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Back Pain

Back pain is an extremely common problem, affecting over 90% of the population at some time in life.  Fortunately, most forms of back pain get better on their own: approximately 50% of patients will experience back pain relief within two weeks and 90% within three months.

There is an excellent patient information site from Sheffield which has very helpful information, and a good explanatory video by Dr Mike Evans on the youtube site which can be accessed here.  

The National Institute for Clinical Excellence (NICE) have recently issued revised guidelines for the management of low back pain and sciatica, NG59, replacing the previous guidelines which were acknowledged to contain a number of errors.

Back pain introduction

The spine and its surrounding structures are designed to provide a great deal of strength.  These complex structures protect the highly sensitive spinal cord and nerve roots, and yet are flexible, providing for mobility in all directions.  More detail on the structure of the spine which you may find useful is given at this page.

However, within the spine a number of different structures can produce back pain, such as irritation to the large nerve roots that run down the legs and arms, irritation to small nerves inside the spine, strains to or pain from the large back muscles, as well as any wear and tear or injury to the discs, bones, joints or ligaments in the spine.

Most cases of back pain are caused by muscle strains and minor injuries or by wear and tear and aging processes in the back, rather than more serious causes, and are often referred to as 'non-specific’, 'simple' or 'mechanical' back pain.  While this condition is not serious, it can still give substantial pain.  Most episodes of pain are of short duration and settle down quite quickly.  The symptoms of simple back pain often occur suddenly and can be triggered by a particular movement.

There are a number of factors can make you more prone to back pain.

The back depends for much of its strength on the muscles surrounding and stabilising it.  One of the problems with back pain is that people often think that it is beneficial to rest when they get an episode of back pain.  Unfortunately, this tends to make things worse in the long run, since the muscles and other supporting structures around the back become weaker and often more painful very quickly without activity.

These muscles are very important to the function of the back.  Think how important the rigging of a ship's mast is.  Inactivity makes the muscles become weak so they are unable to support the back properly, and they can themselves start to become painful and contribute to myofascial pain. This leaves the back more vulnerable to pain when certain movements put too much strain on one area, and contribute to the "vicious cycle" of pain.

There are therefore some very important messages regarding acute low back pain:

  • Rest is bad for you
  • Exercise and activity is good for you
  • Hurt from the back does not equal harm.

There are a number of myths about back pain which can be very counter-productive.  In the past doctors, too, were guilty of encouraging people to rest: interventions like long periods of traction and using corsets often worsened things.  Modern research has shown that this is wrong and that it is critically important to keep things moving.  In addition, descriptions such as "a crumbling spine" and talking about back pain in terms of damage and injury are not helpful since they make people worry that they are going to harm themselves through movement.  They will often therefore avoid activity - we call this "fear-avoidance behaviour".

For advice and further information about how you can improve exercise and fitness see these pages and the Arthritis Research UK recommended back exercises.  The Sheffield Backs site has a useful advice sheet.

 

Red Flags and Warning SIgns

Doctors look for certain factors called Red Flags that could indicate that somethng is going on in the back that could cause concern.  

Anyone with these symptoms with back pain should seek immediate medical care - they could indicate the development of a condition called cauda equina syndrome:

  • Difficulty passing urine or having a bowel movement, or numbness in the "saddle area"
  • Progressive weakness in the legs
  • Severe, continuous abdominal and low back pain.

People should also seek prompt medical attention if other unexplained symptoms accompany their back pain, such as fever, history of cancer, recent unexplained weight loss, pain that is so bad it awakens them from sleep, or pain after a trauma.  There are several warning signs, known as red flag signs, that may indicate that your back pain is caused by a more serious condition that requires immediate medical help. These include:

  • a fever of 38ºC (100.4ºF) or above
  • unexplained weight loss
  • swelling of the back
  • constant back pain that does not ease after lying down
  • pain in your chest or high up in your back
  • pain down your legs and below the knees
  • pain caused by a recent trauma or injury to your back
  • loss of bladder control
  • inability to pass urine
  • loss of bowel control
  • numbness around your genitals, buttocks or back passage
  • pain that is worse at night

 

In addition, doctors also look for other markers, called Yellow Flags, which can indicate an increased risk of back pain becoming chronic, or can suggest other areas which, if addressed, could help with its management.

What structures can cause back pain?

We use the term the "motion segment" to describe the plane at each level of the spine through which movement can happen, comprising the disc and vertebrae, ligaments, the nervous structures and joints (see "the structure of the spine" page).   A number of structures within each motion segment can contribute to pain.  Unfortunately, our brains are not very good at working out which structures are causing pain since many of the structures at each motion segment are supplied by branches of the same nerves.  This makes it difficult to feel which structure is causing pain, and the brain often "thinks" the pain is coming from the other areas the nerve supplies.  We call this referred pain.  For instance, therefore, a painful part of the spine at the L4 or L5 level can cause pain to refer into the lower leg or foot, as well as causing pain in the back itself.  

As discussed above, a very common source of pain in the back is myofascial pain from the muscles around the spine.  This can commonly coexist with and contribute to the pain from other sources.

The vast majority of cases of back pain are from what is described as non-specific low back pain.  A number of types of back pain are discussed further at these pages:

Disc Pain and Sciatica

Joint and other bony pain

Spinal Stenosis

Osteoporosis

Other conditions can cause back pain, including inflammatory diseases such as ankylosing spondylitis and rheumatoid arthritis, which cause the joints to become inflamed and seize up. This can either directly affect the joints in the back or cause problems with other joints that lead to pain in the back.  These, and causes such as cancer pain, may cause some of the red flags mentioned above.

How can back pain be investigated?

The most important part of making a diagnosis in back pain is careful questioning of the symptoms that a patient is experiencing, and examination of the back and nervous system.  A useful tool in initial screening, which is recommended in the NICE guidelines and our local guidelines in Gloucestershire, is the STarT Back tool.  

Investigations of the back do not always give useful information.  Some of the specific tests that may be done are discussed more on this page.

How can back pain be treated?

 Approaches are outlined in the relevant pages.

 

A very well-made and useful video on low back pain by Dr Mike Evans is available via this link.

Links

NICE Guidelines

Link to the excellent Sheffield back site  

Keele STaRTBack

Sheffield Back Pain leaflet

Sheffield Back Pain Myths

Sheffield Sciatic Pain leaflet

British Association of Spinal Surgeons Patient information pages

A well-regarded publication, the Back Book (ISBN  011 322312 9), can be obtained from HMSO The Stationery Office, Tel 0870 600 5522, for £1.25

An article from the Oxford Evidence Based Pain Medicine group's publication, Bandolier, on back pain may be useful.

 

 

 

 

 

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Pain Service Website, Gloucestershire Hospitals NHS Foundation Trust
Webmaster Dr J G de Courcy, Consultant in Pain Medicine and Anaesthesia
email: pain.webmaster[at]glos.nhs.uk

Page updated 6/2/2017