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Typical history, examination findings, X-rays and MRI
Symptoms in the low back can relate to any of the following:
The Lumbar spine is designed so that the vertebrae stacked together can provide a movable support structure while also protecting the spinal cord from injury.
Each vertebra has a strong body in front of the spinal cord to provide a platform suitable for weight bearing, a spinous process - a bony prominence behind the spinal cord which shields the cord's nervous tissue.
Cartilage disks are located between the vertebrae, and serve to cushion the spinal column from shock. Each disc features an inner, pulpy center, called the nucleus pulposus, and a fibrous outer ring, called the annulus fibrosus, which is visible in a lateral view of the spine. These intervertebral discs are easily torn or dislocated when the vertebra column is subjected to inordinate stresses, such as those encountered in lifting a heavy load improperly, or twisting the back sharply, as occurs in many sporting injuries. Such a "slipped" disk is only one of many causes of back pain.
Ligaments are strong fibrous soft tissues that firmly attach the bones to each other. Ligaments attach each of the vertebrae and surround each of the discs.
The nerves that provide sensation and stimulate the muscles of the low back as well as the lower extremities, exit the spinal column through bony portals called "foramen."
Many muscle groups responsible for flexing, extending and rotating the waist, as well as moving the lower extremities, attach to the lumbar spine through tendon insertions.
The aorta and blood vessels that transport blood to and from the lower extremities pass in front of the lumbar spine into the abdomen and pelvis. Surrounding these blood vessels are lymph glands and involuntary nervous system tissues which are important in maintaining bladder and bowel control.
The uterus and ovaries are important pelvic structures in front of the lumbar area of women. The prostate gland is a significant pelvic structure in men. The kidneys are on either side of the back of the lower abdomen, in front of the lumbar spine.
The skin over the lumbar area is supplied by nerves that come from the roots of the lumbar spine.
The low back, or lumbar area, serves a number of important functions for the human body. These functions include structural support, movement, and protection of certain body tissues.
When we stand, the lower back is functioning to hold most of the weight of the body. When we bend, extend or rotate at the waist, the lower back is involved in the movement. Therefore, injury to the lumbar structures important for weight bearing, such as the bony spine, muscles, tendons, and ligaments, often can be detected when the body is standing erect, or used in various movements. Protecting the soft tissues of the nervous system and spinal cord as well as adjacent organs of the pelvis and abdomen is a critical function the lumbar spine and muscles.
Lumbar Strain (Acute, Chronic)
A lumbar strain is a stretching injury to the ligaments, tendons, and/or muscles of the low back. The stretching incident results in microscopic tears of varying degrees in these tissues. Lumbar strain is considered one of the most common causes of low back pain. The injury can occur because of overuse, improper use, or trauma. Soft tissue injury is commonly classified as "acute" if it has been present for days to weeks. If the strain lasts longer than 3 months, it is referred to as "chronic."
Lumbar strain most often occurs in persons in their forties, but can happen at any age. The condition is characterised by localised discomfort in the low back area with onset after an event that mechanically stressed the lumbar tissues. The severity of the injury ranges from mild to severe, depending on the degree of strain and resulting spasm of the muscles of the low back.
The diagnosis of lumbar strain is based on the history of injury, the location of the pain, and exclusion of nervous system injury. Usually, x-ray testing is only helpful to exclude other bone abnormalities.
The treatment of lumbar strain consists :
Long periods of inactivity in bed are no longer promoted as this treatment may actually slow recovery. Spinal manipulation for periods of up to 1 month has been found helpful in some patients that do not have signs of nerve irritation. Future injury is avoided by using back protection techniques during activities and support devices as needed at home or work.
The nerves of the lumbar spine can be irritated by mechanical impingement or disease any where along their path, from their roots at the spinal cord to the skin surface. These conditions include lumbar disc disease (radiculopathy), bony encroachment, and inflammation of the nerves caused by a viral infection (shingles). See discussions of these conditions below.
Lumbar radiculopathy refers to nerve irritation which is caused by damage to the discs between the vertebrae. Damage to the disc occurs because of degeneration ("wear and tear") of the outer ring of the disc, traumatic injury, or both. As a result, the central softer portion of the disc can rupture (herniate) through the outer ring of the disc and abut the spinal cord or its nerves as they exit the bony spinal column. This rupture is what causes the commonly recognised "sciatica" pain that shoots down the lower extremity (commonly known as the leg). Sciatica can be preceded by a history of localised low back aching or it can follow a "popping" sensation and be accompanied by numbness and tingling. The pain commonly increases with movements at the waist and can increase with coughing or sneezing. In more severe instances, sciatica can be accompanied by incontinence of the bladder and/or bowels.
