsets and braces: Corsets and braces
include a number of devices, such as elastic bands and stiff supports
with metal stays, that are designed to limit the motion of the lumbar
spine, provide abdominal support, and correct posture. Although
these may be appropriate after certain kinds of surgery, there is
little, if any, evidence that corsets and braces help treat chronic low
back pain. In fact, by keeping you from using your back muscles, they
may actually cause more problems than they solve by causing lower back
muscles to weaken from lack of use.

Behavioral modification: Developing a
healthy attitude and learning to move your body properly while you do
daily activities – particularly those involving heavy lifting, pushing,
or pulling – are sometimes part of the treatment plan for people with
back pain. Other behavior changes that might help pain include adopting
healthy habits, such as exercise, relaxation, and regular sleep, and
dropping bad habits, such as smoking and eating poorly.

Injections: When medications and other
nonsurgical treatments fail to relieve chronic back pain, doctors may
recommend injections for pain relief. Following are some of the most
commonly used injections, although some are of questionable value:

Nerve root blocks: If a nerve is inflamed or
compressed as it passes from the spinal column between the vertebrae,
an injection called a nerve root block may be used to help ease the
resulting back and leg pain. The injection contains a steroid
medication or anesthetic and is administered to the affected part of
the nerve. Whether the procedure helps or not depends on finding and injecting precisely the right nerve.

Facet joint injections: The facet joints are those
where the vertebrae connect to one another, keeping the spine aligned.
Although arthritis in the facet joints themselves is rarely the source
of back pain, the injection of anesthetics or steroid medications into
facet joints is sometimes tried as a way to relieve pain. The effectiveness of these injections is questionable. One study suggests that this treatment is overused and ineffective.

Trigger point injections: In this procedure, an
anesthetic is injected into specific areas in the back that are painful
when the doctor applies pressure to them. Some doctors add a steroid
medication to the injection. Although the injections are commonly
used, researchers have found that injecting anesthetics or steroids
into trigger points provides no more relief than “dry needling”
(inserting a needle and not injecting a medication).

Prolotherapy: One of the most talked about
procedures for back pain, prolotherapy is a treatment in which a
practitioner injects a sugar solution or other irritating substance
into trigger points along the periosteum (the tough, fibrous tissue
covering the bones) to trigger an inflammatory response that promotes
the growth of dense, fibrous tissue. The theory behind prolotherapy is
that such tissue growth strengthens the attachment of tendons and
ligaments whose loosening has contributed to back pain. As yet, studies have not verified the effectiveness of prolotherapy. The procedure is used primarily by chiropractors and osteopathic doctors.

Complementary and alternative treatments:
When back pain becomes chronic or when medications and other
conventional therapies do not relieve it, many people try complementary
and alternative treatments. Although such therapies won’t cure diseases
or repair the injuries that cause pain, some people find them useful
for managing or relieving pain. Following are some of the most commonly
used complementary therapies.

Manipulation: Spinal manipulation refers to
procedures in which professionals use their hands to mobilize, adjust,
massage, or stimulate the spine or surrounding tissues. This type of
therapy is often performed by osteopathic doctors and chiropractors. It
tends to be most effective in people with uncomplicated pain and when
used with other therapies. Spinal manipulation is not appropriate
if you have a medical problem such as osteoporosis, spinal cord
compression, or inflammatory arthritis (such as rheumatoid arthritis)
or if you are taking blood-thinning medications such as warfarin
(Coumadin) or heparin (Calciparine, Liquaemin).

Transcutaneous electrical nerve stimulation (TENS):
TENS involves wearing a small box over the painful area that directs
mild electrical impulses to nerves there. The theory is that
stimulating the nervous system can modify the perception of pain. Early
studies of TENS suggested it could elevate the levels of endorphins,
the body’s natural pain-numbing chemicals, in the spinal fluid. But subsequent studies of its effectiveness against pain have produced mixed results.

