Back Pain & Back Injuries

What is back pain?

Pain in the back is extremely common and affects people in several different ways. This ranges from mild, dull ache to severe, acute pain which leaves people unable to move or carry out everyday actions. Back pain can develop gradually, usually as a consequence of getting older, or quickly due to an injury, accident or lifting something heavy. Back pain affects most people at some point in their lives.

How common is back pain?

Back pain is one of the most widespread health problems and around eight out of ten people will experience back pain at some point in their lives.

Potential risks for back pain

Back pain can affect anyone, but there are several risk factors that increase the risk. These include:

• Age: the risk of back pain increases with age. Most people develop symptoms of back pain between thirty and forty years old.

• Fitness level: people with a low level of fitness are more inclined to experience back pain, because the muscles supporting the spine may be weak. Regular exercise, especially mild to moderate aerobic exercise, is often the best way to avoid back pain. Doing nothing all week and then exercising at the weekend can also be harmful.

• Diet: diet plays a role in determining the risk of obesity, which is a major basis of back pain. Diets high in sugar and fatty foods increase the risk of obesity and therefore the risk of back pain.

• Heredity: it is possible for certain origins of back pain to be genetic, which is the case with conditions such as disc disease.

• Race: this can affect the risk of certain back problems. For example, African women are between 3 to 4 times more inclined to incur spondylolisthesis. This is a condition which causes a disc in the lumbar spine (the bottom section of the spine) to slip out of position.

• Other health conditions: there are many conditions that play a part in back pain, including arthritis, cancer and ankylosing spondylitis.

• Occupational risks: certain occupations place strain on the back, which can result in pain. If your job requires heavy lifting, repeated twisting or turning movements, there is a high risk of back pain. Having a desk-job or spending long periods of time sitting down can also increase the risk of back pain.

• Smoking: smoking is not a direct cause of pain in the back, but it can increase the risk of lower back pain and sciatica. This occurs when pain radiates from the back to the hip and leg as a consequence of pressure on the sciatic nerve. Smoking also slows the healing process and can cause pain as a consequence of lung problems, which tend to cause persistent coughing.

What causes back pain?

Back pain is a symptom rather than a condition. If you have back pain it is likely that it is caused by another health condition or injury. Medical conditions and problems that play a part in back pain are as follows:

• Mechanical problems: mechanical problems affect the manner in which the spine moves and how you feel when your spine is moving. The most common example is intervertebral disc degeneration; this is when the discs gradually become worn due to age. Degeneration reduces the cushion between the vertebrae and can eventually cause pain. Other mechanical conditions include muscular tension, spasms and ruptured discs (referred to as herniated discs).

• Injuries: strains or fractures to the spine can cause acute (short-term) or chronic (long-term) pain. Fractures can be caused by osteoporosis, while strains are often caused by sudden twisting or heavy lifting that places strain on the ligaments. In less common cases back pain can be caused by severe accidents.

• Acquired health conditions: many health conditions can play a part in back pain, including arthritis (which include rheumatoid arthritis and osteoarthritis), scoliosis (curve of the spine), spinal stenosis and ankylosing spondylitis, causing the spinal column to narrow and increases strain on the spinal cord and surrounding nerves. Osteoporosis does not cause back pain directly, but it can increase the chance of spinal fractures leading to pain. Other health conditions to consider include kidney stones and kidney infections, pregnancy, endometriosis (causes uterine tissue to develop outside of the uterus) as well as fibromyalgia, a condition which causes extreme tiredness and muscle pain all over the body.

• Infections and tumours: infections and tumours are uncommon reasons for back pain, but they can be a source of pain when the vertebrae are involved. Conditions called osteomyelitis and discitis can cause pain. Tumours usually show in the back having spread from other areas of the body, but it is possible for them to develop in the back.

Back pain is predominantly caused by physical factors, but it is worth noting that emotional stress and psychological factors can affect the severity of pain, how long it goes on for and stress may also make back pain worse.

Is it possible to prevent back pain?

The most effective way of preventing back pain is through regular exercise, which keeps the muscles and tissues supporting the spine strong. Activities that improve your balance, such as yoga and Tai Chi, can help to reduce the risk of falls.

