Lower back pain is a symptom, not a disease. As such, lower back pain may lead to several very different diagnoses with very different treatment plans.
The following treatment “pathway” can help you understand what your doctor is thinking as he or she explores your back pain treatment options with you.
Definition of Pain
First of all, what is pain? The International Association for the Study of Pain defines pain as “an unpleasant sensory and emotional experience associated with actual or potential tissue damage, or described in terms of such damage.” Often the patient and doctor just focus on the physical aspect of pain; clearly, however, using this definition, pain is an emotional experience as well.
The Pain Experience
If you look at pain pathway diagrams in medical textbooks, it will quickly become clear that the physical and emotional experience of pain is a very complex one. For most of us, it’s not important to memorize or understand the whole pathway. What is important is the understanding that because there are many pathways that lead to the experience of pain, there are also many ways to treat the experience of pain. This is why so many varied treatments may all be effective in decreasing pain.
Now that we know how we experience pain, what do we do when we have back pain? If it does not go away on its own, we often visit a doctor. In fact, lower back pain is one of the leading causes for visiting your doctor.
Mechanical versus Non-Mechanical Back Pain
Mechanical back pain is caused by abnormalities in the joints, ligaments or muscles. These abnormalities can eventually lead to degeneration or arthritis of joints in the spine or abnormalities in the disc.
The first thing your doctor will want to determine is whether your pain is indeed mechanical back pain and not due to something else like cancer, infection, or pain from an abdominal organ. Red flags or danger signs that may lead one to think of these other diagnoses are sudden and severe low back pain, numbness in the groin area, severe and progressive symptoms such as increasing weakness, bowel or bladder incontinence or lack of control, muscle weakness or previous surgery associated with persistent pain.
If any of these symptoms were present, your doctor would probably want to explore other potential, and possibly serious, diagnoses. He or she may insist of more aggressive testing. Non-mechanical spine diagnoses, such as neurologic (brain or spinal cord), vascular (blood vessel), gynecologic (female reproductive system), genitourinary (urinary tract), cervical (neck), or thoracic (back at the level of the chest) problems, hip and leg disorders, and abdominal organ disease, should also be considered,
If none of these findings are present, then mechanical back pain may be the cause.
The pathway for the treatment of mechanical back pain that follows is adapted from the North American Spine Society (NASS) Guidelines and the work of Robin McKenzie and Stanley Herring.
Types of Mechanical Back Pain
McKenzie has suggested that one way to think about types of mechanical back pain is to organize them into three groups: postural, dysfunction and derangement.
All three arise from mechanical deformation of soft tissue such as muscles, nerves or ligaments. The cause of the deformation is where the three differ.
Postural problems arise from poor posture or the way one carries his or her body. Since it is due to postural stresses, it comes and goes based on one’s body position. Certain positions should make it worse, and other positions should make it better.
Dysfunction problems are the result of shortened structures, such as a muscle. This leads to loss of movement in certain directions. It is characterized by intermittent or off-and-on pain with loss of movement. Diagnoses that fall within this category include low back strain (injury to ligaments) and myofascial pain (injury or knots in muscles).
Finally, derangements are due to abnormalities in structures inside joints. These include osteoarthritis, herniated discs, spinal stenosis, spondylolisthesis, spondylolysis, and instability.
Primary Level of Care: Non-Surgical Treatment Options
Once your doctor makes a diagnosis of mechanical back pain (as previously defined), you may be started on a course of non-surgical treatment consisting of activity modification, medications, self-applied thermal modalities, and physical therapy.
Activity modification involves adjusting your activity so that your body’s key structures are not further stressed. Your doctor may have you focus on joint conservation (protecting the joint) or energy conservation (increasing efficiency of how an activity is done) techniques.
Pain medications may include analgesics like acetaminophen, non-steroidal anti-inflammatory drugs (NSAID) like ibuprofen, steroids like prednisone and opiates like morphine. NSAIDs and steroids decrease inflammation or swelling. Analgesics and opiates relieve pain without necessarily affecting the cause of the pain. Depending on how your doctor is approaching your back pain, he or she may use none, one, or a combination of these pain medications.
Thermal modalities include the use of heat or cold, for example hot or cold packs, ice massages, or ultrasound.
Physical therapy consists of exercises that try to balance muscles through stretching and strengthening. There are many styles of exercise; all have proven equally effective in addressing back pain.
In the same way, all of the non-surgical treatment options above may be effectively combined in many ways; no single approach has proven to be most effective. There are certain similarities to these approaches, however, and one way of thinking about these methods is to use the following framework, proposed by Stanley Herring:
The five aspects of mechanical back pain are:
1. Clinical symptoms refer to your pain and movement limitations.
2. Tissue injury refers to the actual body part that you’ve injured.
3. Tissue overload refers to the other body parts that are overloaded to make up for the problems caused by the initial injured body part.
