Low Back Pain

Low Back Pain

Most Americans suffer from low back pain at some point in their lives. Therefore low back pain is one of the most common reasons for a trip to the doctor.  Low back pain (LBP) can range from severe to mild.  It may debilitate enough to require surgery however this happens only in a small percentage of back pain sufferers.  This article will focus on acute low back pain (less than 6 weeks), review both serious and common causes, and outline treatment options.

The majority of acute low back pain will go away in 4-6 weeks.  The duration and intensity of back pain depends on a number of factors:

• Age

• Previous injury

• Location of back pain

• Mechanism of injury (if any)

• Severity of pain

• General health

• Specific causes (systemic illness, neurological, arthritic, infectious, or mechanical)

Older folks tend to suffer low back pain for longer periods.  This is due to a slower healing time frame in the elderly and because the cause may be more serious than a muscle or tendon strain.  Low back pain causes in the elderly include:

• muscle or tendon strain/sprain
• arthritis, disc degeneration
• compression fracture
• spinal stenosis (narrowing of spinal canal)
• general spondylosis (an abnormality in the vertebrae or discs)
• cancer including metastasis.

Old back injuries can be re-aggravated easily.  A simple bend forward with a twist can overstress previously injured back tissue causing a flash of pain and subsequent muscle spasm. As is the case with ankle sprains, lumbar tendons and ligaments can be sprained easier the second or third time.  As a result, healing and rehabilitation takes longer and the pain and tenderness may be more severe.

Location of back injury makes a difference too.  The upper lumbar area is likely to heal quicker than the lower lumbar area.  For example, neurological symptoms from upper lumbar levels (L1-L3) resolve sooner than in the lower lumbar level.  Incidentally, L5/S1 is the most commonly herniated disc.

Obviously, a high impact injury to the spine (e.g. a roll over car collision) would take a long time to heal depending on the extent of structural damage and any requirement for surgery.  Similarly, a case of sciatica from repetitive heavy lifting can be just as frustrating due to length of recovery time including return to full work duties.  Again, improvement depends on the extent of damage.

It is worth noting at this point that physical fitness level makes a difference not only in preventing back pain but also in recovery.  It will be more difficult for an overweight person with a sedentary lifestyle to adjust to the demands required to rehabilitate the low back.  Studies have shown that inactivity following acute low back pain slows recovery time.

In addition to the above factors, here is a list of risk factors for back pain.

• Obesity

• Smoking

• Sedentary lifestyle

• Physically demanding work(e.g. lifting, pushing, pulling, carrying over 25lbs frequently) psychologically stressful jobs

• Anxiety and depression

• Gender (females tend to have back pain more than men)

One of the jobs of a physician is to diagnose the cause of back pain. This can be difficult since there are many causes.  Therefore we can generalize our diagnosis into broad categories to include mechanical, neurological, infectious, traumatic or systemic causes.

More than 75% of acute low back pain falls into the mechanical or muscle/tendon sprain category. The specific cause of mechanical back pain is often elusive because there are many tendons, ligaments, muscles, and connective tissue in the lumbar spine which can be stressed, strained, or sprained.  The pain pattern is usually localized to the low back area, increases with certain movements and may cause muscle spasms. Acute mechanical low back pain responds well to conservative treatment with about 50% of sufferers improving in 2 weeks and the remainder is back to normal in 4-6weeks.  As long as there are no systemic, infectious, neurological, traumatic (fracture), or malignant causes, then performing daily activities within the limits of pain is encouraged.  Analgesics and muscle relaxers augment activity as tolerated.  Acceptance that the spinal area will not be further damaged as long as pain is the guide will help motivate recovery.

Neurological problems include sciatica, spinal stenosis, herniated disc (which can pinch on nerve roots).  Neurological problems can occur alone or with mechanical back pain.  There can be pain locally in the back which radiates down the leg.  Persons may experience numbness, tingling or muscle twitching in either leg.  The farther away the symptoms the more concerning the neurological symptoms.  Muscle weakness from pinched nerves is a late finding and conveys severe nerve involvement.  Reflexes should be tested as decreased reflexes equate to peripheral nerve damage.

The sciatic nerve is the largest nerve in the body.  It starts deep in the back as a collection of nerve roots from the spinal cord and travels within the pelvis exiting the pelvis under the buttock muscles and into the legs.  Sciatica can be caused by inflammation in the spinal area by a herniated disc or bony spurs.  Or it can be compressed by an overly tight piriformis muscle (in the buttock). Classically, the sciatica pain travels down the back of one leg, around the knee and down to the foot.  Acute sciatica can initially be treated like mechanical back pain -activity as tolerated, analgesics and muscle relaxers – and watch for worsening symptoms in the leg.  If pain, tingling, numbness, weakness, or muscle twitching progresses then an MRI may be needed to judge the extent of nerve damage.

Spinal stenosis is caused by narrowing of the vertebral column and potentially indenting the spinal cord or its branches within the spinal column.  Symptoms include back pain, leg weakness, altered gait and bilateral calf pain which worsens with prolonged standing or walking.  Spinal stenosis is more common in the elderly.  Furthermore, poor blood supply to the lower legs should be ruled out when calf pain occurs with walking.  This is called claudication.