A healthy, balanced diet can also help to reduce the risk of back pain by boosting the strength of the bones and helping to keep weight at a healthy, stable level. If overweight adapting your diet to lose weight will help to reduce the risk of back pain and benefit general health. In order to keep your bones strong it is imperative to take in enough Vitamin D (in dairy products) and calcium, which help to prevent osteoporosis and reduce the risk of fractures. People who do not take in enough Vitamin D and calcium from their diet may be advised to take supplements.

Ensuring that you have good posture will also help to avoid back pain. It is always beneficial to sit straight and support your back with cushions if required. Avoid heavy lifting but if doing so adopt a safe position to prevent injury, with your knees bent and back straight.

When should I visit a doctor for back pain?

It is often not necessary to visit a GP for back pain. However, it is advisable to see a doctor should you have a trip or fall, experience tingling or numbness, or if the pain is not going away after taking pain-relief. If you experience pain in combination with weakness, lack of sensation in the legs, unexplained weight loss and fever (a high temperature), you should arrange to visit your doctor.

Which type of doctor would I visit?

If you experience back pain you should see your family doctor. If they suspect that the cause of back pain requires treatment, they will refer you to the relevant specialist for tests and treatment.

How is back pain diagnosed?

Your physician will ask you questions about your symptoms, take a medical history and perform an examination. They will also ask questions about family health problems. The questions your doctor asks may include:

• Have you had a fall or tripped over recently?
• Does the pain get better or worse if you lie down?
• Do you or some of your relatives have arthritis or health conditions that may affect the spine?
• Have you experienced any tingling or lack of feeling in your legs?
• Are there any positions or activities that make the pain worse?
• Is the pain worse at any particular time of the day?
• Have you experienced back pain before or had surgery on your back?

During the physical examination, your doctor will check:

• Muscle strength.
• Sensation
• Signs of nerve irritation.
• Signs of fibromyalgia, such as tender points in the back.
• How you move and walk.

In many cases your medical history and a physical examination will be sufficient for the doctor to reach a diagnosis and advise appropriate treatment. However, in some cases additional tests may be recommended, including:

• X-rays: X-rays project detailed images of the bones on film for doctors to analyse. Your doctor may order an X-ray if they suspect a fracture or if you have symptoms of osteoarthritis. An X-ray may also be ordered if there is a suspicion that the spine is not properly aligned.

• MRI (Magnetic Resonance Imaging): MRI scans use magnetic force to generate detailed images of structures inside the body. MRI scans produce images of organs, connective tissue and soft tissue, and can be used to diagnose a range of health problems and detect abnormalities. Your doctor may order an MRI scan if you have signs of inflammation, infection or a tumour. It is uncommon for an MRI scan to be ordered for mild back pain, but if pain persists for longer than 3 weeks and does not improve with medication, this test can be very useful.

• CT (Computerised Tomography): a CT scan displays clear 3D images of the spinal structures unable to be seen on normal X-rays. The test may be ordered if you have symptoms of a herniated disc, tumour or spinal stenosis.

• Blood tests: blood tests are not usually ordered for patients with back pain. However, they may be recommended if you have symptoms of infection or inflammation. Examples of blood tests include full blood count to detect inflammation, which is also known as complete blood count and erythrocyte sedimentation rate.

Medical tests cannot always diagnose the cause of back pain and they should always be carried out in conjunction with a physical examination and medical history. In many cases the exact cause of back pain remains unknown.

What is the difference between chronic and acute back pain?

Acute pain comes on suddenly and is short-term, while chronic pain is long-term and tends to develop gradually (although it is possible for it to come on quickly). You may experience acute back pain if you lift something heavy, fall or are involved in an accident or you experience a powerful impact (for example, a tackle in rugby). Chronic back pain may be associated with overuse injuries, repeated actions or movements, underlying health conditions, obesity or poor posture. Acute pain is classed as lasting a maximum of 6 weeks, while chronic pain lasts for several months, even years. Chronic back pain is not as common as acute pain.

How is back pain treated?

Treatment for back pain usually depends on whether the pain is chronic or acute.

