Back pain can be considered an evolutionary side effect of standing upright. Walking on two feet shifts your upper body weight to the lower spine, where most back pain occurs. As a rheumatologist who has had to sort out thousands of cases of back pain, I have come up with practical ways of dividing patients' problems into different categories.
Initially this involves asking a series of quick questions. Although everyone likes to think of him- or herself as unique, recurring themes usually separate back pain into specific groups. For example, if bending down to pick a heavy suitcase causes immediate back pain that lasts for a week, it is likely that you strained a muscle. However, if this pain shoots down the leg, it might be a ruptured disc pressing on a nerve.
Diagnostic Accuracy and Therapy
Pinpointing the cause of your back pain allows for the best treatment plan. Therapies are customized to help with a particular problem, and getting the incorrect one may make the situation worse. Here is an example to illustrate this point: A young patient with unexplained back pain has an inflammation in the back called a spondyloarthropathy (disease in the joints of the back). By having an accurate diagnosis and correct treatment this patient will know to avoid vigorous exercises that will make the pain worse. Likewise, an elderly woman with a vertebral compression fracture should avoid exercise.
Ten Questions
I try to get an answer to the following questions when interviewing new patients with back pain. Although these questions alone may not pin down the culprit behind your back pain, they will uncover valuable clues. :
1. Is the pain mechanical?
Mechanical pain is caused by abnormal or excessive stretching of back muscles, tendons or ligaments. It can also be caused by a vertebra in the back pressing on a nerve or the spinal cord itself.
Pain caused by an injury or unusual movement is typically easy to recall. I like to know if were you playing a sport when it happened, swinging a golf club, bowling or exercising, particularly with weights. Any new type of exercise is always a good clue, even if you think it was mild and don't believe it had anything to do with the current problem.
I also like to know whether you lifted something heavier than usual. Did you reached to get a package while in an awkward position, like pulling a shopping bag from the trunk of a car. Did you lift with your back (the wrong way) or by bending your knees first and then using the strength of your legs to help you? Were you moving furniture while cleaning, or moving boxes during a move at work or at home?
I always like to know what type of work you do, what your leisure activities are, and how you spend your day in general in order to uncover potential instants of extra or unusual physical exertion.
However, when pain is caused by normal everyday activity, the details might be hard to recollect. Even only after a week, recalling the exact event that caused the pain may be difficult. This is not unexpected, since pain may not register right away. After hours or days, muscle spasm can begin or intensify, and events days after the fact may be falsely blamed.
2. Is there the possibility of a bulging or ruptured disc?
If I suspect an injury is causing the pain, there are two possibilities: 1.) a muscle and tendon problem, or 2) a bulging or ruptured vertebral disc. Although both types of injuries can cause immediate pain that ranges from mild to severe, disc pain has some telltale characteristics.
One common symptom of a disc problem is lower back pain that shoots down the back of one or both legs. Called "sciatica," this pain usually arises from a herniated, or ruptured, disc; a tear in the fibrous outer layer of a disc allows fragments of the soft inner material to protrude and press against a nerve. . Other signs that a nerve may be pinched are tingling or a burning sensation anywhere in the buttocks or legs, numbness, or a feeling that part of the leg or foot is "asleep." More serious signs that demand immediate medical attention include weakness in the legs or loss of bladder or bowel control. If any of these are present, the odds are greater that a disc is ruptured. In contrast, if symptoms are limited to a mild tingling down the leg, it's likely that a disc is simply pushing out, or bulging, against a nerve.
3. What position makes the pain worse?
Sitting and standing are worse for a disc injury since more pressure from the upper body is placed on the lower back, whereas lying down helps relieve the pain. The same is often true of vertebral compression fractures, which frequently arise from osteoporosis, or thinning of the bones. In contrast, people with back pain that involves an inflammatory condition (see below) may be uncomfortable in any position. And in yet another condition, gluteal bursitis, pain in the buttocks grows worse when a person sits or lies down. The pain is caused by inflammation in one of the fluid-filled sacs (bursae) between muscles in the area (see below).
