The complaint of low back painis among the most common medical problems. To begin on the positive side, patients must understand that most episodes of back pain resolve, and usually within a few weeks. Understanding the cause of your back pain is the key to proper treatment. Because back pain is sometimes difficult to treat, a better understanding of the causes of this problem will assist patients in their recovery from back pain.

Causes of Back Pain

Lumbar Muscle Strain
  Muscle strains are the most common cause of low back pain. Patients may or may not remember the initial event that triggered their muscle spasm, but the good news is that most episodes of back pain from muscle strains resolve completely within a few weeks.
Ruptured Disc
  A ruptured intervertebral disc, also called a herniated disc, is another common cause of back pain. How to treat the back pain from a herniated disc depends on the particular individual and situation.
Discogenic Back Pain
  Discogenic back pain is thought to be a common cause of low back pain. Discogenic back pain cis the result of damage to the intervertabral disc, but without disc herniation. Diagnosis of discogenic back pain may require the use of a discogram.
Spinal Stenosis
  Spinal stenosis causes back pain in the aging population. As we age, the spinal canal can become constricted, due in part to arthritis and other conditions. If the spinal canal becomes too tight, back pain can be the result.
Lumbar Spine Arthritis
  Arthritis most commonly affects joints such as the knees and fingers. However, arthritis can affect any joint in the body, including the small joints of the spine. Arthritis of the spine can cause back pain with movement.
  Spondylolisthesis causes back pain because adjacent vertebra become unstable and begin to "slip." The most common cause of spondylolisthesis is due to degenerative changes causing loss of the normal stabilizing structures of the spinal column. If the spine becomes unstable enough, back pain can become a problem.
Osteoporosis can cause a number of orthopedic problems and generalized discomfort. Back pain from osteoporosis is most commonly related to compression fractures of the vertebra. Osteoporosis causes weak bones and can lead to these fractures.

Back Pain Treatment
The most frustrating aspect in treatment of back pain is that there is no "magic bullet." Most individuals recover completely by simply avoiding strain to their spine. Patients often find help from ice, heat, and medications. If the basic steps do not alleviate back pain, the next step is to seek medical evaluation. Depending on the symptoms and the length of the problem, your physician can properly organize a treatment schedule.

When do I need to go to my doctor for back pain?
As stated previously, most episodes of back pain last a few days, and have completely resolved within a few weeks. If you have new back pain, you should contact your doctor to see if you need further evaluation. There are also a few warning signs that may indicate a problem that needs immediate evaluation:
        Your back pain persists beyond a few days
         Your back pain awakens you at night
         Your have difficulty controlling your bowels or bladder
         You have a fever, chills, sweats, or other signs of infection
         Any other unusual symptoms

Diagnosing Back Pain

Diagnosis of back pain is generally accomplished by means of a medical history, a physical exam, and sometimes with imaging and lab tests. It is important to realize that diagnosis efforts will never directly reveal back pain. The purpose of back pain diagnosis and testing is to show the normalities and abnormalities of the spine -- the doctor will then correlate back pain signs and symptoms with the results of these examinations to come up with a diagnosis. Very often, doctors can find no anatomical cause of the pain. Additionally, imaging studies might reveal a spine fraught with problems, but the patient experiences no pain.
Medical History
It is important to be thorough and honest when discussing your present condition and your past medical history with your doctor. This is because the information you provide is used as a guideline when planning treatment and selecting specific drugs.

Physical Examination
Physical examination includes a visual look over for posture symmetry/asymmetry. Leg lengths are also compared, along with range of motion tests and checks for muscle tightness. Range of motion is evaluated with the patient assuming a few basic positions such as bending forward and to each side, so the physician can measure how far you can bend as compared with established ranges for healthy joints.

Diagnostic imaging is used to confirm the presence of lesions, rather than to tell what is causing back pain.  Types of diagnostic imaging include:
          Computed Tomography(CT)
           Bone scans diagnose fractures and tumors in the bone by identifying abnormal physiology such as increased blood flow or erratic metabolism in particular areas of vertebrae. This type of test uses injected dye and computer images.
          Ultrasound or sonography can show soft tissue injury. The technology of ultrasound converts sound waves into real-time visual images.

Electrodiagnostic studies measure the electrical activity in nerves, nerve roots and muscles. nids By measuring electrical impulses these tests can tell how well muscles and nerves are working together. Types of electrodiagnostic studies:
          Electromyogram (EMG) measures electrical activity in the nerves that go to muscles and determine if problems in the nerves are causing muscle weakness.
          Nerve Conduction Studies determine if there is any damage to the functioning of the nerves.
          Evoked Potential studies record the speed of nerve transmission from the site of origin to the brain.
Lab Tests
Lab tests are used to find causes of back pain that are unrelated to mechanical or nerve dysfunction. For example (only), if an infection or cancer is responsible for a patient's back pain, lab tests may be done to analyze physiology. Generally lab tests are performed by drawing blood.

