Back pain

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Back pain
Different regions (curvatures) of the vertebral column
ICD-10	M54
ICD-9	724.5
DiseasesDB	15544
MeSH	D001416

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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Robert G. Schwartz, M.D. [2], Piedmont Physical Medicine and Rehabilitation, P.A.; Associate Editor-In-Chief: Cafer Zorkun, M.D., Ph.D. [3], M.Umer Tariq [4]

Synonyms and keywords: Lumbago; backache; dorsalgia

Associated conditions

Back pain can be a sign of a serious medical problem, although this is not most frequently the underlying cause:

• Typical warning signs of a potentially life-threatening problem are bowel and/or bladder incontinence or progressive weakness in the legs. Patients with these symptoms should seek immediate medical care.
• Severe back pain (such as pain that is bad enough to interrupt sleep) that occurs with other signs of severe illness (e.g. fever, unexplained weight loss) may also indicate a serious underlying medical condition, such as cancer.
• Back pain that occurs after a trauma, such as a car accident or fall, should also be promptly evaluated by a medical professional to check for a fracture or other injury.
• Back pain in individuals with medical conditions that put them at high risk for a spinal fracture, such as osteoporosis or multiple myeloma, also warrants prompt medical attention.

In general, however, back pain does not usually require immediate medical intervention. The vast majority of episodes of back pain are self-limiting and non-progressive. Most back pain syndromes are due to inflammation, especially in the acute phase, which typically lasts for two weeks to three months.

A few observational studies suggest that two common diagnoses of back pain, lumbar disc herniation or degenerative disc disease may not be more prevalent among those in pain than among the general population and that the mechanisms by which these conditions might cause pain are not known. Other studies suggest that for as many as 85% of cases, no physiological cause for the pain has been able to be specifically identified.

A few studies suggest that psychosocial factors such as on-the-job stress and dysfunctional family relationships may correlate more closely with back pain than structural abnormalities revealed in x-rays and other medical imaging scans.

Underlying causes

Transient back pain is likely one of the first symptoms of influenza.

Muscle strains (pulled muscles) are commonly identified as the cause of back pain, as are muscle imbalances. Pain from such an injury often remains as long as the muscle imbalances persist. The muscle imbalances cause a mechanical problem with the skeleton, building up pressure at points along the spine, which causes the pain. Ligament strain is a very common cause of back pain as well [5].

Another cause of acute low back pain is a Meniscoid Occlusion. The more mobile regions of the spine have invaginations of the synovial membrane that act as a cushion to help the bones move over each other smoothly. The synovial membrane is well supplied with blood and nerves. When it becomes pinched or trapped it can cause sudden severe pain. The pinching causes the membrane to become inflamed, causing greater pressure and ongoing pain. Symptoms include severe low back pain that may be accompanied by muscle spasm, pain with walking, concentration of pain to one side, and no radiculopathy (radiating pain down buttock and leg). Relief should be felt with flexion (bending forward),and exacerbated with extension (bending backward).

When back pain lasts more than three months, or if there is more radicular pain (sciatica) than back pain, a more specific diagnosis can usually be made. There are several common causes of back pain: for adults under age 50, these include ligament strain, nerve root irritation, spinal disc herniation and degenerative disc disease or isthmic spondylolisthesis; in adults over age 50, common causes also include osteoarthritis (degenerative joint disease) and spinal stenosis [6],trauma, cancer, infection, fractures, and inflammatory disease [7]. Non-anatomical factors can also contribute to or cause back pain, such as stress, repressed anger,[8] or depression. Even if there is an anatomical cause for the pain, if depression is present it should also be treated concurrently.

New attention has been focused on non-discogenic back pain, where patients have normal or near-normal MRI and CT scans. One of the newer investigations looks into the role of the dorsal ramus in patient's pain that have normal radiographic evidence. See Posterior Rami Syndrome. Diagnostic musculoskeletal ultrasonography has been shown to be helpful in objectifying multifidus atropy.

Back Pain During Pregnancy

About 50% of women experience low back pain during pregnancy.

Back pain in pregnancy may be severe enough to cause significant pain and disability and pre-dispose patients to back pain in a following pregnancy. No significant increased risk of back pain with pregnancy has been found with respect to maternal weight gain, exercise, work satisfaction, or pregnancy outcome factors such as birth weight, birth length, and Apgar scores.

Biomechanical factors of pregnancy that are shown to be associated with low back pain of pregnancy include abdominal sagittal and transverse diameter and the depth of lumbar lordosis. Typical factors aggravating the back pain of pregnancy include standing, sitting, forward bending, lifting, and walking. Back pain in pregnancy may also be characterized by pain radiating into the thigh and buttocks, night-time pain severe enough to wake the patient, pain that is increased during the night-time, or pain that is increased during the day-time.

