Causes Of Chronic Lower Back Pain
Pain is considered chronic once it lasts for more than three months and exceeds the bodys natural healing process. Chronic pain in the low back often involves a disc problem, a joint problem, and/or an irritated nerve root. Common causes include:
Lumbar herniated disc. The jelly-like center of a lumbar disc can break through the tough outer layer and irritate a nearby nerve root. The herniated portion of the disc is full of proteins that cause inflammation when they reach a nerve root, and inflammation, as well as nerve compression, cause nerve root pain. The disc wall is also richly supplied by nerve fibers, and a tear through the wall can cause severe pain.
Degenerative disc disease. At birth, intervertebral discs are full of water and at their healthiest. As people age over time, discs lose hydration and wear down. As the disc loses hydration, it cannot resist forces as well, and transfers force to the disc wall that may develop tears and cause pain or weakening that can lead to a herniation. The disc can also collapse and contribute to stenosis.
Facet joint dysfunction. There are two facet joints behind each disc at each motion segment in the lumbar spine. These joints have cartilage between the bones and are surrounded by a capsular ligament, which is richly innervated by nerves. These joints can be painful by themselves, or in conjunction with disc pain.
Signs That Its Time To Call A Doctor For Your Back Pain
Most people have experienced back pain at some point in their lives. It’s actually the leading cause of disability worldwide and the most common reason people call out of work. Back pain can come in many different forms, ranging from a dull ache that lasts only a few days to severe pain that lasts for weeks.
Depending on the intensity of the pain, there are many treatments you can try at home to help. But how do you know when it’s time to stop home remedies and see a physician?
If any of the following applies to your back pain, then it’s time to make an appointment with a doctor as soon as possible.
What Is The Outlook
Most of us will have a bout of nonspecific low back pain at some point in our lives. The severity can vary. However, it is difficult to quote exact figures as to outlook . This is partly because it is so common and many people with back pain do not consult a doctor. Roughly, it is thought that:
- Most nonspecific back pains ease and go quickly, usually within a few weeks.
- In about 4 in 10 cases, the pain has completely gone within four weeks.
- In about 7 in 10 cases the pain has completely gone within one year.
However, once the pain has eased or gone it is common to have further bouts of pain from time to time in the future. Also, it is common to have minor pains on and off for quite some time after an initial bad bout of pain. In a small number of cases the pain persists for several months or longer. This is called chronic back pain.
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Chronic Low Back Pain Of No Specific Origin
Low back pain is defined as pain, tightness, and stiffness between the lower end of the rib cage and the buttocks. “Chronic” means the pain has lasted for twelve weeks or longer, and “no specific origin” means the pain cannot be traced to any specific cause, incident, or injury.
Most susceptible are individuals who perform heavy physical work, especially when there is ongoing anxiety, depression, and emotional stress at the same time. The longer the stress and back pain continue, the more difficult it is to ease the symptoms and return the patient to normal functioning.
Treatment involves nonsteroidal anti-inflammatory drugs and sometimes opioid medications for pain, though both have risks when used long term. Antidepressants may also be tried, along with psychological counseling.
Corticosteroid injections for the back are effective for some patients, and fusion surgery is sometimes attempted. Lifestyle changes in the form of improved diet, exercise, and stress management are very helpful in most cases.
Top Symptoms: lower back pain, unintentional weight loss, back pain that shoots to the butt, fever, involuntary defecation
Symptoms that always occur with chronic low back pain of no specific origin: lower back pain
Symptoms that never occur with chronic low back pain of no specific origin: thigh numbness, buttocks numbness, lower back pain from an injury
Urgency: Primary care doctor
When To See A Healthcare Provider
Everybody handles pain differently. Still, it’s a good idea to talk to your healthcare provider right away if your pain:
- Began with a specific injury
- Wakes you up at night
- Keeps you from sleeping
- Travels to other parts of the body, like your legs
- Comes with signs of infection such as redness, warmth, swelling, or fever
- Comes with weakness, numbness, or tingling in your lower body
You may want to start by checking with your primary healthcare provider. They will be able to treat or refer you to a specialist if needed.
For example, if your healthcare provider thinks your pain may be caused by an inflammatory condition, you may need to see a rheumatologist. A rheumatologist specializes in arthritis and diseases that involve the bones, muscles, and joints.
You may find it helpful to know how pain is categorized:
- Acute pain is short-term–a few days or weeks. It often happens after an injury or specific event.
- Chronic pain is longer-term. It may last for several months or more. In many cases, it isn’t from an injury.
It’s a good idea to seek immediate medical care if you have low back pain and a personal history of cancer. Your pain may need urgent treatment if you also have unexplained weight loss or sudden bladder control issues.
