Back pain overview
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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]
Overview
Back pain is pain felt in the back that may originate from the muscles, nerves, bones, joints or other structures in the spine. The pain may be have a sudden onset or it can be a chronic pain, it can be felt constantly or intermittently, stay in one place or refer or radiate to other areas. It may be a dull ache, or a sharp or piercing or burning sensation. The pain may be felt in the neck (and might radiate into the arm and hand), in the upper back, or in the low back, (and might radiate into the leg or foot), and may include symptoms other than pain, such as weakness, numbness or tingling.
Back pain is one of humanity's most frequent complaints. In the U.S., acute low back pain (also called lumbago) is the fifth most common reason for all physician visits. About nine out of ten adults experience back pain at some point in their life, and five out of ten working adults have back pain every year.[1]
The spine is a complex interconnecting network of nerves, joints, muscles, tendons and ligaments, and all are capable of producing pain. Large nerves that originate in the spine and go to the legs and arms can make pain radiate to the extremities.
Historical Perspective
Classification
On the basis of origin, back pain can be broadly classified into three categories: axial, referred, and radicular. Back pain can also be classified on the basis of its underlying etiology into mechanical and non-mechanical.
Pathophysiology
On the basis of pathogenesis, back pain can be broadly classified into inflammatory, mechanical, degenerative, oncologic and infectious. Genes involved include HLA-B27, SOX5, CCDC26/GSDMC, DCC. Conditions associated with back pain are, heavy lifting, ligaments and muscle strain, back injuries/fractures, arthritis, osteoporosis, metastatic cancer, abnormal posturing, degenerative disc disease, depression, pregnancy, fibromyalgia, sciatica, spinal disc herniation, spinal stenosis.
Causes
The causes of back pain can be stratified according to age. Common causes of back pain in adults under the age of 50 years include, ligament strain, nerve root irritation, spinal disc herniation, degenerative disc disease and isthmic spondylolisthesis. Common causes in adults over the age of 50 years include osteoarthritis (degenerative joint disease), spinal stenosis, trauma, cancer, infection, fractures, and inflammatory disease. Non-anatomical factors can also lead to back pain, such as stress, repressed anger, or depression. Even if an anatomical cause for the pain is present, a coexistent depression should be treated concurrently.
Differentiating Back Pain from other Diseases
There are several life-threatening causes of back pain, including spinal cord or cauda equina compression, aortic dissection, aortic aneurysm, vertebral osteomyelitis, epidural abscess, and metastatic cancer. These should be evaluated alongside other possible causes of back pain by carefully assessing the nature of the pain, and obtaining a thorough patient history.
Epidemiology and Demographics
Risk Factors
Risk factors for back pain include poor posture, obesity, pregnancy, cancer, weight lifting, psychological stress, smoking, sedentary lifestyle, lack of exercise, autoimmune disease, arthritis and trauma.
Screening
There is insufficient evidence to recommend routine screening for back pain.
Natural history, Complications and Prognosis
Natural history, complications and prognosis largely depend on the underlying cause of back pain. Back pain progresses and presents varialbly depending on the pathology. Back pain of any origin can lead to deformity, disability, depression, weight gain, social isolation, decreased quality of life, and sleep disturbances. Prognosis varies according to the underlying etiology, most patients will recover with within weeks. Recurrent and chronic cases are more resistant to treatment.
Diagnosis
Diagnostic Study of Choice
History and Symptoms
Important history question for patients presenting with back pain should focus on, pain onset, duration, radiation, aggravating or relieving factors, intensity, preceding event (surgery, intense exercise, trauma), and associated symptoms including, bowel incontinence, bladder incontinence, progressive weakness in legs, sleep interrupted due to severe back pain, fever, unexplained weight loss.
Physical Examination
Laboratory Findings
There are no diagnostic laboratory findings associated with back pain. However, to investigate the underlying cause of back pain it is crucial to look for the following, complete blood count (CBC), erythrocyte sedimentation rate, C-reactive protein, HLA-B27, antinuclear antibody (ANA), rheumatoid factor, lactate dehydrogenase (LDH), uric acid.
Electrocardiogram
Patients with atypical back pain should undergo an ECG to rule out or investigate life threatening causes of back pain such as thoracic aortic dissection, myocardial ischemia.
X Ray
X-ray imaging includes conventional and enhanced methods that can help diagnose the cause and site of back pain. A conventional x-ray is often the first imaging technique used, it looks for fractured bones, degenerative changes, and vertebral misalignment. Tissues such as injured muscles and ligaments or painful conditions such as a bulging disc are not visible on conventional x-rays. Myelogram enhances the diagnostic imaging of an x-ray. In this procedure, the contrast dye is injected into the spinal canal, allowing spinal cord and nerve compression caused by herniated disc or fractures to be seen on an x-ray.
Echocardiography and Ultrasound
There are no echocardiography/ultrasound findings associated with back pain.
CT
Computerized tomography (CT) is considered when MRI is not an option. It is used if disc rupture, spinal stenosis, or damage to vertebrae is suspected as a cause of back pain. CT scan can be paired with a myelogram by injecting contrast dye in the spinal cord. PET/CT can be used together to increase anatomical accuracy especially in adults with persistent back pain.
MRI
MRI is helpful in the diagnosis of the underlying cause of back pain. Findings on MRI suggestive of the cause of back pain include soft tissue lesions, nerve compression, malignancy, and/or inflammatory lesions. MRI is indicated in back pain if any of following red flags are present, history of cancer, unexplained weight loss, significant trauma, motor weakness, sensory loss, urinary/fecal incontinence.
Other Imaging Findings
Bone scan, SPECT scan, DEXA scan and thermography may be helpful in identifying the cause of back pain.
Other Diagnostic Studies
Other diagnostic studies for back pain include electromyography, nerve conduction studies, somatosensory evoked potentials, and/or diagnostics injections.
Treatment
Conservative Treatment
The management goals when treating back pain are to achieve maximal reduction in pain intensity as rapidly as possible; to restore the individual's ability to function in everyday activities; to help the patient cope with residual pain; to assess for side-effects of therapy; and to facilitate the patient's passage through the legal and socioeconomic impediments to recovery. For many, the goal is to keep the pain to a manageable level to progress with rehabilitation, which then can lead to long term pain relief. Also, for most people the goal is to use non-surgical therapies to manage the pain and avoid major surgery, but for others surgery may be the quickest way to feel better. Not all treatments work for all conditions or for all individuals with the same condition, and many find that they need to try several treatment options to determine what works best for them. The present stage of the condition (acute or chronic) is also a determining factor in the choice of treatment. Only a minority of back pain patients (most estimates are 1% - 10%) require surgery.
References
- ↑ A.T. Patel, A.A. Ogle. "Diagnosis and Management of Acute Low Back Pain". American Academy of Family Physicians. Retrieved March 12, 2007.