Treatment and Prevention of Back Pain

Treatment of low back pain usually begins with a few basic steps. Before beginning any back pain treatment program, be sure you know your diagnosis, and discuss the treatment plan with your doctor. There are some conditions that cause back pain and require immediate treatment. For most cases of back pain, the first treatments are as follows:
The first step in the treatment of low back pain is to rest the spine. Because most cases of back pain are due to muscle strain, it is important to avoid further irritation to the spine and the muscles that surroung the spinal column. Bed rest is fine, so long as this only lasts two to three days. Prolonged bed rest can actually lead to more persistent back pain. Once the acute back pain eases, avoid lifting, twisting, and physical exertion.
Anti-Inflammatory Medications
Anti-inflammatory medications, or NSAIDs, are helpful in treatment of both back pain and the associated inflammation. There are both over-the-counter and prescription NSAIDs, and both work well in the treatment of back pain. Side-effects of NSAIDs include problems of GI bleeding, and these medications should be avoided in patients with stomach ulcers.
Muscle Relaxers
Muscle relaxing medications can be very helpful in the treatment of some types of back pain. These medications help to relieve muscle spasm, but may also make patients quite drowsy.
Heat Application
Applications of heat packs help ease much of the discomfort associated with muscle spasm causing low back pain. Patients can use heating pad, hot water bottles, or even a hot bath to help ease the muscle discomfort that often causes low back pain.
Strengthening of back muscles is probably the most important step in treatment of most causes of back pain. By increasing strength and flexibility of back muscles, weight is better distributed, and less force is placed on the spine.
Physical Therapy Back exercises are the focus of physical therapy. However, there are other modalities that can be used in the treatment of back pain if the exercises alone do not help. Modalities include aquatherapy, ultrasound, electrical stimulation, and others.
Chiropractic Manipulations
Manipulations are usually safe, and have been shown to be as effective as more conventional treatments for some types of back pain. That said, there are situations when spinal manipulations can be dangerous and should be avoided. Patients should generally have a x-ray of their spine to assess for lesions or instability prior to beginning treatment of spinal manipulations. In addition, patients who have any leg pain or neurologic symptoms (weakness, numbness, etc.) associated with their back pain should not have spinal manipulations until evaluated by a physician.
Massage offers symptomatic relief for back pain caused by muscle spasm. The problem with massage treatments, is that the relief seldom lasts beyond the actual treatment. Furthermore, treatments can be quite expensive. That said, if you find relief from massage, there is unlikely any harm to be caused by these treatments.
These simple measures often lead to resolution of the symptoms of low back pain. If not, you should certainly be under the direct care of a physician to aid in the treatment of your condition. There are further steps in the treatment of low back pain that can be considered  :

Narcotic Pain Medications
Narcotic pain medications are excellent at relieving pain, but these can be dangerous, addictive medications.  Using narcotic medications must be under close supervision, and only for a limited period of time. Prolonged use of narcotic medication can be dangerous.

Epidural Steroid Injections
Epidural steroid injections are an option for back pain treatment and inflammation around the spinal nerves. An epidural steroid injection is performed using an x-ray to guide the medication to the area adjacent to the inflamed spinal nerve.

Spine Surgery

Usually a step when extensive efforts at conservative back pain treatment fails to relieve symptoms
Spine surgery is rarely an initial treatment for back pain, however, there are a few emergencies that may require surgical treatment. In the vast majority of patients, spine surgery is only considered after a long course of conservative therapy. As stated earlier, back pain often takes quite some time to resolve. Therefore, rushing into spine surgery may not be the best idea. Most commonly, doctors will advise at least 3 to 6 months of conservative treatment before considering spine surgery.

Spine Surgery Options

A discectomy is a procedure to remove a portion of the disc that rests between each vertebrae. A herniated disc is the most common reason for spine surgery. In this type of spine surgery, the herniated disc is removed and relieve the pressure on the nerves.
A foraminotomy is also a procedure used to relieve pressure on a nerve, but in this case, the nerve is being pinched by more than just herniated disc. A foramenotomy removes a portion of bone and other tissue that may be compressing the nerve as it exits the spinal column.
A laminectomy is done to relieve pressure on the spinal cord itself. A laminectomy is most commonly used to treat conditions such as spinal stenosis and spondylolisthesis. Depending on the amount of bone removed, this procedure may be done with a spinal fusion to prevent instability.
Spine Fusion
A spine fusion is surgery that is done to eliminate motion between adjacent vertebrae. The spine fusion may be done because to treat a problem such as spondylolisthesis (unstable spine), or it may be done because of the extent of other surgery (such as a laminectomy).
Spinal Disc Replacement
Spinal disc replacement is a new surgery that is still quite uncommon. Spine disc replacement is done to treat specific types of back pain, while avoiding the problems associated with spine fusion surgery.

Dr.Sanjay Mongia
Consultant Neurological and Spine Surgeon

Email :
Spine Clinic , India
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