A third neurological condition called cauda equina syndrome is a medical emergency.  When the tail or end branches of the spinal cord are compressed, they can cause leg weakness, sciatica symptoms in both legs, numbness in the lower pelvic area, and inability to urinate.  Medical attention should be sought immediately to prevent lasting damage.

Rare but serious causes of LBP include

• spinal infections in the form of an abscess or bone infection and
• cancer including metastasis.

Risk factors for infection include

• people who are immunocompromised (e.g. chemotherapy, chronic oral steroids),
• IV drug abusers,
• recent history of skin infection or urinary tract infection.

People with a history of cancer may develop bony metastasis or tumors in the spine.

Fever with tenderness over the spinal, spine pain at night, unexplained weight loss, and pain that persists or worsens despite conservative treatment should be suspected of a serious low back pain cause.  Also, a person over 50 y.o. with unexplained onset of back pain should be considered at risk.

Systemic conditions causing back pain include

• kidney infection
• appendicitis
• gall bladder disease
• menstrual cramps

Usually these conditions cause pain in the abdominal area and may radiated to the back.  In the thoracic area, pneumonia, pneumothorax, and myocardial infarction (heart attack) can cause pain.  Other serious but uncommon causes include abdominal aortic aneurysm and dissecting aorta

Traumatic injuries to the spine can cause fractures and dislocations.  Depending on the trauma severity and age of patient, radiographs should be considered.

With mechanical low back pain, xrays are not needed unless symptoms do not improve over 4 weeks time.

Lastly, osteoporosis and compression fractures should be considered in the older individuals with low back pain.  In younger men, spondylitic arthritis should be considered.

When a person visits their physician for acute low back pain, they should expect to give a detailed history and the physician should check the following:

• vital signs

• deep tendons reflexes

• light tough sensation in the lower extremities

• muscle strength in the knees, ankles and toes

• straight leg raise test (sitting or supine)

• palpation of the spine and muscles next to the spine

• active range of motion of the lumbar spine (sitting or standing)

• inspection for scoliosis or kyphosis

Treatment for acute low back pain caused mechanical, muscular, tendonous, sprain, strain, or sciatica includes

• analgesics
• muscle relaxers
• activity as tolerated.

After the acute symptoms resolve, an exercise program should be initiated to prevent re-injury Opioid medication may be helpful in the short term however with pain beyond 4-6 weeks an alternative diagnosis should be sought.  Risk of opioid use for chronic back pain includes tolerance, dependency and addiction…and constipation.

Spinal xrays are rarely needed for acute low back pain unless trauma is involved.  If a neurological problem is suspected then an MRI may be needed but often mild neurological symptoms will resolve on their own or with Physical Therapy.  It is well known that 50% of the adult Americans without back pain have mild disc or vertebral abnormalities show up on MRI.  So unnecessary testing may lead to unnecessary treatment including surgery.

Finally, regarding return to work –   pain will dictate the type and duration of work.  For the desk worker, an adjustment in chair or desk height may be needed.  For the physical laborer light duty for 1-2 weeks is often required.

We hope this give you a good understanding of low back pain.  If you have specific questions or concerns, consult your family physician or send us a question on the Doctor’s Lounge forum.

Pharmacology

Essential Oils

Although not FDA approved to treat acute low back pain, many people have turned to this alternative method to ease pain in and around the spine.  Here are a few types of oils I used.

A series of oils has been proposed by Dr.Gary Young to treat spine pain.  The treatment (Raindrop Therapy) is based on the premise that spine deformity and pain result from latent bacterial or viral infections such as tuberculosis mycobacterium, varicella zoster, Propionibacterium acnes.  These organisms lodge in or near the spinal column and cause localized inflammation leading to spondylosis.   Oils used in raindrop therapy include

• oregano

• thyme

• basil

• cypress

• wintergreen

• marjoram

• peppermint

• Valor

• Aroma Seiz

Basil, oregano, thyme, and marjoram all have proven antibacterial activity but must be used with caution as they can redden and heat the skin.  A plain vegetable oil like olive oil may be use if needed for dilution. ; Peppermint contains menthol which effectively penetrates skin and subcutaneous tissue well so may serve to drive other oils into the tissues.

In addition to the “raindrop” oils, anecdotal evidence has been reported in the use of lemongrass, helichrysum and melrose. Often multiple oils are layered in combinations for individualized therapy.

Lastly, medical research shows that rosemary, basil, and flax seed have anti -inflammatory properties with basil also decreasing nocioception (pain perception).

References

1.Anti-inflammatory and anti-nociceptive effects of Rosmarinus officinalis L. essential oil in experimental animal models. J Med Food. 2008 Dec;11(4):741-6.

2. Evaluation of anti-inflammatory activity of plant lipids containing alpha-linolenic acid. Indian J Exp Biol. 2008 Jun;46(6):453-6.

3. Essential oils in medicine: principles of therapy. Parassitologia. 2008 Jun;50(1-2):89-91.

4. Treatment of low back pain, Christopher Knight MD et. al., Uptodate 2009