Acute back pain: this type of back pain usually improves on its own without any treatment. However, taking pain-relief medication may help to ease symptoms. It is generally not a good idea to do strenuous exercise or lift anything if you have acute back pain, but moving around may help to ease stiffness.

Chronic back pain: treatment is usually classified as surgical or non-surgical. In most cases surgery is not required, but an operation may be recommended if back pain is brought on by an infection, tumour or nerve problems. Examples of non-surgical treatments include:

• Hot or cold therapy: applying ice or heat packs to the back may help to ease tension and pain. Always ensure that you cover packs with a cloth or towel to prevent damage to the skin. Ice packs are beneficial for reducing swelling and inflammation, while heat causes the blood vessels to dilate, boosts oxygen supply and reduces the risk of muscle spasms. Hot and cold therapy may ease symptoms, but it will not treat the cause of back pain.

• Exercise: exercise is not generally recommended for acute back pain, but it can be helpful for chronic back pain. The following types of exercise can be beneficial:

• Flexion: flexion exercises involve bending forward. The aim of flexion exercises is to increase the space between the vertebrae and reduce strain on the nerves, stretch the muscles in the hips and back, and to strengthen the muscles in the abdomen and buttocks. Strengthening the core muscles in the abdomen can help to reduce pressure on the back. It is vital to check contact your doctor if starting an exercise plan, because not all exercises are suitable for everyone. Flexion exercises, for example, are not generally advised for people with herniated discs.

• Extension: extension exercises involve bending backwards (for example, lifting your leg and raising the trunk while you lay down). Extension exercises are designed to open up the spinal column and strengthen surrounding muscles. These exercises can help to ease pain radiating from the back.

• Stretching: stretching exercises help to strengthen the muscle, increase the range of movement and flexibility and condition the back to prevent injuries in the future. Stretching can also help to alleviate pain caused by stiffness.

• Aerobic exercise: aerobic exercise is important for general health and should be employed on a regular basis. Aerobic exercises involve the large muscle groups in the body and include jogging, power walking, rowing, swimming and cycling. It is essential to avoid exercises that require sudden movements or twisting actions if you have back pain, as these can make pain worse. Swimming is often considered a good exercise for individuals with back pain, but it is recommended you ask your doctor or physiotherapist for advice about exercise before you begin.

• Medication: there are many types of medication for the treatment of chronic back pain. Some are available over-the-counter while others are only available on prescription. Examples of medication that treat chronic back pain include:

• Analgesics: analgesics are pain-relieving drugs, which include paracetamol, ibuprofen and aspirin, and prescription drugs including oxycodone with paracetamol and hydrocodone with paracetamol. There are various brand names available and the prices can vary. Topical analgesics (lotions and creams applied directly to the skin) may also be beneficial. These include hot and cold lotions and muscular balms, with various brands available. Ask your pharmacist or doctor for advice and always ensure that you follow the dosage instructions when taking medication.

• Non-steroidal anti-inflammatory drugs (NSAIDs): non-steroidal anti-inflammatory drugs are designed to ease pain and inflammation. Examples of NSAIDs include ibuprofen, ketoprofen and COX-2 inhibitors. NSAIDs work by blocking the action of prostaglandin, which can cause inflammation. NSAIDs are not suitable for everyone and you should ask your pharmacist or doctor for advice before taking them. NSAIDs can result in stomach irritation and affect kidney function, and they should not be taken by anyone who has gastrointestinal problems or kidney conditions. People over the age of 65 should also take care when using NSAIDs. Possible by-products of NSAIDs include stomach ulcers, diarrhoea, fluid retention and heartburn. You should never take NSAIDs if you have history of stomach ulcers of gastrointestinal bleeding.

• Other medication: other medications, including muscle relaxants, may also be beneficial.

• Traction: traction uses weights and pulleys to effectively stretch the back. The aim is to broaden the gaps between the vertebrae to reduce strain on the nerves and permit a bulging disc to pop back into place. Some people find traction beneficial, but the effects are usually only short-term.

• Corsets and braces: these are designed to restrict the movement of the lumbar spine, correct posture and strengthen muscles in the abdomen. Wearing a corset or brace may be beneficial following surgery or an accident, but they are not usually considered a useful treatment for chronic back pain.

