Back Pain Symptoms and Treatment
Lower Back Pain: Low back pain does not discriminate. According to the National Institute of Neurological Disorders and Stroke, men and women between the ages of 30 and 50 are the group most affected by low back pain caused by aging or lack of exercise. An estimated 90% of patients with low back pain can improve the condition of their lower back without surgery. Instead, these patients obtain relief with conservative treatment options like exercise, physical therapy, steroid injections, and physician prescribed anti-inflammatory medications. However, if you are among the small percentage of individuals who do not experience relief from conservative treatment options, you may require surgery.
What is Low Back Pain?
The spine has three main functions: (1) supports the body, (2) protects the spinal cord and nerves, and (3) allows flexible movements. The spinal column is a complex assembly of nerves, disks, and bones. The spinal cord begins at the base of the brain and runs most of the way down the back protected by the bones of the spinal column. Nearly every movement and function of the body is controlled by the spinal cord. Motor nerves leading out of the spinal cord control body movements, while sensory nerves entering the spinal cord communicate feeling from the body back to the brain. Together, the motor and sensory nerves form more than 50 pairs of nerve roots, each pair leaving the spinal column through holes (foramina) along the side of the vertebrae. Each of these nerve roots has the potential to become irritated and cause pain. Separating each of the bones (vertebra) in the spine is a soft flexible disk that acts as a shock absorber. These disks have a rigid outside rim but are soft and gel-like inside. The disks can bulge and press on a nerve root, causing irritation.
Common Causes of Low Back Pain
Herniated Disk (Slipped Disk)
Activity, aging, or a mechanical problem in the spine can cause one of the disks to bulge. When this occurs, the disk may “pinch” or place pressure on a nerve root (“pinched nerve”), causing pain. This is what frequently happens in a case of low back and leg pain.
The spine is made up of vertebrae (bones in the spinal column) and soft gel-like disks. Occasionally, the disk will bulge to the point where it herniates or ruptures and puts even greater pressure on the nerve root. In the lower back, the nerve roots lead to the legs. Irritation or pressure may cause not only back pain, but also pain that radiates down the back of one or both of the legs (sciatica). If a nerve root in the lumbar spine is irritated, there can also be muscle weakness, numbness, or changes in the reflexes in the legs.
The key to initial treatment is to relieve the nerve root pressure or irritation. One of the most common surgical treatments for herniated disk is diskectomy. This procedure is performed to relieve pressure on a nerve root or the spinal cord.
Disk Degeneration (Osteoarthritis in the Spine)
One of the most common disorders of the lower spine is disk degeneration, or osteoarthritis of the spine. As the body ages, the disks in the spine dehydrate or dry out, and lose their ability to act as shock absorbers. The bones and ligaments that make up the spine also become less flexible and thicken. Degeneration in the disks is not uncommon. Degeneration in disks is a part of the normal aging process and is not in itself abnormal. The problem occurs when these disks become painful or begin to pinch and put pressure on the nearby nerve roots or spinal cord. Small nerves surrounding the disk may become irritated and cause low back pain. Treatment options for patients with degenerative disk disease in the spine are numerous, with the main focus on diminishing the low back pain. Neurosurgeons will often prescribe a variety of treatments, including physical therapy, anti-inflammatory medications, steroid injections, and a consultation by a physiatrist (a physician who specializes in rehabilitative medicine). Physical therapy may be directed by the neurosurgeon or rehabilitation physician.
Lumbar Spinal Stenosis
Another result of degeneration of the spine is lumbar spinal stenosis (LSS). This disease involves a narrowing of the canal that houses the spinal cord and nerve roots.
Patient who suffer from LSS often experience pain and weakness in the legs and a dull pain in the lower back. Sometimes those patients find relief when they are sitting or standing hunched over (e.g., forward bending over a shopping cart in a supermarket).