Acupuncture: This ancient Chinese practice has been
gaining increasing acceptance and popularity in the United States.
Acupuncture is based on the theory that a life force called Qi
(pronounced chee) flows through the body along certain channels, which
if blocked can cause illness. According to the theory, the insertion of
thin needles at precise locations along these channels by practitioners
can unblock the flow of Qi, relieving pain and restoring health.

Although few Western-trained doctors would agree with the concept of
blocked Qi, some believe that inserting and then stimulating needles
(by twisting or passing a low-voltage electrical current through them)
may foster the production of the body’s natural pain-numbing chemicals,
such as endorphins, serotonin, and acetylcholine.

A consensus panel convened by the National Institutes of Health
(NIH) in 1997 concluded that there is clear evidence this treatment is
effective for some pain conditions, including postoperative dental
pain. Although there is less convincing evidence to support using
acupuncture for back pain and some other pain conditions, the panel
concluded that acupuncture may be effective when used as part of a
comprehensive treatment plan for low back pain, fibromyalgia, and
several other conditions.

Acupressure: As with acupuncture, the theory behind
acupressure is that it unblocks the flow of Qi. The difference between
acupuncture and acupressure is that no needles are used in acupressure.
Instead, a therapist applies pressure to points along the channels with
his or her hands, elbows, or even feet. (In some cases, patients are
taught to do their own acupressure.) Acupressure has not been well studied for back pain.

Rolfing: A type of massage, rolfing involves using
strong pressure on deep tissues in the back to relieve tightness of the
fascia, a sheath of tissue that covers the muscles, that can cause or
contribute to back pain. The theory behind rolfing is that releasing
muscles and tissues from the fascia enables the back to align itself
properly. So far, the usefulness of rolfing for back pain has not been scientifically proven.

Surgical treatments

Depending on the diagnosis, surgery may either be the first
treatment of choice – although this is rare – or it is reserved for
chronic back pain for which other treatments have failed. If you are in
constant pain or if pain reoccurs frequently and interferes with your
ability to sleep, to function at your job, or to perform daily
activities, you may be a candidate for surgery.

In general, two groups of people may require surgery to treat their
spinal problems. People in the first group have chronic low back pain
and sciatica, and they are often diagnosed with a herniated disc,
spinal stenosis, spondylolisthesis, or vertebral fractures with nerve
involvement. People in the second group are those with only predominant
low back pain (without leg pain). These are people with discogenic low
back pain (degenerative disc disease), in which discs wear with age.
Usually, the outcome of spine surgery is much more predictable in
people with sciatica than in those with predominant low back pain.

Some of the diagnoses that may need surgery include:

Herniated discs: In this potentially
painful problem, the hard outer coating of the discs, which are the
circular pieces of connective tissue that cushion the bones of the
spine, are damaged, allowing the discs’ jelly-like center to leak,
irritating nearby nerves. This causes severe sciatica and nerve pain
down the leg. A herniated disc is sometimes called a ruptured disc.

Spinal stenosis: Spinal stenosis is the narrowing of the spinal canal, through which the spinal cord and spinal nerves run.

It is often caused by the overgrowth of bone caused by
osteoarthritis of the spine. Compression of the nerves caused by spinal
stenosis can lead not only to pain, but also to numbness in the legs
and the loss of bladder or bowel control. Patients may have difficulty
walking any distances and may have severe pain in their legs along with
numbness and tingling.

Spondylolisthesis: In this condition, a
vertebra of the lumbar spine slips out of place. As the spine tries to
stabilize itself, the joints between the slipped vertebra and adjacent
vertebrae can become enlarged, pinching nerves as they exit the spinal
column. Spondylolisthesis may cause not only low back pain but also
severe sciatica leg pain.

Vertebral fractures: These fractures are
caused by trauma to the vertebrae of the spine or by crumbling of the
vertebrae resulting from osteoporosis. This causes mostly mechanical
back pain, but it may also put pressure on the nerves, creating leg
pain.

Discogenic low back pain (degenerative disc disease):
Most people’s discs degenerate over a lifetime, but in some, this aging
process can become chronically painful, severely interfering with their
quality of life.

