Back Pain

Back Pain, Figure 1If you are experiencing low back pain, you are in good company. More than 70 percent of people in the U.S. will experience low back pain at some time in their lives. Low back pain is most common from 35 to 55 years of age. It can be difficult to pinpoint exactly what’s causing your pain, but the good news is that acute low back pain usually is self-limiting; 90 percent of people recover within six weeks.

Low back pain can often be attributed to a muscle strain, and risk factors include heavy physical work, frequent bending, twisting, or lifting, and prolonged static postures. The most common cause of back pain is using your back muscles in activities you are not used to, like lifting heavy furniture or doing yard work. Sometimes, low back pain might be due to a “pinched nerve” or “slipped disc." Rarely, people with low back pain are found to have a compression fracture in their spine, and even more rarely, a few people have tumors or infections in their spines.

What can I do to make myself feel better?

The basics are a little bit of rest, heat and ice, and medicines to reduce inflammation. In addition to these temporary band-aids, maintaining your ideal weight, getting regular aerobic exercise, and not smoking have been proven to decrease recurrence of back and neck pain flare-ups. The good news is that mechanical pain from muscle strains, as well as arm or leg pain from a “pinched nerve” typically respond very well to non-operative care.

Ultimately, treatment of ongoing neck or back problems must be directed at the cause. This may mean losing weight, getting your muscles in better shape, or improving your posture when you are sitting, standing and sleeping.

  • Rest
    Studies show that exercise is more effective at treating cases of simple neck or back pain than bed rest and drugs, but a day or two of rest may help you feel better. Keep bed rest to a minimum! Studies have shown that limiting bed rest is important to a quick recovery.A good position for relief when your back hurts is to lie on your back on the floor with pillows under your knees, with your hips and knees bent and your feet on a chair, or just with your hips and knees bent. This takes the pressure and weight off your back.

    Neck or back pain can cause discomfort with any activity. Lying down may seem like the most logical solution, but more than two days of bed rest can make you weaker, which might ultimately make activity more painful and recovery slower. Even if it hurts, walk around for a few minutes every hour. After one or two days of rest, get up and start moving around. Begin slowly and progress to your previous level of activity.

  • Heat and Ice
    Use ice in the first couple of days of acute pain. Ice reduces inflammation by constricting the blood vessels and reducing blood flow and swelling. Ice should not be applied for more than five minutes at a time, because it could cause frostbite.After 48 hours of acute pain, heat may be applied to the affected area. Heating pads or a hot bath can help relax painful muscle spasms. As with ice, great care must be taken not to leave the heating pad in place for long periods of time risking burns to the skin, so don’t leave heat in one place for more than 20 to 30 minutes at a time.
  • NSAIDs
    NSAIDs stands for “non-steroidal anti-inflammatory drugs.” They have advantages over narcotic painkillers because they are not addictive and they help control the swelling that can cause pain. At the first sign of back or neck pain, start taking NSAIDs as instructed on the bottle. You should do this regularly for a few days to break the cycle of pain and inflammation. If taken regularly, these medications can provide a stable level of the drug in your body. Avoid letting the medications wear off before taking another dose the next day, which allows the cycle of pain to restart.Follow the instructions on the bottle. Take your medication with food to help prevent stomach irritation. Do not take more than one NSAID at a time. For example, if you’re taking ibuprofen, don’t take naproxen, too.

    Acetaminophen (Tylenol) is technically not an NSAID, but it may also help your pain. As long as you do not have liver problems, you can take Tylenol in between doses of NSAID.

    Motrin, Nuprin and Advil are common brand names for ibuprofen, one of the common NSAIDs that should be taken three times a day (every 8 hours) for maximum effectiveness.

    Aleve and Naprosyn are common brand names for naproxen, another common NSAID that only needs to be taken twice a day (every 12 hours).

  • Quit Smoking
    If you smoke, quit. Smoking is a risk factor for arthrosclerosis (hardening of the arteries), which can cause low back pain and degenerative disc disorders.
  • Lose Weight
    Maintain a healthy weight. Extra weight, especially around the midsection, can put strain on your lower back.
  • Stay Active
    Regular exercises to restore the strength of your back and a gradual return to everyday activities are important for your full recovery. During early recovery it is recommend that you exercise 10 to 30 minutes a day, 1 to 3 times a day.Perform crunches and other abdominal-muscle strengthening exercises to provide muscular spine stability. Swimming, stationary bicycling and brisk walking are good aerobic exercises that generally do not put extra stress on your back and help you stay fit overall.

