Why do I have pain in my lower back?

The answer to this question is not that straightforward. The problem may be in the skin, muscles or tendons, in the spine, in the spinal cord, or it may even not be in the back. Each problem presents, and is treated differently, and carries different amount of risk. Following questions and their answers may help to understand it better. Also provided is a brief outline of how each condition may be treated, starting with problems of skin over the back, and going deeper into other structures.

What problems in the skin may cause back pain?

Common examples are bug-bite, sunburn, local hair-bed infection, or shingles. Many other rashes may also result in pain and itching. History, and physical examination can help to make a diagnosis.

Treatment: Depends upon the cause; a local application for a rash, a medicine of infection, and as needed pain meds.

What problems in the tissue under the skin may cause back pain?

Usual reason is an infection, or cellulitis. It can be diagnosed by physical examination. Other problems like enlarged benign swellings (such as a lipoma or a neurofibroma) may or may not cause any pain.

Treatment: Depends upon the cause, usually an antibiotic, and as needed pain meds.

What problems in the muscles may cause back pain?

Muscles can be affected from a muscle disease or they may be affected by an unrelated condition close to them. They may also hurt from an infection in other areas of body, such as flu. An example of the muscle disease is Polymyositis. In this condition muscles get inflamed due to an autoimmune defect. It is diagnosed by a blood test, and sometimes a muscle biopsy. A muscle can also be injured by direct trauma or overstretching causing a muscle-tear. Indirectly, an inflammation or infection around the muscles can also put them into a spasm, causing a lot of pain.

Treatment: Depends upon the cause, anti-inflammatory medicines, steroids like prednisone, and other immune suppressing agents for Polymyositis.

What problems with tendons may cause back pain?

Usual cause is overstretching causing a tear, or local trauma. Tendons do not have good blood supply and may take long time to heal. An inflammation in the tendons may cause spasms of nearby muscles, worsening the pain and disability.

Treatment: Anti-inflammatory medicines, therapy, massage, spine hygiene, back strengthening exercises.

What problems in the spine may cause back pain?

Spine is a complicated structure and is better understood by looking at its different parts separately. Let’s try to understand the normal spine as a whole first.

The Normal Spine

Basically, spine is made up of bones or vertebrae, put one on top of each other. In most of the spine, the main part of vertebrae, or its body, do not touch other vertebrae and have a good amount of space in between. Each of this space between two adjacent vertebrae is filled by a structure we call disc. For understanding, imagine disc as a tennis-ball type of structure with a thick wall, with its inside full of a jelly like material, and somewhat compressed from outside. Now imagine putting about 25 vertebrae one on top of each other, with discs in between. This creates a very flexible but very unstable structure. Thick strong tendons, like bands of thick cloth, wrap around this whole structure to make it stable. The bodies of many vertebrae also extend arms-like projections towards the back, away from the body. These projections somewhat fold downwards and make joints (facet joints) with each other to provide further stability to the spine. One can easily see and feel these projections in a person with back bent over, especially in a well-toned body. Spine in a young person is a very flexible and stable structure, which many teenagers do not hesitate to show-off.

Spine is usually divided in four parts: cervical (in the neck), thoracic (in the middle), lumbar (lower back), and sacral in the lowest part of back and in the pelvis. With aging, many changes take place in the spine. One early change is somewhat drying up of the jelly-like material within the discs, making it less flexible. So is the reason that you may not find an effective gymnast after teen years. As we grow older, spine changes itself from made-for-flexibility to made-for-strength. In varying degrees, the process of drying up of disc material continues. An MRI done even in the so-called healthy adult individuals, with no back symptoms, may reveal degeneration of discs, which is not necessarily a disease. With drying up of disc material, and with wear and tear from different activities one may have undertaken during active years of life, discs change their shape. They become somewhat flattened, less flexible, and rough around the edges instead of round and smooth. In later age, they also shrink in size, making people loose some height. All these are so-called normal changes with aging.

Other than strength and stability, one of the main functions of the spine is that it acts as a conduit for all the large wiring from brain to different areas of the body. The long wires, or the tracts in medical terminology, are lumped together in a structure called spinal cord. Other than the first, at each level, in-between two vertebrae some of its extension or connection come out to reach their destination. They are named based upon the vertebra over or underneath, e.g., S1 comes out at L5/S1 level, between the vertebra L5 above and S1 underneath.