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Lower Back Pain And Cancer
Cancer involving the lumbar spine is not a common cause of back pain. However, in people who have a prior history of cancer, for example, in the breast or prostate, or who have weight loss or loss of appetite along with back pain cancer needs to be considered.
Night pain can be a clue to cancer in the spine. A benign tumor called osteoid osteoma, which most often affects young people, causes pain that tends to respond well to aspirin. Multiple myeloma is a malignancy that occurs when the plasma cells in the bone marrow begin spreading uncontrollably. It is most common in older people, and can cause pain in many parts of the spine. When tumor or infection are suspected, blood tests may be ordered, including a CBC , sedimentation rate , and protein electrophoresis .
Take It Slow When Getting Up
Taking it slow when you get out of bed can be beneficial. You may want to use your arms to sit up slowly before moving your legs off the side of the bed. Once you plant your feet on the ground, shoulder-width apart, you can stand up slowly, using your leg strength instead of your back to help you up.
After carefully standing, you can further relieve tension by reaching your arms up above your head and stretching slowly from side to side.
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Sensations That Might Indicate A Medical Emergency
1. Sharp pain rather than a dull ache: This could indicate a torn muscle or ligament, or a problem with an internal organ in the back or side.2. Radiating pain: This pain “moves” or shoots to the glutes or legs, which could indicate a nerve compression condition.
3. Sudden weakness in the legs: Limb weakness can be caused by compressed nerves in the spine due to conditions like sciatica or spinal stenosis. However, sudden leg weakness could also indicate a stroke.4. Incontinence: Back pain paired with inability to control the bowels or bladder might be a sign of serious nerve compression or a spine infection, such as discitis or meningitis.5. Numbness or pins and needles in the groin or glutes: This is known as saddle anesthesia and is also a sign of a serious nerve or spine condition.
If you have leg weakness, incontinence, and numbness together, you might have cauda equina syndrome, a serious illness characterized by spinal cord nerve damage. This is a medical emergency, and patients usually need surgery immediately to decompress the nerves and reduce permanent damage.
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Can Further Bouts Of Back Pain Be Prevented
Evidence suggests that the best way to prevent bouts of low back pain is simply to keep active and to exercise regularly. This means general fitness exercise such as walking, running, swimming, etc. There is no firm evidence to say that any particular back strengthening exercises are more useful to prevent back pain than simply keeping fit and active. It is also sensible to be back-aware. For example, do not lift objects when you are in an awkward twisting posture.
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What Are The Symptoms Of Lower Back Pain
Symptoms of lower back pain can come on suddenly or appear gradually. Sometimes, pain occurs after a specific event, such as bending to pick something up. Other times, you may not know what caused the pain.
Pain may be sharp or dull and achy, and it may radiate to your bottom or down the back of your legs . If you strain your back during an activity, you may hear a pop when it happened. Pain is often worse in certain positions and gets better when you lie down.
Other symptoms of lower back pain include:
- Stiffness: It may be tough to move or straighten your back. Getting up from a seated position may take a while, and you might feel like you need to walk or stretch to loosen up. You may notice decreased range of motion.
- Posture problems: Many people with back pain find it hard to stand up straight. You may stand crooked or bent, with your torso off to the side rather than aligned with your spine. Your lower back may look flat instead of curved.
- Muscle spasms: After a strain, muscles in the lower back can spasm or contract uncontrollably. Muscle spasms can cause extreme pain and make it difficult or impossible to stand, walk or move.
When To Contact A Medical Professional
- Back pain after a severe blow or fall
- Burning with urination or blood in your urine
- History of cancer
- Loss of control over urine or stool
- Pain traveling down your legs below the knee
- Pain that is worse when you lie down or pain that wakes you up at night
- Redness or swelling on the back or spine
- Severe pain that does not allow you to get comfortable
- Unexplained fever with back pain
- Weakness or numbness in your buttocks, thigh, leg, or pelvis
Also call if:
- You have been losing weight unintentionally
- You use steroids or intravenous drugs
- You have had back pain before, but this episode is different and feels worse
- This episode of back pain has lasted longer than 4 weeks
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What About Nocturnal Intervertebral Disc Swelling
This is one of the classic theories about why people seem to be more vulnerable to back pain in the morning.
Between every pair of vertebrae is a bit of padding, the infamous disc. They probably swell up a wee bit overnight. There are two studies that suggest this2930 . A 2016 paper speculates that disc swelling is why astronauts probably suffer from more disc herniations than they should.31 Weightlessness is undoubtedly like resting your spine, but its another long-term effect, so Im not sure how relevant the astronaut angle is its just a fun angle on the topic.