    Some specific exercises can help your back. One is to gently stretch your back muscles. Lie on your back with your knees bent and slowly raise your left knee to your chest. Press your lower back against the floor. Hold for five seconds. Relax and repeat the exercise with your right knee. Do 10 of these exercises for each leg, switching legs.

    Another important aspect of your home exercise program should be to stretch and improve your overall flexibility. These simple exercises can be done throughout the day.

    You can obtain a prescription from your Primary Care Provider to a Physical Therapist who specializes in physical therapy of the spine to supervise your exercise program. The most important part of your physical therapy is for you to get in the habit of doing some daily exercises at home. Keeping your neck and back strong, flexible and healthy will make you more resistant to future pain.

  • Be Careful
    Good posture and good body mechanics (the way you do things) can help your neck and back feel better longer.Sit in chairs with straight backs or low back support. Keep your knees a little higher than your hips. Adjust the seat or use a low stool to prop your feet on. Turn by moving your whole body rather than by twisting at your waist.

    When driving, sit straight and move the seat forward. This helps you not lean forward to reach the controls. You may want to put a small pillow or rolled towel behind your lower back if you must drive or sit for a long time.

    If you must stand for long periods, rest a foot on a low stool to relieve pressure on your lower back. Every five to 15 minutes, switch the foot you are resting on the stool. Maintain good posture: keep your ears, shoulders, and hips in a straight line, with your head up and your stomach pulled in.

    If you sleep on your back, put pillows under your knees and a small pillow under your lower back. If you sleep on your side, put a pillow under your head to support your neck and a pillow between your knees. Do not sleep on your stomach unless you put a pillow under your hips. Use a firm mattress. If your mattress is too soft, put a board of half-inch plywood under the mattress to add support.

    Use correct lifting and moving techniques, such as squatting to lift a heavy object. Don't bend at the waist and lift. Get help if an object is too heavy or awkward. Using proper lifting form is vital to preventing injury to the spine. Lifting tasks should be performed with good body mechanics and/or with the assistance of another if the object is too cumbersome to lift alone.

  • Be Kind to Yourself
    Avoid stressful situations if possible, as this can cause muscle tension.

When should I see my primary care physician?

The good news is that most people with back pain will eventually feel better without surgery. If you have tried rest, ice/heat, anti-inflammatories and gentle exercise but your pain continues for more than a week, you should probably see your doctor.

In general, you should get medical care right away if:

  • Your leg, foot, groin or rectal area feels numb.
  • The pain was caused by an injury such as a fall or car crash.
  • You have trouble sleeping because of the pain.
  • Your pain is so intense that you cannot move around.
  • You lose weight without trying or have a fever, chills, or a history of cancer.
  • You have trouble urinating or controlling your bowels.
  • Your pain does not seem to be getting any better after two or three weeks.

What can my doctor do for me?

  • Focused Physical Therapy
    A prescription is required for physical therapy, and physical therapists can treat any area of the spine. Physical therapy entails instruction of proper exercise and technique, spine education, and hands-on therapy such as heat, ice, ultrasound, massage (myofascial release), and perhaps trials of traction. The most important part of a physical therapy routine is for you to learn to do some of the exercises on your own every day.
  • Prescription Medications
    Most spinal disorders respond to anti-inflammatory medications, muscle relaxants and pain medications such as narcotics. Low-dose steroids may be prescribed over a short course to also decrease pain and inflammation.
  • Discuss Other Treatment Options
    Massage, chiropractic care or manipulations to the neck can feel good in many cases. You should discuss these with your doctor, since certain conditions should not be manipulated. You should maintain a treatment strategy that is consistent with your physician’s experience.
  • Diagnostic Imaging
    There are several different types of imaging and studies that might help your doctor decide how to help you. The first step would be to take X-rays of your neck or back. Depending on your condition, your doctor might also decide to order MRIs, CT scans or nerve conduction studies. See the section on “How do we figure out what’s wrong?” for more information on each of these.