We have not found a way to stop or reverse the age related changes in spine described above. Many normal adults and elderly, with all these changes, have no significant back pain. Back pain may happen with a variety of problems with discs or the vertebrae, some of them described below.

Why low back pain is so common?

Some parts of our spine are more at risk of a problem than others, especially from mechanical reasons. This is because some parts of our spine are more mobile than others. The neck or the cervical spine is quite mobile, designed to move our head in different directions. The middle or the thoracic part of the spine is relatively less mobile because of the ribs attached on either side. The lumbar part of the spine is also quite mobile helping us walk, run, lift, and twist. The lowest part of the spine, the sacral area, has minimal amount of movement. Most of the problems from mechanical causes happen either in the neck (cervical spine) or the back (lumbar spine). Even in these two areas some joints are more at risk than others. In lumbar spine, the lowest two joints (between S1 and L5, and L5 and L4) are the ones usually affected.

What is scoliosis and can it cause back pain?

In some ways, spine is a straight structure, though not like a metal bar. Shape of the spine may be checked by observing the person in bent over position, and noticing or feeling the sharp projection of each vertebra (the spinous processes). Normally they are in a straight line, not left or right from each other. Spine with scoliosis is not straight; it is rather wavy. The curve may be one, or more than one. Abnormal curvature puts pressure on different structures, and may cause chronic back pain. Extent of the problem depends upon the amount of scoliosis, and age of the patient. Children may not complain of pain but that is the time to get appropriate treatment. Pediatricians routinely screen children for scoliosis by observing them in a bent over position. This kind of screening helps to identify the problem in young age, when appropriate measures can be taken to avoid permanent issues.

Treatment: Orthopedic consultation, spine hygiene.

What does a disc bulge mean?

Imagine disc as a tennis-ball type of structure with a thick wall, with its inside full of a jelly like material, and somewhat compressed from outside. A disc may bulge out due to too much pressure, e.g., from falling, auto accidents, contact sports, or overstretching. In this condition, because of too much vertical pressure on the disc, the tennis-ball bulges out but is still intact. Disc bulges are commonly seen on MRIs of back, and seldom cause any real trouble. For disc bulge to cause a significant issue, it has to be big enough to break the cloth-like tendons wrapped around the spine. Disc bulges may also be an indication of either a previous injury or a weakened spine.

Treatment: Reassurance and education, spine hygiene, back strengthening exercises. Rarely, it may require a surgical treatment.

What is disc herniation?

In case of sudden too much pressure on a disc, e.g., from falling, traffic accident, contact sports, or overstretching, the thick outer wall of the disc may develop a tear or a slit like hole, through which a part of the jelly-like material from inside the disc (the tennis-ball) may come out. Once out, it has no way to return back. The tear may seal and heal up but the disc material stays outside. If that disc material is away from any nerves, the patient may just notice some localized back pain for a few days. On the other hand, if this material is close to a nerve it may impact its function. Presence of disc as a foreign body may also trigger an inflammatory response that may affect any close-by nerve(s). Nerves in this vicinity are really the nerve-roots coming out from inside the spine, which join together to make long nerves going down in legs. Depending upon the trapped nerve-root, patient may feel strong pain and/or numbness traveling down to the leg or even to the foot. If the nerve is pressed too hard or inflamed, it may loose its function. The muscles it is taking messages to may not work, and patient may develop weakness of those muscles. Many people call this condition “sciatica,” which is a misunderstanding. The sciatic nerve has nothing to do with it. True sciatica is a problem with sciatic nerve, which is not in that area. In neurological literature, this condition of “pinched nerve in the back,” is called a radiculopathy. It can be diagnosed based upon its typical pain history, and physical examination showing loss of strength, or a reflex. It can be confirmed by doing an EMG/nerve conduction study, and the cause of the problem can be discovered by an MRI scan.

Treatment: Minor one may self-heal after a few days of pain, and may just be found as a finding on MRI. A little larger requires pain management, anti-inflammatory meds, therapy, and exercise. Some may benefit from a local injection to resolve inflammation. Larger ones, and the ones compromising a nerve, are surgically treated.

What is spinal spondylosis or spinal spondylitis?