4. Functional biomechanical deficits refer to tightness or weakness that result when your tissues are injured or overloaded.
5. Finally, what substitution patterns has your body adopted to make up for the injury.
As an example, your lower back pain may stem from a disc herniation as a result of bending forward too quickly while carrying a heavy load. The clinical symptom is pain in the back. The tissue injury is the herniated disc. This leads to spasms in the back muscles, leading to tissue overload. This may then lead to tightness in the back muscles and weakening of the abdominal muscles, leading to functional biomechanical problems. In order to continue to move without causing increased lower back pain, you may move your neck or hips in a different manner, which in turn could lead to problems in these new areas due to these substitution patterns.
Pain treatment. The goals of treatment are to decrease symptoms, restore lost function, and avoid recurrence of symptoms. We can divide the non-surgical treatment process into three phases: acute, recovery and functional.
In the acute phase, the goal is adequate tissue healing. At this point, the areas affected should have relative rest. Total rest is not advocated since it can lead to deconditioning (muscles lose strength), a problem in itself. Medications and thermal therapeutic methods may be used. Initial exercise and physical therapy may be initiated. This period usually lasts for a few days.
The recovery phase for back pain starts 1-2 weeks after an injury, and usually lasts several weeks. The goal is complete tissue healing, which in most cases, given a good environment for healing, occurs in 4-6 weeks. During this time, the focus should be more aggressive physical therapy. Increased flexibility or suppleness of muscles is important. Your physical therapy will focus on regaining increased control over movement (neuromuscular retraining) and proprioceptive training (knowing where a joint is in space to improve control of movement). In addition, your strength will be improved through progressive exercise.
Finally in the functional phase, the goal is good overall fitness and body mechanics (movement). Your physical therapy will focus on helping you increase power (explosive strength) and endurance. In addition, you’ll be training in specific movements or skills to help you get back to your previous level of activity.
If your back pain problems are resolved using the non-surgical means discussed here, then you’ll be able to return to regular activity, with reliance on a home exercise program to maintain functional gains.
Secondary Level of Care: Re-evaluation
If your back pain remains unresolved after 4-6 weeks, your doctor will do another examination and review your continuing signs and symptoms. At this point, plain lumbar spine x-rays will probably be taken. If the x-rays are normal, it’s likely that your physical therapy will be restarted, and new medications tried.
If abnormalities are found in either the physical examination or the tests, your doctor will most probably refer you to a back specialist.
The specialist will probably begin his or her work by asking you to recount how the symptoms started (history) and will likely do another physical examination. The plain x-ray will be reviewed. At this point, additional views – flexion, extension and oblique – should be considered, since these views enhance the detection of specific disorders.
Your specialist may consider repeating the same treatment you underwent previously. Non-mechanical spine diagnoses such as neurologic, vascular, gynecologic, genitourinary, cervical or thoracic problems, hip and leg disorders and abdominal organ disease should again be considered. If the pain you are experiencing as lower back pain is truly arising from the lower back, the most likely diagnoses are herniated disc, spondylosis or spondylolisthesis, spinal stenosis, and/or low back instability.
Common Diagnoses
Herniated disc. A herniated disc, a protruded vertebral disc, can cause pinching of the spinal cord or nerves. It commonly affects 20-50 year old adults. Pain predominantly affects the legs and buttocks. There may or may not be neurologic deficits (nerve damage usually manifested as weakness or numbness). There may also be pain with movement that stretches nerves, such as when the doctor elevates your straightened leg of while the other leg lays flat on the examining table.
If the symptoms are mild to moderate, non-operative treatment (as described above) may again be done.
If the problem is more severe, that is, manifested by neurologic problems (weakness, numbness, or changes in reflexes), disabling leg pain, or some other debilitating aspect that you describe to your doctor, then he or she may consider further tests to confirm possible diagnoses. This might include an MRI, CT scan, CT myelogram , or electrodiagnostic testing. At this point, surgical options would be discectomy or decompression (see Surgical Treatment Options following).
Spinal stenosis. Spinal stenosis, or tightness of the spinal canal, also leads to pinching of the spinal cord or nerves. It usually presents in patients over 50 years old since it is usually due to osteoarthritis. Back pain and leg pain usually worsen with standing or walking since these positions lead to an increased tightness in the spinal canal because of the way the ligaments are positioned. There may or may not be neurologic symptoms as well.
For mild to moderate symptoms, your doctor may try again the non-operative treatment options described previously, or possibly corticosteroid injections. Corticosteroids or steroids relieve inflammation or swelling of body structures. In the case of spinal stenosis, the covering of the nerves may get swollen from constant hitting against the tight walls of the spinal canal. With this swelling, the canal gets even tighter leading to more difficult nerve gliding and, therefore, more pain. By injecting steroids into the canal, the swelling of the nerve covering is decreased, leading to more space and less pain. The steroid treatment for spinal stenosis is usually a series of three injections.