How do we figure out what is wrong?

The most common and basic diagnostic test is an X-ray. In many cases, regular X-rays are the only diagnostic test that your physician will require. However, if more detailed structural information is needed to devise a treatment plan, then your doctor may go on to order other studies such as Magnetic Resonance Imaging (MRI) or Computed Axial Tomography (CT or CAT) scans.

Other common diagnostic tests include those tests that provide information as to the function of the spinal cord and nerves. These include Electromyography/Nerve Conduction Velocities (EMG/NCVs) and Somatosenory Evoked Potentials (SSEPs). Their use is typically required on a case-by-case basis, and they are not needed as often as the structural diagnostic tests.

  • X-rays
    Plain X-rays are not painful. They are a quick, non-invasive study that can provide good information regarding the structure, or building blocks, of the spine – the bony anatomy of the spine and the overall alignment. The X-rays are performed at a variety of angles around the neck to gain as much diagnostic information as possible. X-rays can help evaluate the alignment of your spine, diagnose fractures, bone spurs (arthritis) and some problems with the spinal discs. In many cases, regular X-rays are the only diagnostic test that your physician will require.In a few cases, your doctor may need more information than we see on the X-rays. For most patients, an MRI is the preferred advanced imaging study.
  • MRI
    MRIs are not painful. They do not involve radiation. MRI images show both bony detail and soft tissue detail such as spinal cord, nerve roots, and ligamentous structures. The actual discs, nerves, spinal cord, and bones can be visualized. MRIs are not recommended for people who have pacemakers or metal within their body (for example, machinists with metal filings in their eyes) that could potentially be attracted by the large magnet that runs the MRI. Patients with artificial joint replacements and devices to fix fractures of other bones in the body generally can undergo MRIs. In patients who cannot undergo MRIs, or in some cases where additional information may be needed, CTs with or without dye may be necessary.
  • CT
    CTs show excellent bony detail. They are not painful and are based on X-ray.
    CT may be combined with the injection of dye to create a “myelogram.”
  • CT Myelogram
    Myelography is an invasive technique in which a needle is introduced into the spinal canal and contrast material is injected into the spinal fluid. This allows for details within the spinal canal, and when combined with CT, shows the relationship of the bone to the contents of the spinal canal.
  • Discography
    Discography is an invasive technique which requires a needle to be entered through the skin and into the disc. A contrast material is then injected. The pressures might be measured and, in conjunction with CTs, may reveal internal disruption of the disc or if the disc is herniated.
  • EMG/Nerve Conduction Velocity
    Electrodiagnostic testing is a minimally invasive procedure in which very tiny needles are placed along the spine and along certain muscles. The electrical response between the nerves and the muscles can determine which nerves are not functioning properly.

Are there non-surgical procedure (physiatry) to help with my back or leg pain?

If initial measures fail to secure significant relief from pain and/or significant progress toward the patient’s functional goals, more aggressive, spine interventions should be considered. Given the health risks associated with long-term use of any medication, particularly NSAIDs or narcotics, these procedures are worthy of consideration.

At the UConn Musculoskeletal Institute and the Comprehensive Spine Center, the following injection therapies are used together with electro diagnostic studies both as diagnostic tools and to directly administer medications to the source of pain.

  • Selective nerve root blocks provide relief for leg and arm pain due to pinched or irritable nerve root caused by disc protrusion or canal narrowing.
  • Facet joint injections relieve low back pain.
  • Sacroiliac injections address low back pain caused by dysfunction of these joints.
  • Transforaminal steroid injections alleviate neck and low back pain arising from degenerative discs.
  • Lumber discogram to determine the level of disc pain.

These minimally invasive procedures are performed under X-ray guidance using today’s best imaging tools and intravenous contrast materials to precisely identify the source of pain and administer medications to the exact site.

Several multi-center studies, including the Spine Patients Outcome Research Trial (SPORT), have shown that these procedures provide significant relief from pain. The studies have also established evidence-based practice guidelines.

When should I see a spine specialist for back and leg pain?