I am putting these terms here because many patients read their MRI reports and come asking about it. Many times, the physician ordering the scan may not have good understanding of these terms either.

As described in detail above in the description of a normal spine, at each level in-between two vertebrae, a pair of nerves comes out of the spine. Pairs are named based upon their location, like right and left C5 in the neck, and L5 in the lower back. Some patients develop a chronic process either due to a genetic tendency or from chronic or multiple traumas, usually a combination of both. In this process, discs get too dehydrated; loose their malleability (flexibility), and their size and height. They bulge, and may also herniate at multiple sites. Exposed to chronic stress, some parts of the adjacent bones get thicker, and may build extra bone structure (or bone spurs), the osteophytes. Medical term for all this process together is spondylosis. In many people, it is a painless process, at least to a certain extent. Frequently, the back gets irritated or inflamed, causing local pain. If any of the nerves get trapped in this process, sharp pain travels down from back to the leg. The terms of spondylitis or spondyloarthritis imply inflammation in this process. MRI scan may reveal all or part of the changes described above.

Treatment: For spondylosis, spine hygiene, and back strengthening exercises. Spondylitis (or spondyloarthritis) may also require additional pain management.

What is lumbar spinal stenosis?

Typically chronic changes of spinal spondylosis (discussed above) may cause narrowing of the holes where the nerves come out, or sometimes narrowing of the whole spinal canal, pressing on multiple nerve roots. Many times there is additional problem from previous surgeries. This process of narrowing is called spinal stenosis. Patients in this condition may have continuous pain, or pain in an erect posture. They may feel comfortable standing or walking with a somewhat stooped posture. They prefer to hold on to a trolley in the grocery store, feeling better in that position. If they walk for long, back pain becomes unbearable and they sit down. Once seated, the pain may disappear, as the pressure on the nerves is relaxed. This condition is diagnosed by its typical symptoms, with some help from examination. EMG/nerve conduction studies can also be helpful. MRI of the back helps to visualize the whole process, confirm the diagnosis, and assess its severity.

Treatment: Most can be managed with therapy, exercise, and as needed pain meds. In acute and severe pain settings, an injection of local anesthesia and steroid at the site of inflammation may also help. Many patients require surgery to open up the space.

What are facet joints, and can they cause back pain?

As I stated above in the description of the normal spine, part of a vertebrae extends backwards and make joints with the vertebra underneath. These are small joints, though similar to the knee joint, helping with stabilizing the spine. Sometimes patients have inflammation in one or many of these joints. Like arthritis, its symptom is back pain in localized area, with no radiation towards the leg, and with no abnormal neurological findings. It can be diagnosed by a CT or MRI scan.

Treatment: Regular exercise, spine hygiene, back strengthening exercises, and pain management. Sometimes a local injection in the joint may also help.

What is vertebral collapse?

Sometimes, usually in elderly and likely due to thinning of bones (osteoporosis), falling may cause significant vertical pressure on a vertebra making it collapse in a crushing manner. Depending upon its exact location and closeness to any nerve, it may be relatively painless, or it may cause tremendous pain. It may permanently change the shape of the spine, and patient’s posture.

Treatment: Pain management and spine hygiene. A procedure called vertebroplasty has been promoted but its value, to treat pain or prevent down-the-road problems, is debatable. In this procedure an epoxy type material is injected in the vertebra to rebuild the bone.

Can spine infection cause back pain?

Any part of the spine may be infected, usually from a bacterial infection, causing progressively worsening severe localized pain, tenderness, and other symptoms and signs of infection. Some infections may linger on for long time, sometimes relatively pain free, like tuberculosis and may result in significant damage to the spine.

Treatment: Antibiotics or appropriate drugs to kill the offending organism(s), pain management, and sometimes surgery.

What about cancer in the spine?

A cancer may start in the spine (primary cancer), or it may be from a different area of the body (a metastatic cancer), resulting in progressively worsening pain, weakness, and other neurological malfunction, without symptoms and signs of infection. If relatively pain free, it may become large enough to press the neurological structures before detection.

Treatment: Pain management, steroids, surgery, radiation, chemotherapy (depending the type of cancer).

And what about fracture of a vertebra?

Trauma may cause fracture of a vertebra, which is diagnosed with an X-ray or a CT scan. MRI scan can help to find if neurological structures are affected.

