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Lower back pain is not a disease, but a symptom experienced by a person due to conditions affecting one or more components of the lower back. These components can be:
• Bones- lumbar vertebral bodies (L1 to L5)
• Intervertebral disc spaces
• Ligaments- structures that attach one bone to another
• Tendons- components that attach muscles to bones
Lower back pain is the commonest cause of disability worldwide which affects people’s ability to perform work and other routine activities. It is estimated to affect about 60 to 80% of adults at some stage in their life.
It is a major problem worldwide which seems to be getting worse predominately due to the aging world population. It is seen affecting all age groups and is generally associated with sedentary work, obesity, smoking, and low socioeconomic status.
The pain can vary in intensity ranging from dull, continuous pain to sudden shooting sensation that leaves the person debilitated. Pain can begin suddenly following an incident of acute exertion on the back such as lifting a heavy object or can develop gradually due to age-related wear and tear of the spine.
Low backache remains one of the commonest causes to visit a doctor. Most of the back pains are short term (acute) which stays for less than a month and tends to resolve on their own with self-care and some medical help. Chronic back pain lasts for more than 3 months, and in some cases may even persist for months and years even after treatment with medicines and surgery.
However, most of the episodes of lower back pain can be treated or prevented. With the help of a healthy lifestyle, exercise, good posture, medicines, home remedies, and alternative medical therapies most of the lower backache issues can be managed effectively. Surgery is rarely required to treat the condition.
• Pain: can be dull aching type in the lower back region. It can be burning or shooting type that may radiate down to one leg suggesting nerve compression. The pain may radiate to one or both legs and extends to different parts of the leg depending on the nerve compressed.
• Altered sensations: there may be tingling sensation or numbness that extends to the lower limb.
• Stiffness of the back and muscle spasm
• Decreased range of motion
• Difficulty in standing or sitting for a long time
The symptoms generally become more prominent on bending or lifting heavy objects or when sitting or standing for a long time.
Most acute back pain gradually resolves with home remedies, over the counter medicines and self-care. However, if the pain doesn’t improve or is accompanied by the following features one should seek medical help:
• Severe pain or pain that doesn’t improve on rest or with medicine.
• Pain that is increasing or not improving with time.
• Pain that affects your work and daily activities.
• Pain that radiates to one or both legs, especially if it extends below the knee.
• Pain that results in weakness, tingling, or numbness in one or both legs.
Less commonly, back pain can also indicate a serious underlying medical condition which should prompt immediate medical attention in the following cases:
• Pain associated with extreme leg weakness.
• Back pain associated with problems in bowel or bladder control.
• Associated with fever or significant weight loss.
• Back pain starts after fall or injury.
• Pain that starts only after the age of 50 years.
• Pain associated with a history of cancer, steroid use, or osteoporosis.
The lower back is a part of the body that is designed to do a variety of functions from bearing the weight of the upper body to doing complex body movements such as bending or rotation to lifting weights. It is made up of multiple structures that work in a complex manner to produce desired work.
• Bones– lumbar vertebral bodies (L1 to L5) that keep the lower back erect, bear weight, and provide attachment to the muscles.
• Intervertebral disc spaces– rubber-like structures present in between the adjacent vertebral bodies that act as a shock absorber to bear pressure and weight.
• Ligaments– structures that attach one bone to another and provide support.
• Muscles- structures that attach to the bones and brings about the movement of the various parts.
• Tendons- components that attach muscles to bones.
• Nerves- these are long cord-like structures that carry information to and fro from muscles to the spinal cord.
Any disease or condition that affects the structure or functioning of these components can result in pain and loss of function.
There are a number of causes of low backache including mechanical causes, infection, inflammation, trauma, osteoporosis, and others. A large majority of cases are due to mechanical causes which can occur due to acute injury, age-related wear and tear, and abnormal structure of the spine. The causes are enumerated below:
1. Muscular problems- muscle spasm and strains: one of the commonest causes of acute back pain. Spasm is a sudden involuntary contraction of the muscle. Whereas, Strain is a tear in muscles or its tendons. These are generally caused by lifting something improperly or something significantly heavy. It is also caused by over-stretching and improper body movement.
2. Ligament problems- sprains: is also a common cause of acute back pain. These are caused by over-stretching or tearing of ligaments that attach one bone to another.
3. Problems of intervertebral disc (IV disc)
• Degenerated IV disc: is one of the common causes of low back pain. Due to regular wear and tear the IV discs that act as a shock absorber of spine becomes dehydrated, loses its structure, and releases chemicals that produce inflammation and pain.