  • Arms
    Pain, numbness, tingling, weakness or clumsiness in your arms or hands can be caused by many different things. For instance, carpal tunnel syndrome is a common type of peripheral neuropathy that can cause numbness and tingling in the hands. Diabetes can also cause numbness and tingling in the arms and hands.Sometimes, problems in your arms or hands are caused by problems in your neck and spinal cord. See the section on Neck Pain for information on how you can help yourself feel better, when to see your doctor, and what a spine surgeon might be able to do for you.

    Most importantly, if your symptoms change or get worse, you should see your doctor right away.

  • Legs
    Pain, numbness, tingling or weakness in your legs or feet can be caused by many different things. For instance, diabetes is a common cause of peripheral neuropathy that leads to numbness and tingling in the feet.Sometimes, problems in your legs or feet are caused by problems in your back and spinal cord.

    Most importantly, if your symptoms change or get worse, you should see your doctor right away.

  • Bowel/Bladder
    If you are having trouble urinating or having a bowel movement, you should see your doctor right away. It is rare, but compression of the nerves in your spinal cord (known as cauda equina syndrome) can cause permanent damage to your bowl and bladder if not treated promptly.

What can a spine surgeon do for my back or leg pain?

Whether or not to undergo surgery is a decision that you and your surgeon and/or physiatrist will make together, based on your symptoms and your overall health. Although spine surgery can be an extensive procedure, most patients, even the elderly, are medically capable of tolerating the procedure.

If you are severely disabled by your back or leg symptoms, and non-operative treatment has not decreased your symptoms, then surgery may be a reasonable option. The choice of a specific surgical technique depends on the exact cause of your pain and your surgeon’s preference. Regardless of the surgical approach that is chosen, if decompression (making room for the nerves) is not adequate, relief of symptoms may be incomplete or the problem may recur following a short period of clinical improvement.

  • Laminectomy: A standard decompressive procedure to enlarge the space available for your nerves. This involves a midline incision over the involved levels, dissection down to the spinous processes, and removal or “unroofing” of parts of your bony vertebrae (spinous processes, laminae, and ligamentum flava) to make room for the nerves in the spinal canal. This procedure is often performed across multiple vertebral levels, since canal stenosis rarely occurs in an isolated fashion. Removal of other bony prominences such as facet joints (oftentimes enlarged because of osteoarthritis) may be necessary to adequately decompress the nerves.
  • Hemilaminectomy: An alternative to the basic laminectomy, with slightly less risk of destabilizing the spine because only half of the structure is removed.
  • Laminotomy: “Windows” or fenestrations are created by removing the superior aspect of the inferior lamina and the inferior aspect of the superior lamina at the involved levels. Proponents of this approach believe that sparing the interspinous ligaments and preserving spinous processes minimizes the risk of postoperative instability.
  • Medial Facetectomy: If you have osteoarthritis in your spine, then your facet joints might be enlarged with osteophytes. Sometimes, in order to adequately decompress your nerves, it may be necessary to remove part of the medial facets. However, this additional procedure has the potential of creating instability in your spine, which may then require instrumentation and fusion.
  • Laminoplasty: Involves the en bloc removal and loose reattachment of the posterior vertebral arches.
  • Vertebroplasty: Used in cases of back pain caused by compression fractures. Percutaneous vertebroplasty involves injecting acrylic cement into the collapsed vertebra to stabilize and strengthen the fracture and vertebral body. This procedure does not restore the shape or height of the compressed vertebra.
  • Kyphoplasty: Used in cases of back pain caused by compression fracture. First, the compressed vertebral body is expanded by a high-pressure balloon, then acrylic cement is injected into the cavity to restore height to the collapsed vertebra.

What are the risks and complications of spine surgery?

The risks of laminectomy depend on how many levels you need decompressed, your other medical problems, difficult anatomy as a result of scarring from previous operations or a markedly stenotic canal that may require extensive bone removal and dissection, as well as the overall risks imposed by general anesthesia.

Potential complications of the standard decompressive surgeries include wound infection, hematoma formation, dural tears with subsequent cerebrospinal fluid leaks and risk of meningitis, nerve root damage and the potential for creating postoperative spinal instability. Surgical blood loss is generally well tolerated, but transfusion may be required. The overall surgical morbidity associated with decompressive laminectomy is approximately 1 percent. Please speak with your spine specialist for specifics of the risks, benefits, and alternatives, and for specific details on what spine surgery or procedure may be appropriate for you.