If your doctor finds abnormalities in either the physical examination or the tests, he or she may consider referring you to a back specialist. The specialist will then again review your recounting of how the back pain symptoms started (history) and do another physical examination. The plain x-ray should be reviewed. At this point, additional views – flexion, extension and oblique – should be considered. These views will enhance the detection of specific disorders.
Your specialist may consider repeating the same treatment you underwent previously. Non-mechanical spine diagnoses such as neurologic, vascular, gynecologic, genitourinary, cervical or thoracic problems, hip and leg disorders and abdominal organ disease should again be considered. If the pain you are experiencing as lower back pain is truly arising from the lower back, the most likely diagnoses are herniated disc, spondylosis or spondylolisthesis, spinal stenosis, and/or low back instability.
Spondylolysis and spondylolisthesis. Spondylolysis is a defect in the pars interarticularis of a vertebra. This is a portion of the bone between the superior and inferior articular facets. Spondylolisthesis is the fracture of a vertebra followed by dislocation or movement away from another vertebra. This manifests as back pain with or without leg pain. Pain is increased by activity. With this condition, you may or may not have neurologic deficits. To confirm or exclude this diagnosis, your doctor may do any of the following tests: (X-ray), MRI, CT scan, CT myelogram, bone scan, discography, facet/lysis injection, psychiatric evaluation, and/or functional capacity evaluation. If none of the treatment approaches outlined previously work to reduce your back pain, surgical options may include decompression, fusion, or instrumentation (see Surgical Treatment Options below).
Instability. Finally, your back pain may be due to instability of the spine. The symptom is predominantly back pain with or without leg pain. You may also have muscle guarding or spasms as well as decreased range of motion. To confirm or exclude this diagnosis, your doctor may perform any of the following tests: MRI, CT scan, CT myelogram, bone scan, discography, facet/lysis injection, psychiatric evaluation or functional capacity evaluation. If none of the treatment approaches outlined previously work to reduce your back pain, your doctor may recommend a surgical option, i.e., fusion of the vertebrae (see Surgical Treatment Options below).
Surgical Treatment Options
The two main goals of surgery to reduce back pain are decompression and stabilization. Decompression leads to an increase in the space for the spinal cord or nerves, allowing them to function without constraint. Stabilization leads to decreased movement of the spinal joints.
Discectomy. Discectomy leads to decompression. It removes a part of or the whole disc. When a disc herniates, it can pinch the spinal cord or a nerve, leading to neurologic problems and pain. Removing a part of or the entire disc relieves the pressure on the spinal cord or nerves, allowing them to function normally.
Laminoplasty or laminectomy. Decompression of the spine may also be achieved through laminoplasty or laminectomy. The back of the vertebra is called the lamina. Removal of this part of the vertebra allows the structures inside, specifically the spinal cord or nerves, to have more space so they can function normally. Laminoplasty is removal of part of the lamina. Laminectomy is the removal of the whole lamina.
Fusion. Fusion is the merging together of vertebrae after a disc is removed. This is achieved by using bone grafts from the hip with or without fusion cages (metal cages placed between the vertebrae and filled with bone grafts encouraging bone ingrowth).
Instrumentation. Instrumentation is used to enhance fusion. It uses screws attached to plates or rods to help stabilize fused vertebrae.
Tertiary Level of Care
The persistence of pain after surgery could be due to non-operative, operative, or structural issues.
Non-operative issues may include biomechanical dysfunction, disease within or throughout the body, psychosocial issues (e.g., stress), or weakened, out-of-condition muscles.
Biomechanical dysfunction is a problem that arises from abnormal body structures, which may lead to faulty body movement, and therefore pain.
Systemic disease includes such conditions as rheumatoid arthritis, which leads to problems affecting your muscles, bones, and possibly internal organs.
Psychosocial issues include problems such as poor job satisfaction, poor family support, and mental illness.
Deconditioning refers to loss of flexibility, strength, endurance and cardiovascular fitness from disuse, which often occurs due to decreased activity because of pain.
If these issues are the source of the problem, then your doctor may refer you to a non-operative back specialist. You may be encouraged to focus on activities of daily living despite symptoms. He or she may also recommend palliative care for your back pain, which focuses on relief of symptoms rather than cure. If questions of compensation or litigation are involved, then you may be labeled as having reached Maximum Medical Improvement (MMI), which means that you have achieved the best level of function that may be expected after maximizing medical treatment of your disease.
Operative issues are often associated with spinal stenosis, spondylolysis, spondylolisthesis or instability. It could be due to incomplete diagnosis; incomplete treatment; or complications such as infection, hardware failure, pseudoarthrosis, or fracture.
Failed improvement after herniated disc surgery is often due to structural or soft tissue issues. This may be because of recurrent herniation, stenosis or instability. Should this happen, your doctor may recommend further surgery or multi-interdisciplinary assessment.