Following are some of the most commonly performed back surgeries:

For Herniated Discs:

Laminectomy/discectomy: In this operation,
part of the lamina, a portion of the bone on the back of the vertebrae,
is removed, as well as a portion of a ligament. The herniated disc is
then removed through the incision, which may extend two or more inches.

Microdiscectomy: As with traditional
discectomy, this procedure involves removing a herniated disc or
damaged portion of a disc through an incision in the back. The
difference is that the incision is much smaller and the doctor uses a
magnifying microscope or lenses to locate the disc through the
incision. The smaller incision may reduce pain and the disruption of
tissues, and it reduces the size of the surgical scar. It appears to
take about the same amount of time to recuperate from a microdiscectomy
as from a traditional discectomy.

Laser surgery: Technological advances in
recent decades have led to the use of lasers for operating on patients
with herniated discs accompanied by lower back and leg pain. During
this procedure, the surgeon inserts a needle in the disc that delivers
a few bursts of laser energy to vaporize the tissue in the disc. This
reduces its size and relieves pressure on the nerves. Although many
patients return to daily activities within 3 to 5 days after laser
surgery, pain relief may not be apparent until several weeks or even
months after the surgery. The usefulness of laser discectomy is still being debated.

For Spinal Stenosis:

Laminectomy: When narrowing of the spine
compresses the nerve roots, causing pain or affecting sensation,
doctors sometimes open up the spinal column with a procedure called a
laminectomy. In a laminectomy, the doctor makes a large incision down
the affected area of the spine and removes the lamina and any bone
spurs, which are overgrowths of bone, that may have formed in the
spinal canal as the result of osteoarthritis. The procedure is major
surgery that requires a short hospital stay and physical therapy
afterwards to help regain strength and mobility.

For Spondylolisthesis

Spinal fusion: When a slipped vertebra
leads to the enlargement of adjacent facet joints, surgical treatment
generally involves both laminectomy (as described above) and spinal
fusion. In spinal fusion, two or more vertebrae are joined together
using bone grafts, screws, and rods to stop slippage of the affected
vertebrae. Bone used for grafting comes from another area of the body,
usually the hip or pelvis. In some cases, donor bone is used.

Although the surgery is generally successful, either type of graft
has its drawbacks. Using your own bone means surgery at a second site
on your body. With donor bone, there is a slight risk of disease
transmission or rejection. In recent years, a new development has
eliminated those risks for some people undergoing spinal fusion:
proteins called bone morphogenic proteins are being used to stimulate
bone generation, eliminating the need for grafts. The proteins are
placed in the affected area of the spine, often in collagen putty or
sponges.

Regardless of how spinal fusion is performed, the fused area of the spine becomes immobilized.

For Vertebral Osteoporotic Fractures³

Vertebroplasty: When back pain is caused
by a compression fracture of a vertebra due to osteoporosis or trauma,
doctors may make a small incision in the skin over the affected area
and inject a cement-like mixture called polymethylacrylate into the
fractured vertebra to relieve pain and stabilize the spine. The
procedure is generally performed on an outpatient basis under a mild
anesthetic.

³ Used only if standard care, rest, corsets and braces, and analgesics fail.

Kyphoplasty: Much like vertebroplasty,
kyphoplasty is used to relieve pain and stabilize the spine following
fractures due to osteoporosis. Kyphoplasty is a two-step process. In
the first step, the doctor inserts a balloon device to help restore the
height and shape of the spine. In the second step, he or she injects
polymethylacrylate to repair the fractured vertebra. The procedure is
done under anesthesia, and in some cases it is performed on an
outpatient basis.

For Discogenic Low Back Pain (Degenerative Disc Disease)

Intradiscal electrothermal therapy (IDT):
One of the newest and least invasive therapies for low back pain
involves inserting a heating wire through a small incision in the back
and into a disc. An electrical current is then passed through the wire
to strengthen the collagen fibers that hold the disc together. The
procedure is done on an outpatient basis, often under local anesthesia.
The usefulness of IDT is debatable.

