LOWER BACK PAIN
Lower back pain is really common. It affects about 80% of adults at some point of their life.
Lower back pain is the most common cause of sick days from work and disability. It affects men and women, young or old. It is usually mild but can be severe and unbearable at times. It can start suddenly or slowly. It can be felt it in a small area of the lower back or over a much wider area. It can last anything between a few days or years. It can sometimes be hard to treat.
Lower back pain is often short term or acute, and lasts a few days to a few weeks and mild. It usually improves on its own with self-care. Sometimes acute lower back pain can be severe.
It is called subacute lower back pain if it lasts between 4 and 12 weeks.
Chronic lower back pain on the other hand, lasts for 3 months or longer, even after the initial injury or underlying cause of pain has been treated. Chronic lower back pain can occur in about 20% of people that get acute lower back pain. This means that the pain can continue for much longer than expected and in some of those cases the chronic lower back pain can be difficult to treat and debilitating.
LOWER BACK PAIN SYMPTOMS
Lower back pain can occur suddenly or slowly, depending on the cause. Lower back pain usually occurs immediately after an injury although sometimes the onset of symptoms can be delayed.
Symptoms may include; a sharp local pain or a broad dull ache, with or without stiffness in the region, pain can radiate down into the buttock or leg and even into the foot. There might also be tingling, numbness, pins and needles and even weakness.
Pain severity can be rated on a scale from 1 to 10, or from mild to severe.
Sometimes people can be very unwell if there is a more serious cause like an infection or fracture of the spine. We’ll discuss this below. If there is an infection, the area could also be red swollen and warm.
LOWER BACK PAIN CAUSES
Lower back pain is mostly mechanical in nature and occurs when there is a disruption in the way the parts of the lower back fit together and work. These include the spine bones (vertebrae), intervertebral discs between the bones, spinal cord, many complex nerves and surrounding muscles, tendons and ligaments.
The parts of the lower back all work seamlessly together like components of a complex piece of machinery but if one part is faulty, the whole system can be affected and malfunction.
The precise location of the lower back pain and associated symptoms can provide valuable clues about the underlying cause.
Problems within the spine and spinal column itself tend to result in pain in the midline, whereas pain that is located on the sides of the lower back is usually caused by problems with muscles, ligaments, tendons and other soft tissues that surround and protect the spine.
When lower back pain experts make an assessment, a few things need to be considered because the pain could be caused by a number of problems in or around the area. A few lower back pain causes are:
- Lower back strain and sprains of surrounding muscles, ligaments, and tendons. Sometimes lower back muscle pain can be related to myofascial pain syndrome which causes muscle spasms and tenderness. The psoas muscle or any other muscle like the quadratus luborum muscles in the lower back could be in spasm, causing pain.
- Joints nearby: the joints that connect one spinal vertebrae with another are called facet joints. The facet joints can become inflamed and swollen (also called zygapophyseal joint arthropathy). The facet joints can cause stiffness and severe pain which can be debilitating and long-lasting.Despite this being a common cause of chronic lower back pain, this can be overlooked for years if not considered by a pain specialist.
- Myofascial pain: this is pain that occurs because of problems with the surrounding muscles, ligaments and tendons of the lower back as mentioned above. The muscles may develop discrete little tight knots (taut bands) that are called myo-fascial trigger points. Trigger points are hypersensitive spots in the covering (fascia) surrounding muscle. These can be very painful and quite debilitating. When a trigger point is touched or examined, it can cause exquisite pain in and around the area. Some muscles in the lower back that can develop trigger points can cause lower back pain include, erector spinae muscles, quadratus lumborum. Higher up the back the thoracolumbar paravertebral muscles, iliocostalis muscles, psoas and iliacus muscles can cause refer pain downwards to the lower back. Lower down the gluteus muscles and the piriformis muscles can refer pain upwards to the lower back.
- Lumbar spondylosis (osteoarthritis) is lumbar spine degeneration and arthritis, which is an age-related condition that affects the joints, discs and ligaments of the spine of the lower back. This can also occur in the sacroiliac joint, there the lower spine joins the pelvis.
- Spondylolisthesis: pronounced spon-di-low-list-thee-sis, is misalignment of spine bones occurs when one vertebra slips over the one below it. It can be caused by problems with the bone or disc degeneration or ligament issues. It usually occurs with spondylosis. Most spondylolisthesis is mild and but sometimes the slippage can be severe, causing nerve compression and require some forms of spinal stabilisation surgery, like a fusion.
- Another type of misalignment is when there is a scoliosis or curved spine. This can also be the cause of mechanical changes in thelower back and hence result in some forms of lower back pain.
- Degenerative disc disease: when lumbar discs degenerate and change, they can sometimes become painful.