I saved this idea for last because its too speculative to be really satisfying.
Discs may swell, but that doesnt mean swelling discs hurt. Mild swelling is hardly a concern in itself, and most people dont wake up in pain, so its unlikely that swelling alone is a problem. Swollen discs may hurt more in the morning if theres already something wrong with them, such as annular tears,32 but such discs might well be uncomfortable regardless. Mildly herniated discs might swell and effectively be more herniated in the morning but many herniations are painless, so thats hardly a smoking gun.
Get Exercise Throughout The Day
Regular exercise throughout the day is key to alleviating back pain. Walking is among the best exercises, and you should aim for at least 10,000 steps per day. However, anything that gets you moving and on your feet can help keep your back strong.
Also, if you have an office job that involves sitting, its important to take frequent breaks. Stand up at least once every 30 minutes and stretch. Standing desks can also help keep the pressure off your back during the day at work so you wont suffer the consequences the next morning.
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Chronic Lower Back Pain
When back pain continues for more than three months, it is considered chronic. Although for most people an episode of back pain is over by that time, in some cases it progresses and can have a major impact on ones ability to function. For some patients, physical therapy with local heat or ice application , combined with a home exercise program and education in proper positions for lifting and other movement techniques can make a major difference. Patients must learn to tolerate a certain degree of pain, or they may allow themselves to become more disabled than necessary. Patients at the Hospital for Special Surgery have had success with graded exercise to work through the pain, gradually increasing the exercise quota at each session so they can learn to tolerate more exercise in spite of the pain, and get back to work and activities. Read more detail on this topic in .
Myofascial Pain Syndrome And/or Fibromyalgia
There are two common causes for widespread moderate body pain, both somewhat mysterious and controversial, both known for affecting the back more than other areas, and both known for their morning hijinks:
Theres likely lots of overlap between these conditions. Fibromyalgia isnt really an explanatory diagnosis it just labels a common pattern of symptoms that could have several different causes. MPS is a hypothetical problem with muscle tissue that is a possile explanation for some body pain, and that type of pain is extremely common in fibromyalgia patients.
Fibromyalgia is associated with morning back pain because:
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Surgery For Lower Back Pain
Because the vast majority of patients recover from their low back pain with little help from a doctor, the rationale behind choosing surgery must be convincing. Eighty percent of patients with sciatica recover eventually without surgery.
Severe progressive nerve problems, bowel or bladder dysfunction and the cauda equina syndrome make up the most clear-cut indications for back surgery. Back surgery will also be considered if the patients signs and symptoms correlate well with studies such as MRI or electromyogram .
In the most serious cases, when the condition does not respond to other therapies, surgery may well be necessary to relieve pain caused by back problems. Some common procedures include:
- Discectomy, such as a or removal of a portion of a
- a bone graft that promotes the vertebrae to fuse together
- removal of the lamina to create more space and reduce irritation and inflammation
References and useful links
- 1, 2. Excerpted from Low Back Pain Fact Sheet, National Institute of Neurological Disorders and Stroke, National Institutes of Health
- Low Back Pain Fact Sheet, National Institute of Neurological Disorders and Stroke, National Institutes of Health. Reviewed, July 26, 2003.
- Deyo RA, Weinstein JN, Low Back Pain, N Engl J Med, Vol 344, No. 5, Feb 1, 2001, pp 363-370.
When Should I See A Doctor If I Have Lower Back Pain
In many cases lower back pain stops on its own. But if it doesnt, here are some guidelines on when you may want to start seeking professional help:
- If the pain lasts four weeks or longer
- If the pain keeps getting worse as time goes by
- If you are experiencing other symptoms, such as fever, major weight loss or weight gain, loss of function or weakness in extremities, bladder problems, etc.
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Complementary And Alternative Techniques Include:
- Acupuncture is moderately effective for chronic low back pain. It involves inserting thin needles into precise points throughout the body and stimulating them , which may cause the body to release naturally occurring painkilling chemicals such as endorphins, serotonin, and acetylcholine.
- Behavioral approaches include:
- Biofeedback involves attaching electrodes to the skin and using an electromyography machine that allows people to become aware of and control their breathing, muscle tension, heart rate, and skin temperature people regulate their response to pain by using relaxation techniques
- Cognitive therapy involves using relaxation and coping techniques to ease back pain
Spinal injections include:Trigger point injections can relax knotted muscles that may contribute to back pain. An injection or series of injections of a local anesthetic and often a corticosteroid drug into the trigger point can lessen or relieve pain.