There are many reasons why people develop back pain. It is important to remember that back pain is a complaint and not a precise diagnosis so the challenge is to identify the specific cause of your back pain. Most conditions are diagnosed with MRIs (magnetic resonance imaging), CT scans (computed tomography), ultrasound, or x-rays. These imaging studies are used to identify abnormal tissues, although occasionally the abnormalities may be too small to detect. There are four main categories of back pain. These are in order of likelihood; mechanical, emotional, acquired injuries, tumors and infections. If you are interested in more details, please take a look at my book, Spine: Rehabilitation Medicine Quick Reference.
Muscle spasms are the most common mechanical condition that occurs in the back and everyone suffers from fleeting to severe muscle spasms in the back at some point in their life. We do not see patients in the doctor’s office unless the spasm pain is very severe or unrelenting. Muscle spasms can be caused by chronic muscle overload and fatigue or can be a symptom of an underlying problem. If the muscle spasm becomes a chronic problem, it can result in thickening of the muscle and fascial tissues. Doctors can easily identify muscle and fascial thickening by using ultrasound imaging.
Disc degeneration is the most common diagnosis that is found on imaging studies. It is a mechanical condition that occurs when there is wear and tear of the shock-absorbing discs between the vertebral bones of the spine. As the intervertebral discs wear down, there is more impact on the bones which start to grind together. As this happens, the hole that the nerve passes through called foramina, from Latin foramen “hole, opening, or aperture”, also narrows, which increases your risk of back pain and nerve pain or sciatica. This process begins after the age of 35 and is found in everyone by the age of 65, though you may never feel any pain from it. I have even seen disc degeneration occur in children beginning in their early teens due to excessive physical activities, so keep this in mind as your kids engage in sports.
Finally, a disc herniation is another example of a mechanical condition that is seen clinically. Disc herniations are associated with mild to moderate degrees of disc degeneration. And like disc degeneration, disc herniations can occur at either a single or multiple levels. Disc herniations occur when a tear forms in the outer portion of the disc called the annulus fibrosis. This allows the gelatinous interior of the disc (called the nucleus pulposus) to herniate or ooze out, like your favorite toothpaste, into the central canal that houses the spinal cord and nerves. If there is a lot of gel that squeezes out, it can compress the nerves resulting in significant weakness, numbness and tingling. Furthermore, your immune system does not realize that the gel is part of your body. It thinks it is a foreign substance like a splinter so it begins attacking and mounting an immune response. The attack begins with increased blood flow and the release of chemicals that try to breakdown the gel, which also causes inflammation. The pain that you experience is this inflammation. If it is minor then you may only experience slight lower back pain, but if there is a tremendous amount of inflammation then you may not only have severe pain but it may also travel down the leg, a condition commonly referred to as sciatica. Disc herniations are more commonly found in people aged 30 to 50 years old and are most likely due to repetitive activities such as bending forward, lifting and twisting or sitting for long periods of time. If any family members or relatives have this condition, you have a much greater chance of having it. It is also related to smoking, so it may prove imperative for you to quit in order to achieve an optimal recovery.
The second most common cause of back pain occurs when you are emotionally stressed. When this occurs, your back muscles instantly tighten, your flexibility decreases and you put additional strain on your spine as well as the many muscles surrounding your spine. If this is severe or goes on for a very long period of time, it can result in chronic back pain. Unfortunately, not only is this area poorly understood, but there has been very little research completed to further our understanding of our emotions as they relate to our physical health.
Acquired injuries, the third most common cause of back pain, can be some of the simplest or the most dangerous causes of back pain. Muscle strains which are micro-tears of the muscles, happen quite often and can resolve on their own. Ligament injuries, micro-tears of the ligaments, can heal on their own as well, however if your ligaments have loosened due to over-stretching or even more simple activities such as slouching, although not dangerous, it can lead to chronic back pain. Fractures, on the other hand, can be very dangerous as they can result in spinal instability which can lead to a spinal cord injury or death. The most common causes of fractures are falls, osteoporosis or high-speed injuries. Believe it or not, some fractures can occur without your knowledge and are incidentally found when imaging your back for other reasons.