In LSS, pain, numbness, and weakness typically worsen when patients are standing erect or walking. Symptoms of LSS usually do not occur until after the age of 50. Many patients respond well to conservative treatment for quite a few years. The surgical treatment focuses on opening up the spinal canal and relieving the pressure on any nerve roots that are being irritated. The surgical treatment of LSS consists of a decompressive laminectomy in which bone that is narrowing the spinal canal is removed. Surgery for LSS improves quality of life in over 80% of patients.
Degeneration in the spine can also lead to spondylolisthesis, a condition characterized by the slippage of a vertebra in the spine. In this condition, a vertebra is displaced out of line with the adjacent vertebra. Like other spine disorders, conservative treatment may provide relief. Conservative treatment may also require a back brace. Some patients may require surgical decompression with possible fusion and instrumentation.
Diagnosing Low Back Pain
Before your doctor can recommend a course of treatment, the source of your low back pain must be thoroughly evaluated. Your evaluation includes a medical history, physical examination, and a review of any available radiographic studies; i.e., x-rays, magnetic resonance imaging (MRI), or computed tomography scan (CT or CAT scan). Your doctor will document your symptoms and find out the extent to which these symptoms affect your daily living. The physical examination will include an assessment of sensation, strength, and reflexes in various parts of your body to help pinpoint which nerve roots or areas are affected. Patients may be treated conservatively and then undergo imaging studies if they fail medication and physical therapy. If your doctor deems them necessary, certain additional radiological and electrical studies may be ordered to determine the nature and extent of the problem. If conservative treatment options, including physical therapy and medications, do not reduce or end the pain altogether, your doctor may recommend surgery. He or she will talk to you about the types of spinal surgery available, and depending on your specific case will help to determine if spinal fusion might be an appropriate treatment for you. As with any surgery, a patient’s age, overall health, and other issues are taken into consideration when spinal fusion is considered.
An x-ray will show the bones of the spine and determine if there is significant wear and tear or disease of the bone. It will also show whether the bones are lined up properly or if the disk has degenerated. In addition, it shows bony spurs which may irritate nerve roots.
Computed Tomography (CT)
A CT (also known as a CAT scan) produces a computerized map of the spine. The CT will show the anatomy of the spine in more detail and from different angles. It will also better define the relationship of the disk or bone spurs (bony outgrowth) to the spinal cord and nerve roots. The CT may be performed in conjunction with a myelogram of the spine to provide additional information. This diagnostic study is ideal for showing bone detail (e.g., stenosis).
Magnetic Resonance Imaging (MRI)
The MRI uses a powerful magnetic field instead of x-rays to produce a detailed anatomical picture of the spine and the structures within it. This diagnostic study is best for soft tissue detail (e.g., disk, nerve roots, spinal cord). It can also help show abnormalities of the spinal cord itself.
Electromyogram and Nerve Conduction Studies (EMG/NCS)
Unlike the other tests – which help your doctor determine anatomy and structure – these tests primarily study how the nerve roots and muscles are actually working together. They measure the electrical impulse along the nerve roots, peripheral nerves, and muscle tissue. Small needles may be placed in the muscle or along the course of a nerve root to measure electrical activity. Slowing of the impulses may reveal which nerve roots or muscles may be functioning abnormally.
This is a special, invasive x-ray test that may help identify which disks are damaged and if they are a source of pain. It utilizes a contrast dye to image the disk on x-ray.
Conservative (Nonsurgical) Treatment Options
Determining the treatment solution depends mainly on why and where the nerve root is irritated. Although low back pain can be quite debilitating and severe to patients, in 90% of cases the pain improves without surgery. However, 50% of all patients who suffer from an episode of low back pain will have a recurrent episode within one year. Depending on patients’ symptoms, lifestyle, exam, imaging studies, and other medical illnesses, conservative or non-surgical treatment may be the most appropriate course of action. Treatment options include physical therapy, weight reduction, steroid injections (epidural steroids), nonsteroidal anti-inflammatory medications, rehabilitation, and limited activity. All of these treatment options are aimed at relieving the inflammation in the back and irritation of nerve roots. Physicians usually recommend four to six weeks of conservative therapy before considering surgery.