Treatment: Pain management, back brace, spine hygiene, sometimes surgery.

What problems with the covering (meninges) of the spinal cord may cause pain?

A viral or bacterial infection, or a cancer may selectively affect the covering or the dura mater. Sometimes, because of this covering infection or an abscess may get large enough to press on the spinal cord or the nerves. This type of conditions may present as neurosurgical emergencies, as they may cause permanent disability, if not quickly treated.

Treatment: Emergency surgery, and depending upon the cause, antibiotics, chemotherapy, pain meds.

Can a problem with the spinal cord cause back pain?

Spinal cord diseases are usually painless presenting as neurological symptoms such as numbness, weakness, unsteadiness, or loss of bladder control. Sometimes, back pain is a part of it. It may also cause indirect neuropathic type of pain.

Treatment: Depends upon the cause, and pain management.

Can a problem with spinal fluid cause back pain?

An infection, inflammation or a cancer may spread to the spinal fluid resulting in headache, back pain and many other symptoms.

Treatment: Depends upon the cause, e.g., antibiotics for bacterial infection, chemotherapy for cancer.

Can a problem in the abdomen cause low back pain?

Many issues in the belly may cause low back pain. Kidneys are placed close to the back, and many kidney conditions may cause or even present with back pain. The big blood vessel called aorta passes close to the back, and its injury can also cause severe back pain.

Treatment: Depends upon the cause.

Can stress cause back pain?

Stress and depression are common cause of back and neck pain. Some patients, due to their genetic makeup and their prior life experiences, seem more at risk for somatic or physical symptoms from psychological causes. There may be multiple mechanisms involved, including muscle spasms, abnormality in pain perception mechanism, and hormonal factors. These patients usually go through battery of tests and may see multiple different physicians, sometimes more than one time, looking for a “treatable,” or a “fixable” cause. Diagnosis is made by appropriate history, and physical examination. It is also possible that our technology is not sophisticated enough to figure out their underlying problem.

Treatment: Reassurance, education, counseling, physical therapy, light regular exercise, medicines, and treatment of psychological issues if properly diagnosed.

Does fibromyalgia cause back pain?

Back pain is one of the most common symptoms of fibromyalgia. Its exact cause is unclear, and is understood to be due to abnormal pain perception mechanism. Available testing may not reveal any significant abnormality. It is a diagnosis based upon particular set of symptoms, and findings on physical examination.

Treatment: Reassurance, education, counseling, physical therapy, light regular exercise, medicines, and treatment of psychological issues if any.

What is Spine Hygiene?

Hygiene means taking all the appropriate measures one can to keep the spine healthy and strong. It may include following measures:

a. Proper posture: Learn to maintain proper posture while walking, sitting, at work, while doing heavy physical work, or lifting heavy objects. Wrong posture may lead to significant back pain, and more serious issues with spine. Generally speaking, proper posture is when there is minimum pressure on the spine.

b. Defensive driving: Sudden stop and go type of driving, or any accident leading to sudden stopping, is a significant risk factor for spine problems. Patients with spine problem should be extra careful and avoid over-speeding, and sudden stop-and-go type of driving.

c. Weight management: Maintain normal weight for your height: Extra weight is a sustained pressure on the spine, especially if it is not balanced (e.g., big belly, large breasts).

d. Proper sleeping place: Avoid a mattress that is too soft, or sleeping in a cushioned couch, or in any bed that causes back pain. We spend almost 1/3rd of our life sleeping; make sure bedding is appropriate.

e. Avoid dangerous activities: Avoid sports and activities that may put your spine at risk, e.g., Football, weight lifting, diving, jumping, mountain biking, etc.

f. Exercise: Adopt a regular back exercise regimen.

What is back exercise regimen?

If back already has some issues, exercises may have to be modified and designed for the type of problem. In general, any back exercise regimen should have three goals: a. strengthening back muscles, b. maintaining proper back posturing, and c. keeping the back flexible. This should include a mixture of stretching, strengthening, and flexibility exercises. I am sorry for not including details of these exercises here, as it is a significant topic by itself. I may try to do it sometimes later. Consider seeing a physical therapist for guidance.

Where may I get more information about back pain?

American Academy of Neurology
American Academy of Physical Medicine & Rehabilitation
American Orthopedic Society for Sports Medicine
Centers for Disease Control and Prevention