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Introduction

About 80 percent of adults experience low back pain at some point in their lifetimes. Affecting Men & Women equally, it is the most common cause of job-related disability and a leading contributor to missed work days.

Acute back pain, or short term lasts for a few days to a few weeks. It tends to resolve on its own with self-care and there is no residual loss of function. The majority of acute low back pain is mechanical in nature, meaning that there is a disruption in the way the components of the back (the spine, muscle, intervertebral discs, and nerves) fit together and move.

Subacute low back pain is defined as pain that lasts between 4 and 12 weeks.

Chronic back pain persists for 12 weeks or longer, even after an initial injury or underlying cause of acute low back pain has been treated. About 20 percent of people affected by acute low back pain develop chronic low back pain with persistent symptoms at one year. In some cases, treatment successfully relieves chronic low back pain, but in other cases pain persists despite medical and surgical treatment.

Causes

As we age, our spines age with us causing degenerative changes in the spine. These changes can start in our 30s - or even younger - and can make us prone to back pain, especially if we overdo our activities.

There are many causes of low back pain. It sometimes occurs after a specific movement such as lifting or bending. Just getting older also plays a role in many back conditions.

  • Over-activity: One of the more common causes of low back pain is muscle soreness from over-activity. Muscles and ligament fibers can be overstretched or injured.
  • Disk tear: Small tears to the outer part of the disk (annulus) sometimes occur with aging. Some people with disk tears have no pain at all. Others can have pain that lasts for weeks, months, or even longer.
  • Disk herniation: A disk herniates when its jelly-like center (nucleus) pushes against its outer ring (annulus). If the disk is very worn or injured, the nucleus may squeeze all the way through. When the herniated disk bulges out toward the spinal canal, it puts pressure on the sensitive spinal nerves, causing pain. A herniated disk often occurs with lifting, pulling, bending, or twisting movements.
  • Disk Degeneration: With age, intevertebral disks begin to wear away and shrink. In some cases, they may collapse completely and cause the joints in the spine to rub against one another which leading to further back problems, including spinal stenosis.
  • Degenerative Spondylolisthesis: Changes from aging and general wear and tear make it hard for your joints and ligaments to keep your spine in the proper position. If too much slippage occurs, the bones may begin to press on the spinal nerves.
  • Spinal Stenosis: Spinal stenosis occurs when the space around the spinal cord narrows and puts pressure on the spinal cord and spinal nerves.
  • Scoliosis: This is an abnormal curve of the spine that may develop in children, most often during their teenage years. It also may develop in older patients who have arthritis.
  • Other Causes: Additional causes include vascular or arterial disease, a history of cancer, or pain that is always there despite your activity level or position.

Risk factors

  • Age
  • Fitness level
  • Pregnancy
  • Weight gain
  • Genetic
  • Occupational risk factors
  • Mental health factors – Anxiety & Depression
  • Backpack overload in children

Symptoms

Back pain varies. It may be sharp or stabbing. It can be dull, achy, or feel like a "throbbing or burning" type cramp. The type of pain you have will depend on the underlying cause of your back pain. Some of the symptoms experienced are

  • Back pain may be worse with bending and lifting.
  • Sitting may worsen pain.
  • Standing and walking may worsen pain
  • Back pain comes and goes, and often follows an up and down course with good days and bad days.
  • Pain may extend from the back into the buttock or outer hip area, but not down the leg.

Regardless of your age or symptoms, if your back pain does not get better within a few weeks, or is associated with fever, chills, or unexpected weight loss, you should call your doctor.

Tests and Diagnosis

  • Medical History and Physical Examination: After discussing your symptoms and medical history, your doctor will examine your back. Your doctor may have you bend forward, backward, and side to side to look for limitations of movements or pain. Your doctor may measure the nerve function in your legs. This includes checking your reflexes at your knees and ankles, as well as strength testing and sensation testing. This might tell your doctor if the nerves are seriously affected.
  • Imaging Tests: Imaging tests which may help your doctor confirm your diagnosis include
    • X-rays
    • Magnetic resonance imaging (MRI
    • Computerized axial tomography (CAT) scans
    • Bone scan
    • Bone density test

Treatment

In general, treatment for low back pain falls into one of three categories

  • Medications
  • Physical medicine
  • Surgery

Medications: Several medications may be used to help relieve your pain.

  • Aspirin or acetaminophen can relieve pain with few side effects.
  • Non-steroidal anti-inflammatory medicines like ibuprofen and naproxen reduce pain and swelling.
  • Narcotic pain medications, such as codeine or morphine, may help.
  • Steroids, taken either orally or injected into your spine, deliver a high dose of anti-inflammatory medicine.

Physical therapy: It includes passive modalities such as heat therapy, ice, massage, ultrasound, and electrical stimulation. Active therapy consists of stretching, weight lifting, and cardiovascular exercises. Exercising to restore motion and strength to your lower back can be very helpful in relieving pain.

Surgical Treatment: Surgery for low back pain should only be considered when nonsurgical treatment options have been tested and have failed. It is best to try nonsurgical options for 6 months to a year before considering surgery. In addition, surgery should only be considered if you doctor can pinpoint the source of your pain.

However, some patients are not candidates for surgery, even though they have significant pain and other treatments have not worked. Some types of chronic low back pain simply cannot be treated with surgery.

  • Spinal Fusion: Spinal fusion is essentially a "welding" process. The basic idea is to fuse together the painful vertebrae so that they heal into a single, solid bone. It is an option when motion is the source of pain. For example, your doctor may recommend spinal fusion if you have spinal instability, a curvature (scoliosis), or severe degeneration of one or more of your disks.

    In most cases, a bone graft is used to fuse the vertebrae. Screws, rods, or a "cage" are used to keep your spine stable while the bone graft heals. The surgery can be done through your abdomen, your side, your back, or a combination of these. No one procedure has been proven better than another.

    Full recovery can take more than a year and the post surgical results could vary from person to person.

  • Disk Replacement. This procedure involves removing the disk and replacing it with artificial parts, similar to replacements of the hip or knee.

    The goal of disk replacement is to allow the spinal segment to keep some flexibility and maintain more normal motion. The surgery is done through your abdomen, usually on the lower two disks of the spine.

Prevention

It may not be possible to prevent low back pain but there are things we can do to lessen the impact of low back problems.

  • Exercise
  • Proper Lifting of heavy items
  • Weight
  • Avoid Smoking
  • Proper Posture

Dr Imtiaz Ghani

MBBS, MS Orthopaedics
Consultant Spine Surgeon

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