If low back pain occurs after a recent injury, such as a car accident, a fall, or a sports injury, patients should call their primary care physician immediately. If there are any neurological symptoms, patients should see a physician immediately. If there are no neurological problems (i.e., numbness, weakness, bowel or bladder dysfunction), patients may benefit by beginning conservative treatment at home for two or three days. In the first couple of days, the goal is to stop the irritation in the back around the nerve roots. Patients should take anti-inflammatory medications, such as aspirin or ibuprofen, and restrict strenuous activities for a few days. Patients should remain active and mobile, and continue to perform normal everyday activities with the knowledge that an overwhelming number of patients will get better with time.
Because the nerve root is being irritated, patients can either get relief or feel intense aggravation in positions such as sitting, lying down, or standing. It is important to find a position that best relieves the pain. If the low back pain gets worse or does not improve after two or three days of home treatment, contacting a primary care physician should be the next step. The physician can evaluate the patient and perform a neurological exam in the office to determine which nerve root is being irritated, as well as to rule out other serious medical conditions. If there are clear signs the nerve root is being compressed, the physician can prescribe medications to relieve the pain, swelling, and irritation, and may also recommend limitation of activities. If these treatment options do not provide relief within two weeks, it may be time to consider other diagnostic studies and possible surgery.
If a patient is referred by a primary care physician to a neurosurgeon, the neurosurgeon will often work closely with other medical professionals, including physical therapists or physiatrists, to coordinate treatment. If surgery is necessary, patients will continue to work with their neurosurgeon on an extensive rehabilitation program, including physical therapy and medications.
When Surgery is Necessary
When conservative treatments for low back pain do not provide relief, surgery may be needed. Signs and symptoms that indicate you could be a candidate for surgery include:
- Leg pain that limits your normal activity.
- Weakness or numbness in your legs.
- Difficulty walking or standing.
- Ineffectiveness of medication and physical therapy in controlling pain.
- New bowel or bladder conditions are occurring.
If surgery is recommended and you are in reasonably good health, the neurosurgeon has a variety of options available to help relieve pressure on the nerve roots. The most common procedure is a diskectomy, which involves removing the soft gel-like material in the disk. This procedure will return the disk to a more normal shape, thereby relieving pressure on the nerve root. The neurosurgeon uses magnification or operating microscopes when performing surgery. This instrument provides the neurosurgeon with improved visualization and improved safety.
In a laminectomy procedure, the neurosurgeon will sometimes remove a small piece of bone near the disk and irritated nerve root to gain access to the disk or to give the nerve root more space to expand and swell in the future. If the nerve root is being pinched as it passes through the vertebrae, the neurosurgeon can also perform a foraminotomy, which is a procedure designed to expand the opening through which the nerve roots travel.
If there are several nerve roots and disks causing the pain, or if there is degeneration and instability in the spinal column, the neurosurgeon may opt to fuse the vertebrae together with bone grafts and stabilize the vertebrae with instrumentation, including metal plates, screws, rods, and cages. A successful fusion will prevent the disk from bulging or herniating again.
Scoliosis and spondylolisthesis are two types of spinal deformities that are commonly treated with spinal fusion. Most often diagnosed in children and teenagers, scoliosis is an “S”-shaped curvatures of the spine. Spondylolisthesis refers to a slippage of one vertebra on another. In addition, surgery for cervical disk herniations often involves removal of the herniated disk (diskectomy) and fusion. In many cases, fusing the spine is often extremely helpful for treatment of a fractured (broken) vertebra, correction of deformity (spinal curve or slippage), elimination of pain, treatment of instability, and treatment of a cervical disk herniation.