Acquired diseases make up the largest number of diagnoses of back pain. These include scoliosis, an abnormal S-shaped curve of your spine, and kyphosis which is an abnormal forward hunch. Spondylosis is simple arthritis of the spine that occurs due to wear and tear. Spondylolysis is a fracture of the small joints in the back. With this type of fracture the bony segments of the spine at that level can slip and become misaligned which is called spondylolisthesis. As arthritis gets worse in the lower back you may develop spinal stenosis – a condition describing a narrowing of the canals that the nerves transit through. Rheumatoid arthritis can loosen the ligaments in the spine resulting in accelerated arthritis and inflammation. Other factors that do not directly affect the spine but can cause back pain include kidney stones, pregnancy, endometriosis and fibromyalgia. If you are interested in further information about these subjects, please take a look at my book, Spine: Rehabilitation Medicine Quick Reference.
Tumors and Infections
Tumors and infections are the most dangerous causes of back pain as they can be fatal if not treated. These include infections of the bone (osteomyelitis) or infections of the disc (discitis). Infections can result from prior surgery or procedures or from an infection brewing in the body such as chronic gingivitis or phlebitis or more dangerous infections such as tuberculosis. Tumors can sneak up at any time and can grow within the spinal cord such as an ependymoma and astrocytoma or grow outside the spinal cord such as a meningioma or schwannoma. Tumors can arise from cancers that begin in other parts of the body such as the breasts, lungs, kidneys, colon and prostate, and ultimately spread or metastasize to the spine. With most of these conditions, back pain is associated with, what doctors call red flag symptoms to signify their importance such as fevers, chills, night sweats and/or unintentional weight loss.
What does it mean when I have back pain?
Think of back pain as a message from your body telling you that you have not been kind to your back and that you probably over did it somehow. Unfortunately, the pain may not tell you the whole story regarding the reason for your pain or the exact location of your pain. A majority of my patients do not know the reason they have back pain. They cannot recollect a specific injury, event or even the year it started. All they know is that it came on gradually. On the other hand, a minority of my patients will know exactly what activity they were doing when the pain began but are not sure why. For instance, they may have bent over to pick up a paper clip or simply got out of bed, which they have done millions of times before. Often very repetitive activities will eventually result in back pain. Your back pain may be due to years of poor posture or may have occurred after a recent recreational activity that you were not prepared for, such as a fitness boot camp or an outdoor adventure race. If your back pain is limiting your basic, day-to-day activities, you should see your doctor.
What is back pain a symptom of?
Back pain is a symptom, not a diagnosis. Your spine has to sustain and transmit a great deal of force during normal everyday activities, so when it is overloaded, you eventually develop back pain. There are also many conditions that may result in back pain as well which include inflammatory arthritis, hypothyroidism, cancer, and gastrointestinal problems. So remember to think of back pain as a symptom of a problem that you need to figure out.
How long will my back pain last?
Luckily our bodies are very resilient when it comes to back pain. Half of all back pain episodes will completely resolve within two weeks and up to 80% of all back pain episodes will resolve within six weeks. The remaining 20% of patients may have pain that lasts for months to years or even a lifetime. You do not want to be in the last group. Unfortunately, you cannot predict the duration or severity of back pain as you wait for it to heal. If it is severe, however, and has not resolved within six weeks, it is best to see your doctor for an evaluation and treatment.
How can I tell if my back pain is from my muscles or spine?
With back pain, it is hard to differentiate muscle pain from spine pain. With any inflammatory process the pain begins as a dull ache and can progress to a very sharp, excruciating pain. Any inflammation in the area can cause the muscles to reflexively spasm as your body attempts to stabilize the injured area. This explains why with an existing back problem your hamstrings and calves will be very tight despite extraordinary attempts to stretch them. Some advice; do not work hard to stretch them; you will fail. You really cannot tell the difference between basic muscle spasms or muscle spasms due to an underlying problem such as disc degeneration, a herniated disc or a fracture. My usual recommendation to my patients is: if you had a specific event that may have caused muscle damage and if your back improves within several days, it is most likely a muscle spasm or strain since muscles have great blood flow and they can heal very fast; if on the other hand you do not heal very quickly, it is most likely due to an injury of the structures that do not have great blood flow such as the discs, tendons, ligaments or nerves. Bones have great blood flow but take 8 to 12 weeks to heal and often result in severe back pain with muscle spasms, making it difficult to sit upri