The usual cause is muscle strain brought on by heavy or improper lifting; unaccustomed twisting, bending, or stretching; standing motionless for long periods; overuse of back muscles, or injury to the muscles, ligaments, and discs that support the spine. Or it could be a combination of all or any of these.
What brings on the pain is the pressure put on nerve roots in the spinal canal. More than 50 nerve roots radiate down the spinal column, each running through a hole called a foramen, to limbs and organs. Somewhere along the line, especially when there is some kind of problem with a vertebra, muscle, ligament, or disc, a nerve gets pinched or irritated, tensing muscles and creating pain.
Such nerve root irritation can be the outcome of:
* Some body motion that has created a sudden heavy strain or has increased pressure to the lower back, thereby herniating a disc.
* Joint degeneration, osteoarthritis, which typically develops with age. Spinal stenosis is another age-related condition in which the spinal canal narrows, and the elderly are also more prone to compression fractures of the spine.
* Ankylosing spondylitis, a form of arthritis that most often affects the spine, frequently appears before old age sets in, and can have dire consequences.
* Spondylolysis and spondylolisthesis; these, besides being tongue twisters, are defects that put vertebrae into misalignment when jostled.
* Fractured vertebrae after a blow to the spine.
* Spinal deformities, such as severe scoliosis, kyphosis, or spina bifida.
* Bacterial infection that enters the spine during surgery or injections, or are carried to the spine through the bloodstream from an infection somewhere else in the body.
* Spinal tumors.
* Paget's disease, causing abnormal bone growth in the spine.
* Scheuermann's disease, which deforms vertebrae.
* Diffuse Idiopathic Skeletal Hyperostosis.
* Degenerative discs.
* Spinal disc herniation (slipped disc).
* Leg length difference.
* Restricted hip motion.
* Misaligned pelvis.
* Osteomalacia.
* Ochronosis.
* Chondrocalcinosis.
* Poor posture.
* Tension myositis syndrome.
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The cause could also be discogenic. Between every vertebra there is a soft, shock-absorbing pad shaped like a hockey puck, gelatinous on the inside and fibrous on the outside. It protects the spinal cord and separates each of the vertebrae. When damaged or worn out, the discs can bulge and press on a nerve root, causing irritation. If it bulges enough, it ruptures (herniates) and puts even greater pressure on the nerve root.
Whatever the cause of pain, the pain itself tends to compound the problem. Muscle strain prompts a person to take on a different gait to compensate for pain coming from the injured area. This, in turn, puts strain on other muscles that have not been used in that way in the past. Those muscles become painful, and lower back pain gets worse. Over time, muscle strain may create an overall imbalance in the spinal structure, leading to chronic back pain. Also, people who are depressed, under stress, or unhappy in their work or with their home life are more likely to have chronic back pain. This is psychogenic pain which must be treated through psychotherapy, psychoactive drugs, or a combination of the two.
Pain itself creates stress that exacerbates the condition. Physical stress affects body chemistry in such a way that it can create more pain in the lower back. Emotional stress does the same thing, sometimes to the point that unhappy thoughts are the primary cause of the back pain. Sometimes pain is accompanied by numbness, tingling, or weakness, all neurologic symptoms. If the neurologic symptoms include bowel or bladder dysfunction or groin or leg weakness or numbness, get immediate medical attention.
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Further complicating matters is that lower back pain may not come from the spine. It may be pain that is referred to the spine from a problem elsewhere in the body. This could be:
* Pelvic inflammatory disease.
* Aortic aneurysm.
* Peptic ulcers.
* Gallbladder disease.
* Pancreatitis.
* Urinary disorders (e.g., kidney stones or urinary tract infections).
* Prostate disease.
In treating lower back pain, unless you are in extreme agony, you will probably start with the least invasive procedure and work your way toward the most invasive. The starting point is to take a non-steroidal anti-inflammatory drug like ibuprofen or Aleve to reduce swelling. Your doctor might also prescribe a pain-killer. Apply ice wrapped in a towel at frequent intervals to the site of the pain for two days, then apply heat indirectly to your skin.
If the pain does not resolve within a few days of this treatment with bed rest, the doctor will probably order tests while putting you in the hands of a physical therapist and ordering that you do some mild workouts (walking, bicycling, or pool aerobics) and trunk stabilizing exercises. He may have you wear a back brace.
Typical tests are x-ray, CAT scan, and MRI. You may then be referred to a spine specialist - a neurologist or orthopedic surgeon. He or she may order additional tests: discography, myelogram, or bone scan. Discography uses a fluoroscope to look at one or more discs which have been injected with a contrast dye. A myelogram does the same, but injecting and looking at the space around your spinal cord. In a bone scan, a specialist injects into a vein a trace amount of radioactive material which travels to and collects in bones. A scanner can then detect spinal problems.
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Should the tests reveal a problem requiring surgery, you will be among the 5% of people with back pain who require the most invasive procedure. Your surgeon will encourage you to try several months of non-surgical treatment first; back surgery does not have a fantastic record for long-term relief of back pain. Eventually, the same or similar problems will show up in other parts of the spine, and you may have to undergo additional surgeries. Get a second opinion.
The surgical procedure may be a factectomy, foraminotomy, laminotomy, or spinal laminectomy, all of which are attempts to relieve pressure on nerve roots or the spinal cord. A discectomy removes those portions of a disc that are protruding. Sometimes the surgeon will perform spinal fusion, fastening two or more vertebrae together to restrict movement in an area that is damaged, deformed, or that simply hurts with movement. A problem with the latter procedure is that it may be difficult to accurately identify the source of a patient's pain. Should the pain come from mental stress, for example, a spinal fusion is extreme, inappropriate, and does not stop the pain.
Most of these procedures can be performed with micro-surgery. With the surgeon using a microscope, very small incisions can be made. This means there will be less pain at the site during recuperation, and you will be able to leave the hospital sooner and return to your regular life more rapidly.
Another recently-developed alternative for quelling chronic lower back pain is the surgical insertion into the spine of an electro stimulation device that delivers small, steady charges of electricity that can be effective in eliminating pain.
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