Spinal fusion: When the degenerated disc
is painful, the surgeon may recommend removing it and fusing the disc
to help with the pain. This fusion can be done through the abdomen, a
procedure known as anterior lumbar interbody fusion, or through the
back, called posterior fusion. Theoretically, fusion surgery
should eliminate the source of pain; the procedure is successful in
about 60 to 70 percent of cases. Fusion for low back pain or any
spinal surgeries should only be done as a last resort, and the patient
should be fully informed of risks.

Disc replacement: When a disc is
herniated, one alternative to a discectomy – in which the disc is
simply removed – is removing the disc and replacing it with a synthetic
disc. Replacing the damaged one with an artificial one restores disc
height and movement between the vertebrae. Artificial discs come in
several designs. Although doctors in Europe had performed disc
replacement for more than a decade, the procedure had been experimental
in the United States until the Food and Drug Administration approved
the Charité artificial disc (http://www.fda.gov/cdrh/pdf4/p040006.html).

What Kind of Research Is Being Done?

The National Institute of Arthritis and Musculoskeletal and Skin
Diseases (NIAMS) is currently supporting a number of studies to better
understand and treat back pain. Goals of current research include the
following:

To compare the effectiveness of surgery versus nonsurgical treatment for low back pain.
Although the percentage of people having spinal surgery in the United
States has increased sharply over time, there is not much information
on whether back surgery is better than nonsurgical treatments. One
study is comparing the most commonly used surgical treatments to the
most commonly used nonsurgical treatments for three common back
problems: herniated discs of the lumbar spine, spinal stenosis, and
spinal stenosis from spondylolisthesis. The study, being conducted at
12 medical centers, will follow patients for at least 24 months after
treatment to determine the medical and cost-effectiveness of treatments.

To identify the best treatments for certain patients with low back pain.
Just as certain treatments are effective for some back problems and not
others, the same treatment may be effective for some people and not
others – even if those people have the same medical problem.
Researchers at several centers will study more than 3,000 patients who
have one of three common causes of back pain – herniated discs, spinal
stenosis, and spondylolisthesis – and who respond well to specific
treatments. Extensive testing and surveys will allow doctors to
identify the best treatments for these patients.

To test the effectiveness of lumbar fusion and other treatments for disc-derived pain.
Discogenic pain is low back pain due to the wearing away of a disc
between the vertebrae. Although treatment for this condition is often
lumbar spinal fusion, its effectiveness, as well as that of other
treatments, has not been established. A new study will compare the
results of spinal fusion with those of nonsurgical care for patients
with similar disc degeneration. Researchers will also try to find out
(1) what distinguishes people who choose surgery from those who do not;
(2) the consequences of common complications of spinal fusion surgery
and how often they occur; (3) what predicts a good response to surgical
therapy but not to other treatments; and (4) what are the
characteristics and outcomes of patients who have repeat back surgery
for this condition.

To measure the frequency of complications in lumbar fusion surgery.

Lumbar spinal fusion is a commonly performed procedure for several back
problems, including disc degeneration, spondylolisthesis, spinal
stenosis, and scoliosis, but the procedure can have complications. A
new study will follow 1,000 people who have spinal fusion for one of
these diagnoses to find out (1) how often complications occur after
surgery, (2) how the rates of specific serious complications vary with
different types of lumbar fusion, (3) the consequences of specific
types of complications, and (4) the characteristics of treatments or
patients that predict particularly severe complications. The
information will help doctors better assess the benefits versus the
risks of the procedure.

To better understand the relationship between the loss of motor control and low back pain.
Compared to people without back problems, those with low back pain show
losses in motor control, including problems with trunk muscle response
and posture. Some researchers believe that losses in motor control may
predispose people to falls that result in back pain. Other researchers
think losses in motor control may result from damage sustained by
tissue during a fall. To explore the relationship between motor control
loss and back pain, scientists will study varsity athletes to determine
whether poor motor control of the lumbar spine increases the risk of
low back injury. They will also study changes in the lumbar spine motor
control of people with low back pain after they complete rehabilitation
programs that emphasize motor control training.