- Referred pain: referred pain is where pain in one part of the body can be felt in another part of the body. This occurs when different parts of the body share the same nerves to send signals to the spine and brain. Lower back problems like facet joint arthritis or disc prolapses can both contribute to spinal nerves being compressed where they leave the spinal column (pinched nerves). This compression condition is called lumbar foraminal stenosis and can cause shooting pain (radiating pain) anywhere down into the buttock, leg or foot, on one or both sides.
- Nerve pain: sometimes neurological problems can cause lower back pain. Neurological causes might include shingles (zoster), post herpetic neuralgia, or even conditions like meningitis.
- When pain persists following acute pain, this can sometimes cause changes within the nerves and set up some forms of nerve pain, also called neuropathic pain. Nerve pain can sometimes be hard to diagnose and usually needs to be assessed and treated by pain specialist physicians.
- When a compression occurs directly into the spinal column itself, this may be called lumbar spinal stenosis and if the compression is serious it can compress the spinal cord itself as it sits in the spinal column. This would be called myelopathy. Myelopathy is when the compression of the spinal cord starts causing symptoms, such as weakness or problems with coordination in the arms, hands, legs, or even feet. Myelopathy usually occurs higher up the spine, in the neck or chest region, but symptoms and complaints can also be experienced in the lower back and or legs.
- Sensitisation: sometimes a problem in the nervous system called sensitisation can occur. This is when the pain, usually a nerve pain seems to be spreading up into the body and or down into the arm, or even into the other side of the body. People with sensitisation can even have sensitive skin in the lower back region and even light touch using a brush can be exquisitely painful. Sensitisation can be hard to treat and usually needs the expertise of a pain specialist physician.
- Post-surgical pain: after an operation or surgery, pain can sometimes persist after the tissue has had sufficient time to heal. This can occur in up to 25% of all surgeries and sometimes the persistent lower back pain can be intolerable and debilitating. Post-surgical pain can be caused by almost any type of operation on or near the lumbar spine, and can be caused by many things, including nerve injury or scarring, ongoing inflammation or infection, muscle weakness and stiffness. This is a complex pain condition and should be assessed and managed by pain specialist physicians in conjunction with the operating surgeons.
- This is called post-laminectomy syndrome or also called Failed Back Surgery Syndrome (FBSS)
Contact us to find out what's causing your pain.
WHO GETS LOWER BACK PAIN?
Anyone can get lower back pain and it can occur at any age, with the majority of first incidents taking place between 20-40 years of age.
Although anyone can get lower back pain some people are more likely to develop it. Here are a few risk factors that might make the development of lower back pain more likely:
- Older age
- Lack of exercise and low fitness level
- Being overweight
- Certain jobs or activities that require heavy lifting, pushing or pulling, particularly when it involves twisting or vibrating the spine. An inactive job like a desk job may also contribute to pain especially with a poor posture or a chair without adequate lower back support.
HOW DO I GET A LOWER BACK PAIN DIAGNOSIS?
Lower back pain is usually mild and settles by itself however in some circumstances the pain can be complex and should be assessed by a medical professional or pain specialist who will take the time to understand the pain story and perform a physical examination before setting forward a diagnosis and treatment plan.
It is not common to require tests and scans for lower back pain. However, in some circumstances imaging tests may be required. Types of imaging tests might be X-rays, CT scan, MRI scan, bone scan or ultrasound.
Once a lower back pain diagnosis is made, the medical professional or pain specialist will determine the best treatment options.
Book an appointment to have a Pain Specialist make a lower back pain diagnosis.
WHAT LOWER BACK PAIN TREATMENT IS AVAILABLE?
Treatment of the lower back pain depends on if the problem is acute (meaning it only occurred recently i.e. days and weeks) or if the problem is chronic (meaning it has been present for more than 2-3 months).
ACUTE LOWER BACK PAIN TREATMENT
Most acute lower back pain is mild and settles with simple treatments. Treatment usually depends on the cause and might include:
- A few days of physical rest. It is not considered good to rest for more than a few days otherwise the lower back muscles will stiffen and even cramp, which will make recovery difficult.
- Simple treatments like hot or cold packs, physical activity, exercise and physical therapy.
- Pain medications like anti-inflammatories and anti-spasm medications to provide pain relief.
If the cause of the pain has been treated but the pain continues and is long lasting (chronic pain), debilitating and has not been responding to treatments an assessment should be made by a pain management specialist physicians, who can assess and treat most types of chronic pain including chronic lower back pain.
CHRONIC LOWER BACK PAIN TREATMENT
Through years of experience, we’ve figured out that good and long-lasting chronic lower back pain relief doesn’t work unless all bases are covered.
The best lower back pain management combines pain-reducing treatments combined with other selected therapies like physical and psychological rehabilitation treatment.
TYPES OF TREATMENT
- Medications to reduce the pain. These may be simple over the counter medications or can be medications prescribed by a pain specialist. Medications might include muscle relaxants like Orphenadrine or anti-neuropathic (nerve pain) medications like Lyrica, Gabapentin, Duloxetine, Venlafaxine or others like Tapentadol. Sometimes analgesic compound creams, applied to the painful area can be used to ease pain.