The avoidance of high impact, weight-bearing activities and especially those that asymmetrically load the involved structures such as: extensive twisting with lifting, single-leg stance postures, stair climbing, and repetitive motions at or near the end-ranges of back or hip motion can ease the pain.

Direct bending to the ground without bending the knee causes severe impact on the lower back in pregnancy and in normal individuals, which leads to strain, especially in the lumbo-saccral region that in turn strains the multifidus.

Treatments with uncertain or doubtful benefit

• While some citations report limited benefit from Injections, such as epidural steroid injections, facet joint injections, or prolotherapy they still enjoy considerable support among the majority of patients and clinicians. Arguments against those citations with negative outcomes include the extreme difficulty in finding literature that has consistent and clearly defined patient populations while accounting for the multifactoral nature of back pain.

• Cold compression therapy is advocated for a strained back or chronic back pain and is postulated to reduce pain and inflammation, especially after strenuous exercise such as golf, gardening, or lifting. However, a meta-analysis of randomized controlled trials by the Cochrane Collaboration concluded "The evidence for the application of cold treatment to low-back pain is even more limited, with only three poor quality studies located. No conclusions can be drawn about the use of cold for low-back pain" Despite this, cryotherapy is inexpensive, easily tolerated and been used with high success for decades in patients with numerous kinds of musculoskeletal conditions.

• Bed rest is rarely recommended as it can exacerbate symptoms, and when necessary is usually limited to one or two days. Prolonged bed rest or inactivity is actually counterproductive, as the resulting stiffness leads to more pain.

• Electrotherapy, such as a Transcutaneous Electrical Nerve Stimulator (TENS) has been proposed. Two randomized controlled trials found conflicting results. Despite the fact the the article by Walsh NE made use of "sham TENS" (essentially a TENS unit that could not be felt compared to a second unit that was off) the expected negative outcome study results have been cited by the Cochrane Collaboration to conclude that there is inconsistent evidence to support use of TENS. In addition, spinal cord stimulation (SCS), where an electrical device is used to interrupt the pain signals being sent to the brain and has been studied for various underlying causes of back pain. While SCS still enjoys limited acceptance, it is expensive, requires lifelong monitoring and is not without complication.

• Inversion therapy may be useful for temporary back relief due to the traction method or spreading of the back vertebra's through (in this case) gravity. The patient hangs in an upside down position for a period of time from ankles or knees until this separation occurs. The effect can be achieved without a complete vertical hang (90 degree) and noticeable benefits can be observed at angles as low as 10 to 45 degrees.

Differential Diagnosis

In alphabetical order.

Common Causes

• Discopathy
• Idiopathic lumbago
• Trauma due to lifting
• Ligament strain
• Radiculopathy
• Posterior Rami Syndrome

Complete Differential Diagnosis of the Causes of Back pain

(In alphabetical order)

Abatacept Abdominal Aortic Aneurysm Abnormal posturing Abnormally flexible ribs Achalasia Acitretin Acute intermittent porphyria Acute prostatitis Addisons disease Adrenal hemorrhage Albuterol Aldesleukin Alexithymia Alkaptonuria Alprazolam Amitriptyline Anagrelide Angina pectoris Angiotensin II receptor antagonist Ankylosing Spondylitis Aortic aneurysm(Abdominal) Aortic Dissection Arachnoiditis Bearberry Bechterew's Disease Bone metastases Borreliosis Bortezomib Breast cancer Bright's disease Budesonide Inhalation Powder Cadmium poisoning Calcitonin Salmon Nasal Spray Candesartan Carbamazepine Carboplatin Cat scratch fever Cauda equina syndrome Cervical cancer Cervical fracture Cetuximab Injection Childbirth Cholelithiasis Cholesterol embolism Chordoma Chronic fatigue syndrome Chronic inflammatory demyelinating polyneuropathy Chronic uteral obstruction Clofarabine Injection Cobb syndrome Coccydynia Colorectal cancer Conversion syndrome Coxarthrosis Cramp Cushing's Disease Cyanocobalamin Injection Darbepoetin Alfa Injection Daunorubicin Degenerative disc disease Desloratadine Desmoplastic small round cell tumor Didanosine Diffuse idiopathic skeletal hyperostosis Diflunisal Disc space infection Discitis Dofetilide Donepezil Dorsopathy Drotrecogin alfa Dural ectasia Dysraphia Ectopic pregnancy Efalizumab Injection Ehlers-Danlos syndrome Endometriosis Epidural abscess Epoetin Alfa Injection