• Herniated or ruptured discs: many of the degenerated discs when loses its structure they bulge outward or ruptures to cause low back pain.
4. Neural problems due to compression of the nerves
• Radiculopathy: Bulging of the IV disc or compression by a bony prominence or ligament can cause injury and inflammation of the nerve roots of the spinal cord. This results in pain, tingling sensation or numbness that involves areas of the back and lower limb that is supplied by the nerve.
• Sciatica: is radiculopathy caused by compression of the sciatic nerve. The sciatic nerve is a large nerve that travels through the buttocks into the back of the leg. Sciatica produces a burning sensation or shock-like pain in the lower back which extends into one of the legs, sometimes reaching the foot. In severe cases, the pain is associated with numbness and muscle weakness of the leg.
5. Bone problems
• Due to bone displacement: called spondylolisthesis where the vertebra slips out of its original place. It sometimes causing compression of the nerves coming out of the spinal column.
• Due to malalignment of the spine: changes in the curvature of the spine from birth or developed during a lifetime can cause muscular or bone problems, or vice versa resulting in pain. These may be seen in scoliosis, exaggerated lordosis, or straightening of the spine.
• Due to changes in the structure of spine: any abnormality in the structure of the spine, its alignment, or due to malunion, since birth can result in the altered transmission of weight causing generation of pain. This can be seen in the transitional vertebra or incomplete vertebra and other abnormalities.
• Due to vertebral fracture or compression: trauma to the spine can cause fracture of the vertebra resulting in compression or displacement which may cause malalignment or compression of nerves.
• Due to reduction in density of the bones (osteoporosis): with age or less commonly due to underlying metabolic diseases, the density of the bone may decrease resulting in softening and decreased strength. This may result in development of thin small fractures that produces pain.
6. Infection of the spine: this is one of the important causes of back pain in India and other developing countries due to a higher risk of developing bone infection and tuberculosis. Common causes are tuberculosis, other bacterial infections, and fungal infection.
The infection can affect multiple structures of the spine such as vertebral bodies, intervertebral discs, or joints.
7. Inflammatory diseases of the joints: such as osteoarthritis, ankylosing spondylitis, rheumatoid arthritis, spondylitis, may also cause pain.
• Abdominal aortic aneurysms
• Kidney stones may cause a sharp pain which is felt in the lower back but on one side.
The back pain can develop at any age from children and adolescents to adults and elderly people. There are several factors that predispose a person to develop back pain.
• Age: Back pain becomes more common with increasing age, usually starting around 30-40 years of age.
With advancing age, there is a decrease in the strength of the muscles, ligaments, and bone. There are increased chances of osteoporosis, decreased muscle elasticity, decreased fluid content, and cushioning provided by the IV discs and increased chances of spinal canal narrowing.
• Excessive weight: puts extra stress on the lower back predisposing to wear and tear.
• Lack of physical activity and exercise: decreases the strength of the back muscles which bears the load of the upper body along with the spine. Weakened muscles shift most of the stress on the spine which gets predisposed to injury and wear-tear.
• Incorrect posture and improper lifting of weights: having a bad posture and lifting weights puts excessive and uneven stress on the spine.
• Job-related risk factors: people with jobs that require long hours of sitting with no significant physical activity increases the risk of developing backache. Similarly, people involved in work with lifting heavyweight, pushing, pulling, or twisting of the spine are more prone. This is more common if associated with bad posture.
• Mental health factors: people with anxiety and depression are found to be more prone to backache. Mental stress affects the body in multiple ways including increased muscle tension. Moreover, chronic pain may also result in worry and depression.
• Smoking and nicotine consumption: nicotine and other substances present in tobacco cause narrowing of blood vessels reducing the blood flow and nutrient supply to IV disks and bone predisposing to injury and inflammation. It also causes slow healing due to the lack of nutrients.
• Pregnancy: there is increased pressure on the spine due to the enlarged uterus and increased body weight. The pain usually resolves after childbirth.
• Backpack overweight in school children: in children, carrying excessive weight due to heavy books in their backpacks can cause muscle strain and fatigue. The American Academy of Orthopaedic Surgeons has recommended that a child should not carry a backpack of weight more than 15 to 20% of his or her body weight.
• Genetics: Some conditions such as ankylosing spondylitis that cause significant back pain have a genetic predisposition.
The doctor would start with a medical history followed by physical examination and tests which may include some blood investigations and imaging tests.
The doctor would enquire about the onset, location, duration, and severity of pain. He will also ask about any limitation of movement and history of any previous episode of pain or disease.
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