- Pain interventions; injection therapies can be used to target, diagnose and manage chronic pain caused by muscle, joint and nerve pain. It includes interventional therapies like nerve blocks (medial branch nerve, lumbar nerve roots, cluneal nerves, gluteal nerves, sciatic nerves and the lumbar plexus) radiofrequency ablation (RFA), pulsed radiofrequency (PRF) to the nerves previously blocked and mentioned above, can provide intermediate-term pain reduction. Epidural and nerve root steroid injections can also be used as can sympathetic nerve blocks.
- Botox injections can be considered for certain types of muscular or nerve pain. For muscular pain, it can be injected into the muscle and for nerve pain it is usually injected under the skin of painful areas and can be helpful in providing pain reduction that can last many months at a time.
- Nerve stimulation, also called neuromodulation or spinal cord stimulation are advanced pain reduction techniques that can work really well for severe lower back pain, that is not responding to therapies already tried. When pain has not responded to therapies already tried, we call the pain refractory. Spinal cord stimulation can be considered when lower back pain is refractory. Some forms of spinal cord stimulation include high frequency stimulation (HF10), tonic stimulation, multi-waveform stimulation, BurstDR stimulation and even dorsal root ganglion (DRG) stimulation. Spinal cord stimulation is a commonly used treatment for lower back pain that does not respond to other forms of treatment. Spinal cord stimulation is best delivered by trained and experienced pain specialist physicians.
- Surgery is generally recommended when tests show structural changes, which needs corrective surgery. These are typically performed by a neurosurgeon or a spinal orthopaedic surgeon. Types of surgery might include, decompression surgery (laminotomy, laminectomy, discectomy) and or stabilisation surgery (fusion). Fusion is not a common treatment for chronic lower back pain. When other therapies fail, surgery may be considered an option to relieve pain caused by serious musculoskeletal injuries or nerve compression.
- Rehabilitation: most types of chronic pain treatment should be managed alongside some form of specialist rehabilitation. This is when the best results occur
HOW DO I GET LOWER BACK PAIN RELIEF?
Significant lower back pain is best assessed by a medical doctor like a general practitioner (GP). They will make an assessment and make sure there are no warning signs for something serious (see below).
If they suspect something more serious is causing the lower back pain, they may do some scans or blood tests and make a referral to the appropriate specialist for treatment. However, if no serious cause is diagnosed, the referral may be to a pain specialist physician for an assessment and therapy with the use of advanced pain reduction techniques.
If the pain is mild or improving, GPs may:
- Reassure that there is no serious cause for concern and advise that the pain should improve with physical activity and simple pain medications.
If the pain persists or returns GPs may:
- Use stronger pain medications
- Suggest management by an expert pain physiotherapist if the lower back muscles are suspected to be a cause or contributor to the pain or if there is significant weakness associated with lack of movement caused by the pain.
- Refer to a pain specialist physician to provide more comprehensive pain management using options like joint and nerve blocks, sympathetic blocks and radiofrequency ablation (RFA), pulsed radiofrequency or nerve stimulation and neuromodulation using spinal cord stimulation as mentioned above.
- Refer to a neurosurgeon or spine surgeon for an opinion.
Contact us to book an appointment with a pain specialist.
WARNING SIGNS OF MORE SERIOUS LOWER BACK PROBLEMS
In some instances, pain can indicate more serious lower back problems or diseases elsewhere. These problems might include cancer, fractures, infection, severe nerve compression (pinched nerve) and ankylosis spondylitis.
- If there is cancer in the bones of the spine, this usually means metastases (the cancer has spread to the spine).
- Fractures of the spine can be caused by a direct hit, fall, accident but sometimes can occur without trauma, called spontaneous fractures. Spontaneous fractures, usually can occur in elderly people with osteoporosis or those who may be taking steroid medications that weaken the bone.
- Infections of the spine tend to occur if patients have a weakened immune system from any cause or medical condition. Sometimes infections of the spine can occur if there is an infection elsewhere in the body. People with spinal infections usually feel unwell and can have sweats and a fever. Other types of infection include cellulitis, which is a bacterial infection of the skin and tissues beneath the skin,
- Nerve compression, called myelopathy, where there is a dangerous compression of the spinal cord in the neck. Myelopathy could cause symptoms that might include, weakness or problems with coordination in the legs or feet.
- Ankylosing spondylitis is progressive arthritis of the spine and can cause widespread inflammation, pain and stiffness throughout the spine, including lower back pain.
Seek urgent and specialist medical advice if you experience:
- Sudden, unrelenting, disabling and severe lower back pain
- Recent weight loss
- Recent injury or fall
- Signs of infection are present like fever or feeling unwell, the area is red, hot or swollen
- Numbness or tingling of the arm
- Weakness in the legs
- Problems with bladder or bowel function
- Stiffness is worsening
- Pain does not settle by itself after a few days or weeks