Lumbar radiculopathy is suspected based on the above symptoms. Increased radiating pain when the lower extremity is lifted supports the diagnosis. Nerve testing (EMG/electromyogram and NCV/nerve conduction velocity) of the lower extremities can be used to detect nerve irritation. The actual disc herniation can be detected with radiology testing, such as CAT or MRI scanning. For more information, please visit the CAT SCANNING and MRI SCANNING areas.
Treatment of lumbar radiculopathy ranges from medical management to surgery. Medical management includes patient education, medications to relieve pain and muscles spasm, cortisone injection around the spinal cord (epidural injection), physical therapy (heat, massage, ultrasound, electrical stimulation), and rest (not strict bed rest, but avoiding re-injury). With unrelenting pain, severe impairment of function, or incontinence (which can indicate spinal cord irritation), surgery may be necessary. The operation performed depends on the overall status of the spine, and the age and health of the patient. Procedures include removal of the herniated disc with laminotomy (a small hole in the bone of the lumbar spine surrounding the spinal cord), laminectomy (removal of the bony wall), by needle technique (percutaneous discectomy), disc-dissolving procedures (chemonucleolysis), and others.
Any condition that results in movement or growth of the vertebrae of the lumbar spine can limit the space (encroachment) for the adjacent spinal cord and nerves. Causes of bony encroachment of the spinal nerves include foraminal narrowing (narrowing of the portal through which the spinal nerve passes from the spinal column, out of the spinal canal to the body), spondylolisthesis (slippage of one vertebra relative to another), and spinal canal stenosis (compression of the nerve roots or spinal cord by bony spurs or other soft tissues in the spinal canal). Spinal nerve compression in these conditions can lead to sciatica pain which radiates down the lower extremities. Spinal canal stenosis can cause lower extremity pains which worsen with walking and are relieved by resting (mimicking poor circulation). Treatment of these afflictions varies, depending on their severity, from rest to surgical decompression by removing the bone that is compressing the nervous tissue.
Bone and joint conditions that lead to low back pain include those existing from birth (congenital), those that result from wear and tear (degenerative) or injury, and those that are from inflammation of the joints (arthritis).
Congenital causes (existing from birth) of low back pain include scoliosis and spina bifida. Scoliosis is a sideways (lateral) curvature of the spine which can be caused when one lower extremity is shorter than the other (functional scoliosis) or because of an abnormal design of the spine (structural scoliosis). Children who are significantly affected by structural scoliosis may require treatment with bracing and/or surgery to the spine. Adults infrequently are treated surgically, but often benefit by support bracing.
Spina bifida is a birth defect in the bony vertebral arch over the spinal canal, often with absence oft he spinous process. This birth defect most common affects the lowest lumbar vertebra and the top of the sacrum. Occasionally, there are abnormal tufts of hair on the skin of the involved area. Spina bifida can be a minor bony abnormality without symptoms. However, the condition can also be accompanied by serious nervous abnormalities of the lower extremities.
As we age, the water and protein content of the body's cartilage changes. This change results in weaker, thinner, and more fragile cartilage. Because both the discs and the joints that stack the vertebrae (facet joints) are partly composed of cartilage, these areas are subject to wear and tear over time (degenerative changes). Degeneration of the disc is called spondylosis. Spondylosis can be noted on x-rays of the spine as a narrowing of the normal "disc space" between the vertebrae. It is the deterioration of the disc tissue that predisposes the disc to herniation and localised lumbar pain ("lumbago") in older patients. Degenerative arthritis (osteoarthritis) of the facet joints is also a cause of localised lumbar pain that can be detected with plain x-ray testing. These causes of degenerative back pain are usually treated conservatively with intermittent heat, rest, rehabilitative exercises, and medications to relieve pain, muscle spasm, and inflammation.
Fractures (breakage of bone) of the lumbar spine and sacrum bone most commonly affect elderly persons with osteoporosis, especially those who have taken long-term cortisone medication. For these individuals, occasionally even minimal stresses on the spine (such as bending to tie shoes) can lead to bone fracture. In this setting, the vertebra can collapse (vertebral compression fracture). The fracture causes an immediate onset of severe localised pain that can radiate around the waist in a band-like fashion and is made intensely worse with body motions. This pain generally does not radiate down the lower extremities. Vertebral fractures in younger patients occur only after severe trauma, such as from motor vehicle accidents. In both younger and older patients, vertebral fractures take weeks to heal with rest and pain relievers. Fractures associated with osteoporosis can also be treated with hormone therapy to stimulate the formation of new bone.