Following a fusion procedure, a patient may gain restored mobility in the back, including the ability to bend over. He or she will most likely experience more mobility after surgery than before. In addition, the patient may require postoperative physical therapy.
What is Spinal Fusion?
Spinal fusion is an operation that creates a solid union between two or more vertebrae. This procedure may assist in strengthening and stabilizing the spine and may thereby help to alleviate severe and chronic back pain.
Almost all of the surgical treatment options for fusing the spine involve placement of a bone graft between the vertebrae. Bone grafts may be taken from the hip or from another bone in the same patient (autograft) or from a bone bank (allograft). Also, fusion may or may not involve use of supplemental hardware (instrumentation) such as plates, screws, and cages. The instrumentation will act as a splint, much like placing a cast on a broken arm, to hold the vertebrae together while the bone graft heals and eventually becomes part of your own bone (i.e., fusion). This fusing of the bone graft with the bones of the spine will provide a permanent union between those bones. Once that occurs, the hardware is no longer needed, but most patients prefer to leave the hardware in place rather than go through another surgery to remove it.
A one-level fusion links or fuses together two vertebral bones located on either side of a diseased disk. A two-level fusion links or fuses together three vertebral bones that have two disks between them. Both procedures limit a portion of the spine’s motion, but this does not necessarily mean that you will be unable to move or bend over. In fact, many patients report increased mobility because their pain has been reduced or eliminated.
Fusion can sometimes be performed through smaller incisions. In some cases an endoscope, which is a small camera, is used to look at the spine through a small opening or tube. The image is then enlarged and projected onto a television screen in the operating room, enabling the surgical team to see the operation without having to peer through the small opening. Advantages of minimally invasive techniques may include:
- Reduced operative time.
- Less soft tissue damage from reduced muscle retraction.
- Less painful surgical incisions.
- Reduced blood loss.
- Faster recovery with less postoperative pain.
- Shortened hospital stay.
- Less noticeable and more cosmetically pleasing scars.
Types of Spinal Fusion
A number of spinal fusion techniques are available, including the following:
Anterior Cervical Diskectomy and Fusion (ACDF)
The disk is approached from the front of the spine in the neck. The disk is removed, and a piece of bone is usually placed in the disk space. Some surgeons will also use a metal plate to help hold the vertebrae and bone graft in place.
Placing bone on the back and side of the spine to achieve a fusion.
Posterior Lumbar Interbody Fusion (PLIF)
Removal of the posterior bone of the spinal canal, retraction of the nerves, and removal of the disk material from within the disk space, followed by insertion of bone graft and sometimes hardware in order to fuse the bones. This procedure is called an “interbody fusion” because it is performed between the “bodies” of the vertebral bones and across the diseased disk space. This procedure is typically performed on both sides of the spine.
Transforaminal Lumbar Interbody Fusion (TLIF)
Removal of the posterior bone of the spinal canal, retraction of the nerves, and removal of the disk material from within the disk space, followed by insertion of bone graft and sometimes hardware in order to fuse the bones. Similar to a PLIF, but frequently performed from only one side.
Direct Lateral Interbody Fusion (DLIF)
Types of Spinal Instrumentation
Pedicle Screw and Rod Instrumentation
Placement of the metal screws through the bone at the back of the vertebrae and then connecting the screws together with metal rods.
Lateral Mass Instrumentation
Use of screws and rods (or plates) in the back of the cervical vertebrae.
Placement of a plate-like or rod-like construct in the front of the spine.
Metal devices filled with bone (or a substance that can form bone) to achieve a fusion. The cage is placed into the disk space once the disk is removed.
Vertebroplasty and Kyphoplasty
New techniques that are used to treat vertebral compression fractures by injecting cement into the affected vertebrate.
The most important thing to remember about back pain is that surgery is one of many possible solutions available to the patient. It is important to seek treatment from a neurosurgeon who can diagnose what is wrong and can work with the patient to develop a treatment plan.
Content Source: American Association of Neurological Surgeon