Back Pain: Causes, Symptoms, Treatment

Back pain is incredibly common. In fact, it is normal. 80% of people have it sometimes in their lives. Low back pain (LBP) is the most common type of back pain. It is one of the commonest causes of time off work.

It’s rarely dangerous. Persistent back pain can be distressing, but it’s rarely life-threatening; and you are unlikely to end up in a wheelchair. Backs are strong and most heal within six weeks.

1. Definition

• Back pain is pain or discomfort in the back region, which can be acute (lasting less than 6 weeks) or chronic (lasting more than 12 weeks).

2. Causes

• Common causes of back pain include mechanical (e.g., muscle strain, ligament sprain, or disc herniation), degenerative conditions (e.g. osteoarthritis or spinal stenosis), and systemic conditions (e.g. ankylosing spondylitis or osteoporosis). Cancer and blood disorders are less common causes.
• Herniated (‘Slipped’) Disc – a very common cause of back pain.

• MRI: showing herniated disc

  • This is a common condition where the soft inner gel of the disc leaks out through a tear in the outer layer, irritating nearby nerves or the spinal cord (see picture above)
  • It occurs when the (rubbery) disc between two vertebrae ‘comes out’. They can rupture as well.
  • Depending on the ‘level’ they can cause neck, thoracic (mid-back) or lower back pian; and/or numbness, and tingling in the arms, buttocks, back and legs. The commonest levels are L4/5 and L5/S1.
  • Pain can be severe, but 90% people are pain-free at 6 weeks. A few get pain for many months, occasionally life-long.

3. Risk Factors

• Risk factors for developing back pain include age, obesity, smoking, sedentary lifestyle, heavy lifting, and previous history of back pain.

4. Symptoms

• Symptoms of back pain can range from a dull ache to sharp stabbing pain, often accompanied by stiffness, limited mobility, and sometimes radiating pain or numbness to the legs.

5. Diagnosis

• Diagnosis typically involves a thorough history and physical examination, with possible imaging studies (e.g. x-rays, MRI) to rule out serious underlying conditions.
• MRIs (and other scans) often are not necessary). Scans like MRIs rarely show the definite cause of back pain and can report findings common in people without pain, like disc bulges or degeneration. So interpretation is difficult.

6. Treatment

• Treatment depends on the cause
• Options for back pain include conservative management (e.g physiotherapy, pain management with NSAIDs or muscle relaxants, lifestyle modifications) and surgical intervention in severe cases (e.g.for neurological deficits or severe structural deformities).

7. Complications

• Complications of back pain can include chronic disability, decreased quality of life, and psychological distress, such as depression or anxiety.

8. Prognosis

• The prognosis for most patients with acute back pain is good, with significant improvement expected within a few weeks. However, chronic back pain can be challenging to manage.
• Natural history of Acute Low Back Pain.
  – 40% cases recover within 1 week
  – 80% cases recover within 3 weeks
  – 90% cases recover within 6 weeks
  – Only 7-10% cases experience symptoms for >6 months
  – Only 1% cases require surgical intervention.
  Note. If you have LBP, like all back pain, remain active. Bed rest is counterproductive both in acute and chronic LBP.

9. Prevention

• Prevention strategies include maintaining a healthy weight, regular exercise (especially core strengthening), proper lifting techniques, and good posture.

10. Referral

• Referral to a specialist (e.g. orthopedic surgeon, rheumatologist) is indicated if there are red flags (e.g. cauda equina syndrome, spinal cord comprerssion, other severe neurological deficits), if conservative management fails, or if there is a suspected underlying systemic condition.
• Back pain red flags: Even though most causes of back pain are not serious, some are. If you have any of these red flags you need to see a doctor soon.

Other Facts

1. Age is not a direct cause: Getting older doesn’t directly cause or worsen back pain; evidence-based treatments can help at any age.
2. Movement is beneficial: Pain with exercise doesn’t mean you’re doing harm; movement and exercise are effective ways to treat back pain.
3. Backs are resilient: Everyday loading and bending do not wear out backs; activities like running and lifting can strengthen your back.
4. Operations (and other invasive treatments) are rarely the solution: Injections, surgery, and strong opiates often are not effective long-term solutions for persistent back pain and, come with risks and side effects.