The spondyloarthropathies are inflammatory types of arthritis that can affect the lower back and sacroiliac joints. Examples of spondyloarthropathies include Reiter's disease, ankylosing spondylitis, psoriatic arthritis, and the arthritis of inflammatory bowel disease. Collectively they are grouped under one heading known as Sero-negative Spondyloarthropathies (SSA) because RA test in majority of these cases is negative. Each of these diseases can lead to pain and stiffness in the low back which is typically worse in the morning. These conditions usually begin in the second and third decades of life. They are treated with medications directed toward decreasing the inflammation.
Kidney infections, stones, and traumatic bleeding of the kidney (hematoma) are frequently associated with low back pain. Diagnosis can involve urine analysis, soundwave tests, or radiological scanning of the abdomen.
Pregnancy can lead to low back pain by mechanically stressing the lumbar spine (changing the normal lumbar curvature), and by the positioning of the baby inside of the abdomen. Pelvic tilt exercises are often recommended for this pain.
Ovarian cysts, uterine fibroids and endometriosis not infrequently cause low back pain.
Low back pain can be caused by tumours, either benign or malignant, that originate in the bone of the spine or pelvis and spinal cord (primary tumours) and those which originate elsewhere and spread to these areas (metastasise). Symptoms range from localised pain to radiating severe pain and loss of nerve and muscle function (even incontinence of urine and stool) depending on whether or not the tumours affect the nervous tissue. Tumours of these areas are detected using radiological tests, such as plain x-rays, nuclear bone scanning, and CAT and MRI scanning.
Paget's Disease Of Bon
Paget's disease of the bone is a condition of unknown cause in which the bone formation is out of synchrony with normal bone remodelling. This condition results in abnormally weakened bone and deformity, and can cause localised bone pain. Paget's disease is more common in people over the age of 50. Heredity (genetic background) and certain unusual virus infections have been suggested as causes. Thickening of involved bony areas of the lumbar spine can cause the radiating lower extremity pain of sciatica.
Paget's disease can be diagnosed on plain x-rays. However, a bone biopsy is occasionally necessary to ensure the accuracy of the diagnosis. Bone scanning is helpful to determine the extent of the disease, which can involve more than one bone area. A blood test, alkaline phosphatase, is useful for diagnosis and monitoring response to therapy. Treatment options include aspirin, other anti-inflammatory medicines, pain medications, and medications that slow the rate of bone turnover, such as calcitonin, etidronate, alendronate and pamidronate.
Bleeding in the pelvis is rare without significant trauma and is usually seen in patients who are taking blood-thinning medications, such as coumarin/warfarin. In these patients, a rapid-onset sciatica pain can be a sign of bleeding in the back of the pelvis and abdomen which is compressing the spinal nerves as they exit to the lower extremities. Infection of the pelvis is infrequent, but can be a complication of conditions such as diverticulosis, Crohn's disease, ulcerative colitis, infection of the tubes or uterus (Pelvic Inflammatory Disease), and even appendicitis. This is a serious complication of these conditions and is often associated with fever, lowering of blood pressure, and a life-threatening state.
Infection of the discs (septic discitis) and bone (osteomyelitis) is extremely rare. These conditions lead to localised pain associated with fever. The bacteria found when these tissues are tested with laboratory cultures include Staphylococcus aureus and Mycobacterium tuberculoses (TB bacteria). TB infection in the spine is called Pott's disease. These are each very serious conditions requiring long courses of antibiotics. The sacroiliac joints rarely become infected with bacteria. Brucellosis is a bacterial infection which can involve the sacroiliac joints, and is usually transmitted in goats' milk.
In the elderly, atherosclerosis can cause weakening of the wall of the large arterial blood vessel (aorta) in the abdomen. This weakening can lead to a bulging (aneurysm) of the aorta wall. While most aneurysms cause no symptoms, some cause a pulsating low back pain. Aneurysms of certain size, especially when enlarging over time, can require surgical repair with a grafting procedure.
Shingles (Herpes zoster) is an acute infection of the nerves that supply sensation to the skin, generally at one or several spinal levels and on one side of the body (right or left). Patients with shingles usually have had chicken pox earlier in life. The Herpes virus that causes chicken pox is believed to exist in a dormant state in the spinal nerve roots after the chicken pox resolves. In persons with shingles, this virus reactivates to cause infection along the sensory nerve, leading to nerve pain and usually an outbreak of shingles (tiny blisters on the same side of the body and at the same nerve level). The back pain in patients with shingles of the lumbar area can precede the skin rash by days. Successive crops of tiny blisters can appear for several days and clear in one to two weeks. Patients occasionally are left with a more chronic nerve pain (post-herpetic neuralgia). Treatment can involve symptomatic relief with lotions, such as calamine, or medications, such as Acyclovir.
As is obvious from the above discussion, the treatment of low back pain depends on the cause, and will vary from patient to patient.