Eszopiclone Etodolac Facet Syndrome Fenoprofen Fexofenadine Fibromyalgia Formoterol Fulvestrant Injection Gemeprost Glatiramer Injection Gonarthrosis Hantavirus Pulmonary Syndrome Hemangioma Herpes Zoster Hyperparathyroidism (primary/secondary) Ibandronate Idiopathic Indinavir Infliximab Injection Injury of disci and ligaments Juvenile osteochondrosis of spine Leflunomide Leg length discrepancy Leriche's Syndrome Listeria monocytogenes Lumbago Syndrome Lumbar disc disease Lumbar strain Lung cancer Malignant processes of vertebral body Marfan syndrome Meclofenamate Mediastinitis Medroxyprogesterone Injection Mefenamic Acid Meningioma Menopause Mesalamine Metastases Modafinil Multiple Myeloma Mycophenolate Myelofibrosis Myocardial infarction Myositis Myotendinosis Nabumetone Nateglinide oral Nephrolithiasis Olanzapine Osteoarthritis Osteochondroma Osteochondrosis Osteogenesis imperfecta Osteogenic Sarcoma Osteomalacia Osteomyelitis Osteoporosis Ovarian cancer Oxaliplatin injection Oxcarbazepine Oxybutynin Paget's Disease Pancreatic cancer Pancreatitis Pelvic inflammatory disease Peptic ulcer disease Pergolide Pilonidal cyst Piriformis syndrome Piroxicam Pleuritis Pneumonia Poliomyelitis Polycystic kidney disease Polymyalgia Rheumatica Posaconazole Posterior Rami Syndrome Postlaminectomy Posttraumatic spinal stenosis

Pott's disease Praziquantel Prednisolone Pregabalin Pregnancy Premenstrual syndrome Prostate cancer Prostatitis Psoriatic Arthritis Psychosomatic Pulmonary embolism Pyelonephritis Ranibizumab injection Reiter's Syndrome Renal osteodystrophy Renal vein thrombosis Repaglinide Retroperitoneal fibrosis Retroperitoneal hematoma Rheumatoid Arthritis Ribavirin Rift Valley fever Risedronate Rituximab injection Rosiglitazone Sacroiliitis Salpingitis Salsalate Saquinavir Sargramostim injection Scheuermann's Disease Sciatica Scoliosis Selegiline Sibutramine Sickle Cell Disease Sirolimus Sodium oxybate Solifenacin Spina Bifida Spinal cord compression Spinal disc herniation Spinal fusion Spinal stenosis Spinal tumor Spondylolisthesis Spondylolysis Spondylosis Subarachnoid hemorrhage Sulfinpyrazone Sulindac Sunitinib Syringomyelia Tabes dorsalis Tacrolimus topical Tadalafil Tamsulosin Tegaserod Telbivudine Telmisartan Temozolomide Tension myositis syndrome Terazosin Tethered cord syndrome Transverse myelitis Traumatic aortic rupture Triamterene Urinary tract infection Valganciclovir Valproic Acid Valsartan Vancomycin Hydrochloride Vardenafil Vertebral Fractures Vertebral subluxation Zolpidem Zonisamide

Complete Differential Diagnosis of the Causes of Back pain

(By organ system)