To develop and evaluate a psychosocial program for people with acute low back pain.
Acute low back pain is a common problem that affects people’s abilities
to work and function, and it contributes to high health care costs.
There are few studies, however, that prove whether or not a treatment
truly reduces limitation and prevents the recurrence of pain. One new
project will develop a program to enhance the social support and
self-efficacy of people with acute low back pain. After developing and
testing the program, researchers will evaluate its effectiveness by
comparing the results of 160 participants with those of 160 people
receiving usual care.

To evaluate the nervous system mechanisms of low back pain.
Scientists think that when a disc ruptures, material leaking from its
jelly-like filling leads to inflammation and the release of chemicals
that irritate cells within the spinal canal. Scientists believe that
the effects of these chemicals on the nerve endings in discs and
adjacent tissue lead to low back pain, while the effects on dorsal
nerve roots lead to sciatica. One study will test these ideas using a
variety of techniques. A better understanding of pain mechanisms
related to herniated discs will allow researchers to develop better
treatments.

To evaluate an Internet-based patient education program.
Patient education can play an important role in managing back pain. Yet
taking part in an educational program can be difficult and
time-consuming for some people, particularly if they live far from an
area where such a program is offered. A study, conducted with patients
recruited from Silicon Valley employers and the Internet, will test the
effectiveness of an Internet-based education program. Participants will
receive a book and videotape, and they will interact with other program
participants through a moderated Internet discussion group. Patient
assessments will also be conducted through the Internet.

For More Information

National Institute of Arthritis and Musculoskeletal and Skin Diseases (NIAMS)
Information Clearinghouse
National Institutes of Health

1 AMS Circle
Bethesda,  MD 20892-3675

Phone: 301-495-4484

Toll Free: 877-22-NIAMS (226-4267)

TTY: 301–565–2966

Fax: 301-718-6366

Email: NIAMSinfo@mail.nih.gov

Website: http://www.niams.nih.gov

National Institute of Neurological Disorders and Stroke (NINDS)
NIH Neurological Institute

P.O. Box 5801
Bethesda,  MD 20824

Phone: 301–496–5751

Toll Free: 800–352–9424

TTY: 301–468–5981

Website: http://www.ninds.nih.gov

National Center for Complementary and Alternative Medicine
National Institutes of Health

P.O. Box 7923
Gaithersburg,  MD 20898

Phone: 301-519-3153

Toll Free: 888-644-6226

TTY: 866-464-3615

Fax: 866-464-3616

Email: info@nccam.nih.gov

Website: http://nccam.nih.gov

Agency for Healthcare Research and Quality
Office of Communications and Knowledge Transfer

540 Gaither Road, Suite 2000
Rockville,  MD 20850

Phone: 301–427–1364

Website: http://www.ahrq.gov

National Institute for Occupational Safety and Health

4676 Columbia Parkway
Cincinnati,  OH 45226

Toll Free: 800–CDC–INFO (232–4636)

TTY: 888–232–6348

Email: cdcinfo@cdc.gov

Website: http://www.cdc.gov/niosh

American Academy of Orthopaedic Surgeons (AAOS)

6300 North River Road
Rosemont,  IL 60018-4262

Phone: 847-823-7186

Toll Free: 800-824-BONE (2663)

Fax: 847-823-8125

Email: pemr@aaos.org

Website: http://www.aaos.org

North American Spine Society (NASS)

7075 Veterans Blvd.
Burr Ridge,  IL 60527

Phone: 630-230-3600

Toll Free: 866-960-NASS (866-960-6277)

Fax: 630-230-3700

Email: info@spine.org

Website: http://www.spine.org

American College of Rheumatology (ACR)