4. How old is the person?
When someone younger than 50 suddenly develops back pain, there is a good chance of it being a disc injury. . But in older patients, the gelatin inside a spinal disc is often more dried out than in younger people. Older discs tend to cause fewer problems in general, although occasionally even patients older than 70 can rupture a disc.
Osteoarthritis is another source for back pain in the above-50 population. The bones in the back are stacked, separated by discs, but joined together by small bridges that form joints. These wear out over time, leading to abnormal bone formations called osteophytes.
Osteophytes frequently cause pain and inflammation, and can pinch nerves. If these abnormal formations grow large enough, they can compress the spinal cord, leading to a condition called spinal stenosis. This typically happens in older patients (over age 60), causing pain that radiates into the buttocks and thighs when they begin to walk. At first, the pain may arise after a person walks a few blocks, but over time it may occur after only a few steps.
5. Is the pain acute or chronic?
Acute pain is present for no longer than a few weeks while. chronic pain is longer lasting. Both may be caused by mechanical injury to the muscles, ligaments, tendons or discs. Chronic back pain can also be caused by acute injuries that never fully healed.
Other sources of chronic back pain include:
- In adolescents:
- congenital back abnormalities such as spondylolysis
- vertebral bones that aren't fully connected (spina bifida)
- In patients 20-50 years old:
- inflammatory conditions:
- ankylosing spondylitis
- psoriatic arthritis
- Reiter's syndrome
- inflammatory bowel disease
- In older patients:
- Osteoarthritis
- spinal stenosis
6. Is there an inflammatory condition?
Inflammatory conditions, like those mentioned above, are often misdiagnosed as mechanical back pain. One example is ankylosing spondylitis, which is marked by chronic back pain, stiffness and a decreased range of motion in a section of the spine that may progress to the entire spine. People with the skin condition psoriasis may develop a particular form of arthritis - psoriatic arthritis - that can cause back pain. Reiter's syndrome is suspected if there is inflammation of the iris (the colored part of the eye) or penile or vaginal discharge. Chronic diarrhea in conjunction with back pain may indicate underlying inflammatory bowel disease. As you can see, these inflammatory disorders differ markedly from mechanical causes of back pain, , so it is important to identify them.
7. Does the back feel as if it is "going out," often with the same motion?
This mainly happens to young patients who may have hurt themselves playing sports. The sensation may be a sign of an unstable back, with structural problems in the bones or soft tissues like ligaments and tendons.
8. Is there pain in the buttock worse when sitting but also lying down?
As mentioned above, this symptom may indicate gluteal bursitis. I can usually rule out a disc problem in these cases, because disc pain typically subsides when you are lying down.
9. Is there a sleep disturbance with pain in other parts of the body besides the back?
If you are not sleeping well and have back pain, fibromyalgia might be the cause. Fibromyalgia is a chronic condition that causes widespread pain, as well as fatigue and sleep disturbances. It is mostly found in young to middle-aged women, and can have back pain as a symptom. This is an important syndrome to diagnose because patients may need sleep aids, as well as other medications.
10. Is there fever, more than 10 percent weight loss, muscle weakness, loss of bowel or bladder control, blood in the urine or excruciating pain?
Very rarely, serious conditions do occur in the back or are manifested as lower back pain. These conditions include some tumors, abdominal aneurysms, kidney stones and infections.
The good news is that it is highly unlikely that back pain will turn out to be a sign of is cancer.
Using this 10-question approach, I can begin to distinguish the cause of your lower back pain and get you started on the right treatment. In some cases, an x-ray or a CT or MRI scan may be necessary to confirm the diagnosis.
I want to leave you with one clear idea: All back pain, whether it is acute or long-standing, is not the same. And some simple information about your pain and your overall health can often offer excellent clues to the most specific diagnoses.
©2007 Healthology, Inc.