• Changes in behaviour: changing the way you sit, move and lift can have positive implications for your health, which is particularly important for people with jobs that require heavy lifting. Lifestyle changes, such as exercising, eating a health diet and maintaining a stable, healthy weight will also help to boost general health and reduce the risk of back pain.

• Injections: when medication and other non-surgical procedures fail to alleviate pain, physicians may advise injections, such as:

• Nerve root blocks: a nerve root block injection may be used if a nerve is trapped or inflamed. Nerve root blocks can help to ease pain in the back and legs. The success of the injection depends heavily on finding the right area of the nerve to inject.

• Facet joint injection: facet joints are the joints where the vertebrae join. They help to keep the spine properly aligned. In some cases facet joint injections may help to ease pain caused by arthritis in the joint. However, there is some debate concerning the efficacy of the treatment.

• Trigger point injections: this treatment involves injecting steroid or other pain-relief medication into specific areas of the back. Injections are inserted into areas that are tender when pressed. Some doctors add steroid medicine to the injection.

• Prolotherapy: this is a treatment which has generated a lot of debate and intrigue. It involves injecting sugar solution into areas of the back to activate an inflammatory response, which causes new thick tissue to develop. The theory behind this is that the new dense tissue strengthens the tendons and ligaments. There is very little evidence as yet to support the use of prolotherapy.

Complementary and alternative therapies

Complementary and alternative therapies are non-medical and can be used in combination with or instead of medical treatments. There is a huge amount of debate among doctors and physicians about the efficacy of complementary therapies. Examples of frequently used complementary therapies include:

• Manipulation: this technique involves using the hands to manipulate, massage or adjust the spine and surrounding tissues. Spinal manipulation is usually carried out by chiropractors. However, the treatment is not suitable for many individuals with back pain as it can be counter-productive.

• Transcutaneous electrical nerve stimulation (TENS): this treatment involves wearing small pads on the back, which are connected to a machine that sends out electrical impulses to stimulate the nerves. There is a theory that TENS may help to adjust the body’s response to pain and increase the level of endorphins. However, some studies have rejected TENS as an effective treatment for chronic back pain.

• Acupuncture: acupuncture uses a series of tiny needles and is based on ancient oriental practices. The needles are inserted at specific locations in line with the energy channels running through the body. There is a great deal of scepticism surrounding the efficacy of acupuncture, but it is becoming more widely accepted. Some people find it beneficial but others may feel no benefit.

• Acupressure: acupressure works on the same principal as acupuncture and claims to relieve pain by restoring energy flow throughout the body. The main distinction between acupressure and acupuncture is that acupressure requires no needles while acupuncture does. The therapist will instead use their hands to apply pressure to areas along the energy channels.

• Rolfing: rolfing is a massage therapy in which deep force is applied to the back to ease pressure on the fascia (the layer of tissue that protects the muscles). The premise of rolfing is that it improves spinal alignment.

Surgical treatments

Surgery may be required in certain cases of chronic back pain, but it is usually used as a last resort when other treatments have been unsuccessful. If your symptoms do not ease with other treatment, you suffer from constant pain or your back pain prevents you from living a normal life, surgery may be an option.

Surgery is generally advised for two sections of people: those with back pain and sciatica, which may result from spondylolisthesis, or a herniated disc; and people who have lower back pain, which is caused by degeneration of the discs (known as degenerative disc disease). In most cases surgery for sciatica produces more predictable results than surgery for lower back pain.

Some conditions that may require surgery include:

• Herniated disc: this condition occurs when the outer coating of the disc is damaged, which allows the jelly-like substance from inside the disc to escape and causes irritation of surrounding nerves. Herniated discs often cause severe sciatica and soreness down the leg. The condition is sometimes referred to as a ruptured disc.

• Spinal stenosis: this occurs when the spinal canal is narrowed and is usually caused by osteoarthritis (which causes bone overgrowth). Spinal stenosis results in pain due to nerve compression and it can also cause loss of bladder and bowel control and lack of feeling in the legs.

• Spondylolisthesis: this condition occurs when a disc in the lumbar vertebrae slips out of position. When this happens the spine attempts to adjust, causing the joint between the slipped disc and the neighbouring disc to become enlarged, which compresses the nerves. Spondylolisthesis can cause sciatica and lower back pain.

• Vertebral fractures: vertebral fractures can be caused by injuries, direct impact on the vertebrae or as a consequence of weakened discs from osteoporosis. Fractures usually cause pain in the back but this can also radiate to the legs.

• Degenerative disc disease (discogenic low back pain): the discs usually degenerate gradually with age, but in some people the process is accelerated. This causes chronic pain and can have severe implications on daily life.

What follows are the main procedures used for herniated discs, spinal stenosis, spondylolisthesis, vertebral fractures and discogenic low back pain:

Treatment for herniated discs

• Laminectomy or discectomy: this requires the removal of the lamina (a section of bone on the rear of the vertebra) and part of the ligament, before the herniated disc is removed through incision.

• Microdiscectomy: this procedure, as with regular discectomy, requires the removal of a herniated disc through an opening in the back. However, the opening is much smaller in a microdiscectomy and the physician uses a microscope to find the disc. Microdiscectomy surgery may lessen pain and also decreases the size of the scar. Recovery times are similar for the two procedures.

• Laser surgery: advances in science and technology mean that laser surgery is becoming increasingly commonplace. Laser surgery can be used to treat herniated discs that cause leg and back pain. Lasers are used to vaporise the disc tissue, causing a reduction in size and decreased nerve pressure. Recovery from laser surgery tends to be quick, although it can take some time for pain-relief to become apparent.

Treatment for spinal stenosis

• Laminectomy: a laminectomy procedure aims to open the spinal canal to reduce strain on the nerves. The procedure is carried out by making an opening in the affected area of the back. The lamina is then removed as are any damaged ligament tissue and growths of bone tissue, which may have developed as a consequence of osteoarthritis.

Treatment for spondylolisthesis

• Spinal fusion: if a slipped vertebra causes the facet joints to become enlarged, treatment may involve a laminectomy and spinal fusion. Spinal fusion involves fusing two or more of the vertebrae together, using grafts (this may involve bone from the hip, pelvis or donor bone tissue), screws and rods to prevent the disc from slipping any further. Surgery is successful in the majority of cases, but there are disadvantages of both types of graft. Using your own bone requires surgery on two sites, while there is a risk of rejection when using donor bone tissue. In recent years the development of proteins called bone morphogenic proteins has helped to reduce risks associated with spinal fusion, and the use of these proteins can help to eliminate the need for grafting. Once the spine has been fused the affected area becomes immobilised.

Treatment for vertebral fractures

• Vertebroplasty: if back pain is brought on by a compression fracture of the vertebra due to osteoporosis or trauma, doctors may recommend surgery. The vertebroplasty procedure involves making a small incision in the affected area of the back and injecting polymethacrylate (a cement-like substance), into the fractured vertebra. The aim of the procedure is to stabilise the spine and reduce pain. In most cases the procedure is carried out as an outpatient procedure.

• Kyphoplasty: kyphoplasty is generally used to treat fractures caused by osteoporosis and is carried out in two stages. The first stage involves inserting a balloon-like device to restore the shape and stability of the spine, and the second stage involves repairing the fracture using polymethacrylate. The procedure can be carried out under general or local anaesthetic and may be done as an outpatient procedure.

Surgery is only carried out for fractures if other procedures have been unsuccessful.

Treatment for discogenic low back pain:

• Intradiscal electrothermal therapy: this procedure involves making a slit in the back and passing a heated wire into the disc. An electric current is passed through the heated wire to boost the strength of the collagen fibres, which are responsible for holding the disc together. The procedure is done under local anaesthetic and is usually an outpatient procedure.

• Spinal fusion: spinal fusion may be carried out if a degenerated disc is causing pain. The procedure involves the removal of the disc and fusing neighbouring discs; fusion can be anterior (done through the abdomen) or posterior (through the back). Spinal fusion for lower back pain is usually only carried out as a last resort.

• Disc replacement: disc replacement is an alternative to a discectomy. The disc is removed and replaced with an artificial disc. Artificial discs come in a range of sizes and can help to restore movement between the discs