Cardiovascular	Abdominal Aortic Aneurysm, Angina pectoris, Aortic Dissection, Endocarditis (bacterial) Leriche's Syndrome, Myocardial infarction, Traumatic aortic rupture,
Chemical / poisoning	No underlying causes
Dermatologic	Pilonidal cyst,
Drug Side Effect	Abatacept , Acitretin , Albuterol , Aldesleukin , Alprazolam, Amitriptyline , Anagrelide , Angiotensin II receptor antagonist, Budesonide Inhalation Powder , Calcitonin Salmon Nasal Spray , Candesartan , Carbamazepine , Carboplatin , Cetuximab Injection , Clofarabine Injection , Cyanocobalamin Injection , Darbepoetin Alfa Injection , Daunorubicin , Desloratadine , Didanosine , Diflunisal , Dofetilide , Donepezil , Drotrecogin alfa, Efalizumab Injection , Epoetin Alfa Injection , Eszopiclone , Etodolac , Fenoprofen , Fexofenadine , Formoterol , Fulvestrant Injection , Glatiramer Injection , Ibandronate , Indinavir , Infliximab Injection , Leflunomide , Meclofenamate , Medroxyprogesterone Injection , Mefenamic Acid , Mesalamine , Modafinil , Mycophenolate , Nabumetone , Nateglinide oral , Olanzapine , Oxaliplatin injection , Oxcarbazepine , Oxybutynin , Pergolide , Piroxicam , Posaconazole , Praziquantel, Pregabalin , Ranibizumab injection , Repaglinide , Ribavirin , Risedronate , Rituximab injection , Rosiglitazone , Salsalate , Saquinavir , Sargramostim injection , Selegiline , Sibutramine , Sirolimus , Sodium oxybate , Solifenacin , Sulfinpyrazone , Sulindac , Sunitinib , Tacrolimus topical , Tadalafil, Tamsulosin, Tegaserod , Telbivudine , Telmisartan , Temozolomide , Terazosin , Valganciclovir , Valproic Acid , Valsartan , Vancomycin Hydrochloride , Vardenafil, Zolpidem , Zonisamide ,
Ear Nose Throat	No underlying causes
Endocrine	Addisons disease, Cushing's Disease, Hyperparathyroidism (primary/secondary),
Environmental	Cadmium poisoning,
Gastroenterologic	Achalasia, Cholelithiasis, Pancreatitis, Peptic ulcer disease,
Genetic	Marfan syndrome, Spina Bifida, Osteogenesis imperfecta, Sickle Cell Disease,
Hematologic	No underlying causes
Iatrogenic	No underlying causes
Infectious Disease	Borreliosis, Cat scratch fever, Herpes Zoster, Pott's disease, Rift Valley fever, Urinary tract infection,
Musculoskeletal / Ortho	Abnormal posturing, Abnormally flexible ribs, Ankylosing Spondylitis, Cervical fracture, Coxarthrosis, Cramp, Degenerative disc disease, Disc space infection, Dorsopathy, Gonarthrosis, Lumbar disc disease, Lumbar strain, Malignant processes of vertebral body, Myelofibrosis, Myositis, Myotendinosis, Osteoarthritis, Osteochondroma, Osteochondrosis, Osteogenesis imperfecta, Osteogenic Sarcoma, Osteomalacia, Osteomyelitis, Osteoporosis, Paget's Disease, Piriformis syndrome, Poliomyelitis, Polymyalgia Rheumatica, Pott's disease, Psoriatic Arthritis, Spinal disc herniation, Spinal fusion, Spinal stenosis, Spinal tumor, Spondylolisthesis, Spondylolysis, Spondylosis, Sacroiliitis, Sciatica, Scoliosis, Vertebral Fractures, Vertebral subluxation,
Neurologic	Arachnoiditis, Chronic inflammatory demyelinating polyneuropathy, Dural ectasia, Epidural abscess, Posterior Rami Syndrome, Subarachnoid hemorrhage, Syringomyelia, Tabes dorsalis, Transverse myelitis,
Nutritional / Metabolic	Osteomalacia, Osteoporosis,
Obstetric/Gynecologic	Cervical cancer, Childbirth, Ectopic pregnancy, Endometriosis, Menopause, Ovarian cancer, Pregnancy, Salpingitis,
Oncologic	Cervical cancer, Desmoplastic small round cell tumor, Hemangioma, Lung cancer, Meningioma, Multiple Myeloma, Osteogenic Sarcoma, Ovarian cancer,
Opthalmologic	Reiter's Syndrome,
Overdose / Toxicity	Bearberry,
Psychiatric	Alexithymia, Conversion syndrome, Psychosomatic, Tension myositis syndrome,
Pulmonary	Hantavirus Pulmonary Syndrome, Lung cancer, Pleuritis, Pneumonia, Pulmonary embolism,
Renal / Electrolyte	Chronic uteral obstruction, Nephrolithiasis, Polycystic kidney disease, Pyelonephritis, Renal osteodystrophy, Renal vein thrombosis,
Rheum / Immune / Allergy	Ankylosing Spondylitis, Chronic inflammatory demyelinating polyneuropathy, Rheumatoid Arthritis,
Sexual	No underlying causes
Trauma	Injury of Disci and ligaments,
Urologic	Acute prostatitis,
Miscellaneous	Fibromyalgia, Chronic fatigue syndrome, Dysraphia, Facet Syndrome, Mediastinitis, Retroperitoneal fibrosis, Retroperitoneal hematoma, Scheuermann's Disease,

Prognosis

Most patients with back pain recover without residual functional loss, but individuals should contact a doctor if there is not a noticeable reduction in pain and inflammation after 72 hours of self-care. Recurring back pain resulting from improper body mechanics or other nontraumatic causes is often preventable. Engaging in exercises that don't jolt or strain the back, maintaining correct posture, and lifting objects properly can help prevent injuries. Many work-related injuries are caused or aggravated by stressors such as heavy lifting, vibration, repetitive motion, and awkward posture. Applying ergonomic principles — designing furniture and tools to protect the body from injury — at home and in the workplace can greatly reduce the risk of back injury and help maintain a healthy back.

See also

• Failed back syndrome
• Low back pain
• Posterior Rami Syndrome
• Tension myositis syndrome
• Upper back pain
• Pregnancy related pelvic girdle pain

External links

• Back Pain - Information for Patients
• Back pain at the Open Directory Project
• Template:NINDS
• Handout on Health: Back Pain at National Institute of Arthritis and Musculoskeletal and Skin Diseases
• Back Pain Information for Patients: Spine-health.com
• Patient's guide to back pain
• Back pain, on Medline plus, a service of the National Library of Medicine

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