1800 Century Place, Suite 250
Atlanta,  GA 30345-4300

Phone: 404-633-3777

Fax: 404-633-1870

Website: http://www.rheumatology.org

Arthritis Foundation

P.O. Box 7669
Atlanta,  GA 30357-0669

Phone: 404-872-7100

Toll Free: 800-283-7800

Website: http://www.arthritis.org

American Chiropractic Association

1701 Clarendon Boulevard
Arlington,  VA 22209

Phone: 703-276-8800

Toll Free: 800–986–4636

Website: http://www.amerchiro.org

American Osteopathic Association

142 East Ontario Street
Chicago,  Il 60611

Phone: 312-202-8000

Toll Free: 800-621-1773

Fax: 312-202-8200

Website: http://www.osteopathic.org/

Glossary

Acupuncture – an ancient Chinese practice that
involves inserting thin needles at various sites on the body to relieve
pain or influence other body processes. Today, doctors use acupuncture
for problems as diverse as addiction, morning sickness, and back pain.

Acute pain – the most common type of back pain.
Acute pain often begins suddenly – after a fall or injury, for example
– and lasts no longer than 6 weeks.

Analgesics – medications designed to relieve pain.
Analgesics used for back pain include both prescription and
over-the-counter products. Some are made to be taken orally, and others
are rubbed onto the skin.

Ankylosing spondylitis – a form of arthritis that
affects the spine, the sacroiliac joints, and sometimes the hips and
shoulders. In severe cases, the joints of the spine fuse and the spine
becomes rigid.

Cauda equina syndrome – a condition in which the
nerves that control the bowels and bladder are pinched as they leave
the spine. Unless treated promptly, the condition can lead to the loss
of bowel or bladder function.

Cervical spine – the upper portion of the spine closest to the skull. The cervical spine comprises seven vertebrae.

Chronic pain – the least common type of back pain. Chronic pain may begin either quickly or slowly; it generally lasts for 3 months or more.

Disc – a circular piece of cushioning tissue
situated between each of the spine’s vertebrae. Each disc has a strong
outer cover and a soft jelly-like filling.

Discectomy – the surgical removal of a herniated
disc. A discectomy can be performed in a number of different ways, such
as through a large incision in the spine or through newer, less
invasive procedures using magnifying microscopes, x rays, small tools,
and even lasers.

Facet joints – the joints where the vertebrae of
the spine connect to one another. Arthritis of the facet joints is
believed to be an uncommon cause of back pain.

Fibromyalgia – a condition of widespread muscle pain, fatigue, and tender points on the body. Fibromyalgia is one cause of low back pain.

Herniated disc – a potentially painful problem in
which the hard outer coating of the disc is damaged, allowing the
disc’s jelly-like center to leak and cause irritation to adjacent
nerves.

Intradiscal electrothermal therapy (IDT) – a
treatment for herniated discs in which a wire is inserted into the disc
through a small incision in the back. An electrical current is then
passed through wire to modify and strengthen the collagen fibers that
hold the disc together.

Kyphoplasty – a procedure for vertebral fractures
in which a balloon-like device is inserted into the vertebra to help
restore the height and shape of the spine and a cement-like substance
is injected to repair and stabilize it.

Laminectomy – the surgical removal of the lamina
(the back of the spinal canal) and spurs inside the canal that are
pressing on nerves within the canal. The procedure is a major surgery
requiring a large incision and a hospital stay.

Lumbar spine – the lower portion of the spine. The lumbar spine comprises five vertebrae.

Osteoarthritis – a disease in which the cartilage
that cushions the ends of the bones at the joints wears away, leading
to pain, stiffness, and bony overgrowths, called spurs. It is the most
common form of arthritis and becomes more likely with age.

Osteoporosis – a condition in which the bones become porous and brittle and break easily.

Prolotherapy – a treatment for back pain in which a
practitioner injects a sugar solution or other irritating substance
into trigger points along the periosteum (tough, fibrous tissue
covering the bones) to trigger an inflammatory response that promotes
the growth of dense, fibrous tissue. The theory behind prolotherapy is
that such tissue growth strengthens the attachment of tendons and
ligaments whose loosening has contributed to back pain.

Rolfing – a type of massage that uses strong
pressure on deep tissues in the back to relieve tightness of the fascia
(a sheath of tissue that covers the muscles) that can cause or
contribute to back pain.

Rheumatoid arthritis – a disease that occurs when
the body’s immune system attacks the tissue that lines the joints,
leading to joint pain, inflammation, instability, and misshapen joints.

Sacroiliac joints – the joints where the spine and
pelvis attach. The sacroiliac joints are often affected by types of
arthritis referred to as spondyloarthropathies.

Sciatica – pain felt down the back and outer side of the thigh. The usual cause is a herniated disc, which is pressing on a nerve root.

Scoliosis – a condition in which the spine curves
to one side as a result of congenital malformations, neuromuscular
disorders, injury, infection, or tumors.

Spinal fusion – the surgical joining of two more
vertebrae together, usually with bone grafts and hardware. The
resulting fused vertebrae are stable but immobile. Spinal fusion is
used as a treatment for spondylolisthesis, scoliosis, herniated discs,
and spinal stenosis.

Spinal stenosis – the narrowing of the spinal canal
(through which the spinal cord runs), often by the overgrowth of bone
caused by osteoarthritis of the spine.

Spondyloarthropathy – a form of arthritis that primarily affects the spine and sacroiliac joints.

Spondylolisthesis – a condition in which a vertebra of the lumbar (lower) spine slips out of place.

Transcutaneous electrical nerve stimulation (TENS) – a treatment designed to relieve pain by directing mild electrical impulses to nerves in the painful area of the body.

Vertebrae – the individual bones that make up the spinal column.

Vertebroplasty – a minimally invasive surgical
procedure that involves injecting a cement-like mixture into a
fractured vertebra to relieve pain and stabilize the spine.

Acknowledgments

The NIAMS gratefully acknowledges the assistance of James Kang,
M.D., University of Pittsburgh, PA; Jeffrey Katz, M.D., Brigham and
Women’s Hospital, Boston, MA; William Lauerman, M.D., Georgetown
University, Washington, DC; and James Panagis, M.D., M.P.H., NIAMS,
NIH, Bethesda, MD, in the preparation and review of this booklet.
Special thanks also go to the other individuals who reviewed this
publication and provided valuable assistance.

The mission of the National Institute of Arthritis and
Musculoskeletal and Skin Diseases (NIAMS), a part of the Department of
Health and Human Services’ National Institutes of Health (NIH), is to
support research into the causes, treatment, and prevention of
arthritis and musculoskeletal and skin diseases; the training of basic
and clinical scientists to carry out this research; and the
dissemination of information on research progress in these diseases.
The National Institute of Arthritis and Musculoskeletal and Skin
Diseases Information Clearinghouse is a public service sponsored by the
NIAMS that provides health information and information sources.
Additional information can be found on the NIAMS Web site at www.niams.nih.gov.

For Your Information

This publication contains information about medications used to
treat the health condition discussed here. When this booklet was
printed, we included the most up-to-date (accurate) information
available. Occasionally, new information on medication is released.

For updates and for any questions about any medications you are taking, please contact

U.S. Food and Drug Administration

Toll Free: 888-INFO-FDA (888-463-6332)

Website: http://www.fda.gov/

For updates and questions about statistics, please contact

Centers for Disease Control and Prevention’s National Center for Health Statistics

Toll Free: 800–232–4636

Website: http://www.cdc.gov/nchs

This page and the associated booklet is not copyrighted. Readers are encouraged to duplicate and distribute as many copies as needed.

Additional copies of this booklet are available from

National Institute of Arthritis and Musculoskeletal and Skin Diseases (NIAMS)
Information Clearinghouse
National Institutes of Health

1 AMS Circle
Bethesda,  MD 20892-3675

Phone: 301-495-4484

Toll Free: 877-22-NIAMS (226-4267)

TTY: 301–565–2966

Fax: 301-718-6366

NIH Publication No. 05-5282

Email: NIAMSinfo@mail.nih.gov

Website